title: Exercise supplementation to dipyridamole prevents hypotension, improves electrocardiogram sensitivity, and increases heart-to-liver activity ratio on Tc-99m sestamibi imaging.
abstract: BACKGROUND
  Myocardial perfusion imaging with dipyridamole is an alternative with which to evaluate patients who are unable to exercise. Many patients who undergo dipyridamole testing are limited in their ability, but are not completely unable, to exercise. There are benefits from adding low workload exercise to dipyridamole testing, including a reduction of thallium 201 concentration in the liver, leading to a higher heart-to-liver activity ratio and better image quality. This prospective study was designed to evaluate a protocol of exercise supplementation during dipyridamole technetium 99m sestamibi imaging and to verify whether a higher heart-to-liver activity ratio could be obtained. We also evaluated the potential of this combined protocol to prevent hypotension and induce ischemic changes on the electrocardiogram (ECG).
  
  
  RESULTS
  Ninety consecutive patients who were not completely disabled for exercise underwent dipyridamole Tc-99m sestamibi cardiac single photon emission computed tomography with a protocol of exercise supplementation (DipEx). The heart-to-liver activity ratio, hemodynamics, and electrocardiographic changes were studied. The findings were compared with those of a control group (Dip) composed of 99 patients who underwent dipyridamole infusion alone. Patients with left bundle branch block, pacemaker, and atrial fibrillation were excluded. The DipEx patients tolerated the protocol, exercising 4.2 +/- 1.3 minutes on the treadmill (Bruce protocol). Compared with Dip, patients in the DipEx group had a higher heart-to-liver activity ratio (1.3 +/- 0.4 vs 1.6 +/- 0.5, respectively; P =.00001), had no incidence of hypotension (6% vs 0%, respectively; P =.03), and had a higher sensitivity of the ECG to detect ischemia (6% vs 34%, respectively; P =.003). The increase in sensitivity seen in the DipEx group was accompanied by a significant decrease in specificity compared with the Dip group (67% vs 100%, P =.000001).
  
  
  CONCLUSIONS
  Our data show that the addition of limited exercise to dipyridamole results in benefits during Tc-99m sestamibi imaging, increasing heart-to-liver activity ratio, preventing vasodilator-induced hypotension, and improving ECG sensitivity for the detection of ischemia. Furthermore, this protocol also provides an estimation of the patient's physical capacity and could be used as an alternative for patients undergoing dipyridamole infusion who are not completely unable to exercise.
authors.affiliation: Heart Institute, the Institute for Nuclear Medicine, and the Division of Nuclear Medicine, Medical School, São José do Rio Preto, Brazil. joaovitola@quantamn.com.br
authors.forename: J V
authors.initials: JV
authors.lastname: Vitola
authors.forename: J C
authors.initials: JC
authors.lastname: Brambatti
authors.forename: F
authors.initials: F
authors.lastname: Caligaris
authors.forename: C R
authors.initials: CR
authors.lastname: Lesse
authors.forename: P R
authors.initials: PR
authors.lastname: Nogueira
authors.forename: A I
authors.initials: AI
authors.lastname: Joaquim
authors.forename: M
authors.initials: M
authors.lastname: Loyo
authors.forename: F V
authors.initials: FV
authors.lastname: Salis
authors.forename: E V
authors.initials: EV
authors.lastname: Paiva
authors.forename: W A
authors.initials: WA
authors.lastname: Chalela
authors.forename: J C
authors.initials: JC
authors.lastname: Meneghetti
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004176:Dipyridamole / Q000627:therapeutic use*; D004562:Electrocardiography / Q000187:drug effects*; D005080:Exercise Test / Q000187:drug effects* / Q000379:methods*; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D006439:Hemodynamics / Q000187:drug effects / Q000502:physiology; D006801:Humans; D007022:Hypotension / Q000517:prevention & control*; D008099:Liver / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D008168:Lung / Q000000981:diagnostic imaging / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D014665:Vasodilator Agents / Q000627:therapeutic use*; D014938:Work Capacity Evaluation
chemical_list: D019275:Radiopharmaceuticals; D014665:Vasodilator Agents; D004176:Dipyridamole; D017256:Technetium Tc 99m Sestamibi