Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
DISCLOSURES
Honorarium Research and Conferences in Nuclear Cardiology
BMS, CVT, Astellas, Pgx Health/Forest laboratories, Lantheus Medical Imaging
International Atomic Energy Agency
Royalties Publications in Nuclear Cardiology
Springer-Verlag-Nuclear Cardiology and Correlative Imaging: a teaching file, NY, 2004
Lippincott Williams & Wilkins, - Nuclear Medicine teaching File, 2009
Topics to cover
Goal of stressing
hyperemia/testing coronary reserve
Decide on type of stress
Discordant ECG changes and Perfusion
Bayes theorem - impact on test result
Advantages, drawbacks and efficacy of different options
Mechanisms of action / Interfering factors: medications and diet
Protocols: a practical approach
IAEA documents and recommendations from 2012 (website)
BAYES THEOREM
Protocols
Most Common
Exercise ( max )
Bruce, Ellestad, Modified Bruce, Kattus, Naughton
Combined (exercise + vasodilator: DipEx)
Dipyridamole (Adenosine)
Less Common
Dobutamine
A2a - agonists
Regadenoson
Apadenoson
hyperemia
Baseline flow
0
20
40
60
80
100
% Stenosis
Sanjiv K, J.Nucl.Cardiol.8:694-700,2001.
Crtical
Not significant
MPI - SPECT
Evaluates the Impact of CAD on Coronary Reserve
(also the presence of adequate collateral flow)
Principles:
1- Stress is Applied to:
Promote a disparity in flow between a stenotic vessel
and a normal vessel
2- Radioactive Tracers :
Distribute proportional to flow up to a limit
(plateau of extraction)
ml/min/g
5
4
3
2
1
0
Base
Exerc
Dobut
Dip
Aden
% Dose.gram tissue
0,08
0,06
99mTc-Mibi
201Tl
0,04
0,02
0,00
Coronary flow
(ml.min.g-1)
Normal Volunteers
MBF - H215O - PET
Dip 0.56 mg/kg
BERGMANN et al.
JACC 1989;14:639-52
9/10
0.56 mg CVR > 3.8
aditional dipyridamole
1/10
0.56 mg CVR = 2.3
Dobutamina
1%
Combinado
11%
Dipiridamol
18%
Stress
Freqncia
Percentual
Exerccio
7421
70,0%
Dipiridamol
1891
17,8%
Combinado
1184
11,2%
Dobutamina
99
0,9%
10595
100,0%
Total
81%
6776
6000
5000
Seqncia1
4000
Seqncia2
3000
2143
2000
1000
0
64.55%
20.41%
477
4.54%
651
6.20%
Normal
Isquemia
Fibrose
F+I
Seqncia1
6776
2143
477
651
Seqncia2
64.55%
20.41%
4.54%
6.20%
Athletes
Low Duke
Exercise Test
Below Average
Female Gender
Phy Active
AverageMean Abnormal Rate
Sedentary
Cholesterol
Male Gender
Diabetes
Typical Pain
Above Average
Dipyridamole
Known CAD
Hx PCI
Hx CABG
High Duke
22.60%
26.90%
30.50%
32.80%
35.40%
38.30%
39.20%
39.80%
52.30%
53.20%
60.30%
63.60%
64%
75%
76%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
MECHANISMS OF ACTION
The goal is hyperemia
Exercse
EXERCISE
Preferred modality
Hemodynamic data - BP, HR
Adicional info
DUKE SCORE: + mins - 5 x ST - 4 x angina
Ex time (mins)
ST (mm)
Angina (0 - 2)
Risk
Low
Interm
High
Score
5
4.... -10
-11
Mortality/year
0.25%
1.25%
5.25%
8
7
6
Death or MI (%)
normal
mild
severe
5
4
3
2
*p<0.05
1
0
low
intermediate
Duke TM Score
high
Hachamovitch,
Circulation 1996
SPECT
10
9
8
7
6
normal
mild
severe
5
4
3
2
1
0
low
intermediate
high
TMT
x5
Ellestad, MH
Mieres J et al. in Vitola and Delbeke: Nuclear Cardiology and Correlative Imaging, Springer 2004
Chapter 12, page 333
Vasodilator
Exercise
IMAGE QUALITY
Exercise vs Vasodilator
BLOOD FLOW distribution
heart/ liver
Dip
Exercise
(46%)
1.3 0.3
1.9 0.5*
Taillefer et al
Dip
Exer + Dip
(23%)
1.3 0.5
1.6 0.6*
Vitola et al
*p<0.05
Dip
Isch Patients
Isch Segts/pt (multivessel)
Extent (% polar map)
Lung Uptake
TID
DipEx
30
39*
1.3 1.5
2.5 2.2*
16.8 12.9 26.4 18.5*
5
16*
4
10*
*p<0.001
Tc-99m-sestamibi
Ad-Ex
Ad-Ex
Ad
Ad
Rest
Rest
Short
Short Axis
Axis
Horizontal
Horizontal Long
Long Axis
Axis
Vertical
Vertical Long
Long Axis
Axis
Ad-EX
Ad-EX
Ad
Ad
Rest
Rest
CF
Normal Volunteers
MBF - H215O - PET
Dip 0.56 mg/kg
BERGMANN et al.
JACC 1989;14:639-52
VASODILATORS
Indication
Incapacity to exercise (consider adding low workload
exercise)
LBBB, PM (vasodilator alone)
On Medications
Limitations compared to exercise
Side effects
Sensitivity of the ECG ( < 6 %)
Information from exercise not available
Liver uptake inferior artifacts
Non-responders
DOBUTAMINE
Indication
Incapacity to exercise
COPD
Protocol
10 / 20 / 30 / 40 microgramas/kg/min (push to max
HR)
ATROPINE (0.5 + 0.5 + 0.5 + 0.5)*
*careful Glaucoma and BPH
DOBUTAMINE
Limitations
HR response variable
BP response variable
Hyperemia variable
Arrythmias/other side effects
Fragile patient (Elderly COPD)
VT (4%)
Side effect
Adenosine
Dipyridamole
Dobutamine
Any
81%
47%
75%
Flushing
Dyspnea
Chest Pain
ST depression
GI disconfort
Headache
AV Block
Arrythmia
37%
35%
35%
6%
15%
14%
8%
3%
43%
3%
20%
8%
6%
12%
0%
5%
14%
14%
31%
30%
14%
0%
50%
General Contraindications
AMI within 24 horas
ACS
Uncontrolled CHF
Specific Contraindications
Adenosine/Dipyridamole
Hypotension
COPD (steroids/hospit)
AV Block > 1
Dobutamine
Hipertension
Frequent Ventr Ectopy
Uncontrolled AF/Flutter
Obstruction LV outflow
Aortic Aneurysm
NH2
Binodenoson
NH
NH2
HO
H3C
OH
OH
O
N
H3C
HO
H2N
N
OH
OH
HO
O
H
N
O
Adenosine
HO
OH
Apadenoson
N
OH
H
N
Regadenoson
CH3
OH
N = 784
Bolus Administration
Time to 2.4-fold above baseline: 33 sec
***
***
REGADENOSON = ADENOSINE
Selectivity
A1
A2A
Undesirable effects
(eg, AV block)
Increase coronary
blood flow
A2B
A3
Undesirable effects
(eg, bronchospasm)
REGADENOSON
Bolus administration
Standard dose
Selectivity and low to moderate receptor
binding
Special issues
Bolus apadenoson
Saline flush
Inject tracer
Minutes
Adapted from Hendel RC et al. Abstract presented during the 2005 Annual Scientific Sessions
of the American Heart Association. Dallas, Texas.
Stress testing
Conclusions
Prefer exercise