Adenosine induced coronary vasospasm during Rubidium PET myocardial perfusion scan in a patient with Takayasu’s Arteritis

Abstract

Adenosine is a commonly used drug in myocardial perfusion imaging. Its action is mediated via stimulation of A 2 receptors leading to vasodilatation while A 1 receptor counteracts this effect. CASE REPORTA 52-year-old lady presented with a 6-month history of angina. She had a background of Takayasu's arteritis and hypertension; her medications included prednisolone, atenolol, and nifedipine. A Rubidium PET myocardial perfusion scan with adenosine was performed. Within 3 minutes of commencing the adenosine infusion, the patient developed severe chest pain. The electrocardiogram showed significant ST depression in the antero-lateral leads ( Figure 1) which settled alongside the chest pain within 15 minutes after stopping the adenosine infusion. No hemodynamic changes were demonstrated during this episode. Furthermore, no perfusion defects were evident on relative perfusion images; however, on quantitative measurement, myocardial perfusion reserve was globally impaired raising the possibility of balanced ischemia (Figures 2, 3). Coronary angiography showed normal epicardial coronary arteries; therefore coronary vasospasm was considered (Figure 4). She was commenced on diltiazem after discontinuing nifedipine and atenolol. This resulted in dramatic improvement of her symptoms. DISCUSSIONPreviously published reports of adenosine-induced vasospasm occurred during recovery, probably due to overdrive of A 1 receptors following withdrawal of A 2 stimulation. 1 In our patient, it occurred during infusion that suggests that different underlying mechanisms were responsible. Patients with Takayasu's arteritis have raised levels of circulating endothelin-1 irrespective of disease activity including patients with a normal ESR. 2,3 Endothelin-1 is a potent vasoconstrictor 2 and regulates arterial tone at rest. 4,5 However, during exercise, endothelin-1 levels decrease facilitating coronary vasodilatation. Work in animals has suggested that high circulating endothelin-1 reduces adenosine-induced coronary vasodilatation. 3 We postulate that endothelin-1 may have modified the response to adenosine contributing to vasospasm with an overdrive of A 1 receptors and probably beta-blocker treatment. During exertion, adrenergic stimulation promotes coronary vasodilatation mainly via the activity of the beta-1 receptors. The use of beta blockers blunts this coronary vasodilatation.

Appropriate Use Criteria for PET Myocardial Perfusion Imaging

“…In symptomatic patients with suspected vasculitis and arteritis, PET MPI is unique, as it provides concurrent information about the presence of epicardial obstructive lesions and potential reductions in MFR, reflecting diffuse CMD. These patients have a poor outcome if the coronary vessels are affected, leading to ischemia and CMD (152,162). Although no specific outcome data are available related to cardiac perfusion PET, given the advantage of PET MPI to concurrently assess CMD, this clinical scenario was deemed appropriate (score 8).…”

Torsades de pointes and myocardial infarction following reversal of supraventricular tachycardia with adenosine: a case report

“…( 16 ) The presence of potentially vasoconstrictive substances, such as catecholamines and endothelin-1, may also contribute to vasospasm. ( 17 , 18 ) The endothelium plays a central role in balancing these substances and its dysfunction may be related to the paradoxical adenosine effect. ( 22 )…”

“…(13,14) In this case, the absence of coronary lesions on angiography, transient cardiovascular impairment, elevated troponin levels, and lack of criteria for Takotsubo syndrome strengthened the hypothesis of a coronary vasospasm-induced myocardial infarction. Some cases of adenosine-induced vasospasm were reported in the literature during pharmacological stress for scintigraphy, (15,16) positron emission tomography, (17) angiotomography, (18) and cardiac catheterization. (19) There are two reports of vasospasm caused by adenosine during the treatment of supraventricular tachycardia.…”

“…(16) The presence of potentially vasoconstrictive substances, such as catecholamines and endothelin-1, may also contribute to vasospasm. (17,18) The endothelium plays a central role in balancing these substances and its dysfunction may be related to the paradoxical adenosine effect. (22) The occurrence of torsades de pointes and myocardial infarction immediately after adenosine administration led us to presume that the drug precipitated these events.…”

Case Report: Acute Heart Failure Induced by the Combination of Takayasu's, Takotsubo and Coronary Vasospasm in an Elementary School Teacher–A Reaction to Return-to-Work Stress After COVID-19?

“…In another case report, 52-year-old female with TA had signs of coronary vasospasm while undergoing a rubidium PET myocardial perfusion scan with adenosine for investigation of angina. The authors postulate that high levels of endothelin-1 that are present in TA might have reduced adenosine-induced coronary vasodilation, contributing to vasospasm ( 18 ).…”