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Gowdar S, Ahlberg AW, Rai M, Perucki WH, Felpel KD, Savino JA, Alter EL, Henzlova MJ, Duvall WL. Risk stratification with vasodilator stress SPECT myocardial perfusion imaging in patients with elevated cardiac biomarkers. J Nucl Cardiol 2020; 27:2320-2331. [PMID: 30815834 DOI: 10.1007/s12350-019-01661-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/06/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the diagnostic accuracy and prognostic utility of vasodilator stress MPI have been well established in the non-acute setting, the efficacy of all of the vasodilator stressors in risk stratifying post-MI patients as well as the evaluation of cardiac troponin elevation of unclear etiology is not established. Accordingly, the aim of the present study was to investigate the prognostic efficacy of vasodilator stress MPI in the setting of elevated cardiac troponin to accurately risk stratify these higher-risk patients. METHODS All patients from two tertiary centers, from 1/1/2010 through 12/31/2012, with elevated cardiac biomarkers within < 7 days and undergoing stress SPECT MPI testing were studied. Results of stress MPI were scored using a 17-segment model based on semiquantitative scoring as normal or abnormal (mild, moderate, or severe) using a total perfusion defect (TPD) of 0%, 1-10%, 10-20%, and > 20%. Mortality data through the year 2014 were obtained from the National Death Index, and survival analyses were performed. The primary endpoint was all-cause mortality with the secondary endpoint being cardiac mortality. RESULTS A total of 503 patients were followed for an average of 33.6 ± 16.2 months, with a mean age of 69.3 years; 53.7% male; and a majority (88.7%) of them undergoing vasodilator stress. A significant increase in all-cause mortality was seen based on the severity of TPD results for all vasodilators (P < .0001) and regadenoson (P < .0001). Similar prognostic ability was seen for all-cause mortality. This association was maintained even after adjustment for cardiac risk factors, previous coronary disease, and troponin quartiles. MPI results (stress TPD and LVEF) added to traditional cardiac risk factors, and troponin values resulted in a significant incremental increase in the ability to predict all-cause and cardiac mortality, and stress TPD remained independently predictive for both all-cause and cardiac mortality in a multivariate model. CONCLUSION Vasodilator stress (including regadenoson) MPI effectively risk stratifies patients with recently elevated cardiac biomarkers, with the increasing risk of mortality with the increasing severity of perfusion defects. It provides incremental prognostic value, in addition to clinical factors and degree of troponin elevation.
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Affiliation(s)
- Shreyas Gowdar
- Hartford Hospital Division of Cardiology, Hartford Healthcare Heart and Vascular Institute, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Alan W Ahlberg
- Hartford Hospital Division of Cardiology, Hartford Healthcare Heart and Vascular Institute, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Mridula Rai
- Hartford Hospital Division of Cardiology, Hartford Healthcare Heart and Vascular Institute, 80 Seymour Street, Hartford, CT, 06102, USA
| | - William H Perucki
- Hartford Hospital Division of Cardiology, Hartford Healthcare Heart and Vascular Institute, 80 Seymour Street, Hartford, CT, 06102, USA
| | - Kevin D Felpel
- Department of Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - John A Savino
- Mount Sinai Division of Cardiology, Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Eric L Alter
- Mount Sinai Division of Cardiology, Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - Milena J Henzlova
- Mount Sinai Division of Cardiology, Mount Sinai Heart, Mount Sinai Medical Center, New York, NY, USA
| | - W Lane Duvall
- Hartford Hospital Division of Cardiology, Hartford Healthcare Heart and Vascular Institute, 80 Seymour Street, Hartford, CT, 06102, USA.
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Abstract
Infiltrative heart diseases are characterized by myocardial tissue alterations leading to mechanical dysfunction which in turn develops into bi-ventricular congestive heart failure. Also the coronary microvasculature undergoes significant remodeling and dysfunction. The effects of the unbalance of the mechanical cross-talk between cardiac muscle and vessels and of the impairment of vasodilatory function can be measured non-invasively by means of positron emission tomography and cardiac magnetic resonance.
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Affiliation(s)
- Ornella Rimoldi
- CNR Istituto di Bioimmagini e Fisiologia Molecolare (IBFM), Via Fratelli Cervi, 93, 20090, Segrate, Italy.
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Agrawal V, Hosey C, Smith GT, Shah C. Detrimental effects of nitroglycerin use during regadenoson vasodilator stress testing: A cautionary tale. J Nucl Cardiol 2018; 25:1718-1723. [PMID: 29362983 DOI: 10.1007/s12350-017-1174-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 12/13/2017] [Indexed: 11/30/2022]
Abstract
Vasodilator agents such as adenosine and regadenoson are commonly used pharmacologic stressors to assess for ischemia in patients undergoing myocardial perfusion studies. The recommended reversal agent for this mode of stress is aminophylline, although nitroglycerin is commonly administered as an attempt to reverse the symptoms or electrocardiographic (EKG) changes during the stress test. We demonstrate through two cases that incorrect administration of nitroglycerin can induce hypotension and worsen coronary steal, whereas appropriate administration of aminophylline can reverse the effects of pharmacologic vasodilators. While nitroglycerin is often used in patients with organic angina, it has the potential to worsen ischemia in the setting of pharmacologic vasodilator administration. These cases underscore the importance of administering the correct reversal agent for pharmacologic stress tests.
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Affiliation(s)
- Vineet Agrawal
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolann Hosey
- Department of Medical Imaging, Tennessee Valley Healthcare, Nashville, TN, USA.
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Gary T Smith
- Department of Medical Imaging, Tennessee Valley Healthcare, Nashville, TN, USA
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chirayu Shah
- Department of Medical Imaging, Tennessee Valley Healthcare, Nashville, TN, USA
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Witbrodt B, Goyal A, Kelkar AA, Dorbala S, Chow BJW, Di Carli MF, Williams BA, Merhige ME, Berman DS, Germano G, Beanlands RS, Min JK, Arasaratnam P, Sadreddini M, van Velthuijsen ML, Shaw LJ. Prognostic significance of blood pressure response during vasodilator stress Rb-82 positron emission tomography myocardial perfusion imaging. J Nucl Cardiol 2017; 24:1966-1975. [PMID: 27659457 DOI: 10.1007/s12350-016-0569-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 05/04/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND A drop in blood pressure (BP) or blunted BP response is an established high-risk marker during exercise myocardial perfusion imaging (MPI); however, data are sparse regarding the prognostic value of BP response in patients undergoing vasodilator stress rubidium-82 (Rb-82) Positron Emission Tomography (PET) MPI. METHODS AND RESULTS From the PET Prognosis Multicenter Registry, a cohort of 3413 patients underwent vasodilator stress Rb-82 PET MPI with dipyridamole or adenosine. We used multivariable Cox proportional hazard regression to analyze the association with mortality of four BP variables: stress minus rest systolic BP (∆SBP), stress minus rest diastolic BP (∆DBP), resting systolic BP (rSBP), and resting diastolic BP (rDBP). Covariates that had univariate P values <.10 were entered into the multivariable model. After median 1.7 years follow-up, 270 patients died. In univariate analyses, ∆SBP (P = .082), rSBP (P = .008), and rDBP (P < .001) were of potential prognostic value (P < .10), but ∆DBP was not (P = .96). After adjustment for other clinical and MPI variables, ∆SBP no longer independently predicted mortality (P = .082); only lower rSBP (P = .026) and lower rDBP (P = .045) remained independently prognostic. CONCLUSIONS In patients undergoing vasodilator stress MPI, only lower resting BP is an independent predictor of mortality along with other clinical and MPI variables; BP response does not appear to add to risk stratification in these patients.
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Affiliation(s)
- Bradley Witbrodt
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd., Room 503, Atlanta, GA, 30322, USA.
| | - Abhinav Goyal
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd., Room 503, Atlanta, GA, 30322, USA
| | - Anita A Kelkar
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd., Room 503, Atlanta, GA, 30322, USA
| | | | - Benjamin J W Chow
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, USA
| | | | | | | | | | | | - Robert S Beanlands
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, USA
| | - James K Min
- Weill Cornell Medical College New York, New York, NY, USA
| | - Punitha Arasaratnam
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, USA
| | - Masoud Sadreddini
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, USA
| | | | - Leslee J Shaw
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1462 Clifton Rd., Room 503, Atlanta, GA, 30322, USA
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Doran JA, Sajjad W, Schneider MD, Gupta R, Mackin ML, Schwartz RG. Aminophylline and caffeine for reversal of adverse symptoms associated with regadenoson SPECT MPI. J Nucl Cardiol 2017; 24:1062-1070. [PMID: 27025843 DOI: 10.1007/s12350-016-0452-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 01/25/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Aminophylline shortages led us to compare intravenous (IV) aminophylline with IV and oral (PO) caffeine during routine pharmacologic stress testing with SPECT MPI. METHODS We measured presence, duration, and reversal of adverse symptoms and cardiac events following regadenoson administration in consecutive patients randomized to IV aminophylline (100 mg administered over 30-60 seconds), IV caffeine citrate (60 mg infused over 3-5 minutes), or PO caffeine as coffee or diet cola. RESULTS Of 241 patients, 152 (63%) received regadenoson reversal intervention. Complete (CR), predominant (PRE), or partial (PR) reversal was observed in 99%. CR by IV aminophylline (87%), IV caffeine (87%), and PO caffeine (78%) were similar (P = NS). Time to CR (162 ± 12.6 seconds, mean ± SD) was similar in treatment arms. PO caffeine was inferior to IV aminophylline for CR + PRE. CONCLUSIONS IV aminophylline and IV caffeine provide rapid, safe reversal of regadenoson-induced adverse effects during SPECT MPI. Oral caffeine appeared similarly effective for CR but not for the combined CR + PRE. Our results suggest PO caffeine may be an effective initial strategy for reversal of regadenoson, but IV aminophylline or IV caffeine should be available to optimize symptom reversal as needed.
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Affiliation(s)
- Jesse A Doran
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA
| | - Waseem Sajjad
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA
| | - Marabel D Schneider
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA
| | - Rohit Gupta
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA
| | - Maria L Mackin
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA
| | - Ronald G Schwartz
- Cardiology Division, Department of Medicine, University of Rochester Medical Center, Box 679-N, Rochester, NY, 14642, USA.
- Nuclear Medicine Division, Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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7
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Rai M, Ahlberg AW, Marwell J, Chaudhary W, Savino JA, Alter EL, Henzlova MJ, Duvall WL. Safety of vasodilator stress myocardial perfusion imaging in patients with elevated cardiac biomarkers. J Nucl Cardiol 2017; 24:724-734. [PMID: 26902485 DOI: 10.1007/s12350-016-0448-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/27/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND While adenosine and dipyridamole as myocardial perfusion imaging (MPI) stress agents have literature supporting their safety in the setting of myocardial infarction (MI), regadenoson does not. Studying a high risk cohort of patients with elevated cardiac biomarkers may shed light on potential safety issues of these agents which might also affect lower risk cohorts. METHODS All patients who had undergone a clinically indicated stress MPI study at two academic centers from 1/1/2010 through 12/31/2012 with elevated troponin ≤7 days prior to testing were included. The primary endpoint was a composite of death, non-fatal MI, congestive heart failure (CHF), stroke, ventricular arrhythmias, atrial fibrillation/flutter, or atrioventricular block requiring intervention within 24 h of testing. RESULTS Of the 703 stress MPI studies that met inclusion criteria, 360 (51.2%), 199 (28.3%), 74 (10.5%), 9 (1.3%), and 61 (8.7%) underwent regadenoson, dipyridamole, adenosine, dobutamine, and exercise stress, respectively. The primary endpoint occurred in 11 (1.6%) patients with an incidence of 1.4% (n = 5), 1.0% (n = 2), 1.4% (n = 1), 11.1% (n = 1), and 3.3% (n = 2) following regadenoson, dipyridamole, adenosine, dobutamine, and exercise stress, respectively (P = 0.137). The adverse events included non-fatal MI in 7 (1.0%) patients, death in 1 (0.1%) patient, CHF in 1 (0.1%) patient, ventricular arrhythmia in 1 (0.1%) patient, and atrial arrhythmia in 1 (0.1%) patient. CONCLUSION In the setting of elevated troponin, serious complications associated with either exercise or vasodilator stress testing appear to be relatively rare with no increased risk attributable to a particular vasodilator agent.
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Affiliation(s)
- Mridula Rai
- Division of Cardiology (Henry Low Heart Center), Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA
| | - Alan W Ahlberg
- Division of Cardiology (Henry Low Heart Center), Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA
| | - Julianna Marwell
- Department of Medicine, University of Connecticut, Farmington, CT, USA
| | - Waseem Chaudhary
- Division of Cardiology (Henry Low Heart Center), Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA
| | - John A Savino
- Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, New York, NY, USA
| | - Eric L Alter
- Department of Medicine, Mount Sinai Medical Center, New York, NY, USA
| | - Milena J Henzlova
- Division of Cardiology (Mount Sinai Heart), Mount Sinai Medical Center, New York, NY, USA
| | - W Lane Duvall
- Division of Cardiology (Henry Low Heart Center), Hartford Hospital, 80 Seymour Street, Hartford, 06102, CT, USA.
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Janvier L, Pinaquy J, Douard H, Karcher G, Bordenave L. A useful and easy to develop combined stress test for myocardial perfusion imaging: Regadenoson and isometric exercise, preliminary results. J Nucl Cardiol 2017; 24:34-40. [PMID: 26542990 DOI: 10.1007/s12350-015-0278-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 07/26/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Regadenoson, a selective A2a receptor agonist, is a vasodilator increasingly used in myocardial perfusion imaging. Adjunction of isometric exercise is a simple method that could improve side effect profile while providing better image quality. METHODS Patients undergoing SPECT MPI were prospectively enrolled in handgrip-Regadenoson (HG-Reg test, N = 20) and Regadenoson (Reg) stress test (N = 40). Investigator blinded to stress test analyzed clinical data and images. RESULTS Heart rate (HR) increase was statistically higher in the HG-Reg group (27 vs 22 bpm, P = .019). Decrease in SBP was less frequent in the HG-Reg group than in the Reg group (55% vs 85.5%, P = .005), there were less drops >10 mmHg (45% vs 77.7%, P = .012). During stress testing, fewer subjects reported at least one side effect in the HG-Reg compared to Reg group (70% vs 92.5%, P = .021). Images were more often classified as good in the HG-Reg group (75% vs 52.5% in the Reg group, P = .25). CONCLUSIONS Adjunction of handgrip exercise to Regadenoson administration is a well-tolerated and easy method, without loss of time. Furthermore, image quality seems to be better.
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Affiliation(s)
- Lucile Janvier
- CHU de Nancy, Service de Médecine Nucléaire, Hôpital Brabois, 54500, Vandoeuvre-lès-Nancy, France.
- CHU de Bordeaux, Service de Médecine Nucléaire, 33000, Bordeaux, France.
| | - J Pinaquy
- CHU de Bordeaux, Service de Médecine Nucléaire, 33000, Bordeaux, France
| | - H Douard
- CHU de Bordeaux, Service de cardiologie, 33000, Bordeaux, France
| | - G Karcher
- CHU de Nancy, Service de Médecine Nucléaire, Hôpital Brabois, 54500, Vandoeuvre-lès-Nancy, France
| | - L Bordenave
- CHU de Bordeaux, Service de Médecine Nucléaire, 33000, Bordeaux, France
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Abstract
Coronary artery disease (CAD) is the leading cause of death in women. Nevertheless, extensive evidence demonstrates under-diagnosis and under-treatment of women for suspected or known ischemic heart disease (IHD). Stress cardiac magnetic resonance (CMR) is becoming readily available and offers significant advantages over other stress imaging modalities. The high spatial and temporal resolution of CMR provides the unique ability to identify subendocardial ischemia, viability, and the presence of microvascular disease. Furthermore, CMR is free from ionizing radiation, and image quality is not compromised by attenuation artifacts or patient size. Over the past two decades, evidence-based data have demonstrated the high diagnostic and prognostic performance of stress CMR in the context of IHD, often superior to other stress imaging techniques. Importantly, ad hoc studies confirmed these results in women with known or suspected IHD. Stress CMR warrants consideration as the modality of choice for women requiring an imaging test for ischemia given its strong evidence base, superior test characteristics, comprehensive nature, and unique ability to characterize both epicardial and microvascular disease.
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Affiliation(s)
- Andrea Cardona
- Ohio State University, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
- Division of Cardiology, University of Perugia, Perugia, Italy
| | - Karolina M Zareba
- Ohio State University, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA
| | - Subha V Raman
- Ohio State University, 473 W 12th Ave, Suite 200, Columbus, OH, 43210, USA.
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Reyes E. Caffeine reduces the sensitivity of vasodilator MPI for the detection of myocardial ischaemia: Pro. J Nucl Cardiol 2016; 23:447-53. [PMID: 26883776 DOI: 10.1007/s12350-015-0371-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
Caffeine is a non-selective antagonist at the adenosine receptors, which is expected to reverse both the intended (coronary vasodilation) and unintended (hypotension, flushing) effects of exogenously administered adenosine and adenosine-related compounds. In the past, several studies were conducted to characterize the effect of caffeine on vasodilator myocardial perfusion imaging (MPI) with conflicting results. However, new evidence supports earlier observations and shows that recent caffeine intake attenuates vasodilator-induced myocardial hyperaemia and may therefore reduce the sensitivity of radionuclide MPI for the detection of inducible perfusion abnormality in patients with coronary artery disease. Although the magnitude of this effect and hence its clinical significance are dose dependent, the acute response to equivalent doses of caffeine varies largely among individuals, and this might be explained by differences in caffeine exposure and genetically determined variations in caffeine metabolism. Abstinence from caffeinated foods and beverages for a minimum of 12 hours before vasodilator stress is therefore recommended although longer abstention might be required in order to prevent the potentially blocking effect of residual caffeine on vasodilator-mediated actions.
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Affiliation(s)
- Eliana Reyes
- Nuclear Medicine Department, Royal Brompton and Harefield Hospitals, Sydney Street, London, SW3 6NP, United Kingdom.
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11
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Poulin MF, Alexander S, Doukky R. Prognostic implications of stress modality on mortality risk and cause of death in patients undergoing office-based SPECT myocardial perfusion imaging. J Nucl Cardiol 2016; 23:202-11. [PMID: 25788401 DOI: 10.1007/s12350-014-0064-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 12/27/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients requiring vasodilator single-photon emission computed-tomography myocardial perfusion imaging (SPECT-MPI) have a higher mortality risk than those selected for exercise or vasodilator with low-level exercise SPECT-MPI. However, it is unknown whether the increased mortality is driven by cardiac deaths alone or cardiac and non-cardiac deaths. METHODS In a prospective cohort of 1,511 consecutive patients referred for SPECT-MPI, patients were classified according to stress test modality: exercise, adenosine with low-level exercise (AdenoEx), and adenosine. Subjects were followed for events of all-cause mortality and cause of death. Survival analyses using multivariate Cox regression and propensity score matching methods were performed. RESULTS During a follow-up of 4.9 ± 0.9 years, a total of 68 (4.5%) deaths occurred: 50 non-cardiac and 18 cardiac. The adenosine group had the highest annual mortality (all-cause 3.65%, non-cardiac 2.36%, cardiac 1.29%), while exercise stress had the lowest mortality (all-cause 0.42%, non-cardiac 0.37%, cardiac 0.05%) and AdenoEx had an intermediate mortality (all-cause 1.3%, non-cardiac 0.91%, cardiac 0.39%); all P values <0.001. The majority of non-cardiac deaths were attributed to cancer. Using exercise stress as a reference standard, multivariable Cox regression analyses demonstrated that adenosine stress was independently predictive of all-cause mortality [HR 3.23 (CI 1.77-5.88); P < 0.001], non-cardiac death [HR 2.67 (CI 1.34-5.31); P = 0.005], and cardiac death [HR 6.30 (CI 1.55-25.56); P = 0.010] after adjusting for univariate predictors of mortality. These findings were consistent in the subgroups of patients with normal and abnormal MPI. AdenoEx was predictive of all-cause, non-cardiac, and cardiac deaths in univariate analysis, but it was not predictive by multivariate analysis. Propensity score matched cohort analysis showed that the adenosine stress group had the highest all-cause (P < 0.001), non-cardiac (P = 0.013), and cardiac deaths (P < 0.001), while the exercise stress group had the lowest mortality of any cause. CONCLUSIONS The inability to perform any level of exercise during a SPECT-MPI stress is associated with high mortality risk, which is derived from both cardiac and non-cardiac deaths.
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Affiliation(s)
| | - Sarah Alexander
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St., Suite # 3620, Chicago, IL, 60612, USA.
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Scholtens AM, Tio RA, Willemsen A, Dierckx RAJO, Boersma HH, Zeebregts CJ, Glaudemans AWJM, Slart RHJA. Myocardial perfusion reserve compared with peripheral perfusion reserve: a [13N]ammonia PET study. J Nucl Cardiol 2011; 18:238-46. [PMID: 21347555 PMCID: PMC3069313 DOI: 10.1007/s12350-011-9339-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2010] [Accepted: 01/16/2011] [Indexed: 11/04/2022]
Abstract
INTRODUCTION [13N]ammonia PET allows quantification of myocardial perfusion. The similarity between peripheral flow and myocardial perfusion is unclear. We compared perfusion flow in the myocardium with the upper limb during rest and adenosine stress [13N]ammonia PET to establish whether peripheral perfusion reserve (PPR) correlates with MPR. METHODS [13N]ammonia myocardial perfusion PET-scans of 58 patients were evaluated (27 men, 31 women, age 64 ± 13 years) and were divided in four subgroups: patients with coronary artery disease (CAD, n = 15), cardiac syndrome X (SX, n = 14), idiopathic dilating cardiomyopathy (DCM, n = 16), and normal controls (NC, n = 13). Peripheral limb perfusion was measured in the muscular tissue of the proximal upper limb and quantified through a 2-tissue-compartment model and the PPR was calculated (stress/rest ratio). MPR was also calculated by a 2-tissue-compartment model. The PPR results were compared with the MPR findings. RESULTS Mean myocardial perfusion increased significantly in all groups as evidenced by the MPR (CAD 1.99 ± 0.47; SX 1.39 ± 0.31; DCM 1.72 ± 0.69; NC 2.91 ± 0.78). Mean peripheral perfusion also increased but not significantly and accompanied with great variations within and between groups (mean PPR: CAD 1.30 ± 0.79; SX 1.36 ± 0.71; DCM 1.60 ± 1.22; NC 1.27 ± 0.63). The mean difference between PPR and MPR for all subpopulations varied widely. No significant correlations in flow reserve were found between peripheral and myocardial microcirculatory beds in any of the groups (Total group: r = -0.07, SEE = 0.70, CAD: r = 0.14, SEE = 0.48, SX: r = 0.17, SEE = 0.30, DCM: r = -0.11, SEE = 0.71, NC: r = -0.19, SEE = 0.80). CONCLUSION No correlations between myocardial and peripheral perfusion (reserve) were found in different patient populations in the same PET session. This suggests a functional difference between peripheral and myocardial flow in the response to intravenously administered adenosine stress.
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Affiliation(s)
- A M Scholtens
- Department of Imaging, University Medical Center Utrecht, E01.132, P.O. Box 85500, 3508GA Utrecht, The Netherlands.
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