Failed heart rate control with oral metoprolol prior to coronary CT angiography: effect of additional intravenous metoprolol on heart rate, image quality and radiation dose

  • Laura Jiménez-Juan
  • Elsie T. Nguyen
  • Bernd J. Wintersperger
  • Hadas Moshonov
  • Andrew M. Crean
  • Djeven P. Deva
  • Narinder S. Paul
  • Felipe S. Torres
Original Paper


The purpose of this study was to evaluate the effect of intravenous (IV) metoprolol after a suboptimal heart rate (HR) response to oral metoprolol (75–150 mg) on HR control, image quality (IQ) and radiation dose during coronary CTA using 320-MDCT. Fifty-three consecutive patients who failed to achieve a target HR of < 60 bpm after an oral dose of metoprolol and required supplementary IV metoprolol (5–20 mg) prior to coronary CTA were evaluated. Patients with HR < 60 bpm during image acquisition were defined as responders (R) and those with HR ≥ 60 bpm as non-responders (NR). Two observers assessed IQ using a 3-point scale (1–2, diagnostic and 3, non-diagnostic). Effective dose (ED) was estimated using dose-length product and a 0.014 mSV/ conversion factor. Baseline characteristics and HR on arrival were similar in the two groups. 58 % of patients didn’t achieve the target HR after receiving IV metoprolol (NR). R had a significantly higher HR reduction after oral (mean HR 63.9 ± 4.5 bpm vs. 69.6 ± 5.6 bpm) (p < 0.005) and IV (mean HR 55.4 ± 3.9 bpm vs. 67.4 ± 5.3 bpm) (p < 0.005) doses of metoprolol. Studies from NR showed a significantly higher ED in comparison to R (8.0 ± 2.9 vs. 6.1 ± 2.2 mSv) (p = 0.016) and a significantly higher proportion of non-diagnostic coronary segments (9.2 vs. 2.5 %) (p < 0.001). 58 % of patients who do not achieve a HR of <60 bpm prior to coronary CTA with oral fail to respond to additional IV metoprolol and have studies with higher radiation dose and worse image quality.


Heart rate Beta-blocker Coronary artery disease Image quality Radiation dose 320 MDCT 


Conflict of interest

Narinder S. Paul has received research support from Toshiba Medical Systems.


  1. 1.
    Taylor AJ, Cerqueira M, Hodgson JM, et al (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate use criteria for cardiac computed tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr 4:407.e1–407.33Google Scholar
  2. 2.
    Abbara S, Arbab-Zadeh A, Callister TQ et al (2009) SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 3:190–204PubMedCrossRefGoogle Scholar
  3. 3.
    Halliburton SS, Abbara S, Chen MY et al (2011) SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr 5:198–224PubMedCrossRefGoogle Scholar
  4. 4.
    Pannu HK, Alvarez W Jr, Fishman EK (2006) Beta-blockers for cardiac CT: a primer for the radiologist. AJR Am J Roentgenol 186:S341–S345PubMedCrossRefGoogle Scholar
  5. 5.
    Maffei E, Palumbo AA, Martini C et al (2009) “In-house” pharmacological management for computed tomography coronary angiography: heart rate reduction, timing and safety of different drugs used during patient preparation. Eur Radiol 19:2931–2940PubMedCrossRefGoogle Scholar
  6. 6.
    Degertekin M, Gemici G, Kaya Z et al (2009) Safety and efficacy of patient preparation with intravenous esmolol before 64-slice computed tomography coronary angiography. Coron Artery Dis 19:33–36CrossRefGoogle Scholar
  7. 7.
    Mahabadi AA, Achenbach S, Burgstahler C et al (2010) Safety, efficacy, and indications of beta-adrenergic receptor blockade to reduce heart rate prior to coronary CT angiography. Radiology 257:614–623PubMedCrossRefGoogle Scholar
  8. 8.
    Roberts WT, Wright AR, Timmis JB, Timmis AD (2009) Safety and efficacy of a rate control protocol for cardiac CT. Br J Radiol 82:267–271PubMedCrossRefGoogle Scholar
  9. 9.
    Reiter MJ (2004) Cardiovascular drug class specificity: beta-blockers. Prog Cardiovasc Dis 47:11–33PubMedCrossRefGoogle Scholar
  10. 10.
    Torres FS, Jeddiyan S, Jimenez-Juan L, Nguyen ET (2011) Beta-blockers to control heart rate during coronary CT angiography. Radiology 259:615–616; author reply 616–617Google Scholar
  11. 11.
    Torres FS, Crean AM, Nguyen ET, Paul N (2010) Strategies for radiation-dose reduction and image-quality optimization in multidetector computed tomographic coronary angiography. Can Assoc Radiol J 61:271–279PubMedCrossRefGoogle Scholar
  12. 12.
    Austen WG, Edwards JE, Frye RL et al (1975) A reporting system on patients evaluated for coronary artery disease. Report of the Ad Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery, American Heart Association. Circulation 51:5–40PubMedCrossRefGoogle Scholar
  13. 13.
    Jack DB, Quarterman CP, Zaman R, Kendall MJ (1982) Variability of beta-blocker pharmacokinetics in young volunteers. Eur J Clin Pharmacol 23:37–42PubMedCrossRefGoogle Scholar
  14. 14.
    Zhou HH, Koshakji RP, Silberstein DJ, Wilkinson GR, Wood AJ (1989) Altered sensitivity to and clearance of propranolol in men of Chinese descent as compared with American whites. N Engl J Med 320:565–570PubMedCrossRefGoogle Scholar
  15. 15.
    Brodde OE (2008) Beta-1 and beta-2 adrenoceptor polymorphisms: functional importance, impact on cardiovascular diseases and drug responses. Pharmacol Ther 117:1–29PubMedCrossRefGoogle Scholar
  16. 16.
    de Graaf FR, Schuijf JD, van Velzen JE et al (2010) Evaluation of contraindications and efficacy of oral Beta blockade before computed tomographic coronary angiography. Am J Cardiol 105:767–772PubMedCrossRefGoogle Scholar
  17. 17.
    Pannu HK, Sullivan C, Lai S, Fishman EK (2008) Evaluation of the effectiveness of oral Beta-blockade in patients for coronary computed tomographic angiography. J Comput Assist Tomogr 32:247–251PubMedCrossRefGoogle Scholar
  18. 18.
    Shapiro MD, Pena AJ, Nichols JH et al (2008) Efficacy of pre-scan beta-blockade and impact of heart rate on image quality in patients undergoing coronary multidetector computed tomography angiography. Eur J Radiol 66:37–41PubMedCrossRefGoogle Scholar
  19. 19.
    Regardh CG, Johnsson G (1980) Clinical pharmacokinetics of metoprolol. Clin Pharmacokinet 5:557–569PubMedCrossRefGoogle Scholar
  20. 20.
    Beck ATSR (1990) Manual for the Beck anxiety inventory. The Psycological Corporation, San AntonioGoogle Scholar
  21. 21.
    Wang Y, Vidan E, Bergman GW (1999) Cardiac motion of coronary arteries: variability in the rest period and implications for coronary MR angiography. Radiology 213:751–758PubMedGoogle Scholar
  22. 22.
    Rybicki FJ, Otero HJ, Steigner ML et al (2008) Initial evaluation of coronary images from 320-detector row computed tomography. Int J Cardiovasc Imaging 24:535–546PubMedCrossRefGoogle Scholar
  23. 23.
    Steigner ML, Otero HJ, Cai T et al (2009) Narrowing the phase window width in prospectively ECG-gated single heart beat 320-detector row coronary CT angiography. Int J Cardiovasc Imaging 25:85–90PubMedCrossRefGoogle Scholar
  24. 24.
    Lee AB, Nandurkar D, Schneider-Kolsky ME et al (2011) Coronary image quality of 320-MDCT in patients with heart rates above 65 Beats per minute: preliminary experience. AJR Am J Roentgenol 196:W729–W735PubMedCrossRefGoogle Scholar
  25. 25.
    Khan M, Cummings KW, Gutierrez FR, Bhalla S, Woodard PK, Saeed IM (2011) Contraindications and side effects of commonly used medications in coronary CT angiography. Int J Cardiovasc Imaging 27:441–449PubMedCrossRefGoogle Scholar
  26. 26.
    Dewey M, Zimmermann E, Deissenrieder F et al (2009) Noninvasive coronary angiography by 320-row computed tomography with lower radiation exposure and maintained diagnostic accuracy: comparison of results with cardiac catheterization in a head-to-head pilot investigation. Circulation 120:867–875PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, B.V. 2012

Authors and Affiliations

  • Laura Jiménez-Juan
    • 1
  • Elsie T. Nguyen
    • 1
  • Bernd J. Wintersperger
    • 1
  • Hadas Moshonov
    • 2
    • 3
  • Andrew M. Crean
    • 1
    • 4
  • Djeven P. Deva
    • 1
  • Narinder S. Paul
    • 1
  • Felipe S. Torres
    • 5
    • 6
  1. 1.Cardiothoracic Division, Department of Medical Imaging, Toronto General HospitalUniversity Health NetworkTorontoCanada
  2. 2.Joint Department of Medical Imaging, Mount Sinai HospitalUniversity Health NetworkTorontoCanada
  3. 3.Women’s College HospitalUniversity Health NetworkTorontoCanada
  4. 4.Department of Cardiology, Toronto General HospitalUniversity Health NetworkTorontoCanada
  5. 5.Cardiothoracic Division, Department of Medical ImagingSunnybrook Health Sciences CentreTorontoCanada
  6. 6.School of MedicineUniversidade Federal do Rio Grande do SulPorto AlegreBrazil

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