An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis
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Increasing numbers of patients are undergoing transcatheter aortic valve replacement, which often involves assessment of coronary artery disease ischemic burden. The safety and diagnostic accuracy of vasodilator stress agents in patients with severe aortic stenosis (AS) undergoing SPECT myocardial perfusion imaging (MPI) has not been established.
Patients with severe AS (valve area <1 cm2) on echocardiography who underwent vasodilator stress SPECT MPI at two centers were identified. Patients with aortic valve intervention prior to MPI or who underwent concurrent exercise during stress testing were excluded. AS patients were matched to controls without AS based on age, gender, BMI, ejection fraction, and stress agent. Symptoms, serious adverse events, hemodynamic response, and correlation to invasive angiography were assessed.
A total of 95 cases were identified with 45% undergoing regadenoson, 31% dipyridamole, and 24% adenosine stress. A significant change in systolic blood pressure (BP), cases vs controls, was observed with adenosine [−17.9 ± 20.1 vs −2.6 ± 24.9 P = .03)], with a trend toward significance with regadenoson [−16.8 ± 20.3 vs −9.4 ± 17.9 (P = .08)] and dipyridamole [−17.8 ± 20.6 vs -9.0 ± 12.1 (P = .05)]. The change in heart rate was significantly different only for adenosine [5.3 ± 16.8 vs 14.2 ± 10.8 (P = .04)]. Overall, 45% of cases vs 24% of controls (P = .004) had a >20 mmHg decrease in systolic BP. Age, BMI, and resting systolic BP were related to a >20 mmHg decrease in systolic BP on univariate analysis, although only higher resting systolic BP was a predictor on multivariate analysis. In 33 patients who underwent angiography, the sensitivity, specificity, and diagnostic accuracy of vasodilator stress MPI was 77%, 69%, and 73%, respectively. No serious adverse events occurred in the severe AS patients.
Severe AS patients are more likely to have a hemodynamically significant decrease in systolic BP with vasodilator stress. There were no serious adverse events in this severe AS cohort with good diagnostic performance of MPI compared to angiography.
KeywordsSevere aortic stenosis regadenoson dipyridamole adenosine SPECT MPI
Coronary artery disease
Coronary artery bypass grafting
Percutaneous coronary intervention
Transcatheter aortic valve replacement
Single photon emission computed tomography
Positron emission computed tomography
Myocardial perfusion imaging
Left ventricular ejection fraction
Congestive heart failure
Authors would like to acknowledge the help of Dr. Poojita Shivamurthy in data collection for this study.
Conflicts of Interest
All funding and support for this work came from within the Division of Cardiology at Hartford Hospital and Mount Sinai Hospital. There was no outside funding, grant or industry support. Dr. Duvall has received research grant support from Astellas Pharmaceuticals within the past 2 years.
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