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Short-duration, submaximal intensity exercise stress combined with adenosine triphosphate decreases artifacts in myocardial perfusion single-photon emission computed tomography. BMC Cardiovasc Disord 2020; 20:438. [PMID: 33028207 PMCID: PMC7542686 DOI: 10.1186/s12872-020-01720-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial perfusion single-photon emission computed tomography (SPECT) imaging with stress is a useful examination for detecting coronary artery disease. Since the presence of artifacts is remaining challenges, we aimed to define the minimum intensity of low-grade exercise stress levels combined with drug stress to reduce undesired artifacts and their related factors. METHODS We divided patients with suspicious coronary artery disease into 4 groups as follows: group A, adenosine triphosphate (ATP) for 6 min; group A + 25 W, ATP + 25 W exercise for 6 min; group A + 35 W, ATP + 35 W exercise for 6 min; group A + 45 W, ATP + 45 W exercise for 6 min) and enrolled only those whose summed stress scores were < 3. Undesired artifacts were evaluated on the basis of heart-to-liver activity (H/L) ratio and heart-to-10 pixels below the heart (H/below the H) ratio. RESULTS The logarithmic values of H/L and H/below the H ratios were significantly higher in groups A + 35 W and A + 45 W than in group A (p < 0.05, each). In all the patients, the logarithmic values of H/L and H/below the H ratios positively correlated with the increment of rate pressure product (RPP, p = 0.002 and p = 0.005, respectively) after stress in the univariate analysis. The left ventricular end-diastolic volume (LVEDV) after stress (p = 0.002) negatively correlated with the logarithmic value of H/below the H ratio, but not H/L ratio. Although the increment of RPP was independently associated with the logarithmic values of both H/L (p = 0.001) and H/below the H ratios (p = 0.005), LVEDV was also independently associated with the logarithmic value of H/below the H ratio (p < 0.001) in multivariate regression analysis under adjusting with age and sex. CONCLUSION ATP plus ≥35 W exercise stress for 6 min was useful for reducing undesired artifacts after stress in myocardial perfusion SPECT. LVEDV after stress in addition to the increment of RPP was independently associated with the H/below the H ratio, but not the H/L ratio.
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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).
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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.
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Cho SG, Jabin Z, Bom HHS. Safer stress tests for myocardial perfusion imaging. J Nucl Cardiol 2019; 26:629-632. [PMID: 29039085 DOI: 10.1007/s12350-017-1083-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Sang-Geon Cho
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, South Korea.
| | - Zeenat Jabin
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
| | - Henry Hee-Seung Bom
- Department of Nuclear Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro Hwasun-eup, Hwasun-gun, Jeonnam, 58128, South Korea
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Jimenez-Heffernan A, Aguade-Bruix S, Casans-Tormo I. Nuclear cardiology practice in Spain. J Nucl Cardiol 2017; 24:2133-2140. [PMID: 28493201 DOI: 10.1007/s12350-017-0912-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 04/04/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND In Spain, nuclear cardiology (NC) procedures represent the second most frequently performed studies in nuclear medicine (NM) centers. METHODS The NC Working Group of the Spanish Society of Nuclear Medicine and Molecular Imaging invited NM departments across the country to answer an online questionnaire regarding 2014 activity. RESULTS Data on 40,161 patients from 42 centers were collected. The responding public centers served 39% of Spain´s population. The estimated NC activity for public hospitals was 2 studies/1,000 population/year. Of all the NC procedures, 69% were SPECT myocardial perfusion imaging (MPI), 17% equilibrium ventriculography, 12% 18F-FDG PET, 1.3% first pass ventriculography, and <1% innervation and amyloidosis imaging, respectively. The most frequent NC study was a 99mTc tracer, exercise, 2-day MPI ECG-gated SPECT ordered by a cardiologist for diagnosis in an outpatient with 21 days of mean waiting time, the stress phase being supervised by both a cardiologist and a NM physician, with a NM physician writing a complete report. CONCLUSIONS A major challenge for NC in Spain is the gradual adoption of high-sensitivity, low-dose-dedicated cardiac SPECT cameras and the broadening of cardiac PET utilization with more cameras, and the availability of MPI tracers alongside the viability/inflammation setup.
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Affiliation(s)
- Amelia Jimenez-Heffernan
- Head of Nuclear Medicine Department, Hospital Juan Ramon Jimenez, Ronda Exterior Norte s/n, 21005, Huelva, Spain.
| | - Santiago Aguade-Bruix
- Nuclear Medicine Department Consultant, Hospital Vall d´Hebron, Passeig de la Vall d´Hebron, 119-129, 08035, Barcelona, Spain
| | - Irene Casans-Tormo
- Head of Nuclear Medicine Department, Hospital Clinico Universitario, Av. de Blasco Ibañez, 17, 46010, Valencia, Spain
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Salgado-Garcia C, Jimenez-Heffernan A, Lopez-Martin J, Molina-Mora M, Aroui T, Sanchez de Mora E, Ramos-Font C, Rivera de Los Santos F, Ruiz-Frutos C. Influence of body mass index and type of low-level exercise on the side effect profile of regadenoson. Eur J Nucl Med Mol Imaging 2017; 44:1906-1914. [PMID: 28547175 DOI: 10.1007/s00259-017-3717-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 04/27/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Regadenoson, an A2A adenosine receptor pharmacologic stress agent for radionuclide myocardial perfusion imaging (MPI), is administered as a single, fixed dose. We studied the side effect profile of regadenoson combined with two types of low-level exercise, according to body mass index (BMI). METHODS Three hundred and fifty-six patients (46.1% men, mean age 67.7±10.7 years, range 31-90 years) underwent regadenoson stress testing combined with low-level exercise. Subjects were classified according to BMI as normal, overweight, or obese, and the type of low-level exercise performed as walking on the treadmill (TE group, n=190) or forcefully swinging legs while sitting (SS group, n=166). Patients' demographics, medical history, clinical symptoms during stress, changes in ECG, oxygen saturation (SatO2), systolic blood pressure (SBP), and heart rate (HR) were evaluated. RESULTS Groups were comparable (p=ns) with regard to cardiovascular risks factors. The incidence of side effects was similar across BMI (p=ns), although the TE patients showed improved profiles over those with SS exercise, with a significantly lower incidence of flushing, dizziness and nausea/gastrointestinal discomfort (12.9% vs. 28.4%; 19.9% vs. 33.4%; 11.4% vs. 19.2%, respectively; all p<0.05). Regarding the hemodynamic response, we did not observe significant changes in SBP and HR after regadenoson administration across BMI categories. Comparing the TE and SS groups, no significant changes were observed in SBP, but there was a higher increase in HR in the TE group (p<0.05). CONCLUSIONS Regadenoson in combination with low-level exercise is safe and well tolerated over a wide range of BMI, with TE exercise showing a better side effect profile than SS.
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Affiliation(s)
- Carlos Salgado-Garcia
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain.
| | - Amelia Jimenez-Heffernan
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | - Juana Lopez-Martin
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | - Manuela Molina-Mora
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | - Tarik Aroui
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | - Elena Sanchez de Mora
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | - Carlos Ramos-Font
- Department of Nuclear Medicine, Hospital Juan Ramon Jimenez. Complejo Hospitalario Universitario de Huelva, Ronda Norte, s/n, 21005, Huelva, Spain
| | | | - Carlos Ruiz-Frutos
- Department of Environmental and Public Health, University of Huelva, 21071, Huelva, Spain
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Kansal P, Holly TA. A helping hand for regadenoson tests. J Nucl Cardiol 2017; 24:41-42. [PMID: 26494646 DOI: 10.1007/s12350-015-0298-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Preeti Kansal
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thomas A Holly
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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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] [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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Doukky R, Hayes K, Frogge N, Nazir NT, Collado FM, Williams KA. Impact of insurance carrier, prior authorization, and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice. Clin Cardiol 2015; 38:267-73. [PMID: 25955195 DOI: 10.1002/clc.22382] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/04/2014] [Accepted: 12/08/2014] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The impact of health insurance carrier and socioeconomic status (SES) on the adherence to appropriate use criteria (AUC) for radionuclide myocardial perfusion imaging (MPI) is unknown. HYPOTHESIS Health insurance carrier's prior authorization and patient's SES impact adherence to AUC for MPI in a fee-for-service setting. METHODS We conducted a prospective cohort study of 1511 consecutive patients who underwent outpatient MPI in a multi-site, office-based, fee-for-service setting. The patients were stratified according to the 2009 AUC into appropriate/uncertain appropriateness and inappropriate use groups. Insurance status was categorized as Medicare (does not require prior authorization) vs commercial (requires prior authorization). Socioeconomic status was determined by the median household income in the ZIP code of residence. RESULTS The proportion of patients with Medicare was 33% vs 67% with commercial insurance. The rate of inappropriate use was higher among patients with commercial insurance vs Medicare (55% vs 24%; P < 0.001); this difference was not significant after adjusting for confounders known to impact AUC determination (odds ratio: 1.06, 95% confidence interval: 0.62-1.82, P = 0.82). The mean annual household income in the residential areas of patients with inappropriate use as compared to those with appropriate/uncertain use was $72 000 ± 21 000 vs $68 000 ± 20 000, respectively (P < 0.001). After adjusting for covariates known to impact AUC determination, SES (top vs bottom quartile income area) was not independently predictive of inappropriate MPI use (odds ratio: 0.9, 95% confidence interval: 0.53-1.52, P = 0.69). CONCLUSIONS Insurance carriers prior authorization and SES do not seem to play a significant role in determining physicians adherence to AUC for MPI.
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Affiliation(s)
- Rami Doukky
- Division of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois.,Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Kathleen Hayes
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Nathan Frogge
- Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Noreen T Nazir
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Fareed M Collado
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Kim A Williams
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
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Ballany W, Mansour K, Morales Demori R, Al-Amoodi M, Doukky R. The impact of regimented aminophylline use on extracardiac radioisotope activity in patients undergoing regadenoson stress SPECT myocardial perfusion imaging: a substudy of the ASSUAGE trial. J Nucl Cardiol 2014; 21:496-502. [PMID: 24519563 DOI: 10.1007/s12350-014-9864-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 01/23/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND In patients undergoing regadenoson stress SPECT myocardial perfusion imaging (MPI), the impact of the regimented administration of aminophylline on the cardiac-to-extracardiac photon activity ratio is unknown. METHODS This is a substudy of the ASSUAGE trial (NCT01250496); a double-blinded, randomized, placebo-controlled clinical trial which investigated the attenuation of regadenoson-related adverse effects using 75 mg of intravenous aminophylline vs placebo, administered 90 seconds following (99m)Tc-tetrofosmin injection in patients undergoing regadenoson stress SPECT-MPI. In subjects with normal MPI enrolled in the trial, we sampled from the antero-posterior planar projection of the post-stress scintigraphic data the mean photon activity in the myocardium, liver, bowel, and lungs. The mean cardiac-to-extracardiac activity ratios were compared between patients randomized to aminophylline vs placebo. RESULTS We studied 158 eligible subjects, randomized to receive aminophylline (n = 86) or placebo (n = 72). The means of photon activity ratios of the heart-to-liver, heart-to-bowel, heart-to-lungs, inferior wall of the heart-to-liver, and inferior wall of the heart-to-bowel were not statistically different between those who received aminophylline vs placebo (P values > .30). Only the time lapse between stress (99m)Tc-tetrofosmin injection and stress SPECT acquisition independently correlated with higher heart-to-liver and heart-to-bowel activity ratios (P values ≤ .01). Patients' body mass index independently correlated with lower heart-to-lung ratio (P = .009). CONCLUSION The regimented intravenous aminophylline use following regadenoson stress does not significantly improve the cardiac-to-extracardiac photon activity ratio in patients undergoing regadenoson stress (99m)Tc-tetrofosmin SPECT-MPI.
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Affiliation(s)
- Wassim Ballany
- Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
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Doukky R, Frogge N, Bayissa YA, Balakrishnan G, Skelton JM, Confer K, Parikh K, Kelly RF. The prognostic value of transient ischemic dilatation with otherwise normal SPECT myocardial perfusion imaging: a cautionary note in patients with diabetes and coronary artery disease. J Nucl Cardiol 2013; 20:774-84. [PMID: 23929206 DOI: 10.1007/s12350-013-9765-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 07/24/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prognostic implications of transient ischemic dilatation (TID) of the left ventricle with otherwise normal single-photon emission computed tomography myocardial perfusion imaging (MPI) remain controversial. Whether this finding may have prognostic implications only in high-risk populations, such as patients with diabetes or manifest coronary artery disease (CAD), is uncertain. METHODS We conducted a prospective cohort study of 1,236 consecutive patients with normal (99m)Tc-sestamibi MPI, defined as normal perfusion (summed stress score = 0) and normal left ventricle volume and function. TID was defined as >2 standard deviations above the mean of patients with low likelihood of CAD. RESULTS The study subjects were followed for 27 ± 9 months. The 76 (6%) patients with TID had a greater rate of cardiac death or myocardial infarction (MI) [4 (5.3%) vs 11 (0.6%), P = .003] independent of covariates [hazard ratio = 6.4, P = .004]. This finding was entirely derived from the subgroup of 294 patients with diabetes or CAD [4 (13.3%) with TID vs 1 (0.4%) without TID, P = .001] independent of covariates. However, TID was not predictive of cardiac death or MI among the 941 patients without diabetes or CAD. Furthermore, TID was not predictive of coronary revascularization. CONCLUSIONS This study confirms a benign prognosis of TID with otherwise normal MPI in patients without diabetes or CAD, but cautions against extending this conclusion to high-risk individuals, particularly those with diabetes or CAD.
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Affiliation(s)
- Rami Doukky
- Division of Cardiology, Rush University Medical Center, 1653 W. Congress Pkwy, Chicago, IL, 60612, USA,
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Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, Golzar Y, Garcia-Sayan E, Hendel RC. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation 2013; 128:1634-43. [PMID: 24021779 DOI: 10.1161/circulationaha.113.002744] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Appropriate use criteria (AUC) have been developed to aid in the optimal use of single-photon emission computed tomography (SPECT)-myocardial perfusion imaging (MPI), a technique that is a mainstay of risk assessment for ischemic heart disease. The impact of appropriate use on the prognostic value of SPECT-MPI is unknown. METHODS AND RESULTS A prospective cohort study of 1511 consecutive patients undergoing outpatient, community-based SPECT-MPI was conducted. Subjects were stratified on the basis of the 2009 AUC for SPECT-MPI into an appropriate or uncertain appropriateness group and an inappropriate group. Patients were prospectively followed up for 27±10 months for major adverse cardiac events of death, death or myocardial infarction, and cardiac death or myocardial infarction. In the entire cohort, the 167 subjects (11%) with an abnormal scan experienced significantly higher rates of major adverse cardiac events and coronary revascularization than those with normal MPI. Among the 823 subjects (54.5%) whose MPIs were classified as appropriate (779, 51.6%) or uncertain (44, 2.9%), an abnormal scan predicted a multifold increase in the rates of death (9.2% versus 2.6%; hazard ratio, 3.1; P=0.004), death or myocardial infarction (11.8% versus 3.3%; hazard ratio, 3.3; P=0.001), cardiac death or myocardial infarction (6.7% versus 1.7%; hazard ratio, 3.7; P=0.006), and revascularization (24.7% versus 2.7%; hazard ratio, 11.4; P<0.001). Among the 688 subjects (45.5%) with MPI classified as inappropriate, an abnormal MPI failed to predict major adverse cardiac events, although it was associated with a high revascularization rate. Furthermore, appropriate MPI use provided incremental prognostic value beyond myocardial perfusion and ejection fraction data. CONCLUSIONS When performed for appropriate indications, SPECT-MPI continues to demonstrate high prognostic value. However, inappropriate use lacks effectiveness for risk stratification, further emphasizing the need for optimal patient selection for cardiac testing.
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Affiliation(s)
- Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL (R.D., K.H., N.F., M.O.R.); Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL (R.D., Y.G.); Department of Medicine, Iowa Methodist Medical Center, Des Moines (G.B.); Division of Hospitalist Medicine, Rockford Memorial Hospital, Rockford, IL (V.S.D.); Division of Cardiology, Mount Sinai Hospital, Chicago, IL (E.G.-S.); and Cardiovascular Division, University of Miami, Miller School of Medicine, Miami, FL (R.C.H.)
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Doukky R, Frogge N, Balakrishnan G, Hayes K, Collado FM, Rangel MO, Trohman RG, Hendel RC. The prognostic value of cardiac SPECT performed at the primary care physician's office. J Nucl Cardiol 2013; 20:519-28. [PMID: 23475438 DOI: 10.1007/s12350-013-9676-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/11/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND The prognostic value of single-photon emission computed-tomography (SPECT)-myocardial perfusion imaging (MPI) is well documented. However, the utility of SPECT-MPI when performed at a low-volume primary care physician's (PCP's) office is unknown. METHODS We conducted a prospective cohort study of consecutive patients referred by their PCP to undergo a stress-MPI at the PCP's office using a mobile laboratory. Major adverse cardiovascular events (MACE) of death, myocardial infarction (MI), and coronary revascularization were prospectively tabulated using mail and telephone interviews, chart review, and social security death index. RESULTS One thousand three hundred ninety subjects [mean age 58 ± 13 years; 44% women] were followed for 27 ± 9 months, with a 99% complete follow-up rate. Subjects with abnormal MPI [174 (12.5%)] had significantly higher rates of all-cause mortality [5.2% vs 1.0%, P < .001], death, or MI [5.7% vs 1.5%, P = .001], and the composite of death, MI, or late revascularization (>60 days post-MPI) [12.6 vs 2.7%, P < .001]. Overall MACE risk was associated with the total perfusion abnormality burden, while the revascularization rate was related to the reversible perfusion abnormality burden. CONCLUSION Contemporary SPECT-MPI performed in the setting of a PCP's office carries a robust prognostic value, similar to that reported in tertiary or large-volume practice settings.
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Affiliation(s)
- Rami Doukky
- Section of Cardiology, Rush University Medical Center, 1653 W. Congress Pkwy, Chicago, IL 60612, USA.
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Parker MW, Morales DC, Slim HB, Ahlberg AW, Katten DM, Cyr G, Mathur S, Ardestani A, Barmpouletos D, Iyah GS, Borer SM, Heller GV. A strategy of symptom-limited exercise with regadenoson-as-needed for stress myocardial perfusion imaging: a randomized controlled trial. J Nucl Cardiol 2013; 20:185-96. [PMID: 23188626 DOI: 10.1007/s12350-012-9641-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 10/14/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Ambulatory patients with uncertain functional capacity may benefit from combined exercise and vasodilator stress protocols for myocardial perfusion imaging (MPI). The safety and MPI image quality with regadenoson administered during symptom-limited exercise have not been prospectively evaluated. METHODS AND RESULTS A total of 140 patients (mean age 61 years, 48% female) referred for exercise with vasodilator stress MPI were randomized 2:1 to a strategy of exercise with regadenoson-as-necessary (Ex-Reg, n = 96) or dipyridamole with exercise (Dip-Ex, n = 44) after Duke Activity Status Index (DASI) scoring (median score 28 vs 24, P = .09). Ex-Reg subjects commenced treadmill exercise and regadenoson was administered only if the subject was unable to reach standard endpoints. Dip-Ex subjects received dipyridamole prior to symptom-limited exercise. Hemodynamics were recorded throughout. Subjects completed symptom questionnaires and MPI image quality was assessed by blinded read. Ex-Reg subjects were more likely to achieve ≥85% age-predicted maximum heart rate than Dip-Ex subjects (57% vs 32%, P < .01). Only 50% of subjects meeting inclusion criteria and randomized to Ex-Reg required regadenoson and none had symptomatic hemodynamic changes. Severe side effects or adverse events occurred in 16% of Ex-Reg and 24% of Dip-Ex subjects (P = .12). MPI image quality was "good" or "excellent" in 88% of Ex-Reg subjects and 86% of Dip-Ex subjects (P = .33). CONCLUSION A strategy of exercise with regadenoson-as-needed for MPI offers similar safety and side effect profile with similar image quality compared to dipyridamole with exercise, with reduced pharmaceutical use.
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Affiliation(s)
- Matthew W Parker
- Division of Cardiology, Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA.
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Ross MI, Wu E, Wilkins JT, Gupta D, Shen S, Aulwes D, Montero K, Holly TA. Safety and feasibility of adjunctive regadenoson injection at peak exercise during exercise myocardial perfusion imaging: The Both Exercise and Regadenoson Stress Test (BERST) trial. J Nucl Cardiol 2013; 20:197-204. [PMID: 23404232 DOI: 10.1007/s12350-013-9679-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 01/21/2013] [Indexed: 01/23/2023]
Abstract
BACKGROUND The data existing in the literature regarding the safety of using regadenoson with symptom-limited exercise are limited, which motivated the authors to undertake this randomized study. METHODS We offered patients scheduled to undergo vasodilator stress nuclear myocardial perfusion imaging the opportunity to exercise instead. Patients who failed to reach target heart rate (THR) were randomized to (1) receive regadenoson at peak exercise or (2) stop exercise and receive regadenoson at rest. Patients who reached THR received a standard Tc-99m sestamibi injection with no regadenoson. RESULTS 200 patients were included (66% male, mean age 52.5 ± 13.6). 125 patients (62%) reached THR with exercise alone. All stress protocols were well tolerated, and there were no significant adverse events. There were no statistically significant differences in the extent of perfusion abnormalities, image quality, or rate of referral to cardiac catheterization within 60 days between the groups. In fully adjusted logistic regression models, beta-blocker use and diabetes remained significant univariate predictors of failure to reach THR (OR 0.21, 95% CI 0.1-0.5, P < .0001, OR 0.34, 95% CI 0.2-0.7, P = .004, respectively). CONCLUSIONS A protocol combining regadenoson at peak exercise in patients unable to reach THR with exercise is feasible, well-tolerated, and yields comparable imaging results to a standard regadenoson injection at rest. In addition, pharmacologic stress testing may be over-ordered in current clinical practice, as patients referred for such testing were often able to exercise.
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Affiliation(s)
- M I Ross
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Partington SL, Lanka V, Hainer J, Blankstein R, Skali H, Forman DE, Di Carli MF, Dorbala S. Safety and feasibility of regadenoson use for suboptimal heart rate response during symptom-limited standard Bruce exercise stress test. J Nucl Cardiol 2012; 19:970-8. [PMID: 22565239 PMCID: PMC3533237 DOI: 10.1007/s12350-012-9562-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Accepted: 04/07/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Regadenoson during exercise stress test (ETT) can provide maximal hyperemia for myocardial perfusion imaging (MPI), along with exercise information. Our aim was to study the feasibility and safety of regadenoson injection at peak ETT for submaximal heart rate (HR) response. METHODS Consecutive patients who underwent SPECT MPI with standard Bruce ETT or supine-regadenoson (Supine-Reg) were analyzed. ETT patients were grouped as ETT-Max [maximal HR > 0.85 * (220 - age), N = 1,522], ETT-Submax (submaximal HR no regadenoson, N = 504), ETT-Reg (submaximal HR and regadenoson, N = 211). RESULTS The HR during ETT was submaximal in 715 (32%) patients. Of these, 211 patients (30%) underwent ETT-Reg (mean exercise duration: 5.5 ± 2.5 minutes). ETT-Reg patients had a higher frequency of hypertension, diabetes, smoking and beta-blocker use, similar rest systolic blood pressure (SBP), but lower rest and peak HR and peak SBP compared to ETT-Max patients. There were no serious complications with regadenoson. Side effects (49% vs 6%, P < .0001) were fewer and aminophylline use was lower with ETT-Reg compared to Supine-Reg (0.5% vs 8.1%, P = .001). CONCLUSIONS Submaximal HR response to ETT is common. ETT-Reg is safe, feasible, and well-tolerated. ETT-Reg facilitates a diagnostic MPI with reporting of functional capacity, exercise ECG/hemodynamic changes and MPI at maximal hyperemia.
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Affiliation(s)
- Sara L Partington
- Noninvasive Cardiovascular Imaging Program, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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17
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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]
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Dvorak RA, Brown RKJ, Corbett JR. Interpretation of SPECT/CT Myocardial Perfusion Images: Common Artifacts and Quality Control Techniques. Radiographics 2011; 31:2041-57. [PMID: 22084188 DOI: 10.1148/rg.317115090] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ryan A Dvorak
- Division of Nuclear Medicine, Department of Radiology, University of Michigan Health System, 1500 E Medical Center Dr, B1 G505 UH, Ann Arbor, MI 48109-5028, USA.
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Pharmacologic Stress Using Selective A2A Adenosine Receptor Agonists. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9086-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Monzen H, Hara M, Hirata M, Suzuki T, Ogasawara M, Higuchi H, Matsuoka T, Kobayashi H, Yuki R, Hirose K. The impact of adenosine pharmacologic stress combined with low-level exercise in patients undergoing myocardial perfusion imaging (BIWAKO adenosine-Ex trial). Ann Nucl Med 2011; 25:381-6. [PMID: 21547476 DOI: 10.1007/s12149-011-0475-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 01/06/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND The combination of adenosine infusion with low-level exercise has become a common approach for inducing stress during stress myocardial perfusion imaging (MPI). We investigated stress MPI performed by combined low-level exercise and adenosine infusion. This combined protocol can decrease adverse reactions and reduce the effect of scattered rays from the liver. METHODS AND RESULTS Subjects were clinically referred for a 53-min rest-stress Tc-99m Sestamibi MPI procedure using BIWAKO PROTOCOL. Ninety-eight patients (44.5%) underwent adenosine infusion with ergometer exercise testing and 122 patients (55.5%) underwent adenosine infusion without exercise testing. We evaluated the liver/heart (L/H) uptake ratio, background activity in the upper mediastinum, and adverse reactions. RESULTS The L/H ratio and background activity were lower in the adenosine-exercise group than in the adenosine-non-exercise group (1.8 ± 0.54 vs. 2.1 ± 0.62, P < 0.0056; 43.1 ± 12.2 vs. 61.5 ± 15.4, P < 0.0001). The adenosine-exercise group had fewer adverse reactions than the adenosine-non-exercise group (11.2 vs. 19.7%). All of the adverse reactions were minor, with the exception of severe back pain in one case. The incidence of adverse reactions in our study was lower than that in previous studies for unknown reason. CONCLUSION Adenosine infusion in combination with low-level exercise seems to result in higher-quality images and fewer adverse reactions than adenosine infusion without exercise. The combined protocol decreases adverse reactions and improves the quality of myocardial perfusion images by decreasing background activity.
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Affiliation(s)
- Hajime Monzen
- Department of Radiology, Otsu Red Cross Hospital, 1-35 Nagara, Otsu, Shiga, 520-8511, Japan.
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Ambulatory cardiac single-photon emission computed tomography at the primary care physician's office: a descriptive study. J Ambul Care Manage 2011; 33:328-35. [PMID: 20838112 DOI: 10.1097/jac.0b013e3181f53458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ambulatory cardiac single-photon emission computed tomography stress testing for the evaluation of coronary artery disease at the primary care physician's office is increasingly utilized without data supporting its safety. In this 2-year prospective pilot study of 1266 consecutive stress-myocardial perfusion imaging studies done in the primary care physician's office using a mobile nuclear cardiology laboratory, adverse events were mild and rare. There were no recorded events of myocardial infarction, serious arrhythmias, severe bronchospasm, hospitalization, or death. This suggests that this practice is safe in this population with these providers. This finding may not apply to a higher-risk population. Further evaluation of referral appropriateness and long-term prognostic value is needed.
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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]
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23
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[Study of efficacy and safety of pharmacological stress tests in nuclear cardiology]. VOJNOSANIT PREGL 2009; 66:193-8. [PMID: 19341223 DOI: 10.2298/vsp0903193b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIM Treadmill test combined with myocardial perfusion scintigraphy (MPS) is a commonly used technique in the assessment of coronary artery disease. Many patients who cannot adequately perform exercise stress testing may nevertheless undergo pharmacological tests, most commonly with the vasodilator agents (adenosine and dipyridamole), as well as the positive inotropic agent dobutamine. Patients undergoing vasodilators stress testing with either dipyridamole or adenosine also perform simultaneous low-intensity exercise. The aim of this study was to compare various pharmacological stress tests alone or in combination with low intensity exercise as preparation for MPS in regard to incidence of adverse effects, quality of diagnostic image and the acquisition initial time. METHODS A total of 2 205 patients underwent pharmacological stress tests. Pharmacological stress test with adenosine was applied in 493 patients. In 405 of them we performed concomitant low level exercise (50 W) by bicycle ergometar (AdenoEX). In 88 of them we performed adenosine abbreviated protocol (AdenoSCAN). In 1 526 patients we performed pharmacological stress test with dipyridamole. In 871 of them we performed concomitant low level exercise (50 W) by bicycle ergometar (DipyEX), and in 775 we used only dipyridamole protocol (DipySCAN). In 186 patients we used pharmacological stress test with dobutamine. We followed side effects of adenosine, dipyiridamole and dobutamine, compared results between protocols with concomitant low level exercise and vasodilatators only. We also compared image quality, and suggested time of acquisition after stress test. RESULTS We found numerous side effects especially with adenosine, but these effects were short-lived and not required active interventions. Benefit with concomitant exercise in booth AdenoEX and DipyEX included decreased side effects (AdenoEX vs AdenoSCAN 620% vs 87%, respectively, and DipyEX vs DipySCAN 37% vs 59%, respectively) improved safety and patients tolerance, improved target-to-background ratios because of less subdiaphragmal activity, and earlier acquisition time. Because of producing a lot of arrhythmias (in 49% of patients) dobutamin was considered a last choice for pharmacological stress testing. CONCLUSION Safety and efficacy of vasodilatators (adenosine, dipyridamole) pharmacological stress tests are good, but with concomitant exercise even better. The safety and efficacy of adenosin are better than those of dipyridamole. AdenoEX protocol provides good safety and patients tolerancy. In light of these benefits we recommend AdenoEX whenever possible. Dobutamine is the last pharmacological toll for MPS.
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Monzen H, Hara M, Nakanishi A, Hirata M, Suzuki T, Ogasawara M, Higuchi H, Kobayashi H, Yuki R, Hirose K. New protocol of myocardial SPECT imaging with technetium-99m sestamibi for reducing the time interval between rest and adenosine stress phases. Radiol Phys Technol 2009; 2:70-6. [PMID: 20821132 DOI: 10.1007/s12194-008-0047-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 11/11/2008] [Accepted: 11/11/2008] [Indexed: 11/25/2022]
Abstract
We have developed a new protocol of myocardial perfusion-gated single-photon emission computed tomography (SPECT), by use of technetium-99m sestamibi (MIBI), in which SPECT imaging at rest followed by SPECT imaging after adenosine with low level ergometer stress can be conducted by use of the Monzen position within a shortened total testing time of 1 h or less. The study group consisted of 137 patients who underwent this new imaging protocol. The diagnostic quality of the images was as good as that of images obtained with the conventional method (30-60 min after the injection of MIBI). The SPECT image quality for the 137 patients was evaluated, and the percentages of images rated as excellent, good, fair, and poor were 65.3, 27.4, 5.8, and 1.5% for the rest image, and 68.2, 21.9, 8.4, and 1.5% for the stress image, respectively. The shortened total testing time reduced the physical and mental burden on the patient compared with that of conventional myocardial perfusion imaging. Because this technique allows us to perform rest and stress myocardial imaging within a short period, it is expected to be very useful in the clinical setting.
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Affiliation(s)
- Hajime Monzen
- Department of Radiology, Otsu Red Cross Hospital, Otsu-shi, Shiga, Japan.
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Akutsu Y, Gregory SA, Kardan A, Zervos GD, Thomas GS, Gewirtz H, Yasuda T. Delayed heart rate recovery after adenosine stress testing with supplemental arm exercise predicts mortality. J Nucl Cardiol 2009; 16:54-62. [PMID: 19152129 DOI: 10.1007/s12350-008-9014-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 07/23/2008] [Accepted: 08/13/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delayed heart rate (HR) recovery after treadmill exercise testing predicts mortality. Patients with suspected ischemic heart disease who cannot perform adequate treadmill exercise are typically evaluated with pharmacological stress myocardial perfusion imaging (MPI) studies, but little prognostic significance has been attributed to the hemodynamic response to vasodilator stress testing with low-level exercise. We hypothesized that a delay in HR recovery after adenosine stress testing with arm exercise is associated with increased mortality. METHODS AND RESULTS Technetium 99m-Sestamibi MPI was performed in 1,455 consecutive patients (70 +/- 12 years, 50.2% men) with adenosine stress and supplemental arm exercise. HRs were recorded at rest, continuously during infusion, and then 5 minutes post-infusion. Delayed HR recovery was defined as a decline of < or = 12 bpm from peak HR at 5 minutes after discontinuation of the infusion. Of 1,356 patients during 5 years of follow up, there were 135 deaths (10%). Delayed HR recovery was strongly predictive of all-cause mortality (16.5% vs 5.3% in those with normal HR recovery, P < .001) with an adjusted hazard ratio of 2.5 (95% CI, 1.7-3.6; P < .001). CONCLUSION Delayed HR recovery after adenosine stress testing with arm exercise is a readily available and powerful predictor of all-cause mortality.
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Affiliation(s)
- Yasushi Akutsu
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Yawkey 5E 55 Fruit Street, Boston, MA 02114, USA
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26
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Stress Test: A Primer for Primary Care Physicians. South Med J 2008; 101:806-14. [DOI: 10.1097/smj.0b013e31817b07c0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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27
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Thompson RC. The problem of radiotracer abdominal activity in myocardial perfusion imaging studies. J Nucl Cardiol 2008; 15:159-61. [PMID: 18371585 DOI: 10.1016/j.nuclcard.2008.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
BACKGROUND/AIM Treadmill test combined with myocardial perfusion scintigraphy (MPS) is a commonly used technique in the assessment of coronary artery disease. There are many patients, however, who may not be able to undergo treadmill test. Such patients would benefit from pharmacological stress procedures combined with MPS. The most commonly used pharmacological agents for cardiac stress are coronary vasodilatators (adenosine, dipyridamol) and catecholamines. Concomitant low-level treadmill exercise with adenosine pharma cologic stress (AdenoEX) during MPS has become commonly used in recent years. A number of studies have demonstrated a beneficial impact of AdenoEX protocol. The aim of the study was, besides introducing into practice the two types of protocols of pharmatological stress test with adenosine, as a preparation for MPS, to compare and monitor the frequency of their side effects to quality, acquisition, as well as to standardize the onset time of acquisition (diagnostic imaging) for both protocols. METHODS A total of 130 patients underwent pharmacological stress test with adenosine (vasodilatator). In 108 of the patients we performed concomitant exercise (AdenoEX) of low level (50W) by a bicycle ergometar. In 28 of the patients we performed Adenosine ab breviated protocol (AdenoSCAN). Side effects of adenosine were followed and compared between the two kinds of protocols AdenoEX and AdenoSCAN. Also compared were image quality and suggested time of acquisition after the stress test. RESULTS Numerous side effects were found, but being short lived they did not require any active interventions. The benefit of AdenoEX versus AdenoSCAN included decreased side effects (62% vs 87%), improved safety and patients tolerance, improved target-to-background ratios because of less subdiaphragmatic activity, earlier acquisition, and improved sensitivity. CONCLUSION The safety and efficacy of adenosine pharmacological stress is even better with concomitant exercise. In the light of these benefits we recommend AdenoEX whenever possible.
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Symptom-limited exercise combined with dipyridamole stress: prognostic value in assessment of known or suspected coronary artery disease by use of gated SPECT imaging. J Nucl Cardiol 2008; 15:42-56. [PMID: 18242479 DOI: 10.1016/j.nuclcard.2007.09.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2007] [Accepted: 09/10/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Combining vasodilator and exercise stress reduces noncardiac side effects, improves image quality, and enhances the detection of ischemia, compared with suboptimal exercise or vasodilator stress alone. However, prognostic data with combined protocols are limited. METHODS AND RESULTS Consecutive patients (n = 2064) who underwent symptom-limited exercise and dipyridamole stress with gated single-photon emission computed tomography (SPECT) imaging, without early revascularization, were studied. Subsequent cardiac death or nonfatal myocardial infarction was related to exercise and gated SPECT variables. Cox proportional hazards regression modeling was performed to identify predictors of adverse outcome. Annualized event rates in patients with normal and abnormal images were 0.96% and 2.71%, respectively (P < .001). With abnormal imaging, annualized event rates were 0.86% and 3.13% in patients with average to high and fair or poor functional capacity, respectively (P = .019). Abnormal imaging, a severely reduced post-stress ejection fraction, transient ischemic dilation, and fair or poor functional capacity emerged as predictors of adverse outcome. Accordingly, patients were stratified into low-risk, intermediate-risk, and high-risk cohorts with annualized event rates of 0.94%, 2.24%, and 8.19%, respectively (P < .001 in any two-way comparison). CONCLUSIONS A protocol that combines symptom-limited exercise and dipyridamole stress with gated SPECT imaging provides highly effective risk stratification for adverse outcomes.
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Thomas GS, Miyamoto MI. Should simultaneous exercise become the standard for adenosine myocardial perfusion imaging? Am J Cardiol 2004; 94:3D-10D; discussion 10D-11D. [PMID: 15261124 DOI: 10.1016/j.amjcard.2004.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Concomitant low-level treadmill exercise with adenosine pharmacologic stress (AdenoEx) during radionuclide myocardial perfusion imaging has become commonly used in recent years, particularly in large-volume laboratories. A number of studies have demonstrated a beneficial impact of AdenoEx protocols. These benefits include decreased side effects, improved safety and patient tolerance, improved target-to-background ratios because of less subdiaphragmatic activity, and improved sensitivity and defect reversibility. In light of these benefits, recent reviews and guidelines call for the addition of low-level exercise to adenosine stress whenever possible.
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Affiliation(s)
- Gregory S Thomas
- Cardiology Division, Mission Internal Medical Group, Mission Viejo, California 92691, USA.
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Beller GA. First annual Mario S. Verani, MD, Memorial lecture: clinical value of myocardial perfusion imaging in coronary artery disease. J Nucl Cardiol 2004; 10:529-42. [PMID: 14569247 DOI: 10.1016/s1071-3581(03)00655-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
I am honored to give this lecture in memory of Dr Mario S. Verani, a friend and a respected colleague in the field of nuclear cardiology. Dr Verani made many immense contributions to the field of nuclear cardiology during his lifetime. He was a pioneer in the field of pharmacologic stress imaging and played a leading role in validating the utility of intravenous adenosine infusion for stress imaging in detecting significant coronary stenoses and assessing prognosis. He and his colleagues at Baylor reported that pharmacologic stress imaging could separate high- and low-risk patient subsets after acute myocardial infarction, particularly among patients who underwent thrombolytic therapy. He informed us that certain drugs that patients took could influence perfusion defect severity. This work led to a clinical study showing that ischemic defect size could be substantially reduced with medical therapy in patients who had recently had an acute infarction. An outcome of this observation was the launching of the INSPIRE (adenosINe technetium-99m Sestamibi single-photon emission computed tomography Post-InfaRction Evaluation) trial in which postinfarction patients are randomized to medical therapy or revascularization. Dr Verani was an able debater when assigned the position for advocating for stress radionuclide perfusion imaging against stress echocardiography. He engaged in these debates with substantial knowledge but always with a touch of humor. Dr Verani's courage was an inspiration to all of us during his illness. His legacy as a pioneer will endure as the field of nuclear cardiology continues to mature and expand.
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Affiliation(s)
- George A Beller
- Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Thomas GS, Miyamoto MI, Morello AP, Majmundar H, Thomas JJ, Sampson CH, Hachamovitch R, Shaw LJ. Technetium 99m sestamibi myocardial perfusion imaging predicts clinical outcome in the community outpatient setting. The Nuclear Utility in the Community (NUC) Study. J Am Coll Cardiol 2004; 43:213-23. [PMID: 14736440 DOI: 10.1016/j.jacc.2003.07.041] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the prognostic value of community-based myocardial perfusion imaging (MPI) and to assess the incremental value of individual components of (99m)Tc-sestamibi single photon emission computed tomography (SPECT). BACKGROUND Although the most rapid growth of MPI has been in community outpatient laboratories, its prognostic value has not been validated in this setting. METHOD We prospectively followed 1,612 consecutive patients undergoing stress (99m)Tc-sestamibi SPECT in an outpatient community laboratory who experienced 71 hard events over 24 +/- 7 months (0.2% lost to follow-up). RESULTS Patients whose scans were normal incurred an annualized event rate of 0.4%, compared with 2.3% for those with abnormal scans (p < 0.0001). Subset analysis demonstrated comparable risk stratification for women and men, diabetics, patients with normal resting ECGs, and those referred for pharmacologic and exercise stress. After adjusting for pre-test variables, multivariable Cox regression analysis found the most potent independent components of MPI to be, in order of importance, transient ischemic dilation, extent of reversibility, post-stress ejection fraction, extent and severity of the stress perfusion defect, and the overall test result (normal or abnormal). Each 1% decrement of ejection fraction predicted a 3% increase in risk (p = 0.0009). Post-MPI angiography and revascularization increased commensurate with the extent and severity of MPI result. CONCLUSIONS The prognostic value of perfusion imaging is portable and transferable to the outpatient community setting, with multiple components of MPI providing incremental prognostic information.
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Affiliation(s)
- Gregory S Thomas
- Mission Internal Medical Group, Mission Viejo, California 92691, USA.
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Holly TA, Satran A, Bromet DS, Mieres JH, Frey MJ, Elliott MD, Heller GV, Hendel RC. The impact of adjunctive adenosine infusion during exercise myocardial perfusion imaging: Results of the Both Exercise and Adenosine Stress Test (BEAST) trial. J Nucl Cardiol 2003; 10:291-6. [PMID: 12794628 DOI: 10.1016/s1071-3581(02)43236-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Failure to achieve an adequate heart rate limits the sensitivity of exercise myocardial perfusion imaging (MPI) for the detection of coronary artery disease. In addition, it is often not possible to discontinue medications that may blunt the heart rate response to exercise, because of conditions such as hypertension or angina. However, if pharmacologic stress testing is performed, the ability to assess functional capacity is lost. Accordingly, we developed a protocol that incorporates adenosine stress with symptom-limited exercise. METHODS AND RESULTS As part of a multicenter study, 35 patients were enrolled prospectively and underwent both exercise MPI and exercise MPI with a 4-minute adenosine infusion on a separate day. Technetium 99m sestamibi was injected at or near peak exercise (exercise only) and at 2 minutes into the adenosine infusion (combined exercise and adenosine). The perfusion images were interpreted in a blinded fashion. The combined adenosine and exercise protocol was well tolerated. The summed stress scores and summed difference scores were greater in the exercise-plus-adenosine group than in the exercise-only group (10.0 vs 8.5, P =.02, and 4.9 vs 3.3, P =.002, respectively). Exercise time was slightly but significantly less with the exercise-plus-adenosine protocol (8 minutes 46 seconds vs 8 minutes 11 seconds, P =.027). CONCLUSION A protocol combining 4 minutes of adenosine infusion with symptom-limited exercise was safe and well tolerated. Furthermore, this protocol resulted in a greater amount of myocardial ischemia detected on MPI while allowing for the assessment of functional capacity. A combined exercise and adenosine protocol may be a useful test for patients undergoing MPI who are unlikely to achieve an adequate chronotropic response.
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Affiliation(s)
- Thomas A Holly
- Northwestern University Medical School and Rush-Presbyterian-St Luke's Medical Center, Chicago, IL 60612, USA
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Hendel RC, Jamil T, Glover DK. Pharmacologic stress testing: new methods and new agents. J Nucl Cardiol 2003; 10:197-204. [PMID: 12673185 DOI: 10.1067/mnc.2003.5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Robert C Hendel
- Rush-Presbyterian-St. Luke's Medical Center, Chicago, Ill. 60612, USA.
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Samady H, Wackers FJT, Joska TM, Zaret BL, Jain D. Pharmacologic stress perfusion imaging with adenosine: role of simultaneous low-level treadmill exercise. J Nucl Cardiol 2002; 9:188-96. [PMID: 11986564 DOI: 10.1067/mnc.2002.119973] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adenosine is commonly used for pharmacologic stress myocardial perfusion imaging (MPI). However, it frequently results in adverse effects, and the subdiaphragmatic tracer uptake may interfere with the image interpretation. Our aim was to determine the feasibility of combining low-level treadmill exercise with adenosine MPI and its impact on adverse effects, image quality, and myocardial ischemia. METHODS AND RESULTS Forty-one patients underwent technetium 99m sestamibi single photon emission computed tomography following adenosine and adenosine with low-level exercise (adenosine-Ex) on separate occasions and rest MPI. A comparison was made of symptoms, hemodynamic response, electrocardiographic changes, image quality, and image interpretation between the 2 protocols. With adenosine-Ex, fewer patients had one or more adverse effects (61% vs 90%; P =.006), more patients had ischemic electrocardiographic changes (34% vs 15%; P =.03), a higher percentage had excellent- or fair-quality images (88% vs 61%; P =.003), and they had higher heart-liver ratios (1.0 +/- 0.37 vs 0.84 +/- 0.29; P =.002) compared with adenosine alone. Four adenosine MPI studies, but only 2 adenosine-Ex studies, were uninterpretable because of excessive subdiaphragmatic radiotracer activity. Of the 39 patients with at least 1 interpretable stress study, interpretation was discordant in 11 (28%): 7 showed greater ischemia with adenosine-Ex, 2 uninterpretable adenosine studies were interpretable with adenosine-Ex, and 2 studies interpreted as abnormal with adenosine were normal by adenosine-Ex (both had normal coronary angiograms). CONCLUSIONS Simultaneous low-level treadmill exercise with adenosine Tc-99m sestamibi imaging is safe and feasible, significantly reduces unfavorable side effects, enhances image quality, and may result in greater ischemia detection compared with adenosine alone.
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Affiliation(s)
- Habib Samady
- Division of Cardiovascular Medicine, University of Virginia Health Systems, Charlottesville, Va, USA
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Vitola JV, Brambatti JC, Caligaris F, Lesse CR, Nogueira PR, Joaquim AI, Loyo M, Salis FV, Paiva EV, Chalela WA, Meneghetti JC. Exercise supplementation to dipyridamole prevents hypotension, improves electrocardiogram sensitivity, and increases heart-to-liver activity ratio on Tc-99m sestamibi imaging. J Nucl Cardiol 2001; 8:652-9. [PMID: 11725261 DOI: 10.1067/mnc.2001.117204] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Myocardial perfusion imaging with dipyridamole is an alternative with which to evaluate patients who are unable to exercise. Many patients who undergo dipyridamole testing are limited in their ability, but are not completely unable, to exercise. There are benefits from adding low workload exercise to dipyridamole testing, including a reduction of thallium 201 concentration in the liver, leading to a higher heart-to-liver activity ratio and better image quality. This prospective study was designed to evaluate a protocol of exercise supplementation during dipyridamole technetium 99m sestamibi imaging and to verify whether a higher heart-to-liver activity ratio could be obtained. We also evaluated the potential of this combined protocol to prevent hypotension and induce ischemic changes on the electrocardiogram (ECG). METHODS AND RESULTS Ninety consecutive patients who were not completely disabled for exercise underwent dipyridamole Tc-99m sestamibi cardiac single photon emission computed tomography with a protocol of exercise supplementation (DipEx). The heart-to-liver activity ratio, hemodynamics, and electrocardiographic changes were studied. The findings were compared with those of a control group (Dip) composed of 99 patients who underwent dipyridamole infusion alone. Patients with left bundle branch block, pacemaker, and atrial fibrillation were excluded. The DipEx patients tolerated the protocol, exercising 4.2 +/- 1.3 minutes on the treadmill (Bruce protocol). Compared with Dip, patients in the DipEx group had a higher heart-to-liver activity ratio (1.3 +/- 0.4 vs 1.6 +/- 0.5, respectively; P =.00001), had no incidence of hypotension (6% vs 0%, respectively; P =.03), and had a higher sensitivity of the ECG to detect ischemia (6% vs 34%, respectively; P =.003). The increase in sensitivity seen in the DipEx group was accompanied by a significant decrease in specificity compared with the Dip group (67% vs 100%, P =.000001). CONCLUSIONS Our data show that the addition of limited exercise to dipyridamole results in benefits during Tc-99m sestamibi imaging, increasing heart-to-liver activity ratio, preventing vasodilator-induced hypotension, and improving ECG sensitivity for the detection of ischemia. Furthermore, this protocol also provides an estimation of the patient's physical capacity and could be used as an alternative for patients undergoing dipyridamole infusion who are not completely unable to exercise.
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Affiliation(s)
- J V Vitola
- Heart Institute, the Institute for Nuclear Medicine, and the Division of Nuclear Medicine, Medical School, São José do Rio Preto, Brazil.
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