Advertisement

Effect of ursodeoxycholic acid in facilitating early hepatic clearance of radiotracer among patients undergoing 99mTc-sestamibi myocardial perfusion scintigraphy: A randomized double blind placebo controlled parallel trial

  • Ashwani Sood
  • Deepa Singh
  • Usha Dutta
  • Bhagwant Rai MittalEmail author
  • Madan Parmar
  • Gurvinder Kaur
  • Komalpreet Kaur
Original Article
  • 27 Downloads

Abstract

Background

Infra-cardiac tracer activity due to persistent hepatic activity interferes in inferior and infero-septal wall assessment during 99mTc-MIBI SPECT/CT myocardial perfusion scintigraphy (MPS) in evaluation of patients with coronary artery disease. It affects image interpretation with increased study duration. Ursodeoxycholic acid (UDCA) is known to enhance hepatic excretion of bilirubin and bile salts, though its role in enhancing the hepatic tracer clearance in facilitating cardiac imaging is not known.

Methods

This prospective, randomized double-blind, placebo controlled clinical trial of 120 patients, referred for adenosine stress or viability MPS studies were randomized 1:1 to receive either UDCA or placebo. Outcome was quantitative & qualitative improvement in imaging for better interpretation and to reduce the waiting time for scan.

Results

118 participants (59 ± 11.9 years; 84 men) underwent adenosine stress MPS or viability MPS. Sixty participants had UDCA while 58 had placebo intervention. The study showed significant decrease in liver counts with improved myocardial to liver ratio at 30 and 60 minutes in adenosine stress MPS group, and marginally significant alteration in liver counts at 60 minutes in viability MPS group receiving UDCA, resulting in better images.

Conclusion

UDCA intervention in MPS provides early and better image due to faster hepatic tracer clearance.

Keywords

99mTc-MIBI Adenosine stress Viability MPS SPECT/CT UDCA (ursodeoxycholic acid) Liver clearance 

Abbreviations

MPS

Myocardial perfusion scintigraphy

UDCA

Ursodeoxycholic acid

CAD

Coronary artery disease

MIBI

Methoxyisobutylisonitrile

RCT

Randomized control trial

SPECT/CT

Single photon emission computed tomography/computed tomography

Pgp

P-glyocprotein

ASNC

American Society of Nuclear Cardiology

Notes

Acknowledgment

The authors acknowledge Prof. Suresh Kumar Sharma, Department of Statistics, Panjab University, Chandigarh for his valuable inputs.

Disclosure

Drs Ashwani Sood, Deepa Singh, Usha Dutta, Bhagwant Rai Mittal, Madan Parmar, Gurvinder Kaur, Komalpreet Kaur have nothing to disclose. No financial support was received for the publication of this manuscript.

Supplementary material

12350_2019_1597_MOESM1_ESM.pptx (927 kb)
Supplementary material 1 (PPTX 926 kb)

References

  1. 1.
    Better N, Karthikeyan G, Vitola J, Fatima A, Peix A, Novak MD, et al. Performance of rest myocardial perfusion imaging in the management of acute chest pain in the emergency room in developing nations (PREMIER trial). J Nucl Cardiol 2012;19:1146-53.CrossRefGoogle Scholar
  2. 2.
    Pennell DJ, Rahman SL. Cardiac stress. In: Ell PJ, Gambhir SS, editors. Nuclear medicine in clinical diagnosis and treatment. 3rd ed. London: Churchill Livingstone; 2004. p. 1093-104.Google Scholar
  3. 3.
    Wackers FJT. Myocardial perfusion imaging. In: Sandler MP, Coleman RE, Patton JA, Wackers FJT, Gottschalk A, editors. Diagnostic nuclear medicine 4th edn. Connecticut: Lippincott, Williams & Wilkins, 2002;273-319Google Scholar
  4. 4.
    Burrell S, MacDonald A. Artifacts and pitfalls in myocardial perfusion imaging. J Nucl Med Technol 2006;34:193-211; quiz 2-4.Google Scholar
  5. 5.
    Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers. J Nucl Cardiol 2016;23:606-39.CrossRefGoogle Scholar
  6. 6.
    Better N, Hicks RJ. Infarct-avid imaging and myocardial perfusion scintigraphy techniques using single-photon radiotracers. In: Ell PJ, Gambhir SS, editors. Nuclear medicine in clinical diagnosis and treatment. 3rd ed. London: Churchill Livingstone; 2004. p. 1047-70.Google Scholar
  7. 7.
    Peace RA, Lloyd JJ. The effect of imaging time, radiopharmaceutical, full fat milk and water on interfering extra-cardiac activity in myocardial perfusion single photon emission computed tomography. Nucl Med Commun 2005;26:17-24.CrossRefGoogle Scholar
  8. 8.
    Malhotra G, Upadhye TS, Nabar A, Asopa RV, Nayak UN, Rajan MG. Can carbonated lime drink intake prior to myocardial perfusion imaging with Tc-99m MIBI reduce the extracardiac activity that degrades the image quality and leads to fallacies in interpretation? Clin Nucl Med 2010;35:160-4.CrossRefGoogle Scholar
  9. 9.
    Boz A, Yildiz A, Gungor F, Karayalcin B, Erkilic M. The volume effect of the stomach on intestinal activity on same-day exercise–rest Tc-99m tetrofosmin myocardial imaging. Clin Nucl Med 2001;26:622-5.CrossRefGoogle Scholar
  10. 10.
    Vorster M, Sathekge MM, Rheeder P. Erythromycin as an alternative to reduce interfering extra-cardiac activity in myocardial perfusion imaging. Cardiovasc J Afr 2010;21:142-7.Google Scholar
  11. 11.
    Purbhoo K, Vangu MD. Efficacy of full-fat milk and diluted lemon juice in reducing infra-cardiac activity of (99m)Tc sestamibi during myocardial perfusion imaging. Cardiovasc J Afr 2015;26:171-6.CrossRefGoogle Scholar
  12. 12.
    Paumgartner G, Beuers U. Ursodeoxycholic acid in cholestatic liver disease: mechanisms of action and therapeutic use revisited. Hepatology 2002;36:525-31.CrossRefGoogle Scholar
  13. 13.
    Palma J, Reyes H, Ribalta J, Hernandez I, Sandoval L, Almuna R, et al. Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. J Hepatol 1997;27:1022-8.CrossRefGoogle Scholar
  14. 14.
    Dinler G, Kocak N, Yuce A, Gurakan F, Ozen H. Ursodeoxycholic acid therapy in children with cholestatic liver disease. Turk J Pediatr 1999;41:91-8.Google Scholar
  15. 15.
    Levine A, Maayan A, Shamir R, Dinari G, Sulkes J, Sirotta L. Parenteral nutrition-associated cholestasis in preterm neonates: evaluation of ursodeoxycholic acid treatment. J Pediatr Endocrinol Metab 1999;12:549-53.CrossRefGoogle Scholar
  16. 16.
    Poddar U, Bhattacharya A, Thapa BR, Mittal BR, Singh K. Ursodeoxycholic acid-augmented hepatobiliary scintigraphy in the evaluation of neonatal jaundice. J Nucl Med 2004;45:1488-92.Google Scholar
  17. 17.
    Basu S, Bhattacharya A. Ursodeoxycholic acid versus phenobarbital pretreatment prior to hepatobiliary scintigraphy in neonatal cholestasis: is it time for shifting gears towards a practice change? Eur J Nucl Med Mol Imaging 2015;42:1160-1.CrossRefGoogle Scholar
  18. 18.
    Joseph B, Bhargava KK, Malhi H, Schilsky ML, Jain D, Palestro CJ, et al. Sestamibi is a substrate for MDR1 and MDR2 P-glycoprotein genes. Eur J Nucl Med Mol Imaging 2003;30:1024-31.CrossRefGoogle Scholar
  19. 19.
    Luker GD, Fracasso PM, Dobkin J, Piwnica-Worms D. Modulation of the multidrug resistance P-glycoprotein: detection with technetium-99m-sestamibi in vivo. J Nucl Med 1997;38:369-72.Google Scholar
  20. 20.
    Becquemont L, Glaeser H, Drescher S, Hitzl M, Simon N, Murdter TE, et al. Effects of ursodeoxycholic acid on P-glycoprotein and cytochrome P450 3A4-dependent pharmacokinetics in humans. Clin Pharmacol Ther 2006;79:449-60.CrossRefGoogle Scholar
  21. 21.
    Bodin K, Bretillon L, Aden Y, Bertilsson L, Broome U, Einarsson C, et al. Antiepileptic drugs increase plasma levels of 4beta-hydroxycholesterol in humans: evidence for involvement of cytochrome p450 3A4. J Biol Chem 2001;276:38685-9.CrossRefGoogle Scholar
  22. 22.
    Caroli-Bosc FX, Iliadis A, Salmon L, Macheras P, Montet AM, Bourgeon A, et al. Ursodeoxycholic acid modulates cyclosporin A oral absorption in liver transplant recipients. Fundam Clin Pharmacol 2000;14:601-9.CrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2019

Authors and Affiliations

  • Ashwani Sood
    • 1
  • Deepa Singh
    • 1
  • Usha Dutta
    • 2
  • Bhagwant Rai Mittal
    • 1
    Email author
  • Madan Parmar
    • 1
  • Gurvinder Kaur
    • 1
  • Komalpreet Kaur
    • 1
  1. 1.Post Graduate Institute of Medical Education and Research (PGIMER), Nuclear MedicineChandigarhIndia
  2. 2.Post Graduate Institute of Medical Education and Research (PGIMER), GastroenterologyChandigarhIndia

Personalised recommendations