Considerations when measuring myocardial perfusion reserve by cardiovascular magnetic resonance using regadenoson

Nicole M Bhave, Benjamin H Freed, Chattanong Yodwut, Denise Kolanczyk, Karin Dill, Roberto M Lang, Victor Mor-Avi, Amit R Patel, Nicole M Bhave, Benjamin H Freed, Chattanong Yodwut, Denise Kolanczyk, Karin Dill, Roberto M Lang, Victor Mor-Avi, Amit R Patel

Abstract

Background: Adenosine cardiovascular magnetic resonance (CMR) can accurately quantify myocardial perfusion reserve. While regadenoson is increasingly employed due to ease of use, imaging protocols have not been standardized. We sought to determine the optimal regadenoson CMR protocol for quantifying myocardial perfusion reserve index (MPRi) - more specifically, whether regadenoson stress imaging should be performed before or after rest imaging.

Methods: Twenty healthy subjects underwent CMR perfusion imaging during resting conditions, during regadenoson-induced hyperemia (0.4 mg), and after 15 min of recovery. In 10/20 subjects, recovery was facilitated with aminophylline (125 mg). Myocardial time-intensity curves were used to obtain left ventricular cavity-normalized myocardial up-slopes. MPRi was calculated in two different ways: as the up-slope ratio of stress to rest (MPRi-rest), and the up-slope ratio of stress to recovery (MPRi-recov).

Results: In all 20 subjects, MPRi-rest was 1.78 ± 0.60. Recovery up-slope did not return to resting levels, regardless of aminophylline use. Among patients not receiving aminophylline, MPRi-recov was 36 ± 16% lower than MPRi-rest (1.13 ± 0.38 vs. 1.82 ± 0.73, P = 0.001). In the 10 patients whose recovery was facilitated with aminophylline, MPRi-recov was 20 ± 24% lower than MPRi-rest (1.40 ± 0.35 vs. 1.73 ± 0.43, P = 0.04), indicating incomplete reversal. In 3 subjects not receiving aminophylline and 4 subjects receiving aminophylline, up-slope at recovery was greater than at stress, suggesting delayed maximal hyperemia.

Conclusions: MPRi measurements from regadenoson CMR are underestimated if recovery perfusion is used as a substitute for resting perfusion, even when recovery is facilitated with aminophylline. True resting images should be used to allow accurate MPRi quantification. The delayed maximal hyperemia observed in some subjects deserves further study.

Trial registration: ClinicalTrials.gov NCT00871260.

Figures

Figure 1
Figure 1
CMR protocol. Perfusion imaging sequences are separated by 15-min intervals as shown.
Figure 2
Figure 2
A. Example of myocardial tracing and segmentation in a short-axis slice. Endocardial border is shown in green and epicardial border in yellow. The LV myocardium was segmented into 4 sectors (anterior, lateral, inferior, septal). B. Blood pool and segmental myocardial time-intensity curves. Maximum up-slopes (black lines) were determined for the blood pool and for each myocardial segment; the mean myocardial up-slope was then normalized to the blood pool up-slope.
Figure 3
Figure 3
Comparison of perfusion up-slopes at stress and recovery, normalized for rest up-slope, on a per-patient basis. Four subjects in the aminophylline group and 3 subjects in the no-aminophylline group had greater perfusion at recovery than at stress. * P < 0.001; † P = 0.08; **P = 0.02; ‡ P = 0.01; ʃ P = 0.38

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