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Pharmacological stress testing.

M I Travain¹, J P Wexler

¹Department of Nuclear Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467-2490, USA.

Seminars in Nuclear Medicine

|October 26, 1999

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Pharmacological stress agents, including vasodilators and inotropic agents, are crucial for noninvasive assessment of coronary artery disease (CAD) using myocardial perfusion imaging. These agents offer high accuracy and safety, aiding in risk stratification for various patient groups.

Area of Science:

Nuclear Cardiology
Cardiovascular Imaging
Pharmacology

Background:

Pharmacological stress combined with radionuclide myocardial perfusion imaging is a key noninvasive method for evaluating coronary artery disease (CAD).
Over one-third of perfusion imaging studies in the U.S. utilize pharmacological stress agents, categorized as vasodilators (e.g., dipyridamole, adenosine) or inotropic agents (e.g., dobutamine, arbutamine).
These agents induce abnormalities in perfusion images by creating heterogeneity in coronary blood flow reserve, essential for diagnosing CAD.

Purpose of the Study:

To review the role and efficacy of pharmacological stress agents in radionuclide myocardial perfusion imaging for diagnosing and risk-stratifying patients with CAD.
To compare the diagnostic accuracy, safety profiles, and clinical applications of different pharmacological stress agents.
To discuss current research and future directions in developing novel pharmacological stress agents and techniques.

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Main Methods:

Review of existing literature on pharmacological stress agents used in myocardial perfusion imaging.
Analysis of pooled data on diagnostic accuracies (sensitivity and specificity) for agents like dipyridamole, adenosine, and dobutamine.
Discussion of clinical utility in risk stratification, post-myocardial infarction assessment, and pre-noncardiac surgery evaluation.

Main Results:

Both vasodilating and inotropic agents demonstrate high accuracy in diagnosing CAD with excellent safety records.
Dipyridamole shows a sensitivity of 85% and specificity of 87%, while adenosine's sensitivity ranges from 83% to 97% and specificity from 38% to 94%.
Dobutamine has a sensitivity of 82% and specificity of 75%, with potential interference with technetium-99m sestamibi uptake, making vasodilators generally preferred.

Conclusions:

Pharmacological stress testing is indispensable for radionuclide myocardial perfusion imaging, particularly for patients unable to undergo exercise stress testing.
These agents are vital for risk stratification, with normal perfusion images indicating a low annual cardiac event rate (<1%).
Ongoing research focuses on developing agents with improved receptor selectivity, fewer side effects, and novel applications like assessing myocardial viability.