ASNC clinical updateAdenosine stress protocols for myocardial perfusion imaging
Section snippets
Issues
About 1 million patients undergo adenosine stress myocardial perfusion imaging each year. Some publications have used reduced lengths of adenosine infusion at variance with the current American Society of Nuclear Cardiology (ASNC) standards. Some nuclear laboratory directors are using or are considering use of the abbreviated adenosine protocols. Also, the US Food and Drug Administration has approved the use of adenosine with thallium. However, the use of adenosine with technetium 99m sestamibi
Background
A review of several large multicenter, prospective, blinded studies comparing adenosine (by a continuous, 6-minute infusion of 140 μg · kg−1 · min−1) with exercise thallium 201 single photon emission computed tomography (in a crossover fashion) has confirmed the safety of adenosine imaging and demonstrated a high degree of diagnostic agreement between these two stress modalities. Several other studies have also demonstrated the efficiency and tolerability of the adenosine infusion at 140 μg · kg−1 · min
Summary
Although there are no large randomized, blinded, prospective trials comparing 3- or 4-minute protocols with the 6-minute adenosine infusion protocol, there has been a history of clinical use of a 4-minute protocol with favorable results.
Kinetic data for adenosine define that the minimum time to injection of tracer should be 2 minutes to provide adequate time to achieve maximal vasodilation, and that the maximal vasodilation should continue for 2 minutes to ensure adequate uptake for both
Recommendations
ASNC continues to recommend the 6-minute infusion protocol for adenosine stress myocardial perfusion imaging as defined in the imaging guidelines.17
The 4-minute adenosine protocol is a reasonable alternative based on the known kinetics of adenosine, the established blood clearance of radiotracers, and the presently published patient series that show comparable sensitivities. In this protocol we recommend injection of tracer at the 2-minute mark, allowing 2 minutes for circulation time.
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Prepared by the American Society of Nuclear Cardiology Quality Assurance Subcommittee for Laboratory Quality, Benjamin D. McCallister, Jr, MD, Chair.
Reviewed by members of the American Society of Nuclear Cardiology Quality Assurance Committee: Edward P. Ficaro, PhD, Chair; Olakunle O. Akinboboye, MBBS, MPH, MBA, Pamela S. Appledorn, CNMT, NCT, Elias H. Botvinick, MD, Floyd W. Burke, MD, Ji Chen, PhD, Frank P. DiFilippo, PhD, David K. Glover, PhD, Richard A. Goldstein, MD, MBA, Darcy L. Green Conaway, MD, Gabriel B. Grossman, MD, PhD, Christopher L. Hansen, MD, Robert C. Hendel, MD, Milena J. Henzlova, MD, Howard C. Lewin, MD, John J. Mahmarian, MD, Haresh Majmundar, CNMT, RT(N), Rupa Mehta, MD, Vahini V. Naidoo, MD, Robert A. Quaife, MD, Joseph G. Rajendran, MD, Patty Reames, CNMT, RT[R], NCT, Vincent J. B. Robinson, MD, Raymond R. Russell III, MD, PhD, Cesar A. Santana, MD, PhD, Albert J. Sinusas, MD, Massimiliano Szulc, PhD, E. Lindsey Tauxe, CNMT, MEd, Peter L. Tilkemeier, MD, Aseem Vashist, MD, R. Parker Ward, MD, Yvonne J. Weaver, MD, and David G. Wolinsky, MD.
Approved by the American Society of Nuclear Cardiology Board of Directors, March 2, 2007.
Reprint requests: American Society of Nuclear Cardiology, 4550 Montgomery Ave, Suite 780 North, Bethesda, MD 20814