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1 Original Articles Korean Circulation J 1999;295: 비대칭적중격비후를가진비후성심근증환자의 디피리다몰부하 Tl-201 SPECT 원경숙 3 문대혁 1 류진숙 1 강덕현 2 박성욱 2 김유호 2 박승정 2 최윤영 4 이희경 1 Dipyridamole Tl-201 SPECT in Hypertrophic Cardiomyopathy with Asymmetric Septal HypertrophyCharacteristics of Perfusion Abnormality and Correlation with Clinical Parameters Kyoung Sook Won, MD 3, Dae Hyuk Moon, MD 1, Jin Sook Ryu, MD 1, Duk-Hyun Kang, MD 2, Seong-Wook Park, MD 2, You-Ho Kim, MD 2, Seung-Jung Park, MD 2, Yun Young Choi, MD 4 and Hee Kyung Lee, MD 1 1 Departments of Nuclear Medicine and 2 Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, 3 Department of Nuclear Medicine, Asan Kangnung Hospital, Kangnung, 4 Department of Nuclear Medicine, Hanyang University, Seoul, Korea ABSTRACT Background and ObjectivesExercise myocardial perfusion scans in patients with hypertrophic cardiomyopathy have shown reversible perfusion abnormalities with unknown clinical significance. We performed this study to characterize dipyridamole Tl-201 SPECT imaging and correlate with clinical findings in patients with hypertrophic cardiomyopathy. MethodsTl-201 SPECT was performed in 25 patients of hypertrophic cardiomyopathy with asymmetric septal hypertrophy and 20 normal controls after dipyridamole infusion 0.56 mgkg. Myocardial wall was divided into 8 segments. Tl-201 uptake and relative washout rate were calculated. ResultsTl-201 SPECT showed significantly lower Tl-201 uptake in basal septal % vs %, p0.05 and apical septal wall on stress % vs %, p0.05 and higher apical septal % vs %, p0.05 and apical anterior wall uptake 88.7%4.0% vs %, p0.05 on redistribution images in patients with hypertrophic cardiomyopathy. Basal lateral wall uptake of hypertrophic cardiomyopathy was significantly lower than normal control on both stress % vs %, p0.05 and redistribution images % vs %, p The septumlateral uptake ratio of patients on rest image was significantly higher than that of normal controls vs , p There was no difference in age, sex, symptom, cardiac medication and the parameters of 2D-echo including left ventricular outflow obstruction between subgroups of normal vs abnormal washout in patients with hypertrophic cardiomyopathy. ConclusionDipyridamole Tl-201 myocardial SPECT shows reduced 465

2 coronary vasodilatory capacity of myocardium, especially septum in patients with hypertrophic cardiomyopathy. High septallateral uptake ratio on redistribution image may be a characteristic finding. However, no correlation between abnormal Tl-201 washout and clinical findings was observed. Korean Circulation J 1999;295: KEY WORDSHypertrophic cardiomyopathy Tl-201 SPECT Dipyridamole. 서론 대상및방법 대상환자 디피리다몰부하심근 SPECT 466 Korean Circulation J 1999;295:

3 심근영상의분석 Fig. 1. The diagram of bull s eye polar map. Myocardium was divided into eight segments and analyzed for relative thallium uptake and washout rate %. ANTanterior wall, SEPseptum, INFinferior wall, LATlateral wall, bbasal, aapical. 통계학적분석 결 Table 1. Normalized dipyridamole stress myocardial thallium uptake in normal control n20 and patients with hypertrophic cardiomyopathy n25 과 Normal control* HCM with ASH* p value bant NS aant NS bsep asep binf NS ainf NS blat alat NS * meanstandard deviation, ANT anterior wall, SEPseptum, INFinferior wall, LATlateral wall, b basal, aapical, HCM with ASHhypertrophic cardiomyopathy with asymmetric septal hypertrophy 467

4 468 고 Table 2. Normalized dipyridamole redistribution myocardial thallium uptake in normal control n20 and patients with hypertrophic cardiomyopathy n25 찰 Normal control* HCM with ASH* p value bant NS aant bsep NS asep binf NS ainf NS blat alat NS * meanstandard deviation, ANT anterior wall, SEPseptum, INFinferior wall, LATlateral wall, b basal, aapical, HCM with ASHhypertrophic cardiomyopathy with asymmetric septal hypertrophy Korean Circulation J 1999;295:

등11)의 연구에서는 72명의 비후성심근증 환자 중 41 디피리다몰 부하 심근관류 검사는 운동부하와 달리 명(57%)에서 운동 부하 탈륨 심근 SPECT상 관류이 산소요구량의 증가 없이 관상동맥혈류를 증가시키고, 상이 보였는데, 비가역적 또는 부분가역적 관류결손이 부하시 혈압이 감소하며 심박동수의 증가가 현저하지 보인 군의 좌심실 수축능이 유의하게

심근벽 장력이 운동부하와 다르고, 심근의 비후에 의하 23) Udelson 등 은 29명의 무증상이거나 매우 경한 증상 여 심근벽 장력에 미치는 영향이 다르므로 운동부하 검 을 가진 비후성심근증 환자를 대상으로, 운동부하 심근 사와 다른 결과를 나타낼 수 있다.

환자를 대상으로 분할용량의 탈륨-디피리다몰 평면 신 Fig. 2. Dipyridamole stress thallium SPECT imaging with abnormal thallium washout in patient with hypertrophic cardiomyopathy. The polar map (Fig.

5 등11)의 연구에서는 72명의 비후성심근증 환자 중 41 디피리다몰 부하 심근관류 검사는 운동부하와 달리 명(57%)에서 운동 부하 탈륨 심근 SPECT상 관류이 산소요구량의 증가 없이 관상동맥혈류를 증가시키고, 상이 보였는데, 비가역적 또는 부분가역적 관류결손이 부하시 혈압이 감소하며 심박동수의 증가가 현저하지 보인 군의 좌심실 수축능이 유의하게 감소되어 있었으 않아서 관동맥 혈류예비능을 결정하는 요인의 하나인 나, 운동성 흉통과 관류이상 사이의 연관성은 없었다. 심근벽 장력이 운동부하와 다르고, 심근의 비후에 의하 23) Udelson 등 은 29명의 무증상이거나 매우 경한 증상 여 심근벽 장력에 미치는 영향이 다르므로 운동부하 검 을 가진 비후성심근증 환자를 대상으로, 운동부하 심근 사와 다른 결과를 나타낼 수 있다.24) 비후성 심근증 환 SPECT를 시행한 결과 14명에서 가역적 혈류결손을 자의 디피리다몰 부하 탈륨 심근 관류 보고는 매우 적 보였고, 14명 중 10명의 환자(71%)에서 verapamil 투 은데, Koga 등25)은 30명의 비폐쇄성 비후성 심근증 여 후 가역적인 혈류 결손이 사라지는 것을 관찰하였다. 환자를 대상으로 분할용량의 탈륨-디피리다몰 평면 신 Fig. 2. Dipyridamole stress thallium SPECT imaging with abnormal thallium washout in patient with hypertrophic cardiomyopathy. The polar map (Fig. 2A) and tomographic images (Fig. 2B) of stress and redistribution show mildly decreased uptake of septum and anterior wall on stress and increased uptake on redistribution images resulting in abnormal washout on that area. Fig. 3. Dipyridamole stress thallium SPECT imaging with normal thallium washout in patient with hypertrophic cardiomyopathy. The polar map (Fig. 3A) and tomographic images (Fig. 3B) of stress and redistribution show mildly decreased uptake of lateral and inferior wall on stress and redistribution image, and normal washout. 469

6 Table 3. Comparison of clinical findings between 12 normal and 13 abnormal thallium washout in patients with hypertrophic cardiomyopathy 470 Abnomal Normal washout n13 washout n12 p value Age mean NS Sex MF NS Chest pain NS Typical 3 2 Atypical 5 9 Dyspnea 8 9 NS Syncope 5 2 NS Verapamil 3 3 NS LVOT obst 5 8 NS LVOT obstleft ventricular outflow tract obstruction, NSnot significant Korean Circulation J 1999;295:

7 결론 중심단어 REFERENCES 1) Wigle ED, Rakowski H, Kimball B. Hypertrophic cardiomyopathy Clinical spectrum and treatment. Circulation ) Maron BJ, Bonow RO, Cannon RO, Leon MB, Epstein SE. Hypertrophic cardiomyopathy Interrelation of clinical manifestations, pathiphysiology, and therapy first of two parts. N Engl J Med ) Nishimura T. Approaches to identify and characterize hypertrophic myocardium. J Nucl Med ) Takata J, Counihan PJ, Gane JN, Doy Y, Chikamori T, Ozawa T, et al. Regional thallium-201 washout and myocardial hypertrophy in hypertrophic cardiomyopathy and its relation to exertional chest pain. Am J Cardiol ) Botvinick EH, Dae MW, Krishnan R, Ewing S. Hypertrophic cardiomyopathy in the young Another form of ischemic cardiomyopathy? editorial; Comment. J Am Coll Cardiol ) Dilsizian V, Bonow RO, Epstein SE, Fananapazir L. Myocardial ischemia detected by thallium scintigraphy is frequently related to cardiac arrest and syncope in young patients with hypertrophic cardiomyopathy see comments. J Am Coll Cardiol ) Pitcher D, Wainwright R, Maisey M, Curry P, Sowton E. Assessment of chest pain in hypertrophic cardiomyopathy using exercise thallium-201 myocardial scintigraphy. Br Heart J ) Navarro-Lpez F, Soler J, Magrina J, Esplugues E, Pare JC, Sanz G, et al. Systolic compression of coronary artery in hypertrophic cardiomyopathy. Int J Cardiol ) Narita M, Kurihara T, Murano K, Usami M. Myocardial perfusion abnormality and chest pain in patients with hypertrophic cardiomyopathy. Japanese Kokue To Junkan ) Rubin KA, Morrison J, Padnick MB, Binder AJ, Chiaramida S, Margouleff D, et al. Idiopathic hypertrophic subaortic stenosis Evaluation of anginal symptoms with thallium-201 myocardial imaging. Am J Cardiol ) O Gara Pt, Bonow RO, Marn BJ, Damske BA, van Lingen A, Bacharach SL, et al. Myocardial perfusion abnormality in patients with hypertrophic cardiomyopathy Assessment with thallium-201 emission computed tomography. Circulation ) Cannon RO, Dilsizian V, O Gara Pt, Udelson JE, Schenke WH, Quyyumi A, et al. Myocardial metabolic, hemodynamic, and electrocardiographic significance of reversible 471

8 thallium-201 abnormalities in hypertrophic cardiomyopathy. Circulation ) Opherk D, Mall G, Zebe H, Schwarz F, Weihe E, Manthey J, et al. Reduction of coronary reserve: A mechanism for angina pectoris in patients with arterial hypertension and normal coronary arteries. Circulation 1984;69: ) James TN, Marshall TK, De subitaneis morbitus XII. Asymmetrical hypertrophy of the heart. Circulation ) Cannon RO, Rosing DR, Maron BJ, Leon MB, Bonow RO, Watson RM, et al. Myocardial ischemia in patients with hypertrophic cardiomyopathy Contribution of inadequate vasodilator reserve and elevated left ventricular filling pressures. Circulation ) Brutsaert DL, Rademarkers FE, Sys SU. Triple control of relaxation Implications in cardiac disease. Circulation ) Wigle ED, Sasson Z, Henderson MA, Ruddy TD, Fulop J, Rakowski H, et al. Hypertrophic cardiomyopathy; The importance of the site and the extent of hypertrophy. A review. Prog cardiovasc dis ) Maron BJ, Wolfson JK, Epstein SE, Roberts WC. Intramural small vessel coronary artery disease in hypertrophic cardiomyopathy. JACC ) Camici P, Chiriatti G, Lorenzonin R, Bellina RC, Gistri R, Italiani G, et al. Coronary vasodilation is impaired in both hypertrophied and nonhypaertrophied myocardium of patients with hypertrophic cardiomyopathy A study with nitrogen-13 ammonia and positron emission tomography. J Am Coll Cardiol ) Grover-Mckay M, Schwaiger M, Krivokapichi J, Perloff JK, Phelps ME, Schelbert HR. Regional myocardial blood flow and metabolism at rest in mildly symptomatic patients with hypertrophic cardiomyopathy. J Am Coll Cardiol ) Nienaber CA, Gambhir SS, Mody FV, Ratib O, Huang S-Cl. Regional myocardial blood flow and glucose utilization in symptomatic patients with hypertrophic cardiomyopathy. Circulation ) Tadamura E, Tamaki N, Matsumori A, Magata Y, Yonekura Y, Nohara R, et al. Myocardial metabolic changes in hypertrophic cardiomyopathy. J Nucl Med ) Udelson JE, Bonow RO, O Gara Pt, Maron BJ, van Lingen A, Bachrach SE, et al. Verapamil prevents silent myocardial perfusion abnormalities during exercise in patients with hypertrophic cardiomyopathy. Circulation ) Kolcke FJ. Cognition in the era of technology. J Am Coll Cardiol ) Koga Y, Yamaguchi R, Ogata M, Kihara K, Toshima H. Decreased coronary vasodilatory capacity in hypertrophic cardiomyopathy determined by split-dose thallium-dipyridamole myocardial scintigraphy. Am J Cardiol ) von Dohlen TW, Prisant LM, Frank MJ. Significance of positive or negative thallium-201 scintigraphy in hypertrophic cardiomyopathy. Am J Cardiol ) Arrighi JA, Soufer R. Reverse redistribution Is it clinically relevant or a washout? J Nucl Cardiol Korean Circulation J 1999;295:

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar