1
|
Davila CD, Udelson JE. Trials and Tribulations of Assessing New Imaging Protocols: Combining Vasodilator Stress With Exercise. JACC Cardiovasc Imaging 2019. [PMID: 29519339 DOI: 10.1016/j.jcmg.2017.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Among all patients referred for stress myocardial perfusion imaging (MPI), a substantial proportion in contemporary practice cannot exercise. Another group of patients are those who are thought to be able to achieve an adequate workload with treadmill (or bicycle) exercise but do not achieve at least 85% of maximum predicted heart rate without developing symptoms. There has been substantial interest and literature on the adjunctive use of vasodilator stress during the same visit to generate best-quality results for patients who do not exercise adequately. Current American Society of Nuclear Cardiology Guidelines recommend the possible use of vasodilator stress agents to supplement exercise in those patients who do not achieve target heart rate. However, optimal timing of administration is not clear. Herein, we summarize literature to date on the combination of vasodilator and exercise stress testing in light of the recently published Exercise to Regadenoson in Recovery Trial (EXERRT).
Collapse
Affiliation(s)
- Carlos D Davila
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts.
| |
Collapse
|
2
|
Gomez J, Doukky R. Artificial Intelligence in Nuclear Cardiology. J Nucl Med 2019; 60:1042-1043. [DOI: 10.2967/jnumed.118.222356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/18/2019] [Indexed: 02/02/2023] Open
|
3
|
Pagnanelli RA, Camposano HL. Pharmacologic Stress Testing with MyocardialPerfusion Imaging. J Nucl Med Technol 2017; 45:249-252. [PMID: 29042473 DOI: 10.2967/jnmt.117.199208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/22/2017] [Indexed: 11/16/2022] Open
Abstract
The preferred method for performing stress testing with myocardial perfusion imaging is physical exercise. However, many patients are unable to reach an adequate endpoint. As an alternative, various pharmacologic options are available, which are explored in this article.
Collapse
Affiliation(s)
| | - Heidi L Camposano
- Department of Radiology, Duke Regional Hospital, Durham, North Carolina
| |
Collapse
|
4
|
Thompson RC, Thomas GS. The EXXERT Study. J Nucl Cardiol 2017; 24:1800-1802. [PMID: 28537038 DOI: 10.1007/s12350-017-0903-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Randall C Thompson
- St. Luke's Mid America Heart Institute and University of Missouri - Kansas City, 4330 Wornall Rd, Kansas City, MO, 64111, USA.
| | - Gregory S Thomas
- Memorial Care Heart & Vascular Institute, Long Beach Memorial Medical Center, Long Beach, USA
- Division of Cardiology, University of California Irvine School of Medicine, Irvine, USA
| |
Collapse
|
5
|
Thomas GS, Cullom SJ, Kitt TM, Feaheny KM, Ananthasubramaniam K, Gropler RJ, Jain D, Thompson RC. The EXERRT trial: "EXErcise to Regadenoson in Recovery Trial": A phase 3b, open-label, parallel group, randomized, multicenter study to assess regadenoson administration following an inadequate exercise stress test as compared to regadenoson without exercise for myocardial perfusion imaging using a SPECT protocol. J Nucl Cardiol 2017; 24:788-802. [PMID: 28224449 PMCID: PMC5491644 DOI: 10.1007/s12350-017-0813-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 01/19/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study assessed the non-inferiority and safety of regadenoson administration during recovery from inadequate exercise compared with administration without exercise. METHODS Patients unable to achieve adequate exercise stress were randomized to regadenoson 0.4 mg either during recovery (Ex-Reg) or 1 hour after inadequate exercise (Regadenoson) (MPI1). All patients also underwent non-exercise regadenoson MPI 1-14 days later (MPI2). The number of segments with reversible perfusion defects (RPDs) detected using single photon emission computerized tomography imaging was categorized. The primary analysis evaluated the majority agreement rate between Ex-Reg and Regadenoson groups. RESULTS 1,147 patients were randomized. The lower bound of the 95% confidence interval of the difference in agreement rates (-6%) was above the -7.5% non-inferiority margin, demonstrating non-inferiority of Ex-Reg to Regadenoson. Adverse events were numerically less with Ex-Reg (MPI1). In the Ex-Reg group, one patient developed an acute coronary syndrome and another had a myocardial infarction following regadenoson after exercise. Upon review, both had electrocardiographic changes consistent with ischemia prior to regadenoson. CONCLUSIONS Administering regadenoson during recovery from inadequate exercise results in comparable categorization of segments with RPDs and with careful monitoring appears to be well tolerated in patients without signs/symptoms of ischemia during exercise and recovery.
Collapse
Affiliation(s)
- Gregory S Thomas
- MemorialCare Heart & Vascular Institute, Long Beach Memorial, 2801 Atlantic Ave, Long Beach, CA, 90806, USA.
- University of California, Irvine, CA, USA.
| | - S James Cullom
- AdaptivePharma, Leawood, KS, USA
- University of Missouri, Columbia, MO, USA
| | - Therese M Kitt
- Astellas Pharma Global Development, Inc., Northbrook, IL, USA
| | | | | | - Robert J Gropler
- Division of Radiological Sciences, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Diwakar Jain
- Cardiovascular Nuclear Imaging Laboratory, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
| | - Randall C Thompson
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- University of Missouri-Kansas City, Kansas City, MO, USA
| |
Collapse
|
6
|
Yuoness SA, Goha AM, Romsa JG, Akincioglu C, Warrington JC, Datta S, Massel DR, Martell R, Gambhir S, Urbain JLC, Vezina WC. Very high coronary artery calcium score with normal myocardial perfusion SPECT imaging is associated with a moderate incidence of severe coronary artery disease. Eur J Nucl Med Mol Imaging 2015; 42:1542-50. [PMID: 26138459 PMCID: PMC4521098 DOI: 10.1007/s00259-015-3072-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 04/15/2015] [Indexed: 01/07/2023]
Abstract
PURPOSE Myocardial perfusion imaging (MPI) has limitations in the presence of balanced multivessel disease (MVD) and left main (LM) coronary artery disease, occasionally resulting in false-normal results despite the high cardiovascular risk associated with this condition. The purpose of this study was to assess the incidence of severe coronary artery disease (CAD) in the presence of a very high Agatston coronary artery calcium (CAC) score (>1,000) in stable symptomatic patients without known CAD but with normal MPI results. METHODS A total of 2,659 prospectively acquired consecutive patients were referred for MPI and evaluation of CAC score by CT. Of this patient population, 8 % (222/2,659) had ischemia without myocardial infarction (MI) on MPIand 11 % (298/2,659) had abnormal MPI (MI and/or ischemia). On presentation 1 % of the patients (26/2,659) were symptomatic, had a CAC score >1,000 and normal MPI results. The definition of normal MPI was strict and included a normal hemodynamic response without ischemic ECG changes and normal imaging, particularly absence of transient ischemic dilation. All of these 26 patients with a CAC score >1,000 and normal MPI findings underwent cardiac catheterization. RESULTS Of these 26 patients, 58 % (15/26) had severe disease (≥70 % stenosis) leading to revascularization. Of this group, 47 % (7/15) underwent percutaneous intervention, and 53 % (8/15) underwent coronary artery bypass grafting. All of these 15 patients had either MVD (14/15) or LM coronary artery disease (1/15), and represented 0.6 % (15/2,659) of all referred patients (95 % CI 0.3 - 0.9 %). The majority, 90 % (8/9), had severe CAD with typical chest pain. CONCLUSION A very high CAC score (>1,000) with normal MPI in a small subset of symptomatically stable patients was associated with a moderate incidence of severe CAD (95 % CI 37 - 77 %). Larger studies and/or a meta-analysis of small studies are needed to more precisely estimate the incidence of CAD in this population. This study also supports the concept that a normal MPI result in patients with severe CAD may be due to balanced MVD.
Collapse
Affiliation(s)
- Salem A Yuoness
- Department of Nuclear Medicine, London Health Sciences Centre, 800 Commissioners Road East, PO Box 5010, London, ON, N6A 5W9, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Vidal I, Beretta M, Alonso O, Mut F. New exercise-dipyridamole combined test for nuclear cardiology in insufficient effort: appropriate diagnostic sensitivity keeping exercise prognosis. Arq Bras Cardiol 2015; 105:123-9. [PMID: 26039661 PMCID: PMC4559120 DOI: 10.5935/abc.20150051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Myocardial perfusion scintigraphy (MPS) in patients not reaching 85% of the
maximum predicted heart rate (MPHR) has reduced sensitivity. Objectives In an attempt to maintain diagnostic sensitivity without losing functional
exercise data, a new exercise and dipyridamole combined protocol (EDCP) was
developed. Our aim was to evaluate the feasibility and safety of this
protocol and to compare its diagnostic sensitivity against standard exercise
and dipyridamole protocols. Methods In patients not reaching a sufficient exercise (SE) test and with no
contraindications, 0.56 mg/kg of dipyridamole were IV administered over 1
minute simultaneously with exercise, followed by 99mTc-MIBI injection. Results Of 155 patients, 41 had MPS with EDCP, 47 had a SE test (≥ 85% MPHR) and 67
underwent the dipyridamole alone test (DIP). They all underwent coronary
angiography within 3 months. The three stress methods for diagnosis of
coronary lesions had their sensitivity compared. For stenosis ≥ 70%, EDCP
yielded 97% sensitivity, SE 90% and DIP 95% (p = 0.43). For lesions ≥ 50%,
the sensitivities were 94%, 88% and 95%, respectively (p = 0.35). Side
effects of EDCP were present in only 12% of the patients, significantly less
than with DIP (p < 0.001). Conclusions The proposed combined protocol is a valid and safe method that yields
adequate diagnostic sensitivity, keeping exercise prognostic information in
patients unable to reach target heart rate, with fewer side effects than the
DIP.
Collapse
Affiliation(s)
- Inés Vidal
- Departamento de Medicina Nuclear, Hospital 'Asociación Española', Montevideo, UY
| | - Mario Beretta
- Departamento de Medicina Nuclear, Hospital 'Asociación Española', Montevideo, UY
| | - Omar Alonso
- Departamento de Medicina Nuclear, Hospital 'Asociación Española', Montevideo, UY
| | - Fernando Mut
- Departamento de Medicina Nuclear, Hospital 'Asociación Española', Montevideo, UY
| |
Collapse
|
8
|
Nair SU, Ahlberg AW, Katten DM, Heller GV. Does risk for major adverse cardiac events in patients undergoing vasodilator stress with adjunctive exercise differ from patients undergoing either standard exercise or vasodilator stress with myocardial perfusion imaging? J Nucl Cardiol 2015; 22:22-35. [PMID: 25124828 DOI: 10.1007/s12350-014-9967-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In patients with functional limitations, the use of adjunctive exercise with vasodilator stress has advantages over vasodilator stress alone in single photon emission computed tomography myocardial perfusion imaging (MPI) for technical reasons and with regards to more effective cardiac risk stratification. Whether patients who undergo vasodilator with adjunctive exercise stress MPI possess clinical characteristics and cardiac risk that differs from those who undergo standard exercise or vasodilator stress MPI is unknown. METHODS Prospectively collected data on 19,367 consecutive patients referred for stress MPI to a tertiary care center (9,331 [48%] underwent exercise-only, 3,793 [20%] underwent vasodilator plus exercise, and 6,243 [32%] underwent vasodilator-only) were analyzed. Perfusion data were scored using the ASNC 17-segment with a summed stress score (SSS) < 4 = normal, 4-8 = mildly abnormal, and > 8 = moderate to severely abnormal. Patients were followed a mean of 1.96 ± 0.95 years. Demographics, clinical characteristics, and the occurrence of major adverse cardiac events (cardiac death or nonfatal myocardial infarction) were compared between the three stress modality groups. RESULTS Comparison of demographics and clinical characteristics revealed significant differences in gender, age, cardiac risk factors, and stress MPI between the three stress modality groups (P < .001). In follow-up, cardiac event-free survival of patients in the vasodilator plus exercise stress group was significantly higher than those in the vasodilator-only group but lower than those in the exercise-only group (P < .001). Annualized cardiac event rates of patients in the vasodilator plus exercise stress group were significantly lower than those in the vasodilator-only group for all three categories of the SSS (P < .001). After multivariable adjustment, with exercise-only as reference category, vasodilator plus exercise and vasodilator-only stress emerged as independent predictors (more likely occurrence) of cardiac death, while vasodilator-only stress emerged as an independent predictor (more likely occurrence) of cardiac death or nonfatal myocardial infarction. With vasodilator-only as the reference category, exercise-only and vasodilator plus exercise stress emerged as independent predictors (less likely occurrence) of cardiac death as well as of cardiac death or nonfatal myocardial infarction. CONCLUSIONS Patients undergoing vasodilator plus exercise stress MPI possess clinical characteristics and cardiac risk that differs significantly from those undergoing either standard exercise or vasodilator stress MPI and places them in a lower risk category compared to vasodilator stress alone.
Collapse
Affiliation(s)
- Sanjeev U Nair
- Division of Cardiology, Lehigh Valley Health Network/University of South Florida College of Medicine, 1250 S Cedar Crest Blvd, Suite 300, Allentown, PA, USA.
| | | | | | | |
Collapse
|
9
|
Padala SK, Ghatak A, Padala S, Katten DM, Polk DM, Heller GV. Cardiovascular risk stratification in diabetic patients following stress single-photon emission-computed tomography myocardial perfusion imaging: the impact of achieved exercise level. J Nucl Cardiol 2014; 21:1132-43. [PMID: 25208530 DOI: 10.1007/s12350-014-9986-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 06/05/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have demonstrated that diabetic patients undergoing exercise stress single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) have significantly lower cardiac events when compared to the diabetic patients undergoing pharmacologic stress SPECT MPI across all perfusion categories. However, there are limited data on the level of exercise achieved during exercise SPECT MPI among diabetic patients and its impact on cardiovascular outcomes. METHODS We retrospectively analyzed 14,849 consecutive patients (3,654 diabetics and 11,195 non-diabetics) undergoing exercise stress, combined exercise and pharmacologic stress, and pharmacologic stress SPECT MPI from 1996 to 2005 at a single tertiary care center. Diabetic and non-diabetic patients were categorized into 3 groups based on the metabolic equivalents (METs) achieved: ≥5 METs, <5 METs, and pharmacologic stress groups. All studies were interpreted using the 17-segment ASNC model. The presence, extent, severity of perfusion defects were calculated using the summed stress score (SSS), and patients were classified into normal (SSS < 4), mildly abnormal (SSS 4-8), and moderate-severely abnormal (SSS > 8) categories. Annualized event rates (AER) for the composite end point of non-fatal myocardial infarction and cardiac death were calculated over a mean follow-up period of 2.4 ± 1.4 years with a maximum of 6 years. RESULTS In moderate-severe perfusion abnormality (SSS > 8) category, diabetic patients who were able to achieve ≥5 METs had significantly lower AER compared to diabetic patients who were unable to achieve ≥5 METs (3% vs 5.5%, P = .04), and non-diabetic patients unable to achieve ≥5 METs (3% vs 4.8%, P < .001). Diabetic patients who achieved a high workload of ≥10 METs had a very low AER of 0.9%. Diabetic patients, who attempted exercise but were unable to achieve ≥5 METs, still had significantly lower AER than diabetics undergoing pharmacologic stress MPI across all perfusion categories [1.5% vs 3.2%, P = .006 (SSS < 4); 2.5% vs 4.9%, P = .032 (SSS 4-8); 5.5% vs 10.3%, P = .003 (SSS > 8)]. After adjustment for cardiovascular risk factors, the percentage decrease in cardiac event rate for every 1-MET increment in exercise capacity was 10% in the overall cohort, 12% in diabetic group, and 8% in non-diabetic group. CONCLUSIONS Despite significant perfusion defects, diabetic patients who achieve ≥5 METs during stress SPECT MPI have significantly reduced risk for future cardiac events. Diabetic patients who achieve ≥10 METs have a very low annualized event rate. These findings support that exercise capacity obtained during SPECT MPI is a surrogate for outcomes among diabetic patients undergoing nuclear stress testing.
Collapse
Affiliation(s)
- Santosh K Padala
- Division of Cardiology, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA,
| | | | | | | | | | | |
Collapse
|
10
|
Prognosis of normal stress-only gated-SPECT myocardial perfusion imaging: a single center study. Int J Cardiovasc Imaging 2013; 29:1639-44. [DOI: 10.1007/s10554-013-0245-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 05/24/2013] [Indexed: 10/26/2022]
|
11
|
Thompson RC, Patil H, Thompson EC, Thomas GS, Al-Amoodi M, Kennedy KF, Bybee KA, Iain McGhie A, O'Keefe JH, Oakes L, Bateman TM. Regadenoson pharmacologic stress for myocardial perfusion imaging: a three-way comparison between regadenoson administered at peak exercise, during walk recovery, or no-exercise. J Nucl Cardiol 2013; 20:214-21; quiz 222-6. [PMID: 23233371 DOI: 10.1007/s12350-012-9660-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 11/20/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Regadenoson (Reg) is being administered with increasing frequency either at peak exercise (ExPeak-Reg) or during a slow-down/walking recovery state (ExRec-Reg) rather than at rest (Rest-Reg). The aim of this study was to compare the clinical response of ExPeak-Reg, ExRec-Reg, and Rest-Reg. METHODS We compared 531 patients divided equally between Rest-Reg, ExPeak-Reg, and ExRec-Reg matched for age, sex, and BMI. RESULTS The average systolic blood pressure (SBP) rise following Reg was modest, but there was considerable heterogeneity and the ExPeak-Reg group had a higher percentage of patients who had a SBP rise of 40 mm Hg or a fall of 20 mm Hg than either the ExRec-Reg or the Rest-Reg groups (≥40 mm Hg rise 6.8%, 1.7%, and 1.7%, respectively) (P < .02) (≥20 mm Hg fall 15.8%, 13.0%, and 7.3%, respectively) (P < .05). Chest discomfort, nausea, dizziness, and interfering abdominal radiotracer activity were less common in both exercise Reg groups compared to Rest-Reg (P < .05). CONCLUSION Regadenoson injected at peak of symptom-limited exercise was generally well tolerated, but some patients had a significant rise or drop in SBP. There is no apparent advantage of administering regadenoson at peak exercise rather than during walk recovery, and the latter approach may have a greater safety margin.
Collapse
Affiliation(s)
- Randall C Thompson
- Saint-Luke's Mid America Heart Institute, 4330 Wornall Road, Suite 2000, Kansas City, MO 64111, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Thomas GS, Hundal HS, Ellestad MH. Advanced hybrid stress testing: a potential new paradigm combining exercise and pharmacologic stress. J Nucl Cardiol 2012; 19:887-90. [PMID: 22926630 DOI: 10.1007/s12350-012-9614-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
13
|
Combining Exercise with Pharmacologic Stress to Optimize the Accuracy and Risk Stratification of SPECT Myocardial Perfusion Imaging: A Systematic Review. CURRENT CARDIOVASCULAR IMAGING REPORTS 2010. [DOI: 10.1007/s12410-010-9019-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|