citric acid cycle during ischemia is glucose (3). Mild tomoderate ischemia increases myocarclial glucose uptake (4).

PET permits assessment of regional myocardial perfusionand metabolism in vivo. Hypoperfused myocardium withincreased uptake of ‘8F-fluorodeoxyglucose (FDG) as anindicator of exogenous glucose utilization is considered tobe ischemic but viable myocardium, with the potential forimprovement of regional function after restoration of bloodflow (5—10).Although a flow-metabolism mismatch patternhas been shown to be indicative of reversibly dysfunctionalmyocardium in patients with chronic coronary artery disease(5—10),this marker has not been as reliable for patients with

recent myocardial infarctions (11—13).In the course of our experience with ‘3N-ammonia

(NH3)—FDGPET, patients with myocardial infarctionsoccasionally were noted to have more severe defects of FDGthan of NH3 (i.e., a reverse flow—metabolism mismatchpattern). In most previous reports, more severe defects ofFDG than of NH3 were included in a flow-metabolismmatch pattern. No study examining the significance ofreverse flow—metabolism mismatch phenomenon is available. To study this phenomenon, NH3 and glucose-loadedFDG PET studies, therefore, were performed in patientswith myocardial infarctions.

MATERIALS AND METHODS

PatientsThirty-five patients suffering their first acute myocardial infarc

tions (AMIs) (29 men, 6 women; mean age 64 ±10y; range 40—79y) and 29 patients with documented previous, old myocardialinfarction (OMI) (25 men, 4 women; mean age 65 ±6 y; range50—76y) underwent myocardial perfusion and metabolism studieswith PET. AM! diagnosis was based on the presence of typical andprolonged chest pain, ST-segment elevation or depression onstandard 12-lead electrocardiograms and elevation of serum crcatine kinase to more than three times the normal upper limit.Patients who had undergone previous coronary angioplasty ofarteries other than the infarct-related artery or coronary arterybypass grafting were excluded from this study. Patients who hadsuffered more than two myocardial infarctions were excluded fromthe group of patients with OMI.

Ofthe35patientswithAMI, 17hadanteriorinfarctionsand18

Hypoperfused myocardium with increased uptake of 18F-fluorodeoxyglucose (FDG) is considered to be ischemic butviable myocardium.However,the significanceof a more severedefect of FDG than of 13Nammonia (NH3) (i.e., reverse flowmetabolism mismatch) is not well understood. Methods: Tostudy a reverse flow—metabolismmismatch pattern, PET withNH3 and FDG under glucose loading was performed in 35patientswithin2 wk afteronsetoffirst acutemyocardialinfarction(AMI)and in 29 patientswithold myocardialinfarction(OMI).Theleft ventriclewas dividedinto ninesegmentson a bull's eye polarmap, and the mean counts of NH3 (%NH3) and FDG (%FDG)were comparedfor the segmentwith the least %NH3. Results:Ten patients in the AMI group demonstrateda marked reverseflow—metabolismmismatch pattem (greater than 10% differencebetween %NH3 and %FDG), whereas only 2 patients in the OMIgroup demonstrated the mismatch pattem (P < 0.05). Sixteenpatients with AMI demonstrated%FDG > %NH3 (group 1), and19 patients with AMI demonstrated%FDG < %NH3 (group 2).There were no significant differences in age, sex, location ofinfarction, diameter of stenosis of infarct-related artery or leftventricular ejection fraction between groups 1 and 2. Elevenpatients in group 2 and only 3 in group 1 had multivessel disease(P < 0.02).Therewas no significantrelationshipbetweenthenumber of diseased vessels and the flow-metabolism pattern inpatients with OMI. ConclusIon: The finding of a reverse flowmetabolism mismatch on PET in the subacute phase of myocardial infarctionwas closely relatedto multivesseldisease.

KeyWords:PET;myocardialinfarction;multivesseldisease

J NucIMed1999;40:1492—1498

lucose, lactate and free fatty acids are the major

sources of energy for the heart. In the fasting state, themyocardium mainly uses free fatty acid, whereas in the fedstate, glucose becomes more important (1,2). Striking changesoccur in substrate utilization during myocardial ischemia.Because @3-oxidationof free fatty acids is very sensitive toischemia, the principal fuel-contributing substrate for the

ReceivedSep.24,1998;revisionacceptedFeb.4, 1999.For correspondence or reprints contact: Hiroyuki Yamagishi, MD, First

Departmentof InternalMedicine,OsakaCityUniversityMedicalSchool,1—5-7Asahi-Machi, Abeno-Ku, Osaka 545—8586, Japan.

1492 THEJou@mi OFNUCLEARMEDICINE•Vol. 40 No. 9 •September 1999

A Reverse Flow—MetabolismMismatch Pattern onPET Is Related to Multivessel Disease in Patientswith Acute Myocardial InfarctionHiroyuki Yamagishi, Kaname Akioka, Kumiko Hirata, Yuji Sakanoue, Kazuhide Takeuchi,Junichi Yoshikawa and Hironobu Ochi

First Department ofinternal Medicine and Division ofNuclear Medicine, Osaka City University Medical School, Osaka, Japan

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had inferior infarctions (including one inferolateral infarction). Ofthe 29 patients with OMI, 21 had suffered anterior infarctions and 8had suffered inferior infarctions. No patient had a pure lateralinfarction. All patients with AM! underwent PET using FDG andNH3 within 2 wk (range 6—14d, mean 10 ±3 d) after the onset ofmyocardial infarction. For patients with OMI, the interval betweenthe onset of infarction and the PET study was 33 ±52 mo (range2—168mo).

RadiopharmaceuticalsA small cyclotron (NKK Corporation, Kanagawa, Japan) was

used for the production of ‘3Nand ‘8F.NH3 was then producedusing the method described by Mulholland et al. (14), and FDGwas synthesized using the method described by Hamacher etal. (15).

PETImagIngFor PET imaging, a Shimadzu-SET 1400 W-lO PET scanner

(HEADTOME IV; Shimadzu Corp., Kyoto, Japan) was used. Thisscanner can obtain 7 slices simultaneously with a 13-mm interval, aslice thickness of 11-mm full width at half maximum (FWHM) andspatial resolution of 4.5-mm FWHM. Axial, 6.5-mm-intervalZ-motion of the scanner provided a total of 14 contiguoustransverse slices of the myocardium.

A 10-mm transmission scan was obtained using a rotating 68Gerod source. The acquired data were used to correct emission imagesof NH3 and FDG for body attenuation. After completion of thetransmission scan, the patient remained in the supine position andwas injected intravenously with 555—740MBq NH3. After a 3-mmdelay to allow pulmonary background activity to clear, myocardialperfusion imaging was performed for 10 mm.

Three to 4 h after completion of the perfusion scan, FDG PETimaging was performed postprandially. Identical patient positioning for the NH3 and FDG images was achieved by marking thesubject's chest wall with ink and aligning the marks with areference beam of light from the gantry. The patient was injectedintravenously with 259—370MBq FDG 30—60mm after the patientate his or her usual meal, supplemented with a 50-g glucosesolution. Forty to 50 mm were allowed for cardiac uptake of FDG.Static imaging of glucose utilization was then performed for 10mm. In this study, 13patients had diabetes mellitus: 6 patients weretreated with diet only, 3 with oral hypoglycemic agents and 4 withinsulin. The treatment for their diabetes mellitus was not withheldduring the studies, and no additional treatment was given inglucose loading for FDG PET imaging.

Images were collected in 256 X 256 matrices and reconstructedby a computer system (Dr. View; Asahi-Kasei Joho System Co.,Ltd., Tokyo, Japan) using Butterworth and ramp filters along theshort axis of the heart.

QuantitativeAnalysisof PETImagesEach short-axis slice was divided into 36 sectors, 10°each, and a

bull's eye polar map was reconstructed from the short-axis slicesextending from the base to the apex. The maximal count in the leftventricle was selected, and the value of each pixel was normalizedto a maximal count of 100. The left ventricle was divided into ninesegments as shown in Figure 1, and the mean of normalized countsofeach segment was calculated. The mean counts ofNH3 (%NH3)and FDG (%FDG) were compared for the segment demonstratingthe least %NH3, which was considered to be the center ofinfarction.

FIGURE 1. Schematicdiagramof ninesegmentsof leftyentricle on bull'seye polarmap.

Coronary Arteriography and Left VentrlculographyEleven patients with AM! underwent successful coronary angio

plasty of the infarct-related artery within 24 h after the onset ofmyocardial infarction. Twenty-four patients underwent coronaryartenography during the subacute phase (within 6 wk after onset)but had undergone no coronary intervention before the PET studies.All patients with OMI underwent coronary arteriography within 2wk of PET study. Coronary arteriography was performed inmultiple projections using standard techniques. Quantitative coronary narrowing analysis was performed using a computer-assisted,automated edge-detection algorithm (QCA-CMS CardiovascularMeasurement System Ver 3.0; MEDIS Medical Imaging System,Leiden, The Netherlands), and coronary artery narrowing wasexpressed as the maximal percentage narrowing of luminal diameter. Narrowing exceeding 50% in the major epicardial coronaryarteries (right coronary artery 1, 2, 3, main left coronary artery 5,left anterior descending artery 6, 7 and left circumflex 11, 13 in theAmerican Heart Association reporting system [16]) was consideredsignificant. Infarct-related arteries were considered diseased regardless of percentage narrowing of diameter. Left ventriculographywas performed in 31 patients with AM! and in all patients withOMI. The ejection fraction of the left ventricle was calculated bythe single plane-area length method.

PeakCreatIneKinaseVenous blood samples for estimation of the peak serum creatine

kinaseweredrawnevery3 h for the first24 h andevery6 h for thenext 24—48h after the onset of infarction. All patients demonstratedsignificant elevations of serum creatine kinase, but peak valuescould be determined for only 27 patients with AM! and weredocumented in only 13 with OMI.

StatisticsContinuous variables were expressed as mean ±SD. The

unpaired t test was used to compare continuous variables betweentwo groups. The paired t test was used to compare %NH3 and%FDG. One-way analysis of variance was used to comparecontinuous variables among four groups. Post hoc comparisonswere made by Scheffe's test. Groups were compared for categoricaldata by the @2test. P > 0.05 was considered significant.

REVERSE FLOW—METABOLISM MISMATCH ON PET •Yamagishi et al. 1493

ANTERIOR

SEPTUM LATERAL

INFERIOR

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AMIOMI%

FDG% FDG<% FDG> % FDG<NH3%NH3NH3%NH3Patient

characteristicsAll AMI(group 1)(group 2)PAll OMI(group 3) (group4)Pn3516192916

13Age(y)64 ±1065 ±1063 ±10ns65 ±664 ±10 65 ±7nsSex(male/female)29/613/316/3ns25/415/110/3nsLocation

ofinfarction(anterior/inferior)17/187/910/9ns21/811/510/3nsDiabetes

mellitus330ns1O@82nsPeakCK(lUlL)2885 ±25813177 ±32482613 ±1848ns3876 ±17692489 ±1613 4742 ±1284nsStenosis

of infarct-relatedartery(%)63±3369 ±3458 ±33ns74 ±3079 ±28 68 ±33nsCollateral

flowtoinfarct-relatedartery(absent/present)27/812/415/4ns14/15*6/108/5nsAngioplasty

of infarct-related artery1156ns945nsNo.of diseasedvesselsSingle-vessel

disease21138<0.0210*64nsMultivesseldisease143111 9109Two-vessel

disease1 0281 376Three-vesseldisease413633Left

ventricularejectionfraction(%)49 ±1249 ±1548 ±9ns40 ±14*43 ±14 37 ±13nsPETstudy%NH348

±1346 ±1250 ±13ns46 ±1447 ±15 46 ±14ns%FDG46±1355 ±1039 ±10<0.00348 ±1655 ±15 39 ±13<0.02Marked

reverse flow—metabolismmismatchpattern102**P

< 0.05 vs. allAMI.AMI= acute myocardial infarction; OMI = oldmyocardial infarction; FDG= 18F-fluorodeoxyglucose; NH3 = 13N-ammonia; ns =notsignificant;

CK = creatine kinase.

RESULTS —17%)ingroup4.The%FDG-to-%NH3ratioswere1.22±0.23 (range 1.00—1.84) in group 1, 0.78 ± 0. 13 (range0.45—0.95) in group 2, 1.23 ±0. 18 (range 1.00—1.62) ingroup 3 and 0.85 ±0.08 (range 0.74—0.99)in group 4.

BaselineCharacteristicsandPETDataforAcuteMyocardial Infarction Patients

As shown in Table 1, there were no significant differencesin age, sex, location of infarction, diabetes mellitus, peakcreatine kinase, stenosis diameter of the infarct-relatedartery, collateral circulation, coronary intervention to theinfarct-related artery or left ventricular ejection fractionbetween groups 1 and 2. However, group 2 included morepatients with multivessel disease (P < 0.02). There was nosignificant difference in %NH3 between the two groups,whereas %FDG was smaller in group 2 than in group 1 (P <0.003).

Baseline Characteristics and PET Data for OldMyocardlal Infarction Patients

As shown in Table 1, there were no significant differencesin age, sex, location of infarction, diabetes mellitus, peakcreatine kinase, stenosis diameter of the infarct-relatedartery, collateral circulation, coronary intervention to the

As shown in Table 1, there was no significant difference inage, sex, location of infarction, peak creatine kinase, diameter of stenosis of the infarct-related artery, coronary intervention in the infarct-related artery, %NH3 or %FDGbetween the AMI and OMI patients. However, the OMIgroup included more patients with diabetes mellitus, collateral circulation to infarct-related artery, multivessel diseaseand low left ventricular ejection fraction than the AMIgroup. The AMI group included 10 patients with a markedreverse flow—metabolism mismatch pattern (>10% difference between %NH3 and %FDG), whereas the OW groupincluded only 2 patients with a marked reverse flowmetabolism mismatch pattern (P < 0.05).

Of the 35 patients with AMI, 16 had %FDG > %NH3 inthe segment with the least %NH3 (group 1), and 19 had%FDG < %NH3 (group 2). Ofthe 29 patients with OMI, 16had %FDG > %NH3 in the segment with the least %NH3(group 3), and 13 had %FDG < %NH3 (group 4).

The differences between %NH3 and %FDG (%FDG -%NH3) were 9% ± 7% (range 0%—26%) in group 1,

—12%±9%(range—2%to—34%)ingroup2,9%±6%(range 0%—19%)in group 3 and —6%±4% (range —1% to

TABLE1Baseline Characteristics and PET Data of 64 Patients

1494 THEJoui@r@@OFNuci@&i@MEDICINE•Vol. 40 •No. 9 •September1999

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AMIOMISingle-vesselMultivesselSingle-vesselMultivesseldiseasediseasediseasedisease(group

AS)(group AM)(group OS)(group OM) P

*P < 0.05 versus %NH3.AMI= acutemyocardialinfarction;OMI= oldmyocardialinfarc

tion NH3 = 13N-ammoniaFDG = fluorodeoxyglucose.

infarct-related artery, number of diseased vessels or leftventricular ejection fraction between groups 3 and 4. Therewas no significant difference in %NH3 between groups 3and 4, whereas %FDG was smaller in group 4 than in group3 (P < 0.02).

Reverse Flow—MetabolismMIsmatch and Number ofDIseased Vessels

As shown in Table 2, there were no significant differencesin %NH3 or %FDG among patients with AM! and singlevessel disease (group AS), with AM! and multivessel disease(group AM), with OMI and single-vessel disease (group OS)and with OMI and multivessel disease (group OM). In groupAM, %FDG was significantly smaller than %NH3 (P <0.05), but there were no significant differences between%NH3 and %FDG in other groups.

As shown in Figure 2, the difference between %NH3 and%FDG (%FDG —%NH3) was significantly smaller ingroup AM than in groups AS and OS. As shown in Figure 3,the %FDG-to-%NH3 ratio was significantly smaller in

TABLE 2Comparison Between Single-Vessel Disease and

Multivessel Disease

group AM than in group AS. Representative cases are shownin Figure4.

DISCUSSION

Hospitalized survivors of AMI with multivessel diseasehave an increased risk of late mortality (I 7,18). After AMI,patients can be risk stratified using prognostic indicatorsfrom stress testing in combination with radionuclide myocardial perfusion imaging (19). Findings have demonstrated theusefulness of exercise testing in the noninvasive identification of multivessel disease (18,20). However, results ofpredischarge submaximal exercise testing in patients withAMI may contribute to a poor predictive value for multivessel disease (21). In this study, we demonstrated that an FDGdefect that was of greater severity than the correspondingNH3 defect, i.e., reverse flow—metabolism mismatch phenomenon, was closely related to multivessel disease in thesubacute phase of myocardial infarction, but not in thechronic phase.

In the report by Maes et al. (22) on myocardial flow,metabolism and function in patients with AMI after successful thrombolysis, 13 of 30 patients showed less normalizeduptake of FDG than of NH3 at 5 d after infarction. Theincidence of reverse flow—metabolism mismatch in theirreport was comparable with our results. However, theirpatients who demonstrated less normalized uptake of FDGthan of NH3 were included in a group without the perfusionmetabolism mismatch, and the significance of this phenomenon was not discussed. Sawada et al. (23) reported that only1 of 192 dysfunctional myocardial segments in patients withcoronary artery disease had normal perfusion and mildlyreduced FDG uptake, but the significance of this segmentwas not interpreted. Bonow et al. (24) reported that 12 of 98segments demonstrating mild to moderate (50%—84% ofpeak activity) irreversible 201'fldefect in exercise-redistribu

n21141019%NH348±1250±1450±1644±13ns%FDG50

±1140 ±13*55 ±1844 ±14ns

pco.02 p@0.02I I I

0

00 0

T9

0 g lo 18J@ 0 i:To io

J.g lo 00 i,@ 0

0 leIo 010

0

02+10 -10+ 13 2+12 1+8

2z

U-

FIGURE 2. Differencebetween %NH3and %FDG (%FDG —%NH3) of patientswith single-vesseldisease and multivesseldisease.Differencewassignificantlysmallerin patients with AMI and multivessel disease(group AM) than in patients with AMI andsingle-vesseldisease (groupAS), or in patients with OMI and single-vessel disease(groupOS).

%40

30

20@

10

0@

-10

-20

-30

-40angIe-vessel multivessel single-vessel muitivessel(grot@AS) (grot@AM) (groupOS) (groupOM)acute myocardial iriarction oldmyocardialinfarction

REVERSE FLOW—METABOLISMMISMATCH ON PET •Yamagishi et a!. 1495

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2.22.01.81.6I .41.21.00.80.60.4

.@

2z

IL

1,08±0.27 0.83±0.24 1,12 ±0.26 1.03±0.22

single-vessel(group AS)

multivessel(groupAM)

single-vessel(groupOS)

multivessel(groupOM)

p@0.05

0

0 0 0

180

8

Ii80

FIGURE 3. Ratioof %FDG to %NH3 inpatientswithsingle-vesseldiseaseandmultivessel disease. Ratio was significantlysmaller in patientswithAMI and multivesseldisease (group AM) than in patients withAMIand single-vessel disease (group AS).

FIGURE4. Representativebull'seyep0-lar maps. (A) Images from patient withinferolateralwaIlAMIandsingle-vesseldisease(groupAS).In inferolateralsegments,NH3 uptakewas severelyreduced,andFDG uptake was moderately reduced. Patient showed flow-metabolism mismatchpattern. Coronary artenography revealed100% stenosis of right coronary artery. (B)Images from patient with inferior wall AMIand three-vessel disease (group AM). Ininferior segments, NH3 uptake was moderately reduced, and FDG uptake was Severely reduced. This patient showed reverse flow—metabolismmismatch pattern.Coronaryarteriographyrevealed100%stenosisof rightcoronaryartery,62% stenosisof left anterior descendingartery and 68%stenosisof left circumflexartery.

0.2

acute myocardlal infarction oldmyocardlelinfarction

A (acase in iroupAS)

NH3 FDGB

(a case in group AM)

1496 Ti@JOURNALOFNUCLEARMEDICINE•Vol. 40 •No. 9 •September1999

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tion 201Tl scintigraphy in patients with chronic coronaryartery disease and left ventricular dysfunction exhibited noFDG uptake (<50% of normal reference activity) underglucose loading. The authors considered these segments to

represent viable myocardium but did not describe themechanism of this phenomenon. Grandin et al. (25) identifled absolute myocardial blood flow and normalized glucoseextraction, but not the normalized FDG-to-normalizedNH3 ratio, as the most powerful predictors of the returnof contractile function after coronary revascularization inpatients with ischemic anterior wall dysfunction. Of the 25patients in the study by Grandin et al., 3 demonstrateda normalized FDG-to-normalized NH3 ratio < 1.0 andhad single-vessel disease. These findings indicated a lowincidence of reverse flow—metabolism mismatch in pa

tients with chronic coronary artery disease, comparable withour results.

Perrone-Filardi et al. (26) reported that regions withmoderately reduced FDG uptake with normal flow occurredcommonly in patients with ischemic left ventricular dysfunction and that the majority of these segments showedimpaired systolic function at rest and exercise-inducedthallium abnormalities that were only partially reversible.The authors suggested that such regions represented anadmixture of fibrotic and reversible ischemic myocardium.We investigated NH3 and FDG uptake in the center ofinfarction and observed reverse flow—metabolism mismatch in the infarcted territory. Although the infarctedregions showing reverse flow—metabolism mismatch phe

nomenon were sure to contain infarcted myocardium, wedid not investigate whether such regions contained viablemyocardium.

Myocardial blood flow is reduced at rest in regionssupplied by vessels with >70% area stenosis (27), andcoronary sinus adenosine is increased in patients withcoronary artery stenosis >70% diameter stenosis (28).Because local myocardial ischemia is associated with release of endogenous adenosine, a sensitive indicator ofischemia (29), myocardium without infarction perfused by astenotic coronary artery might be exposed to chronic ischemia, resulting in increased glucose uptake (4).

After myocardial infarction, there is a severe vasodilatorabnormality, involving not only resistance vessels in infarcted myocardium but also those in myocardium perfusedby normal coronary vessels (30). Beyersdorf et al. (31)determined myocardial blood flow and glucose-6-phosphatecontent in canine models of myocardial infarction simulating single-vessel and multivessel disease. In their study,hypocontractility, unchanged myocardial blood flow and apronounced increase in glucose-6-phosphate content ofremote muscle were observed in dogs with multivesseldisease, whereas compensatory hypercontractility, increased

myocardial blood flow and a mild increase in glucose-6-phosphate content of remote muscle were observed in dogswith single-vessel disease. The decrease of NH3 uptake orthe increase of FDG uptake in remote myocardium in

patients with AM! and multivessel disease could cause arelative increase of NH3 uptake or a relative decrease ofFDG uptake in infarcted myocardium, resulting in a reverseflow—metabolism mismatch pattern on PET images.

StudyLimitationsThe major limitation of this study was the small popula

tion, which included patients with a history of coronaryinterventions of the infarct-related artery. Postinterventionhyperemia may affect the results in this study. However, theincidence of coronary angioplasty was low and there was nodifference in the incidence of angioplasty among the groups.Accordingly, we believe that coronary intervention did notaffect our conclusions. However, to confirm these results,studies should be performed in a large population of patientswho have undergone conservative treatment.

Diabetes mellitus is a coronary risk factor, and impairedinsulin release and insulin resistance affect glucose uptake inmyocardium after glucose loading. In this study, 13 patientshad diabetes mellitus. However, the incidence of diabetesmellitus was low, and there was no difference in theincidence of diabetes mellitus between patients with singlevessel disease and with multivessel disease in this study.Accordingly, we believe that diabetes mellitus did not affectthe conclusions in this study. Moreover, the diabetic population in this study was too small to investigate whetherdiabetic patients had different results from the nondiabeticpatients. It must be determined whether the results of thisstudy are applicable to diabetic patients.

The estimation of relative uptake of tracers on PETimages is simple and widely used. However, quantificationand observation of serial changes in blood flow and glucoseuptake in the myocardium are required to determine thesignificance and mechanism of the reverse flow—metabolismmismatch phenomenon. The quantification of NH3 wouldmake clear whether the myocardial blood flow was increased in infarct areas or decreased in remote areas, and thequantification of FDG would make clear whether themyocardial glucose uptake was decreased in infarct areas orincreased in remote areas in group AM patients.

In this study, the relationship between flow and metabolism was divided into only two categories, %FDG > %NH3and %FDG < %NH3. As a matter of course, patients shouldbe divided into three categories, a flow-metabolism matchpattern, a flow-metabolism mismatch pattern and a reverseflow—metabolism mismatch pattern. The cutoff level ofsignificant difference between %NH3 and %FDG should bedetermined by additional investigations. Analysis of thereverse mismatch phenomenon on PET can be performedeven in the acute or the subacute phase of myocardialinfarction under resting conditions and is very simple. Themethod described herein may thus be useful for the detectionof multivessel disease.

CONCLUSION

The significance of the finding of an FDG defect that wasof greater severity than the corresponding NH3 defect, i.e.,

REVERSE FLOW—METABOLISM MISMATCH ON PET •Yamagishi et al. 1497

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1999;40:1492-1498.J Nucl Med.   OchiHiroyuki Yamagishi, Kaname Akioka, Kumiko Hirata, Yuji Sakanoue, Kazuhide Takeuchi, Junichi Yoshikawa and Hironobu  in Patients with Acute Myocardial InfarctionA Reverse Flow-Metabolism Mismatch Pattern on PET Is Related to Multivessel Disease

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