Prognostic significance of impaired chronotropic response to pharmacologic stress Rb-82 PET.
BACKGROUND
An impaired chronotropic response to exercise is an accepted risk marker but the relationship between heart rate reserve (HRR) with pharmacologic stress is less well-established. The primary aim of this analysis was to evaluate the prognostic significance of HRR in patients undergoing rest/stress myocardial perfusion positron emission tomography (PET) in estimating coronary artery disease (CAD) mortality.


METHODS
This subset analysis from the PET Prognosis Multicenter Registry includes a total of 2,398 patients undergoing rest/stress Rb-PET from three participating sites. The HRR from rest to peak stress was categorized into tertiles of ≤ 4, 5-14, and ≥ 15 beats per minute (bpm). At stress, the % abnormal myocardium was categorized as <5%, 5-9.9%, and ≥ 10%. We estimated CAD mortality using univariable and multivariable Cox proportional hazard models.


RESULTS
CAD mortality was 12.8%, 3.4%, and 0.8%, respectively, for HRR measurements of ≤ 4, 5-14, and ≥ 15 bpm (P < 0.0001). In a multivariable model, the HRR was independently predictive of CAD mortality (P < 0.0001) with adjusted hazard ratios elevated 3.5- and 8.4-fold for HRR of 5-14 and ≤ 4 versus ≥ 15 bpm. In a multivariable model, both the HRR and stress MPI % abnormal myocardium were independently and highly predictive of CAD mortality. Moreover, the net reclassification improvement was 0.18 for the HRR when compared to a model including risk factors, symptoms, rest HR, and PET variables (P = 0.0008). For those with ≥ 10% abnormal myocardium on stress PET, there was a graded relationship between HRR and CAD mortality with adjusted hazards exceeding 50-fold for measurements of 5-14 and ≤ 4 bpm (P < 0.0001) compared to stress MPI with <5% abnormal myocardium and a HRR ≥ 15 bpm.


CONCLUSIONS
A diminished HRR to vasodilator stress is a novel but increasingly important predictor of CAD mortality. HRR measurements of ≤ 4, 5-14, and ≥ 15 bpm were independently predictive of CAD mortality and underscore the importance of optimizing readily available novel markers of risk as highly relevant to identifying high and low risk patient subsets.
Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, 1462 Clifton Road NE, Room 529, Atlanta, GA, 30324, USA.
Naveen
N
Bellam
Emir
E
Veledar
Sharmila
S
Dorbala
Marcelo F
MF
Di Carli
Sana
S
Shah
Danny
D
Eapen
Arshed
A
Quyyumi
Rob S B
RS
Beanlands
Michael E
ME
Merhige
Brent A
BA
Williams
Benjamin J W
BJ
Chow
James K
JK
Min
Daniel S
DS
Berman
Leslee J
LJ
Shaw
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality*; D005080:Exercise Test / Q000379:methods; D005260:Female; D006339:Heart Rate / Q000187:drug effects*; D006801:Humans; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography / Q000379:methods*; D015995:Prevalence; D011379:Prognosis; D019275:Radiopharmaceuticals; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment; D012414:Rubidium Radioisotopes; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014665:Vasodilator Agents
D019275:Radiopharmaceuticals; D012414:Rubidium Radioisotopes; D014665:Vasodilator Agents