1
2020/2021
João Miguel Po ugal An as de Ba os Ba bosa
Myoca dial Pe usion Scin ig aphy in Myoca dial In a c ion:
Impac o ST segmen ele a ion and o Diabe es
melli us
Cin ig a ia de Pe usão Miocá dica no En a e do Miocá dio:
Impac o da ele ação do segmen o ST e da Diabe es
melli us
MARÇO, 2021
2
MARÇO, 2021
Mes ado In eg ado em Medicina
Á ea: Medicina Nuclea
Tipologia: O iginal Repo
T abalho e e uado sob a O ien ação de:
P o . Dou o José Ped o Lopes Nunes
T abalho o ganizado de aco do com as no mas da e is a:
Jou nal O In es iga i e Medicine
João Miguel Po ugal An as de Ba os Ba bosa
Myoca dial Pe usion Scin ig aphy in Myoca dial In a c ion:
Impac o ST segmen ele a ion and o Diabe es melli us
Cin ig a ia de Pe usão Miocá dica no En a e do Miocá dio:
Impac o da ele ação do segmen o ST e da Diabe es melli us
i
DECLARAÇÃO DE INTEGRIDADE
ii
DECLARAÇÃO DE REPRODUÇÃO
iii
DEDICATÓRIA
Há poucos anos a ás, decidi muda de umo, pessoal e p o issionalmen e. Naquilo
que oi o ano mais di ícil da minha ida a é en ão, a mo e do meu A ô ma e ializou
a eno me lacuna que exis ia no meu conhecimen o da saúde humana. A é aí, inha
explo ado o mundo labo al, munido do meu cu so an e io – Ciências
Fa macêu icas – chegando, en ão, à conclusão de que a minha in luência na saúde
do pacien e e ia que se mais in e en i a e mais capaz. Es a escolha le ou-me à
Faculdade de Medicina da Uni e sidade do Po o.
Os úl imos 5 anos cons i uí am uma aje ó ia pa a a qual, isolado, se ia semp e
insu icien e. Consegui comple á-la p ecisamen e po não es a sozinho, de endo
po isso ag adece e dedica o p esen e abalho:
Ao P o esso Dou o José Ped o Nunes, pela assídua, sábia e amá el o ien ação
du an e o cu so no ge al, e du an e a elabo ação des e abalho em pa icula ;
À minha amília – em especial aos meus Pais e i mãos – po odo o apoio
incondicional que me de am ao longo da minha ida;
À minha A ó Ma ia da G aça, ao meu A ô João, e à minha A ó Nina, po me
ensina em a p ocu a se semp e supe io a mim mesmo;
Ao D . Jo ge Pe ei a, à D a. Emília Ba bosa, e à D a. Luciana Pe ei a, pela
impo an e con ibuição na execução des e abalho;
Ao A mindo e à Lab52, pelo mundo de opo unidades que me o e ece am, e pela
ce eza que i e am no meu imp o á el sucesso;
À Ma ga ida d’ “O Fa ol”, pela con iança que deposi ou em mim;
Aos meus amigos, em especial aos LCR e ao Almi an e, pela inabalá el amizade
com que me b indam odos os dias;
Po im, à Te esinha, pelo empo, pelas pala as, pelos a os, pela (imé i a) é em
mim e po udo o que me deu, que qualque ex o se á insu icien e pa a enume a ;
Nas pala as do meu an epassado Manoel de Po ugal Ma eca, o mado pela
Escola Médico-ci ú gica do Po o em 1902, “es e abalho, […] um hesoi o que
osse, a ós pe ence ia”.

1
ORIGINAL REPORT
MYOCARDIAL PERFUSION SCINTIGRAPHY IN MYOCARDIAL INFARCTION -
IMPACT OF ST SEGMENT ELEVATION AND OF DIABETES MELLITUS.
João Miguel Po ugal An as de Ba os Ba bosa
Rua do Pad ão, 32, 2º Di ei o
4150-557 Po o
Po ugal
[email p o ec ed]
Wo d coun (excluding i le page, abs ac , e e ences, igu es and ables): 2049
2
ABSTRACT
Myoca dial pe usion scin ig aphy (MPS) is equen ly used in he e alua ion o
pa ien s wi h myoca dial in a c ion (MI). The goal o he p esen wo k was o
e alua e changes in MPS acco ding o he na u e o he in a c ion (ST ele a ion
e sus non-ST ele a ion s a us) as well as acco ding o he p esence o absence
o Diabe es melli us.
A p ospec i e s udy o 124 consecu i e pa ien s wi h MI was ca ied ou , using
MPS.
Pa ien s wi h ST segmen ele a ion MI (STEMI) had signi ican ly la ge alues bo h
o pe cen age and absolu e a eas o pe usion de ec s, bo h a es and in s ess
si ua ion, when compa ed o pa ien s wi hou ST segmen ele a ion (NSTEMI).
These pa ien s had signi ican ly lowe alues o le en icula ejec ion ac ions
(EF), in a simila compa ison. The alues o pe usion de ec s a es o STEMI
pa ien s we e mo e han double he alues o NSTEMI pa ien s (17.1+14.6%
e sus 6.5+7.8%, p <0.001). Conce ning es ing le en icula EF, STEMI pa ien s
had a mean alue o 47.6+13.6% and NSTEMI pa ien s had a mean alue o
53.2+12.4% (p 0.026).
Rega ding he compa ison be ween pa ien s wi h and wi hou Diabe es melli us,
none o he pa ame e s unde s udy showed signi ican di e ences.
Linea eg ession analysis, aking pe cen age o pe usion de ec , as dependen
a iable, yielded an o e all signi ican esul , howe e only ST segmen ele a ion
was shown o ha e an indi idually signi ican esul .
We conclude ha he p esence o ST segmen ele a ion bu no he p esence o
Diabe es melli us is associa ed o di e en pa e ns o MPS in pa ien s wi h MI.
Wha is al eady known abou his subjec ?
Acu e myoca dial in a c ion (MI) poses as a signi ican cause o dea h and
mo bidi y. Myoca dial pe usion scin ig aphy (MPS) is equen ly used in he
e alua ion o pa ien s wi h MI. Speci ic elec oca diog aphic indings and isk ac o s
lack co ela ion wi h MPS esul s.
3
Wha a e he new indings?
The goal o he p esen wo k was o e alua e speci ic changes in MPS acco ding
o he na u e o he in a c ion (ST ele a ion e sus non-ST ele a ion s a us) as well
as acco ding o he p esence o absence o Diabe es melli us. The p esence o ST
segmen ele a ion was associa ed o di e en pa e ns o MPS in pa ien s wi h MI.
The p esence o DM was no associa ed ei he o di e ences in impo ance o
pe usion de ec s o in he alues o le en icula ejec ion ac ion.
How migh hese esul s change he ocus o esea ch o clinical p ac ice?
The p esence o ST segmen ele a ion in he elec oca diog am was shown o be
associa ed o a dec eased ca diac con ac ili y and o an inc eased pe usion
de ec , when compa ed o he absence o his elec oca diog aphic ea u e.
The e o e, he p esen pape ansla es an impo an and inno a i e co ela ion o
he p esence o ST segmen ele a ion and he myoca dial damage ex en .
Key wo ds: myoca dial pe usion scin ig aphy, myoca dial in a c ion, Diabe es
melli us
4
INTRODUCTION
Acu e myoca dial in a c ion (MI) poses as a signi ican cause o dea h and mo bidi y
1,2, and is de ined as he loss o unc ional ca diac issue, due o a ca diac ischemic
e en 1. Al hough he incidence o his ype o e en has declined s eadily o e he
las decades, i s ill a ec s abou 7 million indi iduals a ound he wo ld annually, o
which many occu in Eu ope, wi h he economic issues i en ails 3. Risk ac o s o
MI include male gende , smoking, a e ial hype ension, dyslipidaemia, Diabe es
melli us and obesi y, among o he s 1,4,5.
MI can ha e di e en causes and be cha ac e ized in e y di e en ways. One o
he mos used classi ica ions is based on he p esence o an ele a ion o he ST-
segmen in he elec oca diog am (ECG), hus allowing us o ca ego ize he e en
as acu e myoca dial in a c ion wi h ST-segmen ele a ion (STEMI) o wi hou ST-
segmen ele a ion (NSTEMI) 1,3. Fu he mo e, he ou h uni e sal classi ica ion o
MI akes in o accoun ae iology and clinical di e ences, and is di ided in o 6 ypes:
ype 1 (due o a he oscle o ic plaque up u e), ype 2 (due o a misma ch be ween
supply and demand), ype 3 (causing sudden dea h), ype 4 (a - i ela ed wi h
pe cu aneous co ona y in e en ion, PCI - and b - i ela ed wi h h ombosis o a
co ona y s en ), and ype 5 ( ela ed wi h co ona y a e y bypass g a ing, CABG) 1.
Rega ding MI p esen a ion and diagnosis, al hough up o 40% o all MI a e
un ecognized in assessmen h ough ECG upon admission 6, i s line MI diagnosis
elies p ima ily on ECG indings, such as he al eady men ioned ST-segmen
ele a ion, oge he wi h symp oms and physical exam 3,4. Second line diagnosis
conce ns biochemical indings, namely ca diac oponin ele a ion (CT), a bioma ke
ha is ele a ed in his con ex , allowing an ea ly con i ma ion, as i p esen s high
sensi i i y o myoca dial nec osis 3,4.
In he s udy o pa ien s wi h suspec ed o con i med ischaemic hea disease (e.g.
on he a e ma h o an MI), pa ien s a e equen ly equi ed o pe o m a myoca dial
pe usion scin ig aphy (MPS), o assess ischemic a eas o he hea , and po en ial
loss o ca diac unc ion 7-9. MPS elies on he di e en ial up ake o a adioiso ope
by he ca diac issue, wi h u he quan i ica ion/imaging, hus esul ing in a
myoca dial pe usion map 1,8,9. Dec eased pe usion in ce ain ca diac a eas
(shown as one o mo e pe usion de ec s) can esul om he na owing o one o
11
DISCUSSION
In he p esen epo , MPS da a ob ained in pa ien s wi h a p e ious MI we e unde
s udy. The p esence o ST segmen ele a ion in he elec oca diog am was shown
o be associa ed o a dec eased ca diac con ac ili y and o an inc eased pe usion
de ec , when compa ed o he absence o his elec oca diog aphic ea u e.
The p esence o ST segmen ele a ion in pa ien s wi h MI is equen ly associa ed
o he p esence o a co ona y a e y h ombus in he acu e se ing 11,12. Pa ien s
wi h MI wi h no ele a ion o he ST segmen a e belie ed usually no o ha e
co ona y a e y h ombo ic acu e occlusion 13. MI is a known heal h and economic
bu den, and is associa ed wi h isk ac o s such as obesi y, hype ension and
Diabe es melli us. MI can o en lead o issue and unc ional changes in he hea ,
which may be e alua ed h ough MPS. As a unc ional imaging echnique, MPS is
widely used, in ischemic hea disease assessmen and p ognosis.
Rega ding Diabe es melli us, cu en li e a u e indica es ha his condi ion is a isk
ac o o co ona y a e y disease (CAD), due o i s associa ion wi h g ea e and
mo e signi ican ascula disease 10.
A p e ious epo showed ha when STEMI and NSTEMI pa ien s we e compa ed,
he o me was associa ed o highe mean alues o oponin elease, howe e no
di e ences we e seen in he angiog aphic impo ance o CAD 14.
This lack o co ela ion be ween he appa en impo ance o myoca dial nec osis
and he impo ance o CAD may be an explana ion o he p esen esul s
conce ning pa ien s wi h Diabe es melli us. These la e pa ien s a e known o o en
ha e di use co ona y a e y disease 15, howe e he p esen esul s show ha he
p esence o his clinical condi ion is no associa ed ei he o di e ences in
impo ance o pe usion de ec s o in he alues o le en icula ejec ion ac ion.
Limi a ions
The numbe o pa ien s is ela i ely small, limi ing he powe o he conclusions
eached. All consecu i e pa ien s wi h a diagnosis o MI we e unde s udy,
ega dless o MI ype o da e o he e en . Addi ionally, pos -e en e ascula iza ion
p ocedu e, as well as medica ion in o ma ion, we e no included in da a collec ion,
and could in luence MPS da a.

12
CONCLUSIONS
We conclude ha he p esence o ST segmen ele a ion bu no he p esence o
Diabe es melli us is associa ed o di e en pa e ns o MPS in pa ien s wi h MI. The
p esence o ST segmen ele a ion in he elec oca diog am was shown o be
associa ed o a dec eased ca diac con ac ili y and o an inc eased pe usion
de ec , when compa ed o he absence o his elec oca diog aphic ea u e.
CONFLICT OF INTEREST
The au ho ce i ies ha he e is no con lic o in e es wi h any inancial o ganiza ion
ega ding he ma e ial discussed in he manusc ip .
FUNDING
No unding ecei ed o his epo .
13
REFERENCES
1. Thygesen K, Alpe JS, Ja e AS, e al. Fou h Uni e sal De ini ion o
Myoca dial In a c ion (2018). J Am Coll Ca diol 2018;72:2231-64.
2. Lobo MF, Azzone V, Aze edo LF, e al. A compa ison o in-hospi al acu e
myoca dial in a c ion managemen be ween Po ugal and he Uni ed S a es: 2000–
2010. In e na ional Jou nal o Quali y in Heal h Ca e 2017;29:669-78.
3. Reed GW, Rossi JE, Cannon CP. Acu e myoca dial in a c ion. Lance
2017;389:197-210.
4. Ande son JL, Mo ow DA. Acu e Myoca dial In a c ion. N Engl J Med
2017;376:2053-64.
5. Dzubu A, Gacic E, Mekic M. Compa ison o Pa ien s wi h Acu e Myoca dial
In a c ion Acco ding o Age. Med A ch 2019;73:23-7.
6. Do M. Silen myoca dial in a c ion: he isk beyond he i s admission.
Hea 2010;96:1434-5.
7. Nudi F, Biondi-Zoccai G, Schillaci O, e al. P ognos ic accu acy o myoca dial
pe usion imaging in oc ogena ians. J Nucl Ca diol 2018;25:1342-9.
8. No ghi A, Low CS. Myoca dial pe usion scin ig aphy: pas , p esen and
u u e. B J Radiol 2011;84 Spec No 3:S229-36.
9. Ziessman H, O'Malley J. Nuclea Medicine: The Requisi es. 4 h ed2013.
10. Ha ne SM, Leh o S, Rönnemaa T, Pyö älä K, Laakso M. Mo ali y om
Co ona y Hea Disease in Subjec s wi h Type 2 Diabe es and in Nondiabe ic
Subjec s wi h and wi hou P io Myoca dial In a c ion. New England Jou nal o
Medicine 1998;339:229-34.
11. F öbe O, Lage q is B, Oli ec ona GK, e al. Th ombus Aspi a ion du ing
ST-Segmen Ele a ion Myoca dial In a c ion. New England Jou nal o Medicine
2013;369:1587-97.
12. Meneguz-Mo eno RA, Cos a RA, A A, Ribama Cos a J, J ., Abizaid A.
Th ombus aspi a ion in ST-segmen ele a ion myoca dial in a c ion. Mine a
Ca dioangiol 2015;63:563-75.
13. Mizuno K, Sa omu a K, Miyamo o A, e al. Angioscopic E alua ion o
Co ona y-A e y Th ombi in Acu e Co ona y Synd omes. New England Jou nal o
Medicine 1992;326:287-91.
14
14. Nunes JPL, Fa ia Mdo S, Ga cia JM, Gonçal es FR. Glome ula il a ion
a e and co ona y a e y disease bu den in pa ien s wi h acu e co ona y synd ome.
Clin Ca diol 2007;30:464-8.
15. Jin C, Lu L, Zhang RY, e al. Associa ion o se um glyca ed albumin, C-
eac i e p o ein and ICAM-1 le els wi h di use co ona y a e y disease in pa ien s
wi h ype 2 diabe es melli us. Clinica Chimica Ac a 2009;408:45-9.
15
TABLES
Table 1.⎯ Desc ip i e s a is ics o he a iables collec ed in 124 pa ien s wi h
myoca dial in a c ion. N – numbe ; STD – s anda d de ia ion. P- Shown a e le els
o signi icance, Mann-Whi ney U es , when pa ien s wi h o wi hou Diabe es
melli us and pa ien s wi h o wi hou ST segmen ele a ion a e compa ed,
espec i ely.
To al numbe o pa ien s
124
Male/ emale N (%)
94 (75.8%)/ 30 (24.2%)
Age, yea s (Mean+ STD)
O e all
Pa ien s wi hou Diabe es melli us (n=78)
Pa ien s wi h Diabe es melli us (n=46)
Pa ien s wi h STEMI (n=58)
Pa ien s wi h NSTEMI (n=66)
68.2±11.4
67.8±12.1
68.9±10.0 (p=0.51)
66.7±10.0
69.5±12.4 (p=0.19)
Age, ange (yea s)
36 – 93
Age g oup, yea s (n)
30-49
50-69
70-89
O e 90
6
67
48
3
Table 2.⎯ Da a om myoca dial pe usion scans in 124 pa ien s wi h myoca dial
in a c ion (MI), acco ding o ST ele a ion s a us (Mean + s anda d de ia ion). EF –
le en icula ejec ion ac ion. PPD – Pe cen age o pe usion de ec . APD - A ea
o pe usion de ec . P- p obabili y, Mann Whi ney U es . N - numbe .
ST segmen
ele a ion MI
N=58
Non-ST segmen
ele a ion MI
N=66
p
EF/ es
47.6+13.6
53.2+12.4
0.026
EF/ s ess
46.8+13.5
51.7+12.0
0.047
PPD/ es (%)
17.1+14.6
6.5+7.8
<0.001
PPD/ s ess (%)
21.3+14.7
11.3+9.2
<0.001
APD/ es (cm2)
26.18+26.68
9.39+12.87
<0.001
APD/ s ess (cm2)
32.90+28.18
15.53+14.58
<0.001
16
Table 3⎯ Da a om myoca dial pe usion scans in 124 pa ien s wi h myoca dial
in a c ion (MI), acco ding o p esence o absence o Diabe es melli us (Mean +
s anda d de ia ion). EF – le en icula ejec ion ac ion. PPD – Pe cen age o
pe usion de ec . APD - A ea o pe usion de ec . P- p obabili y, Mann Whi ney U
es . N - numbe .
No Diabe es melli us
N = 78
Diabe es melli us
N= 46
p
EF/ es (%)
50.7+13.8
50.4+12.3
0.63
EF/ s ess (%)
49.7+13.9
49.9+11.1
0.38
PPD/ es (%)
11.6+12.6
11.1+12.8
0.75
PPD/ s ess (%)
16.1+12.9
15.8+13.4
0.75
APD/ es (cm2)
18.0+23.3
15.9+19.9
0.65
APD/ s ess (cm2)
24.2+24.4
22.8+22.3
0.76
Table 4⎯ Linea eg ession analysis, aking pe cen age o pe usion de ec (a es )
as dependen a iable and se e al independen a iables, as measu ed in 124
pa ien s wi h myoca dial in a c ion. P- signi icance le el.
Dependen a iable - pe cen age o pe usion de ec , a es . O e all
ANOVA p - <0.001
p
Age
0.50
Gende
0.11
ST segmen ele a ion
<0.001
Diabe es melli us
0.21
A e ial hype ension
0.12
Dyslipidemia
0.27
Le bundle b anch block
0.42
Type 2 myoca dial in a c ion
0.82

17
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Wha a e he new indings?
How migh hese esul s change he ocus o esea ch o clinical p ac ice?
Please include a box summa izing in h ee o ou bulle poin s “wha a e he new
indings?”.
20
ANEXO 2 – REPORTING GUIDELINES PARA ESTUDOS OBSERVACIONAIS
DE COORTE (EQUATOR NETWORK)
STROBE S a emen —Checklis o i ems ha should be included in epo s o
coho s udies
I em
No
Recommenda ion
Page
No
Ti le and abs ac
1
(a) Indica e he s udy’s design wi h a commonly used
e m in he i le o he abs ac ;
(b) P o ide in he abs ac an in o ma i e and balanced
summa y o wha was done and wha was ound;
“A p ospec i e s udy o 124 consecu i e pa ien s wi h
MI was ca ied ou , using MPS”.
2
“Pa ien s wi h ST segmen ele a ion MI (STEMI) had
signi ican ly la ge alues bo h o pe cen age and
absolu e a eas o pe usion de ec s, bo h a es and in
s ess si ua ion, when compa ed o pa ien s wi hou ST
segmen ele a ion (NSTEMI)”.
2
In oduc ion
Backg ound/ a ionale
2
Explain he scien i ic backg ound and a ionale o he
in es iga ion being epo ed
“MPS elies on he di e en ial up ake o a adioiso ope
by he ca diac issue, wi h u he
quan i ica ion/imaging,...”.
4
Objec i es
3
S a e speci ic objec i es, including any p especi ied
hypo heses
“The goal o he p esen wo k was o e alua e speci ic
changes in MPS acco ding o he na u e o he
in a c ion (ST ele a ion e sus non-ST ele a ion s a us)
as well as acco ding o he p esence o absence o
Diabe es melli us”.
5
Me hods
S udy design
4
P esen key elemen s o s udy design ea ly in he pape
“The p esen s udy was a p ospec i e, longi udinal
s udy”.
6
Se ing
5
Desc ibe he se ing, loca ions, and ele an da es,
including pe iods o ec ui men , exposu e, ollow-up,
and da a collec ion
“Pa ien s en olled in he p ojec we e gi en a w i en
e sion o he p o ocol o a ull e alua ion, and la e
signed an in o med consen o m, p io o da a
collec ion. Inclusion c i e ia in ol ed: age g ea e han
18, indica ion o MPS om Sep embe 2019- Feb ua y
2020 (inpa ien o ou pa ien ), and a his o y o MI”.
6
Pa icipan s
6
(a) Gi e he eligibili y c i e ia, and he sou ces and
me hods o selec ion o pa icipan s. Desc ibe me hods
o ollow-up
(b) Fo ma ched s udies, gi e ma ching c i e ia and
numbe o exposed and unexposed
“Inclusion c i e ia in ol ed: age g ea e han 18,
indica ion o MPS om Sep embe 2019- Feb ua y
2020 (inpa ien o ou pa ien ), and a his o y o MI”.
6