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Blunted Heart Rate Response to Regadenoson is an Independent Prognostic Indicator

by Jim McGee, BA BS CNMT RT(N)  February 16, 2018

Disclaimer: This article does not purport to be a comprehensive treatment of this subject. Please consult the references & conduct your own research before making any clinical decisions.

Blunted Heart Rate Response to Regadenoson:

It is widely known that a blunted heart rate response (HRR) to exercise is usually not a good sign.

But did you know that heart rate response to regadenoson (Lexiscan) also contains valuable prognostic information, independent of perfusion & LV function results?

There is an expanding body of evidence that heart rate reponse to vasodilators is just as important as HRR to exercise.

We’ll focus on one study in particular:

A blunted heart rate response to regadenoson is an independent prognostic indicator in patients undergoing myocardial perfusion imaging

Hage, F.G., Dean, P., Iqbal, F. et al. J. Nucl. Cardiol. (2011) 18: 1086.

This article describes a study in which 1,156 patients who underwent regadenoson MPI were followed over the next 22 months.

They found that the patient’s heart rate response (HRR) to regadenoson was an independent predictor of death rate during the 22 month follow up period.

Heart rate response (HRR) was defined as:

HRR = ((max heart rate during regadenoson stress test – resting heart rate)/resting heart rate))*100)

Dividing the group into quartiles, the top quartile of patients had an HRR of 43% or greater. The second highest quartile’s HRR was between 28%-43%, the third quartile had HRR between 17%-28%, and the lowest quartile’s HRR was less than 17%.

In other words, the top quartile’s heart rate increased 43% or more after regadenoson infusion, whereas the lowest quartile’s heart rate increased less than 17% compared to their resting heart rate.

Results:

  • After adjusting for age, gender, diabetes mellitus, renal disease & MPI findings, decreasing HRR was associated with a step-wise increase in mortality.
  • Patients with HRR response in the lowest quartile had a five-fold increase in mortality compared to patients in the top quartile [HR 5.2, 95% CI 2.3-12.0, P < .0001]..

Here’s another study that shows similar results:

Prognostic value of heart rate response during regadenoson stress myocardial perfusion imaging in patients with end stage renal disease

AlJaroudi, W., Campagnoli, T., Fughhi, I. et al. J. Nucl. Cardiol. (2016) 23: 560. 

In this study, Aljaroudi et al looked at the prognostic value of HRR to regadenoson in patients with end-stage renal disease (ESRD) by prognostically following patients enrolled in the ASSUAGE and ASSUAGE-CKD trials.

They found that blunted HRR was a strong and independent predictor of death & cardiovascular events in patients with ESRD, and that blunted HRR adds incremental prognostic value.

.

Editorial in the Journal of Nuclear Cardiology:

Heart rate response to regadenoson: Making the case for its value in clinical practice

Andrikopoulou & Hage suggested that there is now sufficient data to support the use of blunted HRR to regadenoson as an independent variable when risk stratifying patients with normal perfusion results.

They proposed that blunted HRR be defined as <15%, and normal HRR as being >30%.

Investigators believe that blunted HRR to regagdenson is associated with cardiac autonomic dysfunction.

Andrikopoulou, E. & Hage, F.G. J. Nucl. Cardiol. (2016) 23: 575. 

As mentioned earlier, there have been many studies published about this topic.  What follows below is a partial list of published material.

References:

Heart rate response during vasodilator stress myocardial perfusion imaging: Mechanisms and implications

Hage, F.G. & Iskandrian, A.E. J. Nucl. Cardiol. (2010) 17: 536. 

Dipyridamole myocardial SPECT with low heart rate response indicates cardiac autonomic dysfunction in patients with diabetes

Lee, KH., Yoon, J.K., Lee, M.G. et al. J Nucl Cardiol (2001) 8: 129. 

A blunted heart rate response to regadenoson is an independent prognostic indicator in patients undergoing myocardial perfusion imaging

Hage, F.G., Dean, P., Iqbal, F. et al. J. Nucl. Cardiol. (2011) 18: 1086. 

Abnormal heart rate response with vasodilator stress myocardial perfusion imaging: Relevance to clinical practice

Dakik, H.A. J. Nucl. Cardiol. (2017) 24: 1672.

Impact of integrating heart rate response with perfusion imaging on the prognostic value of regadenoson SPECT myocardial perfusion imaging in patients with end-stage renal disease

Gomez, J., Fughhi, I., Campagnoli, T. et al. J. Nucl. Cardiol. (2017) 24: 1666.

Blunted heart rate response as a predictor of cardiac death in patients undergoing vasodilator stress technetium-99m sestamibi gated SPECT myocardial perfusion imaging

Mathur, S., Shah, A.R., Ahlberg, A.W. et al. J. Nucl. Cardiol. (2010) 17: 617.

Prognostic Impact of Hemodynamic Response to Adenosine in Patients Older Than Age 55 Years Undergoing Vasodilator Stress Myocardial Perfusion Study

Circulation. 2003;107:2894-2899  

Reclassification of cardiovascular risk in patients with normal myocardial perfusion imaging using heart rate response to vasodilator stress.

Iqbal, Fahad M. et al. American Journal of Cardiology , Volume 111 , Issue 2 , 190 – 195

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