Circulation, Vol 90, 2687-2694, Copyright © 1994 by American Heart Association
KS Lee, TH Marwick, SA Cook, RT Go, JS Fix, KB James, SK Sapp, WJ MacIntyre and JD Thomas
BACKGROUND: The uptake of F-18 deoxyglucose into dysfunction segments after
myocardial infarction identifies metabolically active (FDG+) or inactive
(FDG-) myocardium. Although patients with FDG+ segments have been found to
be at risk for adverse events, the prognostic significance of viable
myocardium in relation to other influences on postinfarction prognosis,
including revascularization, remain ill defined. The purpose of this study
was to investigate the relative prognostic significance of FDG+ tissue and
to establish whether myocardial revascularization in patients with viable
tissue attenuates the risk of adverse outcome. METHODS AND RESULTS: One
hundred thirty- seven patients with left ventricular dysfunction and
resting perfusion defects after myocardial infarction underwent positron
emission tomography with both dipyridamole stress Rb-82 perfusion imaging
and FDG imaging. After the exclusion of 4 patients proceeding to
transplantation, 2 with uninterpretable scans and 2 lost to follow-up, 129
patients were followed clinically for 17 +/- 9 months. Four groups were
defined: patients with FDG+ dysfunctional myocardium who were
revascularized (n = 49) or treated medically (n = 21) and those with FDG-
segments who were revascularized (n = 19) or treated medically (n = 40).
The groups of patients with FDG+ or FDG- findings, with and without
revascularization, did not differ with respect to known determinants of
postinfarction prognosis: age, left ventricular ejection fraction, or the
prevalence of multivessel disease. Nonfatal ischemic events occurred in 48%
of medically treated FDG+ patients compared with 8% of revascularized
patients with FDG+ tissue (P < .001) and 5% of patients with FDG-
myocardium (P < .001). Thirteen patients died from cardiac causes; 11
(85%) had a left ventricular ejection fraction of < 30%, and these
patients were evenly distributed between FDG+ and FDG- groups. Using Cox's
proportional hazards model, only the presence of FDG+ myocardium (odds
ratio, 12.9; P < .001) and the absence of revascularization (odds ratio,
5.8; P = .002) independently predicted ischemic events, while only age (P =
.02) and ejection fraction (P < .001) but not the presence of viable
myocardium were predictive of death. CONCLUSIONS: Residual viable
myocardium after myocardial infarction may act as an unstable substrate for
further events unless it is revascularized. Despite this association, age
and left ventricular dysfunction remained the strongest predictors of
cardiac death after myocardial infarction in these patients with a spectrum
of left ventricular dysfunction.
ARTICLES
Prognosis of patients with left ventricular dysfunction, with and without viable myocardium after myocardial infarction. Relative efficacy of medical therapy and revascularization
Department of Cardiology, Cleveland Clinic Foundation, OH 44195.
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M. F. Di Carli, F. Asgarzadie, H. R. Schelbert, R. C. Brunken, H. Laks, M. E. Phelps, and J. Maddahi Quantitative Relation Between Myocardial Viability and Improvement in Heart Failure Symptoms After Revascularization in Patients With Ischemic Cardiomyopathy Circulation, December 15, 1995; 92(12): 3436 - 3444. [Abstract] [Full Text]
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