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CARDIAC IMAGING

Quantitative hyperemic reactivity in opposed limbs during myocardial perfusion imaging

A new marker of coronary artery disease

Jocelyn Dupuis, MD, PhD^*,*, André Arsenault, MD, Bernard Meloche, François Harel, MD, Cezar Staniloae, MD and Jean Grégoire, MD

^* Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
Department of Nuclear Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
Comprehensive Cardiovascular Center, Saint Vincent's Medical Center Manhattan, New York, New York

Manuscript received November 7, 2003; revised manuscript received February 19, 2004, accepted February 24, 2004.

^* Reprint requests and correspondence: Dr. Jocelyn Dupuis, Research Center, Montreal Heart Institute, 5000 Belanger East, Montreal, Quebec, Canada, H1T 1C8 (Email: jocelyn.dupuis{at}bellnet.ca).

OBJECTIVES: We sought to evaluate the feasibility and validity of a new method to quantify the hyperemic response of the forearms that can be incorporated into a rest myocardial perfusion protocol.

BACKGROUND: Evaluation of the hyperemic response could provide useful clinical information in the detection and risk stratification of atherosclerotic vascular disease.

METHODS: Patients with proven coronary artery disease (CAD) (n = 46) were compared with low-risk subjects without such evidence (n = 47). A regular dose of Myoview was injected after 5 min of right arm ischemia. Three dimensionless parametric ratios (right/left) were derived from the analysis of activity-time curves of the hyperemic right forearm and that of the contralateral left forearm.

RESULTS: The maximal ingress upslope ratio was 40% lower in the CAD group (3.0 ± 0.2 vs. 4.2 ± 0.3, p < 0.0005), and the integral to peak ratio was also lower (23 ± 4 vs. 52 ± 11, p < 0.01), whereas the peak activity ratio was nonsignificantly lower (3.0 ± 0.3 vs. 3.8 ± 0.3, p = 0.07). Using a value of 3.55 for the maximal upslope ratio, this approach could predict the presence of CAD with a sensitivity of 0.70 and a specificity of 0.60.

CONCLUSIONS: This simple and noninvasive method is feasible and can discriminate between patients with known CAD and those at low risk of atherosclerosis. Refinements of this approach and its inclusion in larger clinical trials are needed to determine whether it could provide additional value to myocardial scintigraphic imaging.

Abbreviations and Acronyms   CAD = coronary artery disease   FMD = flow-mediated dilation   HDL = high-density lipoprotein   ROC = receiver operating characteristics   SHR = scintigraphic hyperemic reactivity   SPECT = single-photon emission computed tomographic

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