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Int J Angiol 2014; 23(03): 165-170
DOI: 10.1055/s-0034-1382290
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Angina Relief by Ranolazine Identifies False-Negative SPECT Myocardial Perfusion Scans in Patients with Coronary Disease Demonstrated by Coronary Angiography

Gary L. Murray
1   Director Medical Research, Heart and Vascular Institute, Germantown, Tennessee
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Publication History

Publication Date:
28 August 2014 (online)

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Abstract

Normal myocardial perfusion imaging (MPI) reduces intermediate- or high-risk pretest probability patients to low- or intermediate-risk posttest probability, respectively, for coronary disease (CD). Since ranolazine (RAN) relieves only angina, anginal patients with normal MPI whose angina is relieved by RAN present a significant dilemma. The purpose of this retrospective chart review was to confirm the impression that coronary angiography (CA) is indicated in patients whose class 3 to 4 angina is relieved by RAN, but have normal myocardial single-photon emission computed tomography (SPECT) MPIs. Charts of patients with stable class 3 to 4 angina (typical and atypical) and normal MPIs (left ventricular ejection fraction [LVEF] ≥50% and segmental score = 0) were reviewed. CA was done on all the patients with complete angina relief taking RAN, as well as nonresponders whose anginal etiology could not be explained. Stenoses were considered flow-restrictive when more than 70% diameter stenosis is observed by quantitative CA, or, when 50 to 70%, fractional flow reserve (FFR) measured ≤0.80. RAN relieved angina in 36 of 54 (67%) patients. Of the known cases, 25 of these 36 (69%) had 43 stenoses ≥50% (mean = 66%): 15 (60%) had 1 vessel disease; 9 (36%) had multivessel disease; 18 (72%) had left anterior descending (LAD) disease; 1 (4%) had left main disease. Twenty one of 43 (49%) stenosis were > 70%; 22 (51%) stenoses were 50 to 70% and required FFR measurement. Twenty nine of 43 stenoses (67%) were considered flow-restrictive in 18 of these 25 (72%) patients. Eight RAN nonresponders with no explanation for angina had no CD at CA. RAN angina relief is invaluable in identifying falsely negative SPECT MPI, and 50% of these patients have flow-restrictive stenoses.

Keywords

ranolazine - coronary disease - angina - myocardial SPECT perfusion - cardiac catheterization - fractional flow reserve
 

  • References

  • 1 Fihn SD, Gardin JM, Abrams J , et al; American College of Cardiology Foundation. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: 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. Circulation 2012; 126 (25) 3097-3137
    CrossrefPubMedGoogle Scholar
  • 2 Maddahi J, Rodrigues E, Kiat H , et al. Detection and evaluation of coronary artery disease by thallium-201 myocardial perfusion scintigraphy. In: De Puey EG, Berman DS, Garcia EV. , eds. Cardiac SPECT Imaging. New York, NY: Raven Press; 1995: 103-120
    Google Scholar
  • 3 Nishimura S, Mahmarian JJ, Boyce TM , et al. Quantitative Tl-201 single photon emission computed tomography during maximal pharmacological coronary vasodilatation with adenosine for assessing coronary artery disease. J Am Coll Cardiol 1991; 18 (3) 736-745
    CrossrefPubMedGoogle Scholar
  • 4 Chaitman BR, Pepine CJ, Parker JO , et al; Combination Assessment of Ranolazine In Stable Angina (CARISA) Investigators. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004; 291 (3) 309-316
    CrossrefPubMedGoogle Scholar
  • 5 Pijls NH, Sels JW. Functional measurement of coronary stenosis. J Am Coll Cardiol 2012; 59 (12) 1045-1057
    CrossrefPubMedGoogle Scholar
  • 6 De Bruyne B, Pijls NH, Kalesan B , et al; FAME 2 Trial Investigators. Fractional flow reserve-guided PCI versus medical therapy in stable coronary disease. N Engl J Med 2012; 367 (11) 991-1001
    CrossrefPubMedGoogle Scholar
  • 7 Azzarelli S, Galassi AR, Foti R , et al. Accuracy of 99mTc-tetrofosmin myocardial tomography in the evaluation of coronary artery disease. J Nucl Cardiol 1999; 6 (2) 183-189
    CrossrefPubMedGoogle Scholar
  • 8 Chammas E, Yatim A, Hage C, Sokhn K, Tarcha W, Ghanem G. Evaluation of Tc-99m tetrofosmin scan for coronary artery disease diagnosis. Asian Cardiovasc Thorac Ann 2002; 10 (3) 244-247
    CrossrefPubMedGoogle Scholar
  • 9 Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979; 300 (24) 1350-1358
    CrossrefPubMedGoogle Scholar
  • 10 Boiten HJ, van der Sijde JN, Ruitinga PR , et al. Long-term prognostic value of exercise technetium-99m tetrofosmin myocardial perfusion single-photon emission computed tomography. J Nucl Cardiol 2012; 19 (5) 907-913
    CrossrefPubMedGoogle Scholar
  • 11 Shaw LJ, Hendel R, Borges-Neto S , et al; Myoview Multicenter Registry. Prognostic value of normal exercise and adenosine (99m)Tc-tetrofosmin SPECT imaging: results from the multicenter registry of 4,728 patients. J Nucl Med 2003; 44 (2) 134-139
    PubMedGoogle Scholar
  • 12 Rozanski A, Gransar H, Hayes SW, Friedman JD, Hachamovitch R, Berman DS. Comparison of long-term mortality risk following normal exercise vs adenosine myocardial perfusion SPECT. J Nucl Cardiol 2010; 17 (6) 999-1008
    CrossrefPubMedGoogle Scholar
  • 13 Boden WE, O'Rourke RA, Teo KK , et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356 (15) 1503-1516
    CrossrefPubMedGoogle Scholar
  • 14 Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 Appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012; 59 (9) 857-881
    CrossrefPubMedGoogle Scholar
  • 15 Patel MR, Bailey SR, Bonow RO , et al. ACCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012; 59 (22) 1995-2027
    CrossrefPubMedGoogle Scholar
  • 16 Farooq V, Brugaletta S, Serruys PW. Contemporary and evolving risk scoring algorithms for percutaneous coronary intervention. Heart 2011; 97 (23) 1902-1913
    CrossrefPubMedGoogle Scholar
  • 17 Bernhard S, Möhlenkamp S, Tilgner A. Transient integral boundary layer method to calculate the translesional pressure drop and the fractional flow reserve in myocardial bridges. Biomed Eng Online 2006; 5: 42
    CrossrefPubMedGoogle Scholar
  • 18 Singh I, Subbarao R, Sadanandan S. Limitation of fractional flow reserve in evaluating coronary artery myocardial bridge. J Invasive Cardiol 2008; 20 (5) 161-166
    PubMedGoogle Scholar
  • 19 Van Herck PL, Carlier SG, Claeys MJ , et al. Coronary microvascular dysfunction after myocardial infarction: increased coronary zero flow pressure both in the infarcted and in the remote myocardium is mainly related to left ventricular filling pressure. Heart 2007; 93 (10) 1231-1237
    CrossrefPubMedGoogle Scholar
  • 20 Schannwell CM, Steiner S, Hennersdorf MG, Strauer BE. Cardiovascular end organ impairment due to hypertension [in German]. Internist (Berl) 2005; 46 (5) 496-508
    CrossrefPubMedGoogle Scholar
  • 21 Kofflard MJ, Michels M, Krams R , et al. Coronary flow reserve in hypertrophic cardiomyopathy: relation with microvascular dysfunction and pathophysiological characteristics. Neth Heart J 2007; 15 (6) 209-215
    CrossrefPubMedGoogle Scholar
  • 22 Laine GA, Allen SJ. Left ventricular myocardial edema. Lymph flow, interstitial fibrosis, and cardiac function. Circ Res 1991; 68 (6) 1713-1721
    CrossrefPubMedGoogle Scholar
  • 23 Kamínek M, Myslivecek M, Skvarilová M, Husák V, Lang O. Myocardial perfusion tomography imaging in patients without prior myocardial infarction—comparison between 201Tl, 99mTc-tetrofosmin and dual-isotope protocol (rest 201Tl/stress 99mTc-tetrofosmin) [in Czech]. Vnitr Lek 1999; 45 (2) 81-84
    PubMedGoogle Scholar
  • 24 Matsuda J, Miyamoto N, Onitsuka H , et al. One-hour protocol stress myocardial scintigraphy: prospective study of diagnostic accuracy for the detection of coronary artery stenosis [in Japanese]. J Cardiol 1999; 34 (3) 105-112
    PubMedGoogle Scholar