Comparison of risk stratification with pharmacologic and exercise stress myocardial perfusion imaging: A meta-analysis

Navare, Sachin M.; Mather, Jeff; Shaw, Leslee J.; Fowler, Mike S.; Heller, Gary V.

doi:10.1016/j.nuclcard.2004.06.128

Cited by 197 publications

(127 citation statements)

References 51 publications

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“…In agreement with the literature, we found a higher rate of adverse heart events in the group of patients who were submitted to pharmacological stress both for patients with normal tests and for those with altered tests 33,34 . We believe that this was due to the fact that the population submitted to pharmacological stress was comprised of patients with more severe cardiac disease than the population submitted to physical stress.…”

Section: Discussionsupporting

confidence: 92%

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

Azevedo¹,

Felix²,

Corrêa³

et al. 2007

Arq. Bras. Cardiol.

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SummaryObjective: To evaluate the prognostic value of stress myocardial perfusion scintigraphy (MPS) applied to patients with suspected acute coronary syndrome (ACS).Methods: Retrospective study. Patients with suspected acute coronary syndrome (ACS) admitted into the chest pain unit angina they underwent stress MPS. Results:Conclusion: Presence of ISQ was the major independent factor in prediction of adverse events for patients admitted into the CPU.

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Section: Discussionsupporting

confidence: 92%

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

Azevedo¹,

Felix²,

Corrêa³

et al. 2007

Arq. Bras. Cardiol.

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“…Navarre et al reported an annual hard event rate of 10.9% for pharmacologic MPI patients with severe perfusion defects, compared to 6.4% for exercise MPI patients with severe defects. 5 Similar findings were reported by Hachamovitch et al in elderly patients. 6 The annualized cardiac mortality was 7.8% for patients with moderately abnormal MPI results with pharmacologic stress vs 2.7% with such abnormal results in patients who underwent exercise MPI.…”

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confidence: 84%

Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide

González

2017

Journal of Nuclear Cardiology

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Cardiac imaging of either myocardial perfusion or regional function, under resting and stress conditions, utilizing either nuclear cardiology or ultrasound technology, is the dominant approach to the noninvasive detection of coronary artery disease (CAD) in symptomatic patients. Prior to the advent of imaging technology that permitted assessment of myocardial perfusion and function, symptom-limited exercise electrocardiography (ExECG) alone was the test employed for detecting CAD. Multiple clinical studies showed that combining imaging with symptomlimited exercise enhanced the diagnostic and prognostic values of exercise testing, over the variables derived from ExECG. Pharmacologic stress then emerged as an alternative to exercise for imaging of patients who were deemed unable to attain a target heart rate of C85% of maximum predicted heart rate adjusted for age. Submaximal exercise decreases the sensitivity of MPI for detection of ischemia and prevents accurate measurement of extent of ischemia when present. 1With either SPECT or PET myocardial perfusion imaging (MPI), intravenously administered vasodilators such as dipyridamole, adenosine, and regadenoson substituted as stressors for exercise. These agents allowed for detection of relative flow reserve alterations between stenotic and normal coronary arteries. Dobutamine infusion was reserved for patients with bronchospasm, or those who ingested caffeine prior to testing. For stress echocardiography, dobutamine emerged as the major pharmacologic alternative to exercise stress. New ischemia-induced wall motion abnormalities constituted a positive test for ischemia. Sensitivity for CAD detection is higher, and specificity lower, for stress MPI compared to stress echocardiography. For this reason, stress echocardiography is commonly performed in patients at lower pre-test clinical risk for CAD. Conversely, with a higher sensitivity for CAD detection, stress MPI is advocated for higher risk patients with suspected or known CAD who need testing for appropriate clinical indications.Over the past few decades, the percentage of patients referred for pharmacologic stress imaging, relative to exercise imaging, has been increasing from about 30% to more than 50% of stress imaging tests. 2,3In addition, a substantial number of patients initially referred for exercise stress are being triaged to pharmacologic stress. Patients who are unable to achieve target heart rate with exercise are changed over to predominantly vasodilator stress for the injection of tracer for radionuclide imaging, or dobutamine infusion for completion of stress echocardiographic testing. Currently, patients referred for PET MPI all undergo pharmacologic stress since the positron-emitting tracers (e.g., Rb-82) approved for clinical imaging have very short half-lives, thereby precluding upright exercise testing with its inherent delay in moving patients postexercise for imaging in the positron camera.Because pharmacologic stress testing has been increasing over time, Argulian et al 4 sought to determi...

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“…However, patients undergoing pharmacologic stress studies tend to be a sicker group by the fact that they are not able to exercise, and are at a higher risk for subsequent cardiac events, even when the MPI test is normal. 7 Rozanski et al reported similar findings among patients tested with exercise or adenosine stress protocol. 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.…”

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confidence: 70%

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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Comparison of risk stratification with pharmacologic and exercise stress myocardial perfusion imaging: A meta-analysis

Cited by 197 publications

References 51 publications

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

Prognóstico em médio prazo da cintilografia de perfusão miocárdica de estresse na unidade de dor torácica

Choosing exercise or pharmacologic stress imaging, or exercise ECG testing alone: How to decide

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

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