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Cardiovascular risk stratification in diabetic patients following stress single-photon emission-computed tomography myocardial perfusion imaging: The impact of achieved exercise level

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Journal of Nuclear Cardiology Aims and scope

Abstract

Background

Previous studies have demonstrated that diabetic patients undergoing exercise stress single-photon emission-computed tomography (SPECT) myocardial perfusion imaging (MPI) have significantly lower cardiac events when compared to the diabetic patients undergoing pharmacologic stress SPECT MPI across all perfusion categories. However, there are limited data on the level of exercise achieved during exercise SPECT MPI among diabetic patients and its impact on cardiovascular outcomes.

Methods

We retrospectively analyzed 14,849 consecutive patients (3,654 diabetics and 11,195 non-diabetics) undergoing exercise stress, combined exercise and pharmacologic stress, and pharmacologic stress SPECT MPI from 1996 to 2005 at a single tertiary care center. Diabetic and non-diabetic patients were categorized into 3 groups based on the metabolic equivalents (METs) achieved: ≥5 METs, <5 METs, and pharmacologic stress groups. All studies were interpreted using the 17-segment ASNC model. The presence, extent, severity of perfusion defects were calculated using the summed stress score (SSS), and patients were classified into normal (SSS < 4), mildly abnormal (SSS 4-8), and moderate-severely abnormal (SSS > 8) categories. Annualized event rates (AER) for the composite end point of non-fatal myocardial infarction and cardiac death were calculated over a mean follow-up period of 2.4 ± 1.4 years with a maximum of 6 years.

Results

In moderate-severe perfusion abnormality (SSS > 8) category, diabetic patients who were able to achieve ≥5 METs had significantly lower AER compared to diabetic patients who were unable to achieve ≥5 METs (3% vs 5.5%, P = .04), and non-diabetic patients unable to achieve ≥5 METs (3% vs 4.8%, P < .001). Diabetic patients who achieved a high workload of ≥10 METs had a very low AER of 0.9%. Diabetic patients, who attempted exercise but were unable to achieve ≥5 METs, still had significantly lower AER than diabetics undergoing pharmacologic stress MPI across all perfusion categories [1.5% vs 3.2%, P = .006 (SSS < 4); 2.5% vs 4.9%, P = .032 (SSS 4-8); 5.5% vs 10.3%, P = .003 (SSS > 8)]. After adjustment for cardiovascular risk factors, the percentage decrease in cardiac event rate for every 1-MET increment in exercise capacity was 10% in the overall cohort, 12% in diabetic group, and 8% in non-diabetic group.

Conclusions

Despite significant perfusion defects, diabetic patients who achieve ≥5 METs during stress SPECT MPI have significantly reduced risk for future cardiac events. Diabetic patients who achieve ≥10 METs have a very low annualized event rate. These findings support that exercise capacity obtained during SPECT MPI is a surrogate for outcomes among diabetic patients undergoing nuclear stress testing.

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References

  1. Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with diabetes mellitus: Diagnostic and prognostic value. Circulation 2006;113:583-92.

    Article  PubMed  Google Scholar 

  2. Kang X, Berman DS, Lewin HC, Cohen I, Friedman JD, Germano G, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography in patients with diabetes mellitus. Am Heart J 1999;138:1025-32.

    Article  CAS  PubMed  Google Scholar 

  3. Giri S, Shaw LJ, Murthy DR, Travain MI, Miller DD, Hachamovitch R, et al. Impact of diabetes on the risk stratification using stress single-photon emission computed tomography myocardial perfusion imaging in patients with symptoms suggestive of coronary artery disease. Circulation 2002;105:32-40.

    Article  PubMed  Google Scholar 

  4. Ghatak A, Hendel RC. Role of imaging for acute chest pain syndromes. Semin Nucl Med 2013;43:71-81.

    Article  PubMed  Google Scholar 

  5. Ghatak A, Padala S, Katten DM, Polk DM, Heller GV. Risk stratification among diabetic patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol 2013;20:529-38.

    Article  PubMed  Google Scholar 

  6. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002;346:793-801.

    Article  PubMed  Google Scholar 

  7. Snader CE, Marwick TH, Pashkow FJ, Harvey SA, Thomas JD, Lauer MS. Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: Report of 3,400 patients from a single center. J Am Coll Cardiol 1997;30:641-8.

    Article  CAS  PubMed  Google Scholar 

  8. McAuley PA, Myers JN, Abella JP, Tan SY, Froelicher VF. Exercise capacity and body mass as predictors of mortality among male veterans with type 2 diabetes. Diabetes Care 2007;30:1539-43.

    Article  PubMed  Google Scholar 

  9. Fleg JL, Piña IL, Balady GJ, Chaitman BR, Fletcher B, Lavie C, et al. Assessment of functional capacity in clinical and research applications: An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology. Am Heart Assoc Circ 2000;102:1591-7.

    CAS  Google Scholar 

  10. Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The prognostic value of exercise capacity: A review of the literature. Am Heart J 1991;122:1423-31.

    Article  CAS  PubMed  Google Scholar 

  11. McNeer JF, Margolis JR, Lee KL, Kisslo JA, Peter RH, Kong Y, et al. The role of the exercise test in the evaluation of patients for ischemic heart disease. Circulation 1978;57:64-70.

    Article  CAS  PubMed  Google Scholar 

  12. Podrid PJ, Graboys TB, Lown B. Prognosis of medically treated patients with coronary-artery disease with profound ST-segment depression during exercise testing. N Engl J Med 1981;305:1111-6.

    Article  CAS  PubMed  Google Scholar 

  13. Sawada SG, Ryan T, Conley MJ, Corya BC, Feigenbaum H, Armstrong WF. Prognostic value of a normal exercise echocardiogram. Am Heart J 1990;120:49-55.

    Article  CAS  PubMed  Google Scholar 

  14. Chaitman BR. Exercise stress testing. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Braunwald’s heart disease: A textbook of cardiovascular medicine. 9th ed. Philadelphia: Elsevier Saunders; 2012. p. 168-99.

    Google Scholar 

  15. American Society of Nuclear Cardiology. Updated imaging guidelines for nuclear cardiology procedures, part 1. J Nucl Cardiol 2001;8:G5-58.

    Article  Google Scholar 

  16. Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531-40.

    Article  PubMed  Google Scholar 

  17. Klocke FJ, Baird MG, Lorell BH, Bateman TM, Messer JV, Berman DS, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging-executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol 2003;42:1318-33.

    Article  PubMed  Google Scholar 

  18. Ahlberg AW, Baghdasarian SB, Athar H, Thompsen JP, Katten DM, Noble GL, et al. Symptom-limited exercise combined with dipyridamole stress: Prognostic value in assessment of known or suspected coronary artery disease by use of gated SPECT imaging. J Nucl Cardiol 2008;15:42-56.

    Article  PubMed  Google Scholar 

  19. Imaging guidelines for nuclear cardiology procedures, part 2. American Society of Nuclear Cardiology. J Nucl Cardiol 1999;6:G47-84.

  20. Henzlova MJ, Cerqueira MD, Mahmarian JJ, Yao SS. Quality assurance Committee of the American Society of Nuclear Cardiology. Stress protocols and tracers. J Nucl Cardiol 2006;13:e80-90.

    Article  PubMed  Google Scholar 

  21. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, et al. American Heart Association Writing Group on Myocardial Segmentation and Registration for Cardiac Imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 2002;105:539-42.

    Article  PubMed  Google Scholar 

  22. Nylen ES, Kokkinos P, Myers J, Faselis C. Prognostic effect of exercise capacity on mortality in older adults with diabetes mellitus. J Am Geriatr Soc 2010;58:1850-4.

    Article  PubMed  Google Scholar 

  23. Pierre-Louis B, Aronow WS, Yoon JH, Ahn C, DeLuca AJ, Weiss MB, et al. Incidence of myocardial infarction or stroke or death at 47-month follow-up in patients with diabetes and a predicted exercise capacity ≤85% vs >85% during an exercise treadmill sestamibi stress test. Prev Cardiol 2010;13:14-7.

    Article  PubMed  Google Scholar 

  24. Moe B, Eilertsen E, Nilsen TI. The combined effect of leisure-time physical activity and diabetes on cardiovascular mortality: The Nord-Trondelag Health (HUNT) cohort study. Norway Diabetes Care 2013;36:690-5.

    Article  Google Scholar 

  25. Bourque JM, Holland BH, Watson DD, Beller GA. Achieving an exercise workload of ≥10 metabolic equivalents predicts a very low risk of inducible ischemia: Does myocardial perfusion imaging have a role? J Am Coll Cardiol 2009;54:538-45.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Lee DS, Verocai F, Husain M, Al Khdair D, Wang X, Freeman M, et al. Cardiovascular outcomes are predicted by exercise-stress myocardial perfusion imaging: Impact on death, myocardial infarction, and coronary revascularization procedures. Am Heart J 2011;161:900-7.

    Article  PubMed  Google Scholar 

  27. Bourque JM, Patel CA, Ali MM, Perez M, Watson DD, Beller GA. Prevalence and predictors of ischemia and outcomes in outpatients with diabetes mellitus referred for single-photon emission computed tomography myocardial perfusion imaging. Circ Cardiovasc Imaging 2013;6:466-77.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Mark DB, Lauer MS. Exercise capacity: the prognostic variable that doesn’t get enough respect. Circulation 2003;108:1534-6.

    Article  PubMed  Google Scholar 

  29. Thomas GS, Prill NV, Majmundar H, Fabrizi RR, Thomas JJ, Hayashida C, et al. Treadmill exercise during adenosine infusion is safe, results in fewer adverse reactions, and improves myocardial perfusion image quality. J Nucl Cardiol 2000;7:439-46.

    Article  CAS  PubMed  Google Scholar 

  30. Vitola JV, Brambatti JC, Caligaris F, Lesse CR, Nogueira PR, Joaquim AI, et al. Exercise supplementation to dipyridamole prevents hypotension, improves electrocardiogram sensitivity, and increases heart-to-liver activity ratio on Tc-99m sestamibi imaging. J Nucl Cardiol 2001;8:652-9.

    Article  CAS  PubMed  Google Scholar 

  31. Parker MW, Morales DC, Slim HB, Ahlberg AW, Katten DM, Cyr G, et al. A strategy of symptom-limited exercise with regadenoson-as-needed for stress myocardial perfusion imaging: A randomized controlled trial. J Nucl Cardiol 2013;20:185-96.

    Article  PubMed  Google Scholar 

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Disclosures

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Author information

Authors and Affiliations

  1. Division of Cardiology, Albany Medical Center, 43 New Scotland Avenue, Albany, NY, 12208, USA

    Santosh K. Padala MD

  2. Division of Cardiology, University of Miami Miller School of Medicine, Miami, FL, USA

    Abhijit Ghatak MD, MRCP

  3. Division of Medicine, McLaren Regional Medical Center, Flint, MI, USA

    Sandeep Padala MD

  4. Nuclear Cardiology Laboratory, Hartford Hospital, Hartford, CT, USA

    Deborah M. Katten RN, MPH

  5. Division of Cardiology, Brigham and Women’s Hospital, Boston, MA, USA

    Donna M. Polk MD, MPH

  6. Intersocietal Accreditation Commission, Elicott City, MD, USA

    Gary V. Heller MD, PhD, FACC

Authors
  1. Santosh K. Padala MD
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  2. Abhijit Ghatak MD, MRCP
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  3. Sandeep Padala MD
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  4. Deborah M. Katten RN, MPH
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  5. Donna M. Polk MD, MPH
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  6. Gary V. Heller MD, PhD, FACC
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Corresponding author

Correspondence to Santosh K. Padala MD.

Additional information

Santosh K. Padala and Abhijit Ghatak contributed equally to the project and manuscript and share the first authorship.

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No funding was available for this project.

See related editorial, doi:10.1007/s12350-014-9931-3.

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Padala, S.K., Ghatak, A., Padala, S. et al. Cardiovascular risk stratification in diabetic patients following stress single-photon emission-computed tomography myocardial perfusion imaging: The impact of achieved exercise level. J. Nucl. Cardiol. 21, 1132–1143 (2014). https://doi.org/10.1007/s12350-014-9986-1

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