Rheumatology 2001; 40: 1106-1111
© 2001 British Society for Rheumatology
Original Papers |
The role of technetium-99m sestamibi myocardial perfusion single-photon emission computed tomography (SPECT) in the detection of cardiovascular involvement in systemic lupus erythematosus patients with non-specific chest complaints
Departments of Nuclear Medicine,
3 Family Medicine and
4 Medical Research, China Medicine College Hospital, Taichung,
1 Department of Nuclear Medicine, Far Eastern Memorial Hospital and Institute of Biomedical Engineering, College of Electrical Engineering, National Taiwan University, Taipei and
2 Department of Nuclear Medicine, Show-Chwan Memorial Hospital, Chunghua, Taiwan
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Abstract |
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Objectives. Systemic lupus erythematosus (SLE) can affect multiple organs. Coronary artery disease has received increasing recognition as a major cause of morbidity and mortality in SLE in recent years. The purpose of this study was to evaluate the utility of technetium-99m sestamibi single-photon emission computed tomography (99mTc-sestamibi SPECT) in the detection of cardiovascular involvement in SLE patients with non-specific clinical chest symptoms such as chest discomfort and/or dyspnoea and/or occasional palpitation.
Methods. Thirty-three SLE female patients (age range: 22–45 yr) with non-specific complaints such as chest discomfort and/or dyspnoea and/or occasional palpitation were investigated using a 99mTc-sestamibi myocardial perfusion SPECT scan at rest and after dipyridamole infusion in a stress study. The age- and sex-matched healthy group (24 cases) and SLE patients without any cardiovascular symptoms/signs (28 cases) were also included as controls in this study. The results of the uptake pattern of 99mTc-sestamibi were classified into four types including normal, persistent perfusion defect, reversible perfusion defect and reverse redistribution.
Results. Perfusion abnormalities were detected in 27 cases (seven patients had persistent perfusion defects, 15 patients had reversible perfusion defects, one patient had both persistent and reversible perfusion defects, two patients showed a reverse redistribution pattern and two patients had both reversible perfusion defects and a reverse redistribution pattern). The results of the SPECT in the healthy group were all normal. However, perfusion abnormalities were detected in 12 cases in the group of asymptomatic SLE patients.
Conclusions. 99mTc-sestamibi myocardial perfusion SPECT is a useful non-invasive imaging modality to detect cardiovascular involvement in SLE patients with non-specific clinical complaints of heart disease.
KEY WORDS: 99mTc-sestamibi SPECT, Systemic lupus erythematosus, Coronary artery disease.
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Introduction |
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Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by remission and exacerbation with multisystemic manifestations. SLE can affect every organ directly or indirectly. Coronary artery disease (CAD) has received increasing recognition as a major cause of morbidity and mortality in SLE in recent years and involvement of the cardiovascular system is now considered the third leading cause of death in patients with SLE [1–4]. The reported frequency of clinically recognizable CAD in adults with SLE is between 6.1 and 8.9% [5, 6]. However, previous studies had reported that the frequency of subclinical myocardial perfusion abnormalities in patients with SLE is higher [7, 8]. Thus, we need a useful non-invasive method to detect early cardiovascular involvement in SLE patients with non-specific clinical complaints and to prevent later cardiac events. To our knowledge, the evaluation of myocardial perfusion using technetium-99m sestamibi single-photon emission computed tomography (99mTc-sestamibi SPECT) has not been investigated in SLE patients with non-specific clinical symptoms of heart disease, although few data have been reported [7, 8] on the evaluation of myocardial perfusion in asymptomatic lupus patients. The present study aimed to evaluate the utility of 99mTc-sestamibi SPECT in the detection of cardiovascular involvement in SLE patients with non-specific clinical symptoms of heart disease.
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Patients
Thirty-three SLE female patients (age range: 22–45 yr) with a definite diagnosis of SLE according to the revised criteria of the American College of Rheumatology [9] were enrolled in this study. All patients were undergoing various treatments and had low to moderate disease activity. We were concerned that some drugs used in SLE treatment may influence the results of the scan. Therefore, all treatment was withheld for 24 h before 99mTc-sestamibi myocardial perfusion SPECT. All patients had non-specific clinical complaints such as chest discomfort and/or dyspnoea and/or occasional palpitation and none had a previous operative history of heart disease. In addition, an age- and sex-matched healthy group (24 females; age range: 24–45 yr) and SLE patients without any cardiovascular symptoms/signs (28 females; age range: 20–46 yr) were also included as controls in this study. These 28 asymptomatic SLE female patients followed the same procedures as the above symptomatic SLE female patients. Data on anticardiolipin antibodies (aCL), chest X-ray, resting ECG and cardiovascular risk factors were also obtained in all SLE patients in this study.
99mTc-sestamibi myocardial perfusion SPECT
A 1-day protocol of 99mTc-sestamibi myocardial perfusion SPECT at rest and after dipyridamole infusion (0.56 mg/kg over 4 min during ECG monitoring) in a stress study was performed in all patients. 99mTc-sestamibi, 10 and 25 mCi, was injected in the rest and dipyridamole stress studies, respectively. In the dipyridamole stress imaging, 99mTc-sestamibi was injected 2 min after the end of the infusion. All patients were instructed not to consume drugs or substances containing xanthine for 2 days before this study. Intravenous aminophylline was given 4 min after the administration of the 99mTc-sestamibi if patients had discomfort during dipyridamole infusion. SPECT images were acquired 1 h after 99mTc-sestamibi injection using a large field of view dual-headed gamma camera (ADAC, Vertex plus) equipped with a low-energy, all-purpose, parallel-hole collimator. Data were obtained from 64 projections of 25 s each in the 140 keV photopeak over a 180° arc in a 64x64 matrix. A short axis, vertical long axis and horizontal long axis were reconstructed from the raw data by filtered backprojection with a Butterworth filter, with a cut-off frequency of 0.5 and order of 10 in the rest study and a cut-off frequency of 0.66 and order of 5 in the stress study. All images were interpreted blind and separately by at least two experienced nuclear medicine physicians. The classification of the 99mTc-sestamibi myocardial perfusion SPECT results is shown in Table 1
. The results of the 99mTc-sestamibi uptake pattern were classified into four types including normal, persistent perfusion defect (defects present on both rest and dipyridamole stress images), reversible perfusion defect (defects present only on dipyridamole stress image) and reverse redistribution pattern (defect demonstrated in the redistribution image which is not present in the stress image). The final diagnosis was obtained by consensus where the conclusions of the physicians differed.
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Results |
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No definite perfusion abnormalities were found in the 24 healthy controls. Detailed results and the data on symptomatic and asymptomatic SLE patients are shown in Table 2
and 3. Perfusion abnormalities were noted in 27 symptomatic SLE patients (82%) in this study. Seven patients had persistent perfusion defects (Fig. 1), 15 patients had reversible perfusion defects (Fig. 2), one patient had both persistent and reversible perfusion defects, two patients showed the reverse distribution pattern (Fig. 3) and two patients had both reversible perfusion defects and the reverse distribution pattern. The remaining six cases had normal perfusion during rest and after dipyridamole infusion (Fig. 4). However, perfusion abnormalities were detected in 12 cases (43%) in the group of asymptomatic SLE patients (four patients had persistent perfusion defects, five patients had reversible perfusion defects, one patient had both persistent and reversible perfusion defects and two patients showed the reverse redistribution pattern). ECG had a minor positive change with slight ST-depression (<1 mm) in three patients of the symptomatic SLE patient group and one patient of the asymptomatic SLE patient group. Ten patients of the symptomatic SLE patient group and three patients of the asymptomatic SLE patient group experienced some discomfort during the dipyridamole stress test (dizziness and/or headache and/or flushing and/or chest pain). However, all discomfort symptoms/signs were mild, well-tolerated and promptly reversed by aminophylline. No ECG change and no chest discomfort symptoms/signs were found after dipyridamole infusion in the healthy group. No significant adverse reaction occurred in any patient after dipyridamole infusion in this study. No definite correlation was found between clinical features and aCL data and the results of SPECT in our study.
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Discussion |
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Cardiovascular involvement is one of the most important complications of SLE and may contribute significantly to the morbidity and mortality [10, 11]. However, the diagnosis of cardiovascular involvement in SLE is difficult because clinical manifestations have been reported in only a small percentage of SLE patients and because of the lack of effective non-invasive imaging methods for the detection of cardiovascular involvement when SLE patients have non-specific clinical complaints. Autopsy studies [12, 13] have also documented that the heart is affected in most patients, but clinical manifestations occur in less than 10%. A previous study [7] described that the rest/dipyridamole 99mTc-sestamibi myocardial SPECT can be a useful non-invasive method to identify subclinical myocardial involvement in SLE patients without definite clinical symptoms. In this study, 33 lupus patients with non-specific clinical complaints such as chest discomfort and/or dyspnoea and/or occasional palpitation were investigated and abnormal myocardial perfusion defects were detected in 27 patients using rest/dipyridamole 99mTc-sestamibi myocardial SPECT. It is not surprising that a high prevalence (27 of 33 symptomatic SLE patients; 82%) was revealed in this study because a high prevalence (43%) was also noted in the asymptomatic SLE patient group, which was similar to the results of a previous study [8].
The clinical features of SLE patients related to cardiovascular diseases (pericarditis, myocarditis, valvular disease, CAD, etc.) such as chest discomfort, dyspnoea and occasional palpitation are non-specific clinical symptoms because all cardiac abnormalities may have these symptoms [1]. Thus, the complaints of the SLE patients in this study were non-specific. The pathogenesis of CAD in SLE patients is thought to be multifactorial with disease- and treatment-related factors, as well as independent cardiovascular risk factors contributing to the overall risk [5]. The pathological findings of the myocardium include interstitial infiltration with lymphocytes and neutrophils, coronary vasculitis, anterior intimal proliferation, myocardial degeneration, fibrosis and scarring; all these abnormalities are mainly attributed to the primary immunological damage caused by the lupus process [1]. In our series, none of these patients was submitted to coronary angiography. Schillaci et al. [7] reported that normal results of coronary angiography were noted in all SLE patients with positive 99mTc-sestamibi myocardial SPECT scan. These findings suggest intramyocardial small vessel disease due to the primary immunological damage of SLE. We also found that four of the six patients with normal results on 99mTc-sestamibi myocardial SPECT scan received high-dose corticosteroid therapy over a long period of time. However, we did not have a complete record of corticosteroid doses from the time of initial therapy in most patients and thus we could not obtain statistical differences in this study. Whether there is a relationship between corticosteroid therapy and myocardial perfusion defects in SLE patients needs further investigation. The possible causes of myocardial perfusion abnormalities in SPECT studies in SLE patients include atherosclerosis and/or vasculitis. Therefore, the possible treatments of SLE patients with altered SPECT include high-dose steroids, percutaneous transluminal coronary angioplasty and bypass surgery.
After reviewing the previous literature, we found only one possibly related autoantibody (aCL) to cardiovascular involvement in SLE patients [14]. However, we found no significant correlation between the data on aCL and the results of SPECT in our study. Although at least six common indices (such as BILAG, ECLAM, LAI, SIS, SLAM and SLEDAI) are routinely used to calculate SLE activity index, none of these indices focuses on cardiovascular involvement in SLE [15]. According to a previous study [16], there was no difference in SLE activity (SLEDAI) score between patients with positive SPECT results and those with negative SPECT results. Thus, we did not calculate SLEDAI to correlate the SPECT results in this study. In conclusion, our results show that 99mTc-sestamibi myocardial perfusion SPECT is a useful non-invasive imaging method to detect early cardiovascular involvement in SLE patients with non-specific clinical complaints. Further follow-up studies are needed to evaluate whether patients with these perfusion defects are at risk of later cardiac events.
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Notes |
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Correspondence to: A. Kao, Departments of Nuclear Medicine and Medical Research, China Medical College Hospital, No. 2, Yuh-Der Road, Taichung 404, Taiwan.
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