Pharmacological test with nitroglycerin in combination with perfusion SPECT with ^99mTc-Technetril in assessing the viability of ischemic myocardium in patients after acute infarction

Aim. To evaluate the possibility of using nitroglycerin sublingually in combination with 99mTc-Technetril cardiac perfusion single-photon emission computed tomography (SPECT) as a test for detecting viable myocardium. Material and methods. 28 male patients with coronary heart disease (CHD) and postinfarction cardiosclerosis were examined. Group 1 included 10 patients with CHD without signs of acute myocardial infarction (AMI). Group 2 comprised 18 patients with CHD, postinfarction cardiosclerosis (PICS). The control group consisted of patients who were subsequently rejected a diagnosis of CHD. Patients took 2 tablets (1 mg) of nitroglycerin sublingually, and then, at the peak of the drug’s action (after 3–5 minutes), they were intravenously administered 370 MBq of 99mTc-Technetril (by Diamed, Russia). Myocardial SPECT with 99mTc-Technetril was performed 1 hour after RFP injection. The next day, myocardial SPECT with 99mTc-Technetril was repeated at rest. Results. When taking tableted nitroglycerin at a dose of 1 mg sublingually, its maximum plasma concentration is on average 0.26 ± 0.04 microcgram/l. It is reached by 110–150 s, then maintained within 10 % of the maximum for 7-9 minutes. Nitroglycerin leads to improvement in global and local contractility and increased LV pumping function in CHD patients. This is most pronounced in individuals with a higher class of angina pectoris after AMI and major changes in intracardiac hemodynamics initially. The nitroglycerin test in combination with 99mTc-Technetril SPECT-CT allowed to identify myocardial areas with improved blood flow and increased EFLV after CABG. Conclusion. The nitroglycerin test in combination with 99mTc-Technetril SPECT-CT is effective for detecting viable myocardium in patients with coronary atherosclerosis and CHD, safe and relatively simple due to the sublingual route of nitroglycerin intake.

1. Шляхто Е.В., Баранова Е.И. Основные направления снижения сердечно-сосудистой смертности: что можно изменить уже сегодня? // Росс. кардиол. журн. – 2020. – Т. 25, № 7. – С. 10–18. [Shlyakhto EV, Baranova EI. Central directions for reducing cardiovascular mortality: what can be changed today? Russ J Cardiol. 2020;25(7):10-18. (In Russ.)]. Doi: 10.15829/1560-4071-2020-3983.

2. Лишманов Ю.Б. Национальное руководство по радионуклидной диагностике. В 2 т. Т. 1. / Ю.Б. Лишманов, В.И. Чернов. – Томск: STT, 2010. – 290 c. [Lishmanov YuB. National Guide to radionuclide diagnostics. In 2 vols. Vol. 1. / YuB Lishmanov, VI Chernov. Tomsk, STT, 2010:290. (In Russ.)].

3. Аронов Д.М., Лупанов В.П. Функциональные пробы в кардиологии. – 2-е изд. – М.: МЕДпресс-информ, 2002. – 295 с. [Aronov DM, Lupanov VP. Functional tests in car diology. 2nd ed. Moscow, MEDpress-inform, 2002:295. (In Russ.)].

4. Parikh K, Choy-Shan A, Ghesani M, Donnino R. Multi- modality Imaging of Myocardial Viability. Curr Cardiol Rep. 2021;23(1):5-12. Doi: 10.1007/s11886-020-01433-8.

5. Литвиненко И.В. Возможности ОФЭКТ-КТ в диагностике стенозов коронарных артерий // Мед. визу ализ. – 2015. – № 2. – С. 53–66. [Litvinenko IV. The Pos sibi lity of SPECT-CT in the Diagnosis of Coronary Artery Stenosis. Med Vizualiz. 2015;(2):53-66. (In Russ.)].

6. Солнышков С.К., Келеш М.В. Стресс-эхокардиография с добутамином: физиологические основы, методические аспекты, показания к применению и безопасность // Вестн. Ивановской мед. акад. – 2009. – Т. 14, № 1. – С. 54– 59. [Solnyshkov SK, Kelesh MV. Stress echocardiography with dobutamine: physiological basis, metdic aspects, indications for use and safety. Bull Ivanovo Med Acad. 2009;14(1):54-59. (In Russ.)].

7. Карпова И.Е., Самойленко Л.Е., Соболева Г.Н. и др. Применение однофотонной эмиссионной компьютерной томографии с 99mТс-МИБИ в сочетании с фармакологической пробой с аденозинтрифосфатом натрия в диагностике ишемии миокарда у больных ишемической болезнью сердца // Кардиология. – 2013. – Т. 53, № 2. – С. 91–96. [Karpova IE, Samoilenko LE, Soboleva GN, Sergienko VB, Karpov YuA. Adenosine truiphosphate stress 99mTc-MIBI single-photon emission computed tomography in the diagnosis of ischemic heart disease. Cardiology. 2013;53(2):91-96. (In Russ.)].

8. Никифоров В.С. Методы сердечно-сосудистой визуали зации в диагностике жизнеспособного миокарда при ишемической болезни сердца: учеб. пособие / В.С. Ни кифоров. – СПб.: КультИнформПресс, 2012. – 33 с. [Nikiforov VS. Methods of cardiovascular imaging in the diagnosis of viable myocardium in ischemic heart disease. Saint Petersburg, KultiInformPress, 2012:33. (In Russ.)].

9. Аншелес А.А., Сергиенко В.Б. Ядерная кардиология: монография. – М.: НМИЦ Кардиологии, 2021. – 515 c. [Ansheles AA, Sergienko VB. Nuclear cardiology: The monography. Moscow, NMITs Kardiologii, 2021:515. (In Russ.)].

10. Аншелес А.А., Сергиенко И.В., Сергиенко В.Б. Современное состояние и перспективные технологии радионуклидной диагностики в кардиологии // Кардио логия. – 2018. – Т. 58, № 6. – С. 61–69. [Ansheles AA, Sergienko IV, Sergienko VB. Current state and promising technologies of radionuclide diagnostics in cardiology. Cardiology. 2018; 58(6):61-69. (In Russ.)].

11. Buell U, Schicha H. Nuclear medicine to image applied pathophysiology: evaluation of reserves by emission computerized tomography. Eur J Nucl Med. 1990;16(3):129-135. Doi: 10.1007/BF01146850.

12. Caner B, Beller GA. Are technetium-99m-labeled myocardial perfusion agents adequate for detection of myocardial viability? Clin Cardiol. 1998;21(4):235-242. Doi: 10.1002/clc.4960210402.

13. Altehoefer C, vom Dahl J, Biedermann M, Uebis R, Beilin I, Sheehan F, Hanrath P, Buell U. Significance of defect severity in technetium-99m-MIBI SPECT at rest to assess myocardial viability: comparison with fluorine-18-FDG PET. J Nucl Med. 1994;35(4):569-574.

14. Шелковникова Т.А. Визуальный и количественный анализ картины контрастированной МРТ миокарда при аорто-коронарном шунтировании // Мед. визуализ. – 2011. – № 3. – С. 16–22. [Shelkovnikova TA. Visual and quantitative analysis of the picture of the contrasted MRI of the myocardium during coronary artery bypass grafting. Med Vizualis. 2011;(3):16-22. (In Russ.)].

15. Sciagrà R, Bisi G, Santoro GM, Rossi V, Fazzini PF. Nitrate versus rest myocardial scintigraphy with technetium99m - sestamibi: relationship of tracer uptake to regional left ventricular function and its significance in the detection of viable hibernating myocardium. Am J Card Imaging. 1995; 9(3):157-166.

16. Ivanovskaya EA, Bobleva YuV. Determination of cardiac preparations by stripping voltammetry. J Analyt Chem. 2000;55(11):1077-1079. Doi: 10.1007/BF02757336.

17. Рыбакова М.К., Митьков В.В. Эхокардиография. – М.: Вилар, 2019. – 388 c. [Rybakova MK, Mitkov VV. Echocardiography. Moscow, Vilar, 2019:388. (In Russ.)].

18. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T, Verani MS; American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation. 2002;105(4):539-542. Doi: 10.1161/hc0402.102975.

19. Hendel RC. Single-photon perfusion imaging for the assessment of myocardial viability. J Nucl Med. 1994; 35(4 Suppl):23S-31S.

20. Płońska-Gościniak E, Gackowski A, Kukulski T, Kasprzak JD, Szyszka A, Braksator W, Gąsior Z, Lichodziejewska B, Pysz P. Stress echocardiography. Part I: Stress echocardiography in coronary heart disease. J Ultrason. 2019;19(76):45-48. Doi: 10.15557/JoU.2019.0006.

21. Slart RH, Bax JJ, van Veldhuisen DJ, van der Wall EE, Dierckx RA, Jager PL. Imaging techniques in nuclear cardiology for the assessment of myocardial viability. Int J Cardiovasc Imaging. 2006;22(1):63-80. Doi: 10.1007/s10554-005-7514-8.

22. Sias TM, Watson DD, Beller GA. Is nitroglycerin useful for the enhancement of viability detection with myocardial perfusion imaging? Am Heart J. 1999;138(2 Pt 1):206-209. Doi: 10.1016/s0002-8703(99)70103-1.

23. Katikireddy CK, Samim A. Myocardial viability assessment and utility in contemporary management of ischemic cardiomyopathy. Clin Cardiol. 2022;45(2):152-161. Doi: 10.1002/clc.23779.

24. Агаева Х.А., Хван Д.С., Сирота Д.А. и др. Малоинвазивное коронарное шунтирование: история и перспективы // Кардиол. и сердечно-сосуд. хир. – 2023. – Т. 16, № 1. – С. 711. [Agaeva KhA, Khvan DS, Sirota DA, Zhulkov MO, Bozorov SSh, Chernyavskiy AM. Minimally invasive coronary artery bypass grafting: history and perspectives. Russ Cardiol Cardiovasc Surg. 2023;16(1):711. (In Russ.)]. Doi: 10.17116/kardio2023160117.

25. Усов В.Ю., Бахметьева М.И., Беличенко О.И. и др. Количественная полуавтоматическая оценка повреждения миокарда по данным МР-томографического исследования с парамагнитным контрастным усилением на среднеи высокопольных МР-томографах // Терапевт. – 2019. – № 8. – С. 19–30. [Usov WYu, Bakhmetyeva MI, Belichenko OI, Mochula OV, Yaroshevskyi SP, Alekseeva YV, Priakhin AS, Riabov VV, Lukyanenok PI, Arkhangelskiy VA. Qquantitatiove semiautomatic measurement of myocardial damage, calculated from contrast-enhanced MRI using middle and high-fiald MRI scanners. Therapist. 2019;(8):19-30. (In Russ.)].

26. Алексеева Я.В., Вышлов Е.В., Рябов В.В. и др. Феномены микрососудистого повреждения миокарда при первичном инфаркте миокарда с подъемом сегмента ST // Кардиол. вестн. – 2019. – Т. 14, № 2. – С. 54–60. [Alekseeva YaV, Vyshlov EV, Ryabov VV, Mochula OV, Ussov WYu, Markov VA, Karpov RS. Phenomena of microvascular myocardial injury in primary myocardial infarction with ST segment elevation. Cardiol Bull. 2019;14(2):54-60. (in Russ.)]. Doi: 10.17116/Cardiobulletin20191402154.

27. Сцинтиграфическое определение величины миокардиального кровотока / Кривоногов Н.Г., Минин С.М., Крылов А.Л., Лишманов Ю.Б. // Бюлл. Cиб. мед. – 2013. – Т. 12, № 3. – С. 111– 116. [Krivonogov NG, Minin SM, Krylov AL, Lishmanov YuB. Radionuclide quantitative assessment of myocardial blood flow. Bull Sib Med. 2013;12(3):111-116. (In Russ.)].