Risk stratification with electrocardiographic-gated dobutamine stress technetium-99m sestamibi single-photon emission tomographic imaging: value of heart rate response and assessment of left ventricular function.
OBJECTIVE
The purpose of this research was to evaluate the significance of heart rate response to dobutamine and the assessment of left ventricular (LV) function during risk stratification of patients undergoing dobutamine stress myocardial perfusion imaging (DSMPI).


BACKGROUND
Dobutamine stress myocardial perfusion imaging has been shown to effectively risk stratify highly selected patients. However, based on perfusion alone, patients with normal and abnormal tests have twice the risk as comparable patients with exercise testing. The added value of assessment of LV function and the heart rate response to dobutamine in risk stratification of these patients is unknown.


METHODS
Follow-up information (cardiac death or non-fatal myocardial infarction) was obtained on 1,367 consecutive patients who underwent DSMPI due to inability to perform adequate exercise and contraindications to vasodilators. Perfusion images were interpreted using a 17-segment model. Abnormal perfusion and function were defined as: summed stress score > or =4 and ejection fraction <50%, respectively.


RESULTS
Annualized event rates (AERs) were related to the extent/severity of perfusion defects and worsening LV function. A three-risk category model was constructed from combined assessment of perfusion and function, with AERs of 2.4% (both normal), 5.8% (discordant), and 11.3% (both abnormal); p < 0.001. Stress electrocardiogram (ECG) data added incremental value to myocardial perfusion alone but not to combined assessment of perfusion and function. Importantly, inability to achieve 85% of mean predicted heart rate was associated with worse outcomes and was an independent predictor of cardiac events. For patients in whom perfusion, function, and stress ECG response were normal, inability to achieve target heart rate was associated with significantly higher AER (1.5% vs. 3.4%, respectively, p = 0.021).


CONCLUSIONS
In highly selected patients undergoing DSMPI, assessment of perfusion and function is effective in risk stratification. The stress ECG and heart rate response to dobutamine have prognostic value and should be incorporated into image interpretation so as to maximize risk stratification.
Navare
Sachin M
SM
Nuclear Cardiology Laboratory of the Henry Low Heart Center, Hartford Hospital, Hartford, Connecticut 06102, USA.
Katten
Deborah
D
Johnson
Lynne L
LL
Mather
Jeffery F
JF
Fowler
Michael S
MS
Ahlberg
Alan W
AW
Miele
Nicholas
N
Heller
Gary V
GV
D000368:Aged; D003326:Coronary Circulation; D003327:Coronary Disease / Q000000981:diagnostic imaging* / Q000503:physiopathology; D016757:Death, Sudden, Cardiac / Q000209:etiology; D004280:Dobutamine / Q000494:pharmacology; D004562:Electrocardiography / Q000187:drug effects; D005080:Exercise Test; D005260:Female; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D011379:Prognosis; D016016:Proportional Hazards Models; D019275:Radiopharmaceuticals; D018570:Risk Assessment; D012307:Risk Factors; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D016277:Ventricular Function, Left / Q000187:drug effects
D019275:Radiopharmaceuticals; D004280:Dobutamine; D017256:Technetium Tc 99m Sestamibi