title: An assessment of the safety, hemodynamic response, and diagnostic accuracy of commonly used vasodilator stressors in patients with severe aortic stenosis.
abstract: 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.
authors.affiliation: Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
authors.forename: Nasir
authors.initials: N
authors.lastname: Hussain
authors.affiliation: Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
authors.forename: Waseem
authors.initials: W
authors.lastname: Chaudhry
authors.affiliation: Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
authors.forename: Alan W
authors.initials: AW
authors.lastname: Ahlberg
authors.affiliation: Department of Medicine, Mount Sinai Hospital, New York, NY, USA.
authors.forename: Richard S
authors.initials: RS
authors.lastname: Amara
authors.affiliation: Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Elfar
authors.affiliation: Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester, MA, USA.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Parker
authors.affiliation: Mount Sinai Heart, Mount Sinai Hospital, New York, NY, USA.
authors.forename: John A
authors.initials: JA
authors.lastname: Savino
authors.affiliation: Department of Medicine, Mount Sinai Hospital, New York, NY, USA.
authors.forename: Ruwanthi
authors.initials: R
authors.lastname: Titano
authors.affiliation: Mount Sinai Heart, Mount Sinai Hospital, New York, NY, USA.
authors.forename: Milena J
authors.initials: MJ
authors.lastname: Henzlova
authors.affiliation: Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA. lane.duvall@hhchealth.org.
authors.forename: William L
authors.initials: WL
authors.lastname: Duvall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D005080:Exercise Test / Q000379:methods*; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D008297:Male; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D012189:Retrospective Studies; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D014665:Vasodilator Agents / Q000009:adverse effects / Q000494:pharmacology*
chemical_list: D014665:Vasodilator Agents
keywords: SPECT MPI; Severe aortic stenosis; adenosine; dipyridamole; regadenoson