More risk factors, less ischemia, and the relevance of MPI testing

Thompson, Randall C.; Allam, Adel H.

doi:10.1007/s12350-015-0072-0

Cited by 21 publications

(12 citation statements)

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“…Nuclear imaging laboratories in the United States currently report less ischemia than a decade or two ago and this trend likely played a role 27,28. The frequency of ischemia seen in our study is comparable to that reported by contemporary nuclear laboratories 27,28. In this sense, the study population was appropriate for testing the efficacy and safety of the Ex-Reg protocol.…”

Section: Discussionsupporting

confidence: 77%

“…Compared to the pivotal regadenoson trials, fewer RPDs were seen in the current trial 17. Nuclear imaging laboratories in the United States currently report less ischemia than a decade or two ago and this trend likely played a role 27,28. The frequency of ischemia seen in our study is comparable to that reported by contemporary nuclear laboratories 27,28.…”

Section: Discussionsupporting

confidence: 59%

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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

Thomas

Cullom

Kitt

et al. 2017

Journal of Nuclear Cardiology

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BackgroundThis study assessed the non-inferiority and safety of regadenoson administration during recovery from inadequate exercise compared with administration without exercise.MethodsPatients 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.Results1,147 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.ConclusionsAdministering 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.Electronic Supplementary MaterialThe online version of this article (doi:10.1007/s12350-017-0813-3) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 77%

Section: Discussionsupporting

confidence: 59%

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

Thomas

Cullom

Kitt

et al. 2017

Journal of Nuclear Cardiology

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“…169 Adoption of a stress-rest over a rest-stress imaging protocol is further justified based on temporal trends indicating that most patients with suspected or known CAD (without prior MI) referred for imaging will have a normal stress MPI. 170,171 Stressonly imaging has been previously endorsed by ASNC. 172 Of note, AC was performed in most series that showed the efficacy of low dose stress-only SPECT imaging, and the use of AC, upright/supine or supine/ prone imaging (Figure 27), advanced post processing, or advanced camera designs substantially increases the number of patients that can be imaged stress-only.…”

Section: Stress-first/stress-only Imagingmentioning

confidence: 99%

Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging Guidelines: Instrumentation, Acquisition, Processing, and Interpretation

Dorbala

Ananthasubramaniam

Armstrong

et al. 2018

Journal of Nuclear Cardiology

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286

186

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“…8 Dakik et al also reported that, in spite of the decline in the rate of abnormal or ischemic MPI that has been reported in the USA and in the Middle East region over the last two decades, the rates of ischemia at the American University of Beirut Medical Center remain relatively high. 2,9 Indeed, the rates of abnormal or ischemic MPI in their population remain higher than that reported by Rozanski during the same time period. Dakik et al cautioned that this difference might be secondary to the higher rates of diabetes and smoking among patients in the Middle East.…”

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confidence: 72%

The mystery poor prognosticator! Pharmacologic stress MPI prevalence and predictors: Insights from the Middle East

Ali

Allam

2018

Journal of Nuclear Cardiology

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In this issue of The Journal, Dakik et al. compared the referral patterns of pharmacologic and physical stress myocardial perfusion imaging (MPI) at the American University of Beirut Medical Center (AUMC), a large tertiary hospital serving Lebanon and the Middle East region.The message from this study would seem to be of significant importance to the daily practice of nuclear cardiology in many developing countries worldwide. The authors concluded that patients referred for pharmacologic stress were older and predominantly female compared to patients undergoing exercise stress. The pharmacologic stress patients also had a higher prevalence of diabetes mellitus and hypertension. The study also showed interesting differences between MPI data from the pharmacologic and physical stress groups. In the pharmacologic stress group, there was a higher prevalence of abnormal scans as well as a higher prevalence of ischemia on MPI and more frequent impaired left ventricular function with an ejection fraction \ 50%. The significant predictors for referral to pharmacologic stress were older age and diabetes mellitus. The authors showed similar results on a separate analysis including only patients with no history of prior CAD. They also showed similar results for both genders.The message coming from this article provokes several important questions and thoughts.What are the reasons behind differences in utilization of pharmacologic MPI between developed and developing countries?The cost and lack of availability of the new pharmacologic stressors represent a challenge to world regions where CAD mortality is continuously on the rise. How does this affect the availability and utilization of MPI in these regions?Metabolic syndrome is one of the great health problems in the world right now, particularly in developing countries, and is tightly linked to physical inactivity and sedentary life styles. It represents a link between higher referral to pharmacologic rather than physical exercise, and at the same time is an important direct cause of high-risk myocardial perfusion studies. How can optimal utilization of MPI help in addressing this global critical health problem?Among the limitations of this study, as stated by the authors, is the relatively small number of patients, and that the study is a single-center investigation that may not necessarily represent the whole country or the region. Also, there was no follow-up data in this study. However, to our knowledge this is the first prospective study comparing referral patterns and predictors of pharmacologic versus physical MPI coming out of the Middle East region.The robust data over many decades from multiple scientific reports and meta-analysis have proved the clear effectiveness of both physical and pharmacologic MPI studies as diagnostic and prognostic tools in the evaluation of patients with known or suspected CAD. 1 Moreover, in terms of safety, all pharmacologic stressors used in conjunction with MPI have proved safety margin comparable to treadmill exercise, and to each...

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More risk factors, less ischemia, and the relevance of MPI testing

Cited by 21 publications

References 5 publications

Single Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging Guidelines: Instrumentation, Acquisition, Processing, and Interpretation

The mystery poor prognosticator! Pharmacologic stress MPI prevalence and predictors: Insights from the Middle East

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