Post-stress left ventricular ejection fraction drop in patients with diabetes: a gated myocardial perfusion imaging study

Abstract

BackgroundTo evaluate the relevance of stress-induced decrease in left ventricular ejection fraction (LVEF) in patients with type-2 diabetes.MethodsA total of 684 diabetic patients with available rest and post-stress gated myocardial perfusion single-photon emission computed tomography (MPS) data were enrolled. An automated algorithm was used to determine the perfusion scores using a 17-segment model. LVEF drop was considered significant if the post-stress LVEF was ≥5% below the rest value. Follow-up data were available in 587 patients that were followed for the occurrence of cardiac death, nonfatal myocardial infarction, or unstable angina requiring revascularization.ResultsA post-stress LVEF drop ≥5% was observed in 167 (24%) patients. Patients with LVEF drop had higher summed stress score (p < 0.05), summed difference score (p < 0.001), and rest LVEF (p < 0.001) compared to patients without. Conversely, summed rest score, a measure of infarct size, was comparable between the two groups. At multivariable analysis, summed difference score and rest LVEF were independent predictors (both p < 0.001) of post-stress LVEF drop. Myocardial perfusion was abnormal in 106 (63%) patients with post-stress LVEF drop and in 296 (57%) of those without (p = 0.16). The overall event-free survival was lower in patients with post-stress LVEF drop than in those without (log rank χ2 7.7, p < 0.005). After adjusting for clinical data and MPS variables, the hazard ratio for cardiac events for post-stress LVEF drop was 1.52 (p < 0.01).ConclusionsIn diabetic patients stress-induced ischemia is an independent predictor of post-stress LVEF drop; however, a reduction in LVEF is detectable also in patients with normal perfusion. Finally, post-stress LVEF drop increases the risk of subsequent cardiac events in diabetic patients.

Gender- and age-related differences in rest and post-stress left ventricular cardiac function determined by gated SPECT

“…We further found an impairment of LV contractile reserve in older females after adenosine stress when categorized age groups were compared, a phenomenon that was not observed in men. Interestingly, similar post-exercise changes in cardiac performance have previously been observed in postmenopausal women and in diabetic patients [18][19][20][21]. LV diastolic decompensation or sub-endocardial ischemia following pharmacological stress could account for these observations [22], however, determining what factors play a key role in the depression of LV contractile reserve in aged women warrants further investigation.…”

Prevalence and determinants of exercise‐induced left ventricular dysfunction in patients with coronary artery disease

“…These findings corroborate and extend previous pilot studies on the incidence and determinants of exercise‐induced LVD . To our best knowledge, this is the first study incorporating cardiovascular biomarkers in the evaluation of exercise‐induced LVD.…”

“…19 Exercise-induced LVD is defined according to the widely used definition: LVEF drop of at least 5% after maximal bicycle test. [13][14][15][21][22][23]…”

“…Microvascular and endothelial dysfunction may be additional contributors to exerciseinduced LVD and require further study in this context. 13 Some of the mechanisms contributing to exercise-induced LVD may be similar to those thought to be involved in the pathogenesis of Takotsubo cardiomyopathy including direct cardiotoxic effect of the hormones of the sympathetic nervous system and microvascular inflammation and dysfunction. 37 The careful interpretation of the clinical significance of exercise-induced LVD in patients without functionally relevant CAD may be a challenging task requiring further research Figure 2.…”

How variable are the volumetric measurements from gated perfusion SPECT when a one-day stress-rest protocol is used?

“…Post-stress end-systolic volume, as measured by echocardiography, has been shown to be an independent predictor of mortality;19 and increased post-stress end-systolic volume has been suggested as a marker for ischemia. A fall in LV EF post stress compared with rest may also indicate extensive inducible ischemia and an impaired prognosis 19,20. However, the value of such measures is limited without sufficient knowledge of normal intraindividual variation between stress and rest assessments.…”