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September 20, 1995, Vol 274, No. 11 >
ARTICLE | September 20, 1995

Changes in Myocardial Perfusion Abnormalities by Positron Emission Tomography After Long-term, Intense Risk Factor Modification FREE

K. Lance Gould, MD; Dean Ornish, MD; Larry Scherwitz, PhD; Shirley Brown, MD; R. Patterson Edens, PhD; Mary Jane Hess, RN; Nizar Mullani; Leonard Bolomey; Frank Dobbs, PhD; William T. Armstrong, MD; Terri Merritt, MS; Thomas Ports, MD; Stephen Sparler, MA; James Billings, PhD
[+] Author Affiliations

Reprint requests to Division of Cardiology, Room 4.258MSB, 6431 Fannin, University of Texas Medical School at Houston, Houston, TX 77030 (Dr Gould).


JAMA. 1995;274(11):894-901. doi:10.1001/jama.1995.03530110056036
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Published online
Article
References

Objective.  —To quantify changes in size and severity of myocardial perfusion abnormalities by positron emission tomography (PET) in patients with coronary artery disease after 5 years of risk factor modification.

Design.  —Randomized controlled trial.

Setting.  —Outpatient community setting.

Intervention.  —Randomization of patients to risk factor modification consisting of very low-fat vegetarian diet, mild to moderate exercise, stress management, and group support (experimental group, n=20) or to usual care by their own physicians, consisting principally of antianginal therapy (control group, n=15).

Main Outcome Measures.  —Quantitative coronary arteriography and PET at baseline and 5 years after randomization. Automated, objective measures of size and severity of perfusion abnormalities on rest-dipyridamole PET images and of stenosis severity on arteriograms were made by computer algorithms.

Results.  —Size and severity of perfusion abnormalities on dipyridamole PET images decreased (improved) after risk factor modification in the experimental group compared with an increase (worsening) of size and severity in controls. The percentage of left ventricle perfusion abnormalities outside 2.5 SDs of those of normal persons (based on 20 disease-free individuals) on the dipyridamole PET image of normalized counts worsened in controls (mean ±SE, +10.3%±5.6%) and improved in the experimental group (mean ±SE, −5.1 %±4.8%) (P=.02); the percentage of left ventricle with activity less than 60% of the maximum activity on the dipyridamole PET image of normalized counts worsened in controls (+13.5%± 3.8%) and improved in the experimental group (−4.2%±3.8%) (P=.002); and the myocardial quadrant on the PET image with the lowest average activity expressed as a percentage of maximum activity worsened in controls (−8.8%±2.3%) and improved in the experimental group (+4.9%±3.3%)(P=.001 ). The size and severity of perfusion abnormalities on resting PET images were also significantly improved in the experimental group as compared with controls. The relative magnitude of changes in size and severity of PET perfusion abnormalities was comparable to or greater than the magnitude of changes in percent diameter stenosis, absolute stenosis lumen area, or stenosis flow reserve documented by quantitative coronary arteriography.

Conclusions.  —Modest regression of coronary artery stenoses after risk factor modification is associated with decreased size and severity of perfusion abnormalities on rest-dipyridamole PET images. Progression or regression of coronary artery disease can be followed noninvasively by dipyridamole PET reflecting the integrated flow capacity of the entire coronary arterial circulation.(JAMA. 1995;274:894-901)

REFERENCES

1 +
References 2, 5, 11, 14, 15, 17-19, 22, 24.
2 +
Ornish DM, Brown SE, Scherwitz LW, et al.  Can lifestyle changes reverse atherosclerosis? Lancet . 1990;;336:129-133.
3 +
Brown G, Albers JJ, Fisher LD, et al.  Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med . 1990;; 323:1289-1298.
4 +
Kane JP, Malloy MJ, Ports TA, Phillips NR, Diehl JC, Havel RJ.  Regression of coronary atherosclerosis during treatment of familial hypercholesterolemia with combined drug regimens. JAMA . 1990;;264:3007-3012.
5 +
Gould KL, Ornish D, Kirkeeide R, et al.  Improved stenosis geometry by quantitative coronary arteriography after vigorous risk factor modification. Am J Cardiol . 1992;;69:845-853.
6 +
Watts GF, Lewis B, Brunt JN, et al.  Effects on coronary artery disease of lipid-lowering diet, or diet plus cholestyramine, in the St Thomas' Atherosclerosis Regression Study (STARS). Lancet . 1992;;339:563-569.
7 +
Schuler G, Hambrecht R, Schlierf G, et al.  Myocardial perfusion and regression of coronary artery disease in patients on a regimen of intensive physical exercise and low fat diet. J Am Coll Cardiol . 1992;;19:34-42.
8 +
Schuler G, Hambrecht R, Schlierf G, et al.  Regular physical exercise and low-fat diet: effects on progression of coronary artery disease. Circulation . 1992;;86:1-11.
9 +
Buchwald H, Varco RL, Matts JP, et al.  Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. N Engl J Med . 1990;; 323:946-955.
10 +
Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L.  Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts. JAMA . 1987;;257:3233-3240.
11 +
Cashin-Hemphill L, MackWJ, Pogoda JM, Sanmarco ME, Azen SP, Blankenhorn DH.  Beneficial effects of colestipol-niacin on coronary atherosclerosis: a 4-year follow-up. JAMA . 1990;;264:3013-3017.
12 +
Haskell WL, Alderman EL, Fair JM, et al.  Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. Circulation . 1994;;89:975-990.
13 +
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II).  Second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II), National Cholesterol Education Program. Circulation . 1994;;89:1329-1445.
14 +
Blankenhorn DH.  Angiographic trials testing the efficacy of cholesterol lowering in reducing progression or inducing regression of coronary atherosclerosis. Coron Artery Dis . 1991;;2:875-879.
15 +
Singh RB, Rastogi SS, Verna R, et al.  Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction. BMJ . 1992;;304:1015-1019.
16 +
Buchwald H, Matts JP, Fitch LL, et al.  Changes in sequential coronary arteriograms and subsequent coronary events. JAMA . 1992;;268:1429-1433.
17 +
Gould KL, Martucci JP, Goldberg DI, et al.  Short-term cholesterol lowering decreases size and severity of perfusion abnormalities by positron emission tomography after dipyridamole in patients with coronary artery disease—a potential noninvasive marker of healing coronary endothelium. Circulation . 1994;;89:1530-1538.
18 +
Scandinavian Simvastatin Survival Study Group.  Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease. Lancet . 1994;;344:1383-1389.
19 +
deLogeril M, Renaud S, Mamelle N, et al.  Mediterranean alpha-linolenic acid—rich diet in secondary prevention of coronary heart disease. Lancet . 1994;;343:1454-1459.
20 +
Furberg CD, Adams HP, Applegate WB, et al.  Effect of lovastatin on early carotid atherosclerosis and cardiovascular events. Circulation . 1994;;90: 1679-1687.
21 +
Waters D, Higginson L, Gladstone P, et al.  Effects of monotherapy with an HMG-CoA reductase inhibitor on the progression of coronary atherosclerosis as assessed by serial quantitative arteriography. Circulation . 1994;;89:959-968.
22 +
Blankenhorn DH, Azen S, Kramsch DM, et al, and the MARS Research Group.  Coronary angiographc changes with lovastatin therapy. Ann Intern Med . 1993;;119:969-976.
23 +
Pitt B, Mancini J, Ellis SG, Rosman HS, McGovern ME.  Pravastin limitation of atherosclerosis in the coronary arteries (PLAC I). J Am Coll Cardiol . 1994;;23:131A. Abstract.
24 +
MAAS Investigators.  Effect of simvastatin on coronary atheroma. Lancet . 1994;;344:633-638.
25 +
Zhao XQ, Grown BG, Hillger L, et al.  Effects of intensive lipid-lowering therapy on the coronary arteries of asymptomatic subjects with elevated apolipoprotein B. Circulation . 1993;;88:2744-2753.
26 +
Gould KL. Coronary Artery Stenoses: A Text-book of Coronary Pathophysiology, Quantitative Coronary Arteriography, PET Perfusion Imaging and Reversal of Coronary Artery Disease . New York, NY: Elsevier Science Publishing Co Inc; 1991;.
27 +
Gould KL, Kelley KO.  Experimental validation of quantitative coronary arteriography for determining pressure-flow characteristics of coronary stenoses. Circulation . 1982;;66:930-937.
28 +
Kirkeeide RL, Gould KL, Parsel L.  Assessment of coronary stenoses by myocardial imaging during coronary vasodilation, VII: validation of coronary flow reserve as a single integrated measure of stenosis severity accounting for all its geometric dimensions. J Am Coll Cardiol . 1986;;7:103-113.
29 +
Gould KL, Kirkeeide RL, Buchi M.  Coronary flow reserve as a physiologic measure of stenosis severity, part I: relative and absolute coronary flow reserve during changing aortic pressure and cardiac workload; part II: determination from arteriographic stenosis dimensions under standardized conditions. J Am Coll Cardiol . 1990;;15:459-474.
30 +
Gould KL.  Identifying and measuring severity of coronary artery stenosis—quantitative coronary arteriography and positron emission tomography. Circulation . 1988;;78:237-245.
31 +
Marcus ML, Harrison DG, White CW, McPherson DD, Wilson RF, Kerber KE.  Assessing the physiologic significance of coronary obstructions in patients: importance of diffuse undetected atherosclerosis. Prog Cardiovasc Dis . 1988;;31:39-56.
32 +
White CW, Wright CB, Doty DB, et al.  Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? N Engl J Med . 1984;;310:819-824.
33 +
Marcus ML, Skorton DJ, Johnson MR, Collins SM, Harrison DG, Kerber RE.  Visual estimates of percent diameter coronary stenosis: 'a battered gold standard.' J Am Coll Cardiol . 1988;;11:882-885.
34 +
Seiler C, Kirkeeide RL, Gould KL.  Basic structure-function relations of the epicardial coronary vascular tree—the basis of quantitative coronary arteriography for diffuse coronary artery disease. Circulation . 1992;;85:1987-2003.
35 +
Seiler C, Kirkeeide RL, Gould KL.  Measurement from arteriograms of regional myocardial bed size distal to any point in the coronary arterial tree for assessing anatomic area at risk. J Am Coll Cardiol . 1993;;21:783-797.
36 +
Hodgson JM, Reddy KG, Suneja R, Nair RN, Lesnefsky EJ, Sheehan HW.  Intracoronary ultrasound imaging: correlation of plaque morphology with angiography, clinical syndrome and procedural results in patients undergoing coronary angioplasty. J Am Coll Cardiol . 1993;;21:35-44.
37 +
Gould KL, Goldstein RA, Mullani N, et al.  Non-invasive assessment of coronary stenoses by myocardial imaging during pharmacologic coronary vasodilation, VIII: feasibility of 3D cardiac positron imaging without a cyclotron using generator produced Rb-82. J Am Coll Cardiol . 1986;;7:775-792.
38 +
Demer LL, Gould KL, Goldstein RA, Kirkeeide RL.  Diagnosis of coronary artery disease by positron emission tomography. Circulation . 1989;;79: 825-835.
39 +
Gould KL.  PET perfusion imaging and nuclear cardiology. J Nucl Med . 1991;;32:579-606.
40 +
Gould KL.  Clinical cardiac positron emission tomography. Circulation . 1991;;84( (suppl) ):I-22—I-36.
41 +
Hicks K, Ganti G, Mullani N, Gould KL.  Automated quantitation of 3D cardiac PET for routine clinical use. J Nucl Med . 1989;;30:1787-1797
42 +
Demer LL, Gould KL, Goldstein RA, Kirkeeide RL.  Noninvasive assessment of coronary collaterals in man by PET perfusion imaging. J Nucl Med . 1990;;31:259-270.
43 +
Mullani NA, Goldstein RA, Gould KL, Fisher DJ, Marani SK, O'Brien HA.  Myocardial perfusion with rubidium-82,I: measurement of extraction fraction and flow with external detectors. J Nucl Med . 1983;;24:898-906.
44 +
Goldstein RA, Mullani NA, Fisher D, Marani S, Gould KL, O'Brien HA.  Myocardial perfusion with rubidium-82, II: the effects of metabolic and pharmacologic interventions. J Nucl Med . 1983;;24:907-915.
45 +
Xu EZ, Mullani NA, Gould KL, Anderson WL.  A segmented attenuation correction for PET. J Nucl Med . 1991;;32:161-165.
46 +
45. Snedecor GW, Cochran WG. Statistical Methods . 8th ed. Ames: Iowa State University Press; 1989;.
47 +
Glantz SA. Primer of Biostatistics . New York, NY: McGraw-Hill International Book Co; 1987;.
48 +
Spatz C, Johnston JD. Basic Statistics . 3rd ed. Monterey, Calif: Brooks/Cole Publishing Co; 1984;.
49 +
Stat View . Berkeley, Calif: Abacus Concepts Inc; 1992;.
50 +
Demer L, Gould KL, Kirkeeide R.  Assessing stenosis severity: coronary flow reserve, collateral function, quantitative coronary arteriography, positron imaging, and digital subtraction angiography. Prog Cardiovasc Dis . 1988;;30:307-322.
51 +
Brown BG, Zhao XQ, Sacco DE, Albers JJ.  Lipid lowering and plaque regression: new insights into prevention of plaque disruption and clinical events in coronary artery disease. Circulation . 1993;; 87:1781-1791.
52 +
Fuster V, Badimon L, Badimon JJ, Chesebro JH.  The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med . 1992;;326:242-250.
53 +
Cohen RA, Zitnay KM, Haudenschild CC, Cunningham LD.  Loss of selective endothelial cell vasoactive functions caused by hypercholesterolemia in pig coronary arteries. Circ Res . 1988;;63:903-910.
54 +
Shimokawa H, Vanhoutte PM.  Dietary cod liver oil improves endothelium-dependent responses in hypercholesterolemic and atherosclerotic porcine coronary arteries. Circulation . 1988;;78:1421-1430.
55 +
Selke FW, Armstrong ML, Harrison DG.  Endothelium-dependent vascular relaxation is abnormal in the coronary microcirculation of atherosclerotic primates. Circulation . 1990;;81:1586-1593.
56 +
Chilian WM, Dellsperger KC, Layne SM, et al.  Effects of atherosclerosis on the coronary microcirculation. Am J Physiol . 1990;;258( (2) , pt 2):H529-H539.
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Tomita T, Ezaki M, Miwa M, Nakamura K, Inoue Y.  Rapid and reversible inhibition by low-density lipoprotein of the endothelium-dependent relaxation to hemostatic substances in porcine coronary arteries. Circ Res . 1990;;66:18-27.
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Andrews HE, Bruckdorfer KR, Dunn RC, Jacob M.  Low-density lipoproteins inhibit endothelium-dependent relaxation in rabbit aorta. Nature . 1987;;327:237-239.
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Harrison DG, Armstrong ML, Freiman PC, Heistad DD.  Restoration of endothelium-dependent relaxation by dietary treatment of atherosclerosis. J Clin Invest . 1987;;80:1801-1811.
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Verbeuren TJ, Jordaens FH, Zonnekeyn LL, Van Hove CE, Coene MC, Herman AG.  Effect of hypercholesterolemia on vascular reactivity in the rabbit. Circ Res . 1986;;58:552-564.
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Tanner FC, Noll G, Boulanger CM, Luescher TF.  Oxidized low density lipoproteins inhibit relaxations of porcine coronary arteries. Circulation . 1991;;83:2012-2020.
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Kuo L, Davis MJ, Cannon S, Chilian WM.  Pathophysiological conseqences of atherosclerosis extend into the coronary microcirculation. Circ Res . 1992;; 70:465-476.
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Gordon JB, Ganz P, Nabel EG, et al.  Atherosclerosis influences the vasomotor response of epicardial coronary arteries to exercise. J Clin Invest . 1989;;83:1946-1952.
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Zeiher AM, Drexler H, Wollschlager H, Just H.  Endothelial dysfunction of the coronary microvasculature is associated with impaired coronary blood flow regulation in patients with early atherosclerosis. Circulation . 1991;;84:1984-1992.
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Zeiher AM, Drexler H, Wollschlager H, Just H.  Modulation of coronary vasomotor tone. Circulation . 1991;;83:391-401.
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Ludmer PL, Selwyn AP, Shook TL, et al.  Paradoxical vasoconstriction induced by acetylcholine in atherosclerotic coronary arteries. N Engl J Med . 1986;;315:1046-1051.
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Hodgson JM, Marshall JJ.  Direct vasoconstriction and endothelium-dependent vasodilation. Circulation . 1989;;79:1043-1051.
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Waters D, Craven TE, Lesperance J.  Prognostic significance of progression of coronary atherosclerosis. Circulation . 1993;;87:1067-1075.
72 +
Gould KL.  Reversal of coronary atherosclerosis: clinical promise as the basis for the non-invasive management of coronary artery disease. Circulation . 1994;;90:1558-1571.
73 +
Wackers FJ.  Artifacts in planar and SPECT myocardial perfusion imaging. Am J Card Imaging . 1992;;6:42-58.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
References 2, 5, 11, 14, 15, 17-19, 22, 24.
2 +
Ornish DM, Brown SE, Scherwitz LW, et al.  Can lifestyle changes reverse atherosclerosis? Lancet . 1990;;336:129-133.
3 +
Brown G, Albers JJ, Fisher LD, et al.  Regression of coronary artery disease as a result of intensive lipid-lowering therapy in men with high levels of apolipoprotein B. N Engl J Med . 1990;; 323:1289-1298.
4 +
Kane JP, Malloy MJ, Ports TA, Phillips NR, Diehl JC, Havel RJ.  Regression of coronary atherosclerosis during treatment of familial hypercholesterolemia with combined drug regimens. JAMA . 1990;;264:3007-3012.
5 +
Gould KL, Ornish D, Kirkeeide R, et al.  Improved stenosis geometry by quantitative coronary arteriography after vigorous risk factor modification. Am J Cardiol . 1992;;69:845-853.
6 +
Watts GF, Lewis B, Brunt JN, et al.  Effects on coronary artery disease of lipid-lowering diet, or diet plus cholestyramine, in the St Thomas' Atherosclerosis Regression Study (STARS). Lancet . 1992;;339:563-569.
7 +
Schuler G, Hambrecht R, Schlierf G, et al.  Myocardial perfusion and regression of coronary artery disease in patients on a regimen of intensive physical exercise and low fat diet. J Am Coll Cardiol . 1992;;19:34-42.
8 +
Schuler G, Hambrecht R, Schlierf G, et al.  Regular physical exercise and low-fat diet: effects on progression of coronary artery disease. Circulation . 1992;;86:1-11.
9 +
Buchwald H, Varco RL, Matts JP, et al.  Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia. N Engl J Med . 1990;; 323:946-955.
10 +
Blankenhorn DH, Nessim SA, Johnson RL, Sanmarco ME, Azen SP, Cashin-Hemphill L.  Beneficial effects of combined colestipol-niacin therapy on coronary atherosclerosis and coronary venous bypass grafts. JAMA . 1987;;257:3233-3240.
11 +
Cashin-Hemphill L, MackWJ, Pogoda JM, Sanmarco ME, Azen SP, Blankenhorn DH.  Beneficial effects of colestipol-niacin on coronary atherosclerosis: a 4-year follow-up. JAMA . 1990;;264:3013-3017.
12 +
Haskell WL, Alderman EL, Fair JM, et al.  Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. Circulation . 1994;;89:975-990.
13 +
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II).  Second report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II), National Cholesterol Education Program. Circulation . 1994;;89:1329-1445.
14 +
Blankenhorn DH.  Angiographic trials testing the efficacy of cholesterol lowering in reducing progression or inducing regression of coronary atherosclerosis. Coron Artery Dis . 1991;;2:875-879.
15 +
Singh RB, Rastogi SS, Verna R, et al.  Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction. BMJ . 1992;;304:1015-1019.
16 +
Buchwald H, Matts JP, Fitch LL, et al.  Changes in sequential coronary arteriograms and subsequent coronary events. JAMA . 1992;;268:1429-1433.
17 +
Gould KL, Martucci JP, Goldberg DI, et al.  Short-term cholesterol lowering decreases size and severity of perfusion abnormalities by positron emission tomography after dipyridamole in patients with coronary artery disease—a potential noninvasive marker of healing coronary endothelium. Circulation . 1994;;89:1530-1538.
18 +
Scandinavian Simvastatin Survival Study Group.  Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease. Lancet . 1994;;344:1383-1389.
19 +
deLogeril M, Renaud S, Mamelle N, et al.  Mediterranean alpha-linolenic acid—rich diet in secondary prevention of coronary heart disease. Lancet . 1994;;343:1454-1459.
20 +
Furberg CD, Adams HP, Applegate WB, et al.  Effect of lovastatin on early carotid atherosclerosis and cardiovascular events. Circulation . 1994;;90: 1679-1687.
21 +
Waters D, Higginson L, Gladstone P, et al.  Effects of monotherapy with an HMG-CoA reductase inhibitor on the progression of coronary atherosclerosis as assessed by serial quantitative arteriography. Circulation . 1994;;89:959-968.
22 +
Blankenhorn DH, Azen S, Kramsch DM, et al, and the MARS Research Group.  Coronary angiographc changes with lovastatin therapy. Ann Intern Med . 1993;;119:969-976.
23 +
Pitt B, Mancini J, Ellis SG, Rosman HS, McGovern ME.  Pravastin limitation of atherosclerosis in the coronary arteries (PLAC I). J Am Coll Cardiol . 1994;;23:131A. Abstract.
24 +
MAAS Investigators.  Effect of simvastatin on coronary atheroma. Lancet . 1994;;344:633-638.
25 +
Zhao XQ, Grown BG, Hillger L, et al.  Effects of intensive lipid-lowering therapy on the coronary arteries of asymptomatic subjects with elevated apolipoprotein B. Circulation . 1993;;88:2744-2753.
26 +
Gould KL. Coronary Artery Stenoses: A Text-book of Coronary Pathophysiology, Quantitative Coronary Arteriography, PET Perfusion Imaging and Reversal of Coronary Artery Disease . New York, NY: Elsevier Science Publishing Co Inc; 1991;.
27 +
Gould KL, Kelley KO.  Experimental validation of quantitative coronary arteriography for determining pressure-flow characteristics of coronary stenoses. Circulation . 1982;;66:930-937.
28 +
Kirkeeide RL, Gould KL, Parsel L.  Assessment of coronary stenoses by myocardial imaging during coronary vasodilation, VII: validation of coronary flow reserve as a single integrated measure of stenosis severity accounting for all its geometric dimensions. J Am Coll Cardiol . 1986;;7:103-113.
29 +
Gould KL, Kirkeeide RL, Buchi M.  Coronary flow reserve as a physiologic measure of stenosis severity, part I: relative and absolute coronary flow reserve during changing aortic pressure and cardiac workload; part II: determination from arteriographic stenosis dimensions under standardized conditions. J Am Coll Cardiol . 1990;;15:459-474.
30 +
Gould KL.  Identifying and measuring severity of coronary artery stenosis—quantitative coronary arteriography and positron emission tomography. Circulation . 1988;;78:237-245.
31 +
Marcus ML, Harrison DG, White CW, McPherson DD, Wilson RF, Kerber KE.  Assessing the physiologic significance of coronary obstructions in patients: importance of diffuse undetected atherosclerosis. Prog Cardiovasc Dis . 1988;;31:39-56.
32 +
White CW, Wright CB, Doty DB, et al.  Does visual interpretation of the coronary arteriogram predict the physiologic importance of a coronary stenosis? N Engl J Med . 1984;;310:819-824.
33 +
Marcus ML, Skorton DJ, Johnson MR, Collins SM, Harrison DG, Kerber RE.  Visual estimates of percent diameter coronary stenosis: 'a battered gold standard.' J Am Coll Cardiol . 1988;;11:882-885.
34 +
Seiler C, Kirkeeide RL, Gould KL.  Basic structure-function relations of the epicardial coronary vascular tree—the basis of quantitative coronary arteriography for diffuse coronary artery disease. Circulation . 1992;;85:1987-2003.
35 +
Seiler C, Kirkeeide RL, Gould KL.  Measurement from arteriograms of regional myocardial bed size distal to any point in the coronary arterial tree for assessing anatomic area at risk. J Am Coll Cardiol . 1993;;21:783-797.
36 +
Hodgson JM, Reddy KG, Suneja R, Nair RN, Lesnefsky EJ, Sheehan HW.  Intracoronary ultrasound imaging: correlation of plaque morphology with angiography, clinical syndrome and procedural results in patients undergoing coronary angioplasty. J Am Coll Cardiol . 1993;;21:35-44.
37 +
Gould KL, Goldstein RA, Mullani N, et al.  Non-invasive assessment of coronary stenoses by myocardial imaging during pharmacologic coronary vasodilation, VIII: feasibility of 3D cardiac positron imaging without a cyclotron using generator produced Rb-82. J Am Coll Cardiol . 1986;;7:775-792.
38 +
Demer LL, Gould KL, Goldstein RA, Kirkeeide RL.  Diagnosis of coronary artery disease by positron emission tomography. Circulation . 1989;;79: 825-835.
39 +
Gould KL.  PET perfusion imaging and nuclear cardiology. J Nucl Med . 1991;;32:579-606.
40 +
Gould KL.  Clinical cardiac positron emission tomography. Circulation . 1991;;84( (suppl) ):I-22—I-36.
41 +
Hicks K, Ganti G, Mullani N, Gould KL.  Automated quantitation of 3D cardiac PET for routine clinical use. J Nucl Med . 1989;;30:1787-1797
42 +
Demer LL, Gould KL, Goldstein RA, Kirkeeide RL.  Noninvasive assessment of coronary collaterals in man by PET perfusion imaging. J Nucl Med . 1990;;31:259-270.
43 +
Mullani NA, Goldstein RA, Gould KL, Fisher DJ, Marani SK, O'Brien HA.  Myocardial perfusion with rubidium-82,I: measurement of extraction fraction and flow with external detectors. J Nucl Med . 1983;;24:898-906.
44 +
Goldstein RA, Mullani NA, Fisher D, Marani S, Gould KL, O'Brien HA.  Myocardial perfusion with rubidium-82, II: the effects of metabolic and pharmacologic interventions. J Nucl Med . 1983;;24:907-915.
45 +
Xu EZ, Mullani NA, Gould KL, Anderson WL.  A segmented attenuation correction for PET. J Nucl Med . 1991;;32:161-165.
46 +
45. Snedecor GW, Cochran WG. Statistical Methods . 8th ed. Ames: Iowa State University Press; 1989;.
47 +
Glantz SA. Primer of Biostatistics . New York, NY: McGraw-Hill International Book Co; 1987;.
48 +
Spatz C, Johnston JD. Basic Statistics . 3rd ed. Monterey, Calif: Brooks/Cole Publishing Co; 1984;.
49 +
Stat View . Berkeley, Calif: Abacus Concepts Inc; 1992;.
50 +
Demer L, Gould KL, Kirkeeide R.  Assessing stenosis severity: coronary flow reserve, collateral function, quantitative coronary arteriography, positron imaging, and digital subtraction angiography. Prog Cardiovasc Dis . 1988;;30:307-322.
51 +
Brown BG, Zhao XQ, Sacco DE, Albers JJ.  Lipid lowering and plaque regression: new insights into prevention of plaque disruption and clinical events in coronary artery disease. Circulation . 1993;; 87:1781-1791.
52 +
Fuster V, Badimon L, Badimon JJ, Chesebro JH.  The pathogenesis of coronary artery disease and the acute coronary syndromes. N Engl J Med . 1992;;326:242-250.
53 +
Cohen RA, Zitnay KM, Haudenschild CC, Cunningham LD.  Loss of selective endothelial cell vasoactive functions caused by hypercholesterolemia in pig coronary arteries. Circ Res . 1988;;63:903-910.
54 +
Shimokawa H, Vanhoutte PM.  Dietary cod liver oil improves endothelium-dependent responses in hypercholesterolemic and atherosclerotic porcine coronary arteries. Circulation . 1988;;78:1421-1430.
55 +
Selke FW, Armstrong ML, Harrison DG.  Endothelium-dependent vascular relaxation is abnormal in the coronary microcirculation of atherosclerotic primates. Circulation . 1990;;81:1586-1593.
56 +
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Compression-Only CPR: Pushing the Science Forward
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AAM 2010;304:1493-1495.
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BMJ 2010;341:c5893-c1494.
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