The routine use of sublingual GTN with resting 99Tcm-tetrofosmin myocardial perfusion imaging

Nitrates can be used to improve resting myocardial blood flow in patients with severe coronary artery disease. This may enhance tracer uptake during rest myocardial perfusion imaging. Recent studies using nitrates at rest have shown increased detection of reversible ischaemia in this patient group with the 201Tl and 99Tcm perfusion tracers MIBI and tetrofosmin. However, it is not always possible to assess the severity of coronary artery disease before the rest injection and therefore whether a patient would benefit from nitrate administration. To improve the sensitivity for the detection of reversible ischaemia and to avoid a repeat study with nitrates (especially in patients with 'fixed' defects), a protocol in which all patients routinely receive nitrates prior to the rest injection is required. This prospective study evaluated the effect of nitrate administration prior to rest imaging in a randomly selected group of patients. Thirty patients selected at random from routine referrals had stress, rest and rest + GTN tetrofosmin imaging on three separate days. Changes in reversibility between the rest and rest + GTN images were assessed both visually and using semi-quantitative analysis. Defects at stress were seen in 43 coronary artery territories, 33 of which were reversible at rest and 37 reversible at rest + GTN. Of these 43 defects, 82% demonstrated either increased or the same degree of reversibility at rest + GTN imaging compared to standard rest imaging. All defects with reduced reversibility at rest + GTN imaging (i.e. the remaining 18%) were, however, still reversible compared to the stress images. Some of this reduced reversibility may be due to attenuation artefacts. We conclude that the routine use of GTN with rest tetrofosmin imaging will result in increased detection of ischaemic areas with no loss of sensitivity or specificity.