Superiority of nitrate-enhanced Tl-201 over conventional redistribution Tl-201 imaging for prognostic evaluation after myocardial infarction and thrombolysis

Background Tl-201 imaging has been widely used for postinfarction risk stratification. However, thrombolytic therapy and aspirin have significantly changed outcome, and there are few nuclear imaging studies that assess prognosis in such patients. Furthermore, newer techniques of Tl-201 imaging, such as reinjection and nitrate-enhanced rest Tl-201 imaging, have been shown to improve the detection of viable but jeopardized myocardium. Methods and Results We studied 100 consecutive patients, who remained event free 6 weeks after myocardial infarction and thrombolysis. Patients underwent conventional exercise and 4-hour redistribution imaging, followed on a separate day by nitrate-enhanced rest Tl-201 study. Planar images were reported semiquantitatively by two experienced observers blinded to clinical data. Redistribution and rest injection images were classified as demonstrating reversible ischemia if they showed improvement in uptake by at least two grades in at least two segments in comparison with the initial exercise scintigram. Patients were followed up fur 8 to 32 months (mean, 21 months), during this period, 37 patients had first cardiac events. Reversible ischemia was present in 29 patients on redistribution, of whom 14 (48%) had events; of 71 without reversible defects, 23 (32%) had events (hazard ratio, 1.5; 95% CI, 0.8 to 3.0; P=NS), Nitrate-enhanced rest Tl-201 imaging detected reversible defects in 68 patients, of whom 33 (49%) had events, whereas of 37 without reversible defects, only 4 (13%) had subsequent cardiac events (hazard ratio, 8.1; 95% CI 2.7 to 23.8; P<.001). Conclusions Thus, after myocardial infarction and thrombolysis, even ''stable'' patients have a high (68%) incidence of viable but jeopardized myocardium, causing a high event rate. Those identified to be at high risk by perfusion imaging may benefit from early intervention.