Comparison between dipyridamole and adenosine as pharmacologic coronary vasodilators in detection of coronary artery disease with thallium 201 imaging

doi:10.1016/S1071-3581(96)90034-3

Journal of Nuclear Cardiology

Volume 3, Issue 3, May–June 1996, Pages 204-211

https://doi.org/10.1016/S1071-3581(96)90034-3 Get rights and content

Abstract

Background. Both dipyridamole and adenosine are widely used as pharmacologic stressors with ²⁰¹Tl imaging for detection of coronary artery disease. The purpose of this study was to compare dipyridamole and adenosine ²⁰¹Tl imaging directly in patients with angiographically proved coronary artery disease.

Methods and Results. Fifty-four patients were submitted to two planar ²⁰¹Tl studies: one with dipyridamole and the other with adenosine. The interval between the two studies varied from 2 to 7 days and the order was assigned randomly. Three standard planar views were obtained 10 minutes and 4 hours after the injection of 3.0 mCi ²⁰¹Tl. Administration of dipyridamole was as follows: 0.142 mg/kg/min during 4 minutes, followed by a slight exercise and ²⁰¹Tl injection. The infusion of adenosine was as follows: 0.140 mg/kg/min during 6 minutes with injection of ²⁰¹Tl after the third minute of infusion. Patients were asked to give their preference considering the number, type, severity, and duration of side effects on a scale from 0 (worst) to 5 (best). Reading was done by two experienced observers. The heart was divided into three segments per view. The change in systolic blood pressure was −12 ± 11 mm Hg for adenosine and −5 ± 10 mm Hg for dipyridamole (p < 0.001), and the change in heart rate was 18 ± 10 beats/min for adenosine and 8 ± 7 beats/min for dipyridamole (p < 0.001). With regions of interest, ischemic/normal wall ratios were determined: 0.78 ± 0.06 for adenosine and 0.83 ± 0.08 for dipyridamole (p < 0.001). Adenosine detected 295 normal, 170 ischemic, and 21 scar segments, whereas dipyridamole detected 326, 135, and 25 segments, respectively. Patients preferred adenosine (4.3 ± 1.0 for adenosine vs 3.8 ± 1.5 for dipyridamole; p < 0.04) mainly because of the short duration of side effects.

Conclusion. This study shows that the use of adenosine with ²⁰¹Tl imaging may have some advantages over dipyridamole.

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Although ATP has a greater initial action, adenosine as the metabolic product of ATP then plays a role in maintaining vasodilation.18 As such, when 2 pharmacologic stress agents with similar effects and indications, such as adenosine and ATP, are available for the diagnosis of coronary artery disease, a comparison of the diagnostic accuracy, technical feasibility, incidence of side effects, and cost is important for routine clinical application.4 The overall sensitivity and specificity of Tl-201 SPECT imaging with ATP for coronary artery disease detection are 84% to 92% and 87% to 89%, respectively, which are similar to those reported with adenosine or dipyridamole.19-21
Adenosine 5′-triphosphate (ATP), a potent and inexpensive coronary vasodilator, was introduced as a pharmacologic stress agent for thallium 201 single photon emission computed tomography (SPECT). However, there has been no direct comparison of ATP and adenosine as myocardial stressors in the same subjects.
Thirty-six patients underwent consecutive Tl-201 SPECT imaging with adenosine and ATP in a randomly assigned order. There were no changes in clinical status and no invasive procedures were performed between the two tests. The hemodynamic response and side effects were monitored, and myocardial tracer uptake was assessed by use of a visual grading system and quantitative analysis via a CEqual map. The hemodynamic changes and adverse effects did not differ significantly between the two groups. There were no changes in the detection of any perfusion defect on a per-subject basis, except in one. The exact agreement rate for the visual grading of the myocardial tracer uptake was 84.8%. However, the average extent of the perfusion defect and the severity score were higher with adenosine.
The hemodynamic changes and the degree of myocardial uptake were similar between the adenosine and ATP infusion. However, quantitative analysis by use of a CEqual map revealed smaller perfusion defects and lower severity scores in subjects undergoing Tl-201 SPECT with ATP.
Effect of Caffeine on Ischemia Detection by Adenosine Single-Photon Emission Computed Tomography Perfusion Imaging
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This is an important difference because caffeine is a competitive inhibitor, which means that the very high adenosine interstitial concentration may overwhelm the receptors and continue to produce coronary hyperemia. This difference between adenosine and dipyridamole is seen as a more robust blood pressure decrease and heart rate increase and more defect severity and extent with adenosine compared with dipyridamole (26–28). Further, even if the degree of hyperemia is slightly reduced, it may have no important impact on the results of perfusion imaging because the tracer extraction levels off at flow rates above 2.5-fold of the baseline flow.
The purpose of this research was to study the effect of one cup of coffee taken 1 h before adenosine stress on the results of myocardial perfusion imaging.
Caffeine is believed to attenuate the coronary hyperemic response to adenosine by competitive blockade of the A2a receptor. Caffeine is commonly withheld before adenosine single-photon emission computed tomography (SPECT) perfusion imaging so as not to mask ischemia detection.
We studied the effect of one 8-oz cup of coffee taken 1 h before adenosine stress in patients who had demonstrable reversible defects on adenosine SPECT perfusion imaging performed while off caffeine.
There were 22 men and 8 women, age 64 ± 9 years. The blood level of caffeine 1 h after intake was 3.1 ± 1.6 mg/l. There were two patients with ST-segment depression before and one after caffeine intake (p = NS). The summed stress score (SSS) based on 17 segments (scale of 0 to 3, 3 being normal) was 44 ± 5 before and 45 ± 5 after caffeine (p = NS). The summed difference score was 3.8 ± 1.9 before and. 3.9 ± 2.3 after caffeine (p = NS), reflecting that around 50% of the perfusion abnormality was reversible before and after caffeine. Using polar maps, the perfusion abnormality was 12 ± 10% at baseline and 12 ± 10% after caffeine (p = NS) in agreement with SSS. The left ventricular ejection fraction by gated SPECT was 50 ± 13% at baseline and 51 ± 13 % after caffeine (p = NS).
A cup of coffee does not mask the presence or severity of reversible defects induced by adenosine SPECT imaging.
Myocardial perfusion imaging with adenosine triphosphate predicts the rate of cardiovascular events
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Adenosine triphosphate (ATP) has effects similar to adenosine, including a very short half-life, with the advantage of a much lower cost. Our aim was to evaluate whether myocardial single photon emission computed tomography (SPECT) with ATP can predict the rate of hard events.
We studied 299 patients (188 men; mean age, 64 ± 10 years) with known or suspected coronary disease with thallium 201 SPECT during ATP infusion and at rest. Perfusion defects were divided into the following: absent/mild reversible, moderate/severe reversible, and mixed/fixed. During a maximum follow-up of 87 months (mean, 32.7 ± 20.3 months), the rate of cardiovascular events was studied. The prognostic value of different variables that can influence survival was calculated with the Cox proportional hazards model. The total number of cardiovascular events was 115 (43 hard events). The annual rate of hard events according to type of perfusion defect was 3.44% (95% confidence interval [CI], 2.12-5.26) for absent/mild reversible, 6.06% (95% CI, 2.23-13.20) for moderate/severe reversible, and 15.12% (95% CI, 8.64-24.55) for mixed/fixed. In the Cox model the variables that significantly predicted hard events were age greater than 55 years (P = .0293), diabetes (P = .0036), and severe perfusion defects (P = .0008).
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Original articleComparison between dipyridamole and adenosine as pharmacologic coronary vasodilators in detection of coronary artery disease with thallium 201 imaging

Abstract

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Cardiol Clin

J Nucl Cardiol

J Am Coll Cardiol

Am Heart J

Original article
Comparison between dipyridamole and adenosine as pharmacologic coronary vasodilators in detection of coronary artery disease with thallium 201 imaging