Quantitative relation between hemodynamic changes during intravenous adenosine infusion and the magnitude of coronary hyperemia

Mishra, Rakesh; Dorbala, Sharmila; Logsetty, Giridhar; Hassan, Alita; Heinonen, Therèse; Schelbert, Heinrich R.; Carli, Marcelo F. Di; Investigators, Rampart

doi:10.1016/j.jacc.2004.10.064

Cited by 46 publications

(15 citation statements)

References 18 publications

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“…The lack of significant correlation between ΔSI spleen or ΔT1 spleen with rate pressure product is consistent with existing evidence showing dissociation between imaging and hemodynamic markers of stress response [5, 6], and further suggests that stress responses during clinical CMR cannot be reliably assessed using hemodynamic observations alone [5]. This deserves further investigation.…”

Section: Discussionsupporting

confidence: 82%

“…However, perfusion CMR has a reported false-negative rate of between 5 and 16% [2–4], which may lead to suboptimal management strategies. In the absence of poor image quality, inadequate adenosine stress response is the commonest cause of false-negative perfusion scans [4], because conventional hemodynamic markers of stress response, such as heart rate and systolic blood pressure, are unreliable predictors of myocardial vasodilatation and the achievement of maximal hyperemia [5]. …”

Section: Introductionmentioning

confidence: 99%

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Splenic T1-mapping: a novel quantitative method for assessing adenosine stress adequacy for cardiovascular magnetic resonance

Liu

Wijesurendra

Ariga

et al. 2016

Journal of Cardiovascular Magnetic Resonance

101

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BackgroundPerfusion cardiovascular magnetic resonance (CMR) performed with inadequate adenosine stress leads to false-negative results and suboptimal clinical management. The recently proposed marker of adequate stress, the “splenic switch-off” sign, detects splenic blood flow attenuation during stress perfusion (spleen appears dark), but can only be assessed after gadolinium first-pass, when it is too late to optimize the stress response. Reduction in splenic blood volume during adenosine stress is expected to shorten native splenic T1, which may predict splenic switch-off without the need for gadolinium.MethodsTwo-hundred and twelve subjects underwent adenosine stress CMR: 1.5 T (n = 104; 75 patients, 29 healthy controls); 3 T (n = 108; 86 patients, 22 healthy controls). Native T1spleen was assessed using heart-rate-independent ShMOLLI prototype sequence at rest and during adenosine stress (140 μg/kg/min, 4 min, IV) in 3 short-axis slices (basal, mid-ventricular, apical). This was compared with changes in peak splenic perfusion signal intensity (ΔSIspleen) and the “splenic switch-off” sign on conventional stress/rest gadolinium perfusion imaging. T1spleen values were obtained blinded to perfusion ΔSIspleen, both were derived using regions of interest carefully placed to avoid artefacts and partial-volume effects.ResultsNormal resting splenic T1 values were 1102 ± 66 ms (1.5 T) and 1352 ± 114 ms (3 T), slightly higher than in patients (1083 ± 59 ms, p = 0.04; 1295 ± 105 ms, p = 0.01, respectively). T1spleen decreased significantly during adenosine stress (mean ΔT1spleen ~ −40 ms), independent of field strength, age, gender, and cardiovascular diseases. While ΔT1spleen correlated strongly with ΔSIspleen (rho = 0.70, p < 0.0001); neither indices showed significant correlations with conventional hemodynamic markers (rate pressure product) during stress. By ROC analysis, a ΔT1spleen threshold of ≥ −30 ms during stress predicted the “splenic switch-off” sign (AUC 0.90, p < 0.0001) with sensitivity (90%), specificity (88%), accuracy (90%), PPV (98%), NPV (42%).ConclusionsAdenosine stress and rest splenic T1-mapping is a novel method for assessing stress responses, independent of conventional hemodynamic parameters. It enables prediction of the visual “splenic switch-off” sign without the need for gadolinium, and correlates well to changes in splenic signal intensity during stress/rest perfusion imaging. ΔT1spleen holds promise to facilitate optimization of stress responses before gadolinium first-pass perfusion CMR.Electronic supplementary materialThe online version of this article (doi:10.1186/s12968-016-0318-2) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 82%

Section: Introductionmentioning

confidence: 99%

Splenic T1-mapping: a novel quantitative method for assessing adenosine stress adequacy for cardiovascular magnetic resonance

Liu

Wijesurendra

Ariga

et al. 2016

Journal of Cardiovascular Magnetic Resonance

101

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“…Nevertheless, adenosine stress CMR remains an accurate clinical investigation in patients with AF,24 and RPP should not be used to demonstrate adequacy of adenosine stress because the coronary hyperemic effects of adenosine are largely independent of changes in hemodynamics 16. Rates of splenic switch‐off, a validated technique for excluding inadequate stress,14 were high and similar between groups in our study.…”

Section: Discussionmentioning

confidence: 53%

“…In accordance with previous studies, adenosine‐stress–induced MBF was not corrected because this parameter is grossly independent of RPP 16. The myocardial perfusion reserve index was calculated by dividing the numerical value of stress MBF by the numerical value of baseline MBF corrected .…”

Section: Methodsmentioning

confidence: 95%

Myocardial Perfusion Is Impaired and Relates to Cardiac Dysfunction in Patients With Atrial Fibrillation Both Before and After Successful Catheter Ablation

Wijesurendra

Liu

Notaristefano

et al. 2018

JAHA

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BackgroundAtrial fibrillation (AF) is associated with myocardial infarction, and patients with AF and no obstructive coronary artery disease can present with symptoms and evidence of cardiac ischemia. We hypothesized that microvascular coronary dysfunction underlies these observations.Methods and ResultsMyocardial blood flow (MBF) at baseline and during adenosine stress and left ventricular and left atrial function were evaluated by magnetic resonance in 49 patients with AF (25 paroxysmal, 24 persistent) with no history of epicardial coronary artery disease or diabetes mellitus, before and 6 to 9 months after ablation. Findings were compared with those obtained in matched controls in sinus rhythm (n=25). Before ablation, patients with AF had impaired left atrial function and left ventricular ejection fraction and strain indices (all P<0.05 versus controls). MBF was impaired in patients both under baseline conditions (1.21±0.24 mL/min per g·[mm Hg·bpm/104]−1 versus 1.34±0.28 mL/min per g·[mm Hg·bpm/104]−1 in controls, P=0.044) and during adenosine stress (2.29±0.48 mL/min per g versus 2.73±0.37 mL/min per g in controls, P<0.001). Under baseline conditions, MBF correlated with left ventricular strain and left atrial function (all P≤0.001), so that cardiac function was most impaired in patients with the lowest MBF. Baseline and stress MBF remained unchanged postablation (both P=ns), and baseline MBF showed similar correlations with functional indices to those present preablation (all P≤0.001).ConclusionsBaseline and stress MBF are significantly impaired in patients with AF but no epicardial coronary artery disease. Reduction in MBF is proportional to severity of left ventricular and left atrial dysfunction, even after successful ablation. Coronary microvascular dysfunction may be a relevant pathophysiological mechanism in patients with a history of AF.

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“…Previous studies looking into the relation between the peripheral hemodynamic actions of adenosine and its coronary vasodilator effect have shown that despite a lack of peripheral response to adenosine, coronary vasodilatation remains adequate for the purpose of myocardial perfusion imaging [25]. This observation would suggest that a further increase to adenosine dose in order to induce better systemic and coronary vasodilatation to non-responders to standard dose is not needed.…”

Section: Discussionmentioning

confidence: 99%

Feasibility and safety of high-dose adenosine perfusion cardiovascular magnetic resonance

Karamitsos

Ntusi

Francis

et al. 2010

Journal of Cardiovascular Magnetic Resonance

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IntroductionAdenosine is the most widely used vasodilator stress agent for Cardiovascular Magnetic Resonance (CMR) perfusion studies. With the standard dose of 140 mcg/kg/min some patients fail to demonstrate characteristic haemodynamic changes: a significant increase in heart rate (HR) and mild decrease in systolic blood pressure (SBP). Whether an increase in the rate of adenosine infusion would improve peripheral and, likely, coronary vasodilatation in those patients is unknown. The aim of the present study was to assess the tolerance and safety of a high-dose adenosine protocol in patients with inadequate haemodynamic response to the standard adenosine protocol when undergoing CMR perfusion imaging.Methods98 consecutive patients with known or suspected coronary artery disease (CAD) underwent CMR perfusion imaging at 1.5 Tesla. Subjects were screened for contraindications to adenosine, and an electrocardiogram was performed prior to the scan. All patients initially received the standard adenosine protocol (140 mcg/kg/min for at least 3 minutes). If the haemodynamic response was inadequate (HR increase < 10 bpm or SBP decrease < 10 mmHg) then the infusion rate was increased up to a maximum of 210 mcg/kg/min (maximal infusion duration 7 minutes).ResultsAll patients successfully completed the CMR scan. Of a total of 98 patients, 18 (18%) did not demonstrate evidence of a significant increase in HR or decrease in SBP under the standard adenosine infusion rate. Following the increase in the rate of infusion, 16 out of those 18 patients showed an adequate haemodynamic response. One patient of the standard infusion group and two patients of the high-dose group developed transient advanced AV block. Significantly more patients complained of chest pain in the high-dose group (61% vs. 29%, p = 0.009). On multivariate analysis, age > 65 years and ejection fraction < 57% were the only independent predictors of blunted haemodynamic responsiveness to adenosine.ConclusionsA substantial number of patients do not show adequate peripheral haemodynamic response to standard-dose adenosine stress during perfusion CMR imaging. Age and reduced ejection fraction are predictors of inadequate response to standard dose adenosine. A high-dose adenosine protocol (up to 210 mcg/kg/min) is well tolerated and results in adequate haemodynamic response in nearly all patients.

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Quantitative relation between hemodynamic changes during intravenous adenosine infusion and the magnitude of coronary hyperemia

Abstract: Changes in cardiac hemodynamics during intravenous ADO are generally poor predictors of changes in MBF and CVR during peak hyperemia, and, thus, they should not be used to assess the effectiveness of vasodilator stress in myocardial perfusion imaging.

Cited by 46 publications

References 18 publications

Splenic T1-mapping: a novel quantitative method for assessing adenosine stress adequacy for cardiovascular magnetic resonance

Splenic T1-mapping: a novel quantitative method for assessing adenosine stress adequacy for cardiovascular magnetic resonance

Myocardial Perfusion Is Impaired and Relates to Cardiac Dysfunction in Patients With Atrial Fibrillation Both Before and After Successful Catheter Ablation

Feasibility and safety of high-dose adenosine perfusion cardiovascular magnetic resonance

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