Original Article
Evaluating the use of pharmacological stress agents during single-photon emission computed tomography myocardial perfusion imaging tests after inadequate exercise stress test

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Abstract

Background

Past clinical trial findings suggest that the availability of regadenoson in a nuclear imaging center may affect real-world center practices related to the transition of patients from an inadequate exercise stress test (EST) to a pharmacological stress agent (PSA).

Methods and Results

This was a cross-sectional study using one-on-one telephone interviews with nuclear imaging center staff to facilitate survey development, followed by an online survey to evaluate patterns and processes around use of PSAs during single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in patients with inadequate ESTs. Of the 50 participants, 35 (70%) used only regadenoson, 3 (6%) only adenosine, 3 (6%) regadenoson and adenosine, 7 (14%) regadenoson and dipyridamole, and 2 (4%) all 3 agents for converting patients from an inadequate EST to a PSA. Nearly all centers (94%) used protocols to guide conversions. Of 12 centers using > 1 PSA, 11 reported regadenoson to be the most preferred PSA. Total staff time required from PSA transition to post-test monitoring was shortest for regadenoson.

Conclusions

Compared to adenosine and dipyridamole, regadenoson is preferred by nuclear imaging center staff and associated with operational efficiencies after inadequate EST in real-world practice SPECT-MPI.

Introduction

Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is a common non-invasive form of cardiac testing, with imaging performed at rest before and after exercise. Patients who are unable to exercise to an adequate workload are considered to have an inadequate exercise stress test (EST); a pharmacological stress test can be used to increase myocardial perfusion and induce flow heterogeneity in those with obstructive coronary artery disease.1,2 There are a variety of pharmacological stress agents (PSAs) available, including regadenoson, adenosine, dipyridamole, and dobutamine. Regadenoson, adenosine, and dipyridamole are cardiac vasodilators, which dilate coronary vessels to increase blood velocity and flow rate in normal vessels and cause less of a response in stenotic vessels; they are the preferred agents for MPI.2 In clinical practice, the choice of agent depends on patient characteristics, the stress imaging techniques being performed, and provider preference.

Regadenoson, administered intravenously via a pre-filled syringe,3 is one of the most widely used PSAs.4 The EXERRT (EXErcise to Regadenoson in Recovery Trial) phase 3 trial showed that administration of regadenoson could occur during recovery from the inadequate EST at the same visit, rather than in a follow-up visit.5 These clinical trial findings suggest that the availability of regadenoson in a nuclear imaging center may affect real-world center practices related to the transition of patients from an inadequate EST to a PSA.

The objective of the current study was to evaluate how PSAs are currently used for patients during SPECT-MPI assessments following an inadequate EST and, more specifically, to (1) describe the protocol/practice implemented in nuclear imaging centers to convert patients from an inadequate EST to a PSA, and (2) assess resource use and time associated with the use of regadenoson compared to other PSAs.

Section snippets

Study Design

This was a cross-sectional study utilizing an online survey conducted between June and July 2019 to evaluate the use of PSAs during SPECT-MPI tests following an inadequate EST (the survey is 27 pages and is therefore not included). One-on-one telephone interviews with staff from nuclear imaging centers were conducted to facilitate survey development. The interviews were conducted with 6 staff members from different United States (US) nuclear imaging centers: 3 nuclear technicians/technologists,

Nuclear Imaging Staff and Center Characteristics

Of the 105 respondents, 50 completed the survey and were included in the analysis. Among the 55 respondents who did not complete the survey, 46 initiated but terminated the survey before completion for unknown reasons, 6 indicated they did not work closely with patients undergoing SPECT-MPI, 2 indicated they worked at centers that only did de novo pharmacological stress tests, and 1 did not initiate completion of the survey.

Characteristics of the nuclear imaging staff and centers are summarized

Discussion

Using an online survey, this study sought to characterize the resources, best practices, and time involved in PSA use during SPECT-MPI for patients with an inadequate EST from the perspective of nuclear imaging center staff. The findings show that regadenoson was the most commonly used and most preferred PSA for conversion after an inadequate EST. Regadenoson was used by centers because of convenience and a reasonable adverse event profile. The majority of patients using regadenoson were

New Knowledge Gained

This article provides new information on the efficiency of PSA use for patients converting from EST to PSA SPECT-MPI tests in real-world settings and confirms same-day conversion occurs for the majority of patients. Past research on the testing of conversion patients has been in clinical trial settings, focused on a subset of the available stress agents on the market, or been limited to perspectives from staff at single centers. This study compares real-world use of adenosine, dipyridamole, and

Acknowledgements

Medical writing/editorial support was provided by Laurie Orloski and Stephanie Bird from Xcenda and funded by the study sponsor.

Disclosures

H Yang, E. Faust, E. Gao, and S. Sethi are employed by Analysis Group, which provides consulting services to Astellas. R.M. Kristy and, J.R. Spalding are employees of and may have equity ownership in Astellas Pharma. T.M. Kitt and Y. Xu were employees of Astellas when the study was conducted, but have remained actively involved with the development of the manuscript.

Funding

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Presented at Quality of Care and Outcomes Research 2020 Scientific Sessions, May 15–16, 2020, Reston, VA.

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