Four experienced coronary angiographers (two radiologists and two cardiologists) independently assessed the location and degree of coronary artery stenosis, and the location and degree of left ventricular wall motion abnormalities in 20 coronary angiograms. Marked interobserver variability was noted in quantifying percent coronary artery stenosis and degree of left ventricular wall motion abnormalities. For example, in only 13/20 (65%) of the coronary angiograms did all observers agree about the significance of a stenosis (defined as greater than 50% in diameter luminal narrowing) in the proximal or mid left anterior descending coronary artery. In 3/20 (15%) angiograms there was disagreement by at least one observer about the significance of lesions noted in the main left coronary artery. The ventricle was divided into five segments and the degree of wall motion abnormality graded into six categories of increasing severity from normal to dyskinesis. There was a 42% mean disagreement among all four observers where a disagreement between observers was defined as any difference in grading wall motion abnormalities. Interobserver variability reveals a significant limitation of coronary angiography.

Myocardial 201Tl uptake and regional blood flow by the microsphere technique were determined in anesthetized dogs undergoing either 20 min of coronary occlusion and 100 min of reperfusion (N = 10) or 120 min of occlusion (N = 4). In both groups, 201Tl was injected intravenously after 10 min of occlusion. In transiently occluded dogs, regional flow at the time of 201Tl administration was reduced to 8 +/- 3% of normal flow in endocardial layers of the central ischemic zone. After 100 min of reperfusion, flow values were not significantly different from normal. 201Tl activity after reperfusion rose to 56 +/- 5% of normal, demonstrating that redistribution of the radionuclide occurred during the reflow period. In animals with persistent occlusion, there was a significant relationship between 201Tl uptake and flow (r = 0.95) and no evidence of redistribution of 201Tl during the two hour occlusion period. In another five dogs receiving 201Tl, serial gamma camera images obtained during reperfusion showed increasing uptake of the tracer in apical defects which returned to normal by 4 hours of reflow. Thirteen patients with stable angina received 2 mCi of 201Tl intravenously at peak exercise, and multiple gamma camera images obtained serially. All demonstrated zones of diminished 201Tl uptake 10 min after exercise. Defects which partially or completely disappeared within 1-6 hours postexercise corresponded to areas supplied by coronary arteries with significant stenoses. Persistent defects were present in regions of old myocardial infarction. Six additional patients with acute myocardial infarction demonstrated 201Tl myocardial defects which showed no significant change over 6 hours. Thus, redistribution of 201Tl into ischemic myocardium was demonstrated during transient coronary occlusion in dogs and after exercise stress in man. Sequential imaging after a single dose of 201Tl at the time of exercise may provide a means for distinguishing between transient perfusion abnormalities or ischemia and myocardial infarction of scar.

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