Evolution of symptoms in patients with stable angina after normal regadenoson myocardial perfusion imaging: The Radionuclide Imaging and Symptomatic Evolution study (RISE)

doi:10.1007/s12350-020-02298-8

Journal of Nuclear Cardiology

Volume 29, Issue 2, April 2022, Pages 612-621

https://doi.org/10.1007/s12350-020-02298-8 Get rights and content

Abstract

Background

Assessment of quality of life in patients with stable angina and normal gated single-photon emission computed tomography myocardial perfusion imaging (MPI) remains undefined. Symptom evolution in response to imaging findings has important implications on further diagnostic testing and therapeutic interventions.

Methods

Prospective cohort study was conducted at the University of Alabama at Birmingham enrolling 87 adult participants with stable chest pain from the emergency room, hospital setting, and outpatient clinics. Patients underwent MPI with technetium-99m Sestamibi and had a normal study. Participants filled out Seattle Angina Questionnaires initially and at 3-month follow-up.

Results

Among the 87 participants (60 ± 12 years; 40% African American, 70% women, 29% diabetes), the mean score increased by an absolute value of 14.2 [95% CI 10.4–18.7, P < .001] in physical limitation, 23.2 [95% CI 17.1–29.4, P < .001] in angina stability, 10.9 [95% CI 7.6–14.1, P < .001] in angina frequency, and 20.6 [95% CI 16.5–24.7, P < .001] in disease perception. There was no significant change in the mean score of treatment satisfaction [− 1.4, 95% CI − 4.7 to 1.8, P = .38]. At 3-month follow-up, 28 of 87 participants (32%) were angina free.

Conclusions

Patients with stable chest pain and normal MPI experience significant improvement in functional status, quality of life, and disease perception in the short term.

Introduction

Chest pain of suspected cardiac origin is one of the most common presenting complaints across the United States, with an estimated 9 million adults living with chronic stable angina.1, 2, 3 The diagnostic investigation and management of patients presenting with suspected cardiac chest pain or its equivalence is a common dilemma faced by medical providers. Given the myriad of possibilities as to the cause of chest pain, clinical care pathway models have been developed which often include cardiac stress testing with imaging such as single-photon emission computed tomography myocardial perfusion imaging (MPI) to evaluate for myocardial ischemia.⁴

MPI provides diagnostic and risk stratification information that guides clinical management.⁵ In general, a normal MPI is associated with low risk of future adverse cardiovascular events and is therefore reassuring to the patient and referring provider.6, 7, 8 However, both patients and providers are increasingly focusing on quality of life (QOL) domains in addition to hard cardiovascular outcomes.⁹The change in symptoms and QOL measures in patients after undergoing a normal MPI has important implications on the implementation of further diagnostic tests and procedures in addition to therapeutic interventions in symptomatic patients. The aim of this study is to assess the evolution of symptoms after a normal MPI in patients with or suspected of having stable coronary artery disease (CAD) by serial administration of the Seattle Angina Questionnaire (SAQ).¹⁰

Section snippets

Methods

The Radionuclide Imaging and Symptomatic Evolution study (RISE) is a prospective cohort study conducted at the University of Alabama at Birmingham (UAB) and The Kirklin Clinic. The study was approved by the Institutional Review Board at UAB and was performed in accordance with the ethical standards laid down in the 1975 Declaration of Helsinki and its later amendments. The participants were enrolled between November 2015 and February 2016, with data collection completed by June 2016.

Baseline Clinical Characteristics

Of the 104 patients we screened for the study, 15 had abnormal perfusion and were excluded per protocol. Another 2 patients completed the initial SAQ but were lost to follow-up and were excluded from the analysis. Follow-up was complete on the remaining 87 patients (98%) who had a normal MPI and they constituted the study cohort of the current report. The baseline characteristics of the cohort are summarized in Table 1. The age of the participants ranged from 33 to 88 with a mean of 60 years.

Discussion

According to the National Center for Health Statistics, chest pain accounts for more than 5.5 million emergency department visits annually.¹⁹ Typical angina or angina variants as a potential manifestation of underlying CAD affects approximately 20% of people 1 year after MI ²⁰^,²¹ as well as approximately 45% of those with CAD who live with chronic stable angina.²² Current American College of Cardiology Foundation/American Heart Association Guidelines for the diagnosis and management of patients

Limitations

First, we used telephone follow-up at 3 months instead of in-person administration of the SAQ. This was done in order to improve loss to follow-up as much as possible. We attempted to mitigate reporting bias by informing patients that responses would not be disclosed to their physicians and would not affect clinical management. Second, our assessment was based on patient assessment of their symptoms at 2 time points (baseline and 3 months) rather than based on a daily angina assessment

New Knowledge Gained

This study suggests that patients with chest pain who have normal MPI as part of a clinical care diagnostic pathway can be reassured that they will experience clinically meaningful improvement in their symptoms in the short term even in the absence of uptitration of anti-anginal medications or CR. Importantly, one-third of symptomatic patients referred for MPI who have a normal study become symptom free within 3 months.

Disclosures

Dr. Hage reports research Grant support from Astellas Pharma and GE Healthcare. Drs. McRee, Brice, Farag, and Iskandrian report no conflicts of interest.

References (40)

ShawLJ et al.
Prognosis in the era of comparative effectiveness research: Where is nuclear cardiology now and where should it be?
J Nucl Cardiol
(2012)
HachamovitchR et al.
Determinants of risk and its temporal variation in patients with normal stress myocardial perfusion scans: What is the warranty period of a normal scan?
J Am Coll Cardiol
(2003)
IqbalFM et al.
Comparison of the prognostic value of normal regadenoson with normal adenosine myocardial perfusion imaging with propensity score matching
JACC Cardiovasc Imaging
(2012)
HageFG et al.
The prognostic value of regadenoson myocardial perfusion imaging
J Nucl Cardiol
(2015)
SpertusJA et al.
Development and evaluation of the Seattle Angina Questionnaire: A new functional status measure for coronary artery disease
J Am Coll Cardiol
(1995)
HenzlovaMJ et al.
ASNC imaging guidelines for SPECT nuclear cardiology procedures: Stress, protocols, and tracers
J Nucl Cardiol
(2016)
Al JaroudiW et al.
Regadenoson: A new myocardial stress agent
J Am Coll Cardiol
(2009)
LesterD et al.
Prognostic value of transient ischemic dilation with regadenoson myocardial perfusion imaging
J Nucl Cardiol
(2016)
FicaroEP et al.
Corridor4DM: The Michigan method for quantitative nuclear cardiology
J Nucl Cardiol
(2007)
FihnSD et al.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
J Am Coll Cardiol
(2012)

SimonsenJA et al.

Prognosis in patients with suspected or known ischemic heart disease and normal myocardial perfusion: Long-term outcome and temporal risk variations

J Nucl Cardiol

(2013)

IskanderS et al.

Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging

J Am Coll Cardiol

(1998)

SpertusJA et al.

Monitoring the quality of life in patients with coronary artery disease

Am J Cardiol

(1994)

BurkhoffD et al.

Transmyocardial laser revascularisation compared with continued medical therapy for treatment of refractory angina pectoris: A prospective randomised trial. ATLANTIC Investigators. Angina Treatments-Lasers and Normal Therapies in Comparison

Lancet

(1999)

KimbleLP et al.

Knowledge and use of sublingual nitroglycerin and cardiac-related quality of life in patients with chronic stable angina

J Pain Symptom Manage

(2000)

LadapoJA et al.

Physician decision making and trends in the use of cardiac stress testing in the United States: An analysis of repeated cross-sectional data

Ann Intern Med

(2014)

NawarEW et al.

emergency department summary

Adv Data

(2005)

MozaffarianD et al.

Heart disease and stroke statistics-2016 update: A report from the American Heart Association

Circulation

(2016)

Mettler FA, Guiberteau MJ. Essentials of nuclear medicine imaging;...

MarkDB

Assessing quality-of-life outcomes in cardiovascular clinical research

Nat Rev Cardiol

(2016)

Cited by (3)

Review of cardiovascular imaging in the Journal of Nuclear Cardiology 2022: single photon emission computed tomography
2023, Journal of Nuclear Cardiology
In this review, we will summarize a selection of articles on single-photon emission computed tomography published in the Journal of Nuclear Cardiology in 2022. The aim of this review is to concisely recap major advancements in the field to provide the reader a glimpse of the research published in the journal over the last year. This review will place emphasis on myocardial perfusion imaging using single-photon emission computed tomography summarizing advances in the field including in prognosis, non-perfusion variables, attenuation compensation, machine learning and camera design. It will also review nuclear imaging advances in amyloidosis, left ventricular mechanical dyssynchrony, cardiac innervation, and lung perfusion. We encourage interested readers to go back to the original articles, and editorials, for a comprehensive read as necessary but hope that this yearly review will be helpful in reminding readers of articles they have seen and attracting their attentions to ones they have missed.
Stress testing and myocardial perfusion imaging for patients after recovery from severe COVID-19 infection requiring hospitalization: A single-center experience
2021, Journal of Nuclear Cardiology
As the coronavirus pandemic progresses, patients that have recovered from COVID-19-related hospitalization require resumption of care for other medical issues. Thus far, the literature has not detailed the experience of stress testing in this patient population.
We retrospectively reviewed patients that recovered from COVID-19-related hospitalizations and underwent SPECT MPI studies at the University of Alabama at Birmingham Medical Center.
15 patients (median age 60 years, 67% male) were identified with COVID-19-related hospitalization and then underwent SPECT MPI imaging after recovery. During COVID-19-related hospitalization (median length of stay 8 days), patients received various COVID-19 therapies; 3 required mechanical ventilation. Stress tests (4 Exercise, 11 Pharmacologic) were performed 65 days (interquartile range 31-94 days) after the diagnosis of COVID-19. None of the patients experienced serious adverse events during or after stress testing. One patient required regadenoson reversal using aminophylline due to chest pain.
Over time, more patients that recover from COVID-19 infection will require MPI testing for myocardial ischemia evaluation. Our study provides some information regarding performing stress testing in patients who have recently recovered from COVID-19 infections requiring hospitalization. Further studies are recommended to establish formal protocols for testing in this cohort.
Prevalence of abnormal SPECT myocardial perfusion imaging during the COVID-19 pandemic
2021, European Journal of Nuclear Medicine and Molecular Imaging

View full text

Original ArticleEvolution of symptoms in patients with stable angina after normal regadenoson myocardial perfusion imaging: The Radionuclide Imaging and Symptomatic Evolution study (RISE)

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Baseline Clinical Characteristics

Discussion

Limitations

New Knowledge Gained

Disclosures

J Nucl Cardiol

J Am Coll Cardiol

JACC Cardiovasc Imaging

J Nucl Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Am Coll Cardiol

Am J Cardiol

Lancet

J Pain Symptom Manage

Physician decision making and trends in the use of cardiac stress testing in the United States: An analysis of repeated cross-sectional data

Ann Intern Med

emergency department summary

Adv Data

Heart disease and stroke statistics-2016 update: A report from the American Heart Association

Circulation

Assessing quality-of-life outcomes in cardiovascular clinical research

Nat Rev Cardiol

Original Article
Evolution of symptoms in patients with stable angina after normal regadenoson myocardial perfusion imaging: The Radionuclide Imaging and Symptomatic Evolution study (RISE)