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Prognostic value of vasodilator response using rubidium-82 positron emission tomography myocardial perfusion imaging in patients with coronary artery disease

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Abstract

Background

Prognostic value of positron emission tomography (PET) myocardial perfusion imaging (MPI) is well established. There is paucity of data on how the prognostic value of PET relates to the hemodynamic response to vasodilator stress. We hypothesize that inadequate hemodynamic response will affect the prognostic value of PET MPI.

Methods and results

Using a multicenter rubidium (Rb)-82 PET registry, 3406 patients who underwent a clinically indicated rest/stress PET MPI with a vasodilator agent were analyzed. Patients were categorized as, “responders” [increase in heart rate ≥ 10 beats per minute (bpm) and decrease in systolic blood pressure (SBP) ≥10 mmHg], “partial responders” (either a change in HR or SBP), and “non-responders” (no change in HR or SBP). Primary outcome was all-cause death (ACD), and secondary outcome was cardiac death (CD). Ischemic burden was measured using summed stress score (SSS) and % left ventricular (LV) ischemia. After a median follow-up of 1.68 years (interquartile range = 1.17- 2.55), there were 7.9% (n = 270) ACD and 2.6% (n = 54) CD. Responders with a normal PET MPI had an annualized event rate (AER) of 1.22% (SSS of 0–3) and 1.58% (% LV ischemia = 0). Partial and non-responders had higher AER with worsening levels of ischemic burden. In the presence of severe SSS ≥12 and LV ischemia of ≥10%, partial responders had an AER of 10.79% and 10.36%, compared to non-responders with an AER of 19.4% and 12.43%, respectively. Patient classification was improved when SSS was added to a model containing clinical variables (NRI: 42%, p < 0.001) and responder category was added (NRI: 61%, p < 0.001). The model including clinical variables, SSS and hemodynamic response has good discrimination ability (Harrell C statistics: 0.77 [0.74–0.80]).

Conclusion

Hemodynamic response during a vasodilator Rb-82 PET MPI is predictive of ACD. Partial and non-responders may require additional risk stratification leading to altered patient management.

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Acknowledgements

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Authors and Affiliations

  1. Canada, Department of Medicine (Cardiology), University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada

    Punitha Arasaratnam, Masoud Sadreddini, Yeung Yam, Vinay Kansal, Rob S. Beanlands, Terrence D. Ruddy & Benjamin J. W. Chow

  2. Division of Cardiovascular Medicine and Division of Nuclear Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Sharmila Dorbala & Marcelo F. Di Carli

  3. Departments of Cardiology, Internal Medicine, and Nuclear Medicine, Niagara Falls Memorial Medical Center, Buffalo, NY, USA

    Michael E. Merhige

  4. Department of Center for Health Research, Geisinger Medical Center, Danville, PA, USA

    Brent A. Williams

  5. Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA

    Emir Veledar & Leslee J. Shaw

  6. Department of Radiology and Department of Imaging, Weill Cornell Medical College, New York, NY, USA

    James K. Min

  7. Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, ON, Canada

    Li Chen

  8. Department of Radiology, University of Ottawa, Ottawa, ON, Canada

    Terrence D. Ruddy & Benjamin J. W. Chow

  9. Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Guido Germano & Daniel S. Berman

Authors
  1. Punitha Arasaratnam
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  2. Masoud Sadreddini
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  3. Yeung Yam
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  4. Vinay Kansal
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  5. Sharmila Dorbala
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  6. Marcelo F. Di Carli
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  7. Rob S. Beanlands
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  8. Michael E. Merhige
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  9. Brent A. Williams
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  10. Emir Veledar
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  11. James K. Min
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  12. Li Chen
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  14. Guido Germano
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  15. Daniel S. Berman
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  17. Benjamin J. W. Chow
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Corresponding author

Correspondence to Benjamin J. W. Chow.

Ethics declarations

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.”

Disclosures

This study was supported in part by an unrestricted grant from Astellas Pharma Global Development; Bracco Diagnostics, Inc.; a National Heart, Lung, and Blood Institute grant (K23HL092299), and a program grant from the Heart and Stroke Foundation of Ontario (PRG6242). Dr. Dorbala has received research grants from Astellas Pharma and owns General Electric stocks. Dr. Di Carli has received research grants from Toshiba. Dr. Merhige has served on Speakers’ Bureaus for Bracco Diagnostics, has received honoraria from the Positron Group, and served as medical director for the Positron Group. Dr. Williams is an employee of Geisinger Health System. Dr. Berman has received research grants from Lantheus Medical Imaging, Siemens, and Cardium Therapeutics, Inc.; has received honoraria from Spectrum Dynamics; has served on advisory boards for Bracco Diagnostics; and has received royalties from Cedars-Sinai Software. Dr. Beanlands is a career investigator supported by the Heart and Stroke Foundation of Ontario and Tier 1 Chair in Cardiovascular Research supported by the University of Ottawa. He is a consultant for Lantheus Medical Imaging and JubilantDRAXImage (JDI) and has received grant funding from GE Healthcare, Lantheus Medical Imaging, and JDI. Dr. Shaw has received research grants from Astellas Pharma and Bracco Diagnostics. Dr. Ruddy has received research grants from GE Healthcare and Advanced Accelerator Applications International. Dr. Chow receives research and fellowship training support from GE Healthcare and educational support from TeraRecon Inc. and holds the Saul and Edna Goldfarb Chair in Cardiac Imaging Research. The rest of the authors have no conflict of interest to disclose.

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Arasaratnam, P., Sadreddini, M., Yam, Y. et al. Prognostic value of vasodilator response using rubidium-82 positron emission tomography myocardial perfusion imaging in patients with coronary artery disease. Eur J Nucl Med Mol Imaging 45, 538–548 (2018). https://doi.org/10.1007/s00259-017-3878-y

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  • DOI: https://doi.org/10.1007/s00259-017-3878-y

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