João V. Vitola, MD, PhD Cardiologist and Nuclear Medicine Physician Quanta Diagnostico Nuclear Curitiba - Brazil Pharmacological stress agents and protocols 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
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João V. Vitola, MD, PhD
Cardiologist and Nuclear Medicine Physician Quanta Diagnostico Nuclear
Curitiba - Brazil
Pharmacological stress agents and protocols
DISCLOSURES
Honorarium – Research and Conferences in Nuclear Cardiology
BMS, CVT, Astellas, Pgx Health/Forest laboratories, Lantheus Medical ImagingInternational 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
1- Collect data – medical historyTalk to the patient – define the ideal stress protocol for that patientEstimation of pre test probability based on age, symptoms, risk factorsWhy pharm stress ? Any contraindication ? COPD/ AVB/ LV arr?
Stein et al., Am J Cardiol, 75:568-72, 1995 *p<0.001
Increased Sensitivity of MPIDipEx(n=54)
AdAd
AdAd
Short AxisShort Axis
Vertical Long AxisVertical Long Axis
Ad-ExAd-Ex
Rest Rest
RestRest
Ad-EXAd-EX
Horizontal Long AxisHorizontal Long Axis
CF
Tc-99m-sestamibi
Samady H et al, J Nucl Cardiol 2002;9:188-196
0 1 2 3 54 6 7 8
Tc-99m
Thomas, Thompson et al. 2008RCT trialn=60
Exercise 1.7 mph at 0% grade
Regadenoson + exercise
Reg
Thomas,Thompson, et al. J Nucl Cardiol 2009;16:63–72
Eixo Curto
Eixo Longo Vertical
Eixo Longo Horizontal
Cortes Tomográficos-Referência
Potential for “ on the fly ” protocol
• 30 secs from peak hyperemia•Pts on meds•Depressed chronotropic response
5%7%
17%
0%
5%
10%
15%
20%
2001 2002 2003 2004 2005
Adapted from imv Nuclear Medicine Census Market Summary Reports 11-02, 12-03, 7-06
% of Vasodilator Stress Studies Performed with Exercise (US)
G Thomas
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
VASODILATORS
LBBB or RV pacing
• O’Keefe AHJ 1992;124:614-21
O’Keefe AHJ 1992;124:614-21
Indication– Incapacity to exercise – COPD
Protocol– 10 / 20 / 30 / 40 microgramas/kg/min (push to max
HR)
DOBUTAMINE
ATROPINE up to 2 mg in 4 boluses (0.5 + 0.5 + 0.5 + 0.5)* *careful Glaucoma and BPH
• HR response variable• BP response variable• Hyperemia variable• Arrythmias/other side effects• Fragile patient (Elderly COPD)• VT (4%)