Quantitative hyperemic reactivity in opposed limbs during myocardial perfusion imaging: a new marker of coronary artery disease

Quantitative CMR markers of impaired vascular reactivity associated with age and peripheral artery disease

BACKGROUND

The aim of this study was to develop and evaluate an integrated CMR method incorporating dynamic oximetry, blood flow and pulse-wave velocimetry to assess vascular reactivity in patients with peripheral artery disease (PAD) and healthy controls.

METHODS AND RESULTS

The study population consisted of young healthy subjects (YH, 30 ± 7 yrs, N = 19),PAD (71 ± 9 yrs, N = 38), and older healthy controls (OHC, 68 ± 9 yrs, N = 43). Peripheral vascular reactivity was evaluated with two methods, time-resolved quantification of blood flow velocity and oxygenation level in the femoral artery and vein, respectively, performed simultaneously both at rest and hyperemia. Aortic stiffness was assessed via pulse-wave velocity. Oximetric data showed that compared to OHC, the time-course of the hemoglobin oxygen saturation in PAD patients had longer washout time (28.6 ± 1.2 vs 16.9 ± 1.1 s, p < 0.0001), reduced upslope (0.60 ± 0.1 vs 1.3 ± 0.08 HbO2/sec, p < 0.0001) and lower overshoot (8 ± 1.4 vs 14 ± 1.2 HbO2, p = 0.0064). PAD patients also had longer-lasting antegrade femoral artery flow during hyperemia (51 ± 2.1 vs 24 ± 1.8 s, p < 0.0001), and reduced peak-to-baseline flow rate (3.1 ± 0.5 vs 7.4 ± 0.4, p < 0.0001). Further, the pulsatility at rest was reduced (0.75 ± 0.32 vs 5.2 ± 0.3, p < 0.0001), and aortic PWV was elevated (10.2 ± 0.4 vs 8.1 ± 0.4 m/s, p = 0.0048).

CONCLUSION

The proposed CMR protocol quantifies multiple aspects of vascular reactivity and represents an initial step toward development of a potential tool for evaluating interventions, extrapolating clinical outcomes and predicting functional endpoints based on quantitative parameters.

Differential short-term repeated forearm hyperaemic reactivity in coronary artery disease patients compared to healthy low risk participants

The hyperaemic response of the forearm is a widely used technique to assess the vascular reactivity. Little is known about the short-term reproducibility and the possible exhaustion of this response in normal or diseased states. As such, the current study was conducted to assess this phenomenon using a unique nuclear medicine- (NM-) based technique. 19 patients with coronary artery disease (CAD) undergoing NM exercise stress tests and 15 low risk (LR) participants completed 2 reactive hyperaemia tests, using a SPECT-based technique, separated by 15  min. Analyses revealed that CAD patients had lower hyperaemic responses than LR participants (P < .001), and that there was a significant group × time interaction (P < .005), such that LR participants showed a larger decrease in the reactivity (5.2 ± 0.4 to 3.6 ± 0.4) than the CAD patients (2.9 ± 0.3 to 2.6 ± 0.3). These results suggest that there is a variability, due to disease states, in the reproducibility of the hypaeremic reactivity. This needs to be taken into account in short-term repeated measure studies.

The Relationship between Multiple Health Behaviours and Brachial Artery Reactivity

Background. The effects of smoking, alcohol consumption, obesity, and a sedentary lifestyle on endothelial function (EF) have only been examined separately. The relative contributions of these behaviours on EF have therefore not been compared. Purpose. To compare the relative associations between these four risk factors and brachial artery reactivity in the same sample. Methods. 328 patients referred for single-photon emission computed tomography (SPECT) exercise stress tests completed a nuclear-medicine-based forearm hyperaemic reactivity test. Self-reported exercise behaviour, smoking habits, and alcohol consumption were collected and waist circumference was measured. Results. Adjusting for relevant covariates, logistic regression analyses revealed that waist circumference, abstinence from alcohol, and past smoking significantly predicted poor brachial artery reactivity while physical activity did not. Only waist circumference predicted continuous variations in EF. Conclusions. Central adiposity, alcohol consumption, and smoking habits but not physical activity are each independent predictors of poor brachial artery reactivity in patients with or at high risk for cardiovascular disease.

Simultaneous mapping of temporally-resolved blood flow velocity and oxygenation in femoral artery and vein during reactive hyperemia

BACKGROUND

Post-occlusive hyperemia is often used as a paradigm to evaluate vascular reactivity, for example by measuring post-ischemic flow-mediated dilation, arterial blood flow or temporally resolved venous blood oxygenation (HbO2). Here we demonstrate the feasibility of a simultaneous measurement of blood flow and HbO2 in the femoral circulation as part of a single procedure.

METHODS

A multi-echo GRE pulse sequence was designed and implemented to collect velocity-encoded projections in addition to full-image echoes for field mapping as a means to quantify intravascular magnetic susceptibility. The method's feasibility was evaluated at 3T in a small pilot study involving two groups of healthy subjects (mean ages 26 ± 1.6 and 59 ± 7.3 years, N = 7 and 5, respectively) in terms of six parameters characterizing the time-course of reactive hyperemia and their sensitivity to differentiate age effects. The reproducibility was assessed on two of the seven young healthy subjects with three repeated measurements.

RESULTS

The physiological parameters agree with those obtained with current methods that quantify either velocity or HbO2 alone. Of the six measures of vascular reactivity, one from each group was significantly different in the two subject groups (p < 0.05) even though the study was not powered to detect differences. The mean coefficient of variation (CV) from two subjects undergoing repeat scans were approximately 8% for the oximetric and the arterial velocimetric parameters in the femoral vein and artery, respectively, considerably below intersubject CVs (20 and 35%, for the young and older subject groups, respectively).

CONCLUSION

The proposed method is able quantify multiple parameters that may lead to more detailed assessment of peripheral vascular reactivity in a single cuff paradigm rather than in separate procedures as required previously, thereby improving measurement efficiency and patient comfort.

The research on endothelial function in women and men at risk for cardiovascular disease (REWARD) study: methodology

Background

Endothelial function has been shown to be a highly sensitive marker for the overall cardiovascular risk of an individual. Furthermore, there is evidence of important sex differences in endothelial function that may underlie the differential presentation of cardiovascular disease (CVD) in women relative to men. As such, measuring endothelial function may have sex-specific prognostic value for the prediction of CVD events, thus improving risk stratification for the overall prediction of CVD in both men and women. The primary objective of this study is to assess the clinical utility of the forearm hyperaemic reactivity (FHR) test (a proxy measure of endothelial function) for the prediction of CVD events in men vs. women using a novel, noninvasive nuclear medicine -based approach. It is hypothesised that: 1) endothelial dysfunction will be a significant predictor of 5-year CVD events independent of baseline stress test results, clinical, demographic, and psychological variables in both men and women; and 2) endothelial dysfunction will be a better predictor of 5-year CVD events in women compared to men.

Methods/Design

A total of 1972 patients (812 men and 1160 women) undergoing a dipyridamole stress testing were recruited. Medical history, CVD risk factors, health behaviours, psychological status, and gender identity were assessed via structured interview or self-report questionnaires at baseline. In addition, FHR was assessed, as well as levels of sex hormones via blood draw. Patients will be followed for 5 years to assess major CVD events (cardiac mortality, non-fatal MI, revascularization procedures, and cerebrovascular events).

Discussion

This is the first study to determine the extent and nature of any sex differences in the ability of endothelial function to predict CVD events. We believe the results of this study will provide data that will better inform the choice of diagnostic tests in men and women and bring the quality of risk stratification in women on par with that of men.

Evaluation of cuff-induced ischemia in the lower extremity by magnetic resonance oximetry

OBJECTIVES

The aim of this study was to evaluate vascular function in the lower extremities by making direct time-course measurement of oxygen saturation in the femoral/popliteal arteries and veins during cuff-induced reactive hyperemia with magnetic resonance imaging-based oximetry.

BACKGROUND

Magnetic resonance imaging-based oximetry is a new calibration-free technique taking advantage of the paramagnetic nature of blood that depends on the volume fraction of deoxyhemoglobin in red blood cells.

METHODS

We compared post-occlusive blood oxygenation time-course of femoral/popliteal vessels in: 1) young healthy subjects (YH) (n = 10; mean ankle-brachial index [ABI] 1.0 +/- 0.1, mean age 30 +/- 7 years); 2) peripheral arterial disease (PAD) patients (n = 12; mean ABI 0.6 +/- 0.1, mean age 71 +/- 9 years); and 3) age-matched healthy control subjects (AHC) (n = 8; mean ABI 1.1 +/- 0.1, mean age 68 +/- 9 years). Blood oxygenation was quantified at 3.0-T field strength with a field mapping pulse sequence yielding the magnetic susceptibility difference between blood in the vessels and surrounding muscle tissue from which the intravascular blood oxygen saturation is computed as %HbO(2).

RESULTS

Significantly longer washout time (42 +/- 16 s vs. 14 +/- 4 s; p < 0.0001) and lower upslope (0.60 +/- 0.20 %HbO(2)/s vs. 1.32 +/- 0.41 %HbO(2)/s; p = 0.0008) were observed for PAD patients compared with healthy subjects (YH and AHC combined). Furthermore, greater overshoot was observed in YH than in AHC (21 +/- 8 %HbO(2) vs. 10 +/- 5 %HbO(2); p = 0.0116).

CONCLUSIONS

Post-occlusive transient changes in venous blood oxygenation might provide a new measure of vascular competence, which was found to be reduced in subjects with abnormal ABI, manifesting in prolonged recovery during the early phase of hyperemia.