Coronary vasodilation by the use of sublingual nitroglycerin on coronary dual source CT angiography

Transcription

1 Coronary vasodilation by the use of sublingual nitroglycerin on coronary dual source CT angiography Poster No.: 446 Congress: ESCR 2012 Type: Authors: Keywords: DOI: Scientific Exhibit M. Okada 1, Y. Nakashima 2, N. Matsunaga 2 ; 1 Yamaguchi/JP, 2 Ube/ JP Computer Applications-3D, CT-Angiography, Cardiac, Quality assurance /ESCR.2012.P-446 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Purpose Nitroglycerin (glyceryl trinitrate: NTG) has been used for the treatment of angina and heart failure for a long time. Nitrates increase the coronary blood flow in the epicardial coronary arteries by vasodilation (Fig 1: coronary CTA before the administration of NTG to Fig 2:coronary CTA after the use of NTG). The purpose of our study was to assess the impact of sublingual nitroglycerin on coronary dual-source CT angiography (CTA) in same patients using dual-source CT without heart rate control. The coronary diameter, vasodilation ratio (VR), mean attenuation, signal-to-noise ratio (SNR) and contrast-tonoise ratio (CNR) were measured in each coronary segment, before and after the administration of nitroglycerin. Images for this section: Page 2 of 15

3 Fig. 1: Coronary CTA before the use of NTG Page 3 of 15

4 Fig. 2: Coronary CTA after the use of NTG Page 4 of 15

5 Methods and Materials Between August 2010 and November 2011, fifty-two patients (15 male and 37 female, mean age: 65.9 ± 9.6 years, age range: years, mean body weight: 56.3 ± 9.3 kg, BMI: 23.0 ± 3.4 kg/m 2 ) suspected to have atypical chest pain were prospectively included in this study (Table 1) and underwent coronary CTA before and after nitroglycerin using dual-source CT (DSCT; Somatom Definition, Siemens Healthcare, Forchheim, Germany). The local institutional review board approved this study, and written informed consent was obtained from each patient. The patients suspected to have typical effort angina or with a previous history of percutaneous coronary intervention or coronary artery bypass graft surgery were excluded from the study. The patients with renal dysfunction were also excluded from this study. We evaluated 15 coronary segments according to the AHA classification and a segment-based (#1 to #15, including high lateral branch), vessel-based (right coronary artery: RCA, left coronary artery including left main trunk: LCA, left circumflex artery: LCx), major (#1-3, #5-7, #11, #13) or minor segment (#4PD, #4PL, #8-10,#12,#14,#15) and patient-based analysis were performed to determine the VR, SNR and CNR. The image quality of coronary CTA was evaluated by two readers before and after administration of sublingual nitroglycerin. Results All subjects completed the study without any complications. Nitroglycerin caused a small but significant systemic effect, and there was a 10.6 % decrease in systolic blood pressure (from ± 22.9 mm Hg to ± 17.0 mm Hg), a 9.1 % decrease in diastolic blood pressure (from 78.0 ± 11.6 mmhg to 70.9 ± 10.3 mmhg) (Table 1), 6.5 % increase in HR (from 72.2 ± 16.3 to 76.9 ± 15.5 beats/min, p < 0.001) and a % decrease in HR variability (from13.1 ± 20.2 to 10.0 ± 18.5 beats/min, p=0.19) (Table 2). With the significant increase in HR by the use of nitroglycerin, the optimal reconstruction phase of the right and left coronary arteries on coronary CTA was slightly shifted from the diastolic (the percentage of diastolic reconstruction: 50.0 % in RCA and 50.0 % in LCA) to the systolic phase (the percentage of diastolic reconstruction: 44.2 % in RCA and 46.2 % in LCA) in both coronary arteries by the use of nitroglycerin, but there was no significant difference in the optimal reconstruction window of coronary CTA or radiation exposure using the CT dose index volume (CTDI) on both scan protocols (Table 2). The vasodilation ratio (VR) of each segment is listed in Table 3, and ranged from 7.54 % (#5) to % (high lateral branch) and the mean VR on coronary CTA was % when sublingual nitroglycerin was used. The VR in minor segments (16.91 ± %) was larger than that in major segments (11.35 ± 9.72 %) and, a higher correlation was Page 5 of 15

6 noted between the baseline cross-sectional diameter and VR (r=-0.52, r 2 =0.27, p<0.001) (Table 4). The patients-based analysis showed a moderate correlation between the VR and baseline cross-sectional coronary diameter (r = -0.48, p < 0.001) (Figure 3). The VR was smaller in the LAD, including the LMT (11.97 ± %), but a higher correlation was noted in the LAD (r=-0.53) than in the RCA (-0.46) or LCx (r=-0.38) (Table 4). With regard to the baseline cross-sectional diameter, the mean diameter of the LAD was similar to that of the RCA, but the ratios of evaluable coronary segments and VR were lower in the LAD than those in the RCA, because the LAD included more small branches, such as #8, #9 and #10 (Table 3). The low VR of #5-6 with large coronary diameters also have led to the low VR of the LAD. The number of patients who were evaluable for their mean attenuation, CNR or SNR of the coronary lumen was lower than that for the coronary diameter (Tables 3 and 5), because the small branch did not have a large enough coronary lumen to place the ROI, even using a small fixed ROI (1.0 mm 2 ). The mean attenuation of the coronary lumen significantly increased and the SD of the coronary lumen decreased after the administration of nitroglycerin, but there were no differences between mean attenuation and SD of the ascending aorta by the additional administration of contrast material (Table 2). However, the SNR and CNR of the coronary lumen significantly increased after administration of nitroglycerin by the patients- and vessel-bias except for the LCx (Table 5). Before the use of nitroglycerin, the mean attenuation, SNR and CNR had a fair to moderate correlation with the baseline cross-sectional coronary diameter (mean attenuation: r = 0.49, SNR: r = 0.37, CNR: r = 0.32, p < by patient-bias) without minor segments (CNR: r = 0.06, p = 0.28) (Table 6). Image scoring was performed by two readers (15- and 10-years of experience with cardiovascular imaging) showed high scores in both coronary CTA images before or after the use of nitroglycerin. The patient-based analysis showed no significant differences in the coronary CTA images using DSCT related to the use of nitroglycerin, but on the vessel-based analysis, there was a slight improvement of the coronary CTA image scoring of the RCA in reader 1 after the use of nitroglycerin. However, there were good to excellent agreements on image scoring for both readers by the patient- and vesselbased analysis (ICC ranging from , p < 0.001), regardless of nitroglycerin use. Images for this section: Page 6 of 15

7 Table 1: The patients characteristics Page 7 of 15

8 Table 2: The heart rate, heart rate variability, reconstruction window and radiation exposure during coronary CTA by the use of nitroglycerin Page 8 of 15

9 Table 3: The evaluable coronary number and mean diameters of each coronary segment by the use of nitroglycerin Page 9 of 15

10 Table 4: The correlation between mean cross-sectional diameter and vasodilation ratio Page 10 of 15

11 Table 5: The mean coronary lumen attenuation, SNR and CNR by the use of nitroglycerin Page 11 of 15

12 Table 6: The correlation between the cross-sectional diameter and coronary lumen attenuation, CNR and SNR Page 12 of 15

13 Conclusion Routine administration of sublingual nitroglycerin spray should be recommended to dilate the coronary lumen and increase the evaluable number of coronary segments. Further evaluation of the influence of sublingual nitroglycerin spray is necessary for various lesions, including calcified or soft plaque lesions, and the evaluation of the epicardial coronary endothelial dysfunction would be needed in the patients with atypical chest pain in the presence of nitroglycerin. References 1) Vanhoenacker PK, Heijenbrok-Kal MH, Van Heste R, Decramer I, Van Hoe LR, Wijns W, Hunink M. Diagnostic performance of multidetector CT angiography for assessment of coronary artery disease: meta-analysis. Radiology 2007; 244 : ) Weustink AC, Meijboom WB, Mollet NR, Otsuka M, Pugliese F, van Mieghem C, Malago R, van Pelt N, Dijkshoom ML, Cademartiri F, Krestin GP De Feyter PJ. Reliable high-speed coronary computed tomography in symptomatic patients. J Am Coll Cardiol 2007; 50 : ) Hamon M, Biondi-Zoccai GG, Malagutti P, Agostoni P, Morello R, Valgimigli M, Hamon M. Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 2006; 48: ) Schoepf UJ, Becker CR, Ohnesorge BM, Yucel EK. CT of coronary artery disease. Radiology 2004; 232: ) Gerber TC, Breen JF, Kuzo RS, Kantor B, Williamson EE, Safford RE, Morin RL. Computed tomographic angiography of the coronary arteries: techniques and applications. Semin Ultrasound CT MR2006; 27: ) Vanovermeire OM, Duerinckx AJ. A practical approach to 64-slice coronary CT angiography. JBR-BTR2006; 89:1-7 7) Murel W. Nitroglycerin as a remedy for angina pectoris. Lancet. 1879; 1: 80. 8) Kleschyov AL, Oelze M, Daiber A, Huang Y, Mollnau H, Schulz E, Sydow K, Fichtlscherer B, Mulsch A, Munzel T. Does nitric oxide mediate the vasodilator activity of nitroglycerin? Circ Res. 2003; 93: e104-e112. Page 13 of 15

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