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==Perfusion Scintigraphy with Pharmacologic Stress==
==Perfusion Scintigraphy with Pharmacologic Stress==
Many patients with known or suspected [[angina pectoris]] are unable to perform adequate exercise tests owing to [[peripheral vascular disease]], musculoskeletal disorders, diseases of the lower extremities, severe [[obesity]], or deconditioning.  Myocardial perfusion scintigraphy during pharmacologic stress can be employed in these groups of patients.


*Non endothelium dependent coronary vasodilators such as [[dipyridamole]] or [[adenosine]] can be used to increase flow to the non ischemic myocardial segments. During the test they produce perfusion defects in ischemic areas that can be detected by scintigraphy.  
*Many patients with known or suspected [[angina pectoris]] are unable to perform adequate exercise tests owing to [[peripheral vascular disease]], musculoskeletal disorders, diseases of the lower extremities, severe [[obesity]], or deconditioning. Myocardial perfusion scintigraphy during pharmacologic stress can be employed in these groups of patients.  


*Alternatively, [[dobutamine]] can be used to increase [[heart rate]] and contractility, which increases myocardial oxygen demand, and this too may compromise perfusion of ischemic areas; the resultant [[ischemia]] can be detected by perfusion scintigraphy.
:*Non endothelium dependent coronary vasodilators such as [[dipyridamole]] or [[adenosine]] can be used to increase flow to the non ischemic myocardial segments. During the test they produce perfusion defects in ischemic areas that can be detected by scintigraphy.  
[[Dobutamine]] may cause true [[myocardial ischemia]], not simply a relative increase in flow to nonischemic myocardium. Hence, it must be administered carefully with close monitoring and rapid cessation for potential symptomatic ischemia.  


All three of these pharmacologic stress tests have diagnostic accuracies (sensitivity, specificity, and predictive values) comparable with those of exercise perfusion scintigraphy.
:*Alternatively, [[dobutamine]] can be used to increase [[heart rate]] and contractility, which increases myocardial oxygen demand, and this too may compromise perfusion of ischemic areas; the resultant [[ischemia]] can be detected by perfusion scintigraphy. [[Dobutamine]] may cause true [[myocardial ischemia]], not simply a relative increase in flow to nonischemic myocardium. Hence, it must be administered carefully with close monitoring and rapid cessation for potential symptomatic ischemia.  


Both dipyridamole and adenosine produce similar side effects, which consist of [[bronchospasm]], [[flushing]], [[dizziness]], [[headache]], [[nausea]], atypical chest pain, and throat or jaw pain. [[Dipyridamole]] infusion has been reported to induce severe myocardial ischemia and, rarely, myocardial infarction. [[Adenosine]], on the other hand, can produce significant bradyarrhythmias. Adenosine stress tests are therefore contraindicated in patients with [[atrioventricular block]] and [[sick sinus syndrome]].
*All three of these pharmacologic stress tests have '''diagnostic accuracies''' (sensitivity, specificity, and predictive values) comparable with those of exercise perfusion scintigraphy.


==ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Diagnosis in Patients With Chronic Stable Angina Who Are Unable to Exercise (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref>==
*Both [[dipyridamole]] and [[adenosine]] produce similar '''side effects''', which consist of [[bronchospasm]], [[flushing]], [[dizziness]], [[headache]], [[nausea]], atypical chest pain, and throat or jaw pain.
:*[[Dipyridamole]] infusion has been reported to induce severe [[myocardial ischemia]] and, rarely, myocardial infarction.
:*[[Adenosine]], on the other hand, can produce significant bradyarrhythmias. Adenosine stress tests are therefore '''contraindicated''' in patients with [[atrioventricular block]] and [[sick sinus syndrome]].
 
==ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Diagnosis in Patients With Chronic Stable Angina Who Are Unable to Exercise (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
{{cquote|
{{cquote|
===Class I===
===Class I===
Line 27: Line 29:
:a. Electronically paced ventricular rhythm. ''(Level of Evidence: C)''
:a. Electronically paced ventricular rhythm. ''(Level of Evidence: C)''
:b. [[Left bundle-branch block]]. ''(Level of Evidence: B)''}}
:b. [[Left bundle-branch block]]. ''(Level of Evidence: B)''}}
==ESC Guidelines for the use of exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
{{cquote|
===Class I===
'''1.''' Patients with [[Chronic stable angina electrocardiography|resting ECG]] abnormalities, [[LBBB]], more than 1 mm [[ST-depression]], paced rhythm, or [[WPW]] which prevent 12 ESC Guidelines accurate interpretation of ECG changes during stress. ''(Level of Evidence: B)''
'''2.''' Patients with a non-conclusive [[Chronic stable angina exercise electrocardiography|exercise ECG]] but reasonable exercise tolerance, who do not have a high probability of significant [[coronary artery disease]] and in whom the diagnosis is still in doubt. ''(Level of Evidence: B)''
===Class IIa===
'''1.''' Patients with prior [[revascularization]] ([[PCI]] or [[CABG]]) in whom localization of [[ischaemia]] is important. ''(Level of Evidence: B)''
'''2.''' As an alternative to [[Chronic stable angina exercise electrocardiography|exercise ECG]] in patients where facilities, cost, and personnel resources allow. ''(Level of Evidence: B)''
'''3.''' As an alternative to [[Chronic stable angina exercise electrocardiography|exercise ECG]] in patients with a low pre-test probability of disease such as women with atypical chest pain. ''(Level of Evidence: B)''
'''4.''' To assess functional severity of intermediate lesions on coronary arteriography. ''(Level of Evidence: C)''
'''5.''' To localize [[ischaemia]] when planning [[revascularization]] options in patients who have already had arteriography. ''(Level of Evidence: B)''}}


==See Also==
==See Also==
Line 32: Line 52:


==Sources==
==Sources==
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>
 
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref>
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Disease state]]
[[Category: Disease state]]  
[[Category:Ischemic heart diseases]]
[[Category: Ischemic heart diseases]]
[[Category:Cardiology]]
[[Category: Cardiology]]
[[Category:Emergency medicine]]
[[Category: Emergency medicine]]


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Revision as of 05:09, 19 July 2011

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editor-in-Chief: Smita Kohli, M.D.

Perfusion Scintigraphy with Pharmacologic Stress

  • Many patients with known or suspected angina pectoris are unable to perform adequate exercise tests owing to peripheral vascular disease, musculoskeletal disorders, diseases of the lower extremities, severe obesity, or deconditioning. Myocardial perfusion scintigraphy during pharmacologic stress can be employed in these groups of patients.
  • Non endothelium dependent coronary vasodilators such as dipyridamole or adenosine can be used to increase flow to the non ischemic myocardial segments. During the test they produce perfusion defects in ischemic areas that can be detected by scintigraphy.
  • Alternatively, dobutamine can be used to increase heart rate and contractility, which increases myocardial oxygen demand, and this too may compromise perfusion of ischemic areas; the resultant ischemia can be detected by perfusion scintigraphy. Dobutamine may cause true myocardial ischemia, not simply a relative increase in flow to nonischemic myocardium. Hence, it must be administered carefully with close monitoring and rapid cessation for potential symptomatic ischemia.
  • All three of these pharmacologic stress tests have diagnostic accuracies (sensitivity, specificity, and predictive values) comparable with those of exercise perfusion scintigraphy.

ACC / AHA Guidelines- Cardiac Stress Imaging as the Initial Test for Diagnosis in Patients With Chronic Stable Angina Who Are Unable to Exercise (DO NOT EDIT)[1]

“

Class I

1. Adenosine or dipyridamole myocardial perfusion imaging or dobutamine echocardiography in patients with an intermediate pretest probability of CAD. (Level of Evidence: B)

2. Adenosine or dipyridamole stress myocardial perfusion imaging or dobutamine echocardiography in patients with prior revascularization (either PTCA or CABG). (Level of Evidence: B)

Class IIb

1. Adenosine or dipyridamole stress myocardial perfusion imaging or dobutamine echocardiography in patients with a low or high probability of CAD in the absence of electronically paced ventricular rhythm or left bundle-branch block. (Level of Evidence: B)

2. Adenosine or dipyridamole myocardial perfusion imaging in patients with a low or high probability of CAD and 1 of the following baseline ECG abnormalities:

a. Electronically paced ventricular rhythm. (Level of Evidence: C)
b. Left bundle-branch block. (Level of Evidence: B)
 ”

ESC Guidelines for the use of exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT)[2]

“

Class I

1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST-depression, paced rhythm, or WPW which prevent 12 ESC Guidelines accurate interpretation of ECG changes during stress. (Level of Evidence: B)

2. Patients with a non-conclusive exercise ECG but reasonable exercise tolerance, who do not have a high probability of significant coronary artery disease and in whom the diagnosis is still in doubt. (Level of Evidence: B)

Class IIa

1. Patients with prior revascularization (PCI or CABG) in whom localization of ischaemia is important. (Level of Evidence: B)

2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B)

3. As an alternative to exercise ECG in patients with a low pre-test probability of disease such as women with atypical chest pain. (Level of Evidence: B)

4. To assess functional severity of intermediate lesions on coronary arteriography. (Level of Evidence: C)

5. To localize ischaemia when planning revascularization options in patients who have already had arteriography. (Level of Evidence: B)

”

See Also

Sources

  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [2]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [3]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [4]

References

  1. ↑ 1.0 1.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
  2. ↑ 2.0 2.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  3. ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758
  4. ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72. DOI:10.1161/CIRCULATIONAHA.107.187930 PMID: 17998462


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