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Addition of atropine to submaximal exercise stress testing in patients evaluated for suspected ischaemia with SPECT imaging: a randomized, placebo-controlled trial

  • Fiore Manganelli
  • Marco Spadafora
  • Paola Varrella
  • Giuseppina Peluso
  • Rosario Sauro
  • Emilio Di Lorenzo
  • Giuseppe Rosato
  • Stefania Daniele
  • Alberto CuocoloEmail author
Original Article

Abstract

Purpose

To evaluate the effects of the addition of atropine to exercise testing in patients who failed to achieve their target heart rate (HR) during stress myocardial perfusion imaging with single-photon emission computed tomography (SPECT).

Methods

The study was a prospective, randomized, placebo-controlled design. Patients with suspected or known coronary artery disease who failed to achieve a target HR (≥85% of maximal predicted HR) during exercise SPECT imaging were randomized to receive intravenous atropine (n = 100) or placebo (n = 101).

Results

The two groups of patients did not differ with respect to demographic or clinical characteristics. A higher proportion of patients in the atropine group achieved the target HR compared to the placebo group (60% versus 3%, p < 0.0001). SPECT imaging was abnormal in a higher proportion of patients in the atropine group as compared to the placebo group (57% versus 42%, p < 0.05). Stress-induced myocardial ischaemia was present in more patients in the atropine group as compared to placebo (47% versus 29%, p < 0.01). In both groups of patients, no major side effects occurred.

Conclusion

The addition of atropine at the end of exercise testing is more effective than placebo in raising HR to adequate levels, without additional risks of complications. The use of atropine in patients who initially failed to achieve their maximal predicted HR is associated with a higher probability of achieving a diagnostic myocardial perfusion study.

Keywords

Exercise stress testing Atropine Myocardial perfusion imaging 

Notes

Conflicts of interest

None.

References

  1. 1.
    Iskandrian AS, Heo J, Kong B, Lyons E. Effect of exercise level on the ability of thallium-201 tomographic imaging in detecting coronary artery disease: analysis of 461 patients. J Am Coll Cardiol 1989;14:1477–86.CrossRefPubMedGoogle Scholar
  2. 2.
    Verzijlbergen JF, Vermeersch PH, Laarman GJ, Ascoop CA. Inadequate exercise leads to suboptimal imaging. Thallium-201 myocardial perfusion imaging after dipyridamole combined with low-level exercise unmasks ischemia in symptomatic patients with non-diagnostic thallium-201 scans who exercise submaximally. J Nucl Med 1991;32:2071–8.PubMedGoogle Scholar
  3. 3.
    Heller GV, Ahmed I, Tilkemeier PL, Barbour MM, Garber CE. Influence of exercise intensity on the presence, distribution, and size of thallium-201 defects. Am Heart J 1992;123:909–16.CrossRefPubMedGoogle Scholar
  4. 4.
    Sharir T, Rabinowitz B, Livschitz S, Moalem I, Baron J, Kaplinsky E, et al. Underestimation of extent and severity of coronary artery disease by dipyridamole stress thallium-201 single-photon emission computed tomographic myocardial perfusion imaging in patients taking antianginal drugs. J Am Coll Cardiol 1998;31:1540–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Taillefer R, Ahlberg AW, Masood Y, White CM, Lamargese I, Mather JF, et al. Acute beta-blockade reduces the extent and severity of myocardial perfusion defects with dipyridamole Tc-99m sestamibi SPECT imaging. J Am Coll Cardiol 2003;42:1475–83.CrossRefPubMedGoogle Scholar
  6. 6.
    Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation 1997;96:345–54.PubMedGoogle Scholar
  7. 7.
    Picano E, Mathias W Jr, Pingitore A, Bigi R, Previtali M. Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicentre study. Echo Dobutamine International Cooperative Study Group. Lancet 1994;344:1190–2.CrossRefPubMedGoogle Scholar
  8. 8.
    Poldermans D, Rambaldi R, Bax JJ, Cornel JH, Thomson IR, Valkema R, et al. Safety and utility of atropine addition during dobutamine stress echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction. Eur Heart J 1998;19:1712–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Sitges M, Paré C, Azqueta M, Bosch X, Miranda-Guardiola F, Velamazán M, et al. Feasibility and prognostic value of dobutamine-atropine stress echocardiography early in unstable angina. Eur Heart J 2000;21:1063–71.CrossRefPubMedGoogle Scholar
  10. 10.
    Banerjee S, Yalamanchili VS, Abdul-Baki T, Stoddard MF. Use of atropine to maintain higher heart rate after exercise during treadmill stress echocardiography. J Am Soc Echocardiogr 2002;15:43–5.CrossRefPubMedGoogle Scholar
  11. 11.
    Cosín-Sales J, Maceira AM, García-Velloso MJ, Macías A, Gimenez M, García-Bolao I, et al. Safety and feasibility of atropine added to submaximal exercise stress testing with Tl-201 SPECT for the diagnosis of myocardial ischemia. J Nucl Cardiol 2002;9:581–6.CrossRefPubMedGoogle Scholar
  12. 12.
    De Lorenzo A, Foerster J, Sciammarella MG, Suey C, Hayes SW, Friedman JD, et al. Use of atropine in patients with submaximal heart rate during exercise myocardial perfusion SPECT. J Nucl Cardiol 2003;10:51–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Sarullo FM, Ventimiglia C, Taormina A, Azzarello V, Felice F, Martino A, et al. Safety and feasibility of atropine added in patients with sub-maximal heart rate during exercise myocardial perfusion SPECT. Int J Cardiovasc Imaging 2007;23:511–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Hesse B, Tägil K, Cuocolo A, Anagnostopoulos C, Bardiés M, Bax J, et al. EANM/ESC procedural guidelines for myocardial perfusion imaging in nuclear cardiology. Eur J Nucl Med Mol Imaging 2005;32:855–97.CrossRefPubMedGoogle Scholar
  15. 15.
    Berman DS, Kiat H, Friedman JD, Wang FP, van Train K, Matzer L, et al. Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. J Am Coll Cardiol 1993;22:1455–64.CrossRefPubMedGoogle Scholar
  16. 16.
    Hachamovitch R, Berman DS, Shaw LJ, Kiat H, Cohen I, Cabico JA, et al. Incremental prognostic value of myocardial perfusion single photon emission computed tomography for the prediction of cardiac death: differential stratification for risk of cardiac death and myocardial infarction. Circulation 1998;97:535–43.PubMedGoogle Scholar
  17. 17.
    Ferro A, Pellegrino T, Spinelli L, Acampa W, Petretta M, Cuocolo A. Comparison between dobutamine echocardiography and single-photon emission computed tomography for interpretive reproducibility. Am J Cardiol 2007;100:1239–44.CrossRefPubMedGoogle Scholar
  18. 18.
    McLaughlin PR, Martin RP, Doherty P, Daspit S, Goris M, Haskell W, et al. Reproducibility of thallium-201 myocardial imaging. Circulation 1977;55:497–503.PubMedGoogle Scholar
  19. 19.
    Ladenheim ML, Pollock BH, Rozanski A, Berman DS, Staniloff HM, Forrester JS, et al. Extent and severity of myocardial hypoperfusion as predictors of prognosis in patients with suspected coronary artery disease. J Am Coll Cardiol 1986;7:464–71.CrossRefPubMedGoogle Scholar
  20. 20.
    Hachamovitch R, Berman DS, Kiat H, Cohen I, Cabico JA, Friedman J, et al. Exercise myocardial perfusion SPECT in patients without known coronary artery disease: incremental prognostic value and use in risk stratification. Circulation 1996;93:905–14.PubMedGoogle Scholar
  21. 21.
    Shaw LJ, Berman DS, Maron DJ, Mancini GB, Hayes SW, Hartigan PM, et al.; COURAGE Investigators. Optimal medical therapy with or without percutaneous coronary intervention to reduce ischemic burden: results from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial nuclear substudy. Circulation 2008;117:1283–91.CrossRefPubMedGoogle Scholar
  22. 22.
    Poldermans D, Fioretti PM, Boersma E, Bax JJ, Thomson IR, Roelandt JR, et al. Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: a single-center experience. Circulation 1999;99:757–62.PubMedGoogle Scholar
  23. 23.
    Geleijnse ML, Elhendy A, van Domburg RT, Cornel JH, Rambaldi R, Salustri A, et al. Cardiac imaging for risk stratification with dobutamine-atropine stress testing in patients with chest pain. Echocardiography, perfusion scintigraphy, or both? Circulation 1997;96:137–47.PubMedGoogle Scholar
  24. 24.
    Schinkel AF, Elhendy A, van Domburg RT, Bax JJ, Roelandt JR, et al. Prognostic value of dobutamine-atropine stress (99m)Tc-tetrofosmin myocardial perfusion SPECT in patients with known or suspected coronary artery disease. J Nucl Med. 2002;43:767–72.PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Fiore Manganelli
    • 1
  • Marco Spadafora
    • 2
  • Paola Varrella
    • 2
  • Giuseppina Peluso
    • 2
  • Rosario Sauro
    • 1
  • Emilio Di Lorenzo
    • 1
  • Giuseppe Rosato
    • 1
  • Stefania Daniele
    • 3
  • Alberto Cuocolo
    • 3
    • 4
    • 5
    Email author
  1. 1.Department of Cardiology and Heart SurgerySan Giuseppe Moscati HospitalAvellinoItaly
  2. 2.Nuclear Medicine UnitSan Giuseppe Moscati HospitalAvellinoItaly
  3. 3.Institute of Diagnostic and Nuclear Development (SDN)NaplesItaly
  4. 4.Department of Biomorphological and Functional SciencesUniversity Federico IINaplesItaly
  5. 5.Institute of Biostructures and BioimagesNational Council of ResearchNaplesItaly

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