The prognostic value of the heart rate response to adenosine in relation to diabetes mellitus and chronic kidney disease

doi:10.1016/j.ahj.2011.05.014

American Heart Journal

Volume 162, Issue 2, August 2011, Pages 356-362

https://doi.org/10.1016/j.ahj.2011.05.014 Get rights and content

Background

Myocardial perfusion imaging (MPI) is a useful method for risk assessment in patients with diabetes mellitus (DM) and chronic kidney disease (CKD), but these patients have a residual risk that is not accounted for by MPI. The objective of this study is to determine whether the heart rate response (HRR) to adenosine has an incremental prognostic value to MPI in high-risk patients.

Methods

The study group included 879 (age 61 ± 13 years, 48% women, 58% white, 40% DM, 49% CKD) consecutive patients who underwent adenosine MPI. Chronic kidney disease was defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m² or dialysis replacement therapy. An HRR <10% (change from baseline) was considered blunted. The outcome of interest was overall mortality.

Results

During a follow-up period of 40 ± 14 months, 212 patients (24%) died. Patients with DM (23.4% ± 16.3% vs 29.4% ± 21.4%, P < .0001) and CKD (22.7% ± 17.6% vs 30.5% ± 20.4%, P < .0001) had lower HRR as compared with patients without DM and CKD, respectively. A blunted HRR was associated with increased mortality in the overall population and in those with DM and CKD and helped in risk stratification when added to traditional MPI findings. In a Cox regression model, a blunted HRR was the strongest predictor of mortality (hazard ratio 2.8, P < .0001) and provided additional prognostic data to MPI (hazard ratio 1.9, P < .0001) after controlling for age, gender, race, history of myocardial infarction, DM, CKD, β-blocker use, and presence of chest pain.

Conclusions

A blunted HRR to adenosine is an independent predictor of poor outcome, adds incremental value to MPI, and helps in better risk stratification in high-risk patient groups.

Section snippets

Study population

The study population consisted of all patients who underwent adenosine MPI at the University of Alabama at Birmingham Hospital during a 4-month period extending from September to December of 2006. Patients with previous kidney transplants were excluded (n = 3). Patients who lacked data on the baseline and/or peak heart rate during the adenosine MPI were also excluded (n = 8). Variables extracted from the medical records included patient demographics (age, gender, race), comorbidities (history

Results

The study population consisted of 879 patients who underwent adenosine MPI. The baseline characteristics of the population are listed in Table I. Almost one-half had CKD, and 40% had DM. The HRR in the entire population was 27.1% ± 20% (median 23.9%, interquartile range 12.5-37.7%). More than one-third had an HRR ≥30% (n = 324, 37%), whereas 20% had an HRR <10%, which was defined as blunted (n = 177). Patients with a blunted HRR were slightly older; more often male; and had a higher prevalence

Discussion

The major finding of this study is that the HRR to adenosine is an independent prognosticator and that it can be used to supplement traditional MPI findings to further risk stratify high-risk patients such as those with DM and CKD. Multiple known risk factors such as DM, CKD, age, gender, and LVEF influence the HRR, making it an ideal reflection of overall risk; and furthermore, a blunted HRR strongly predicts risk on top of all of these factors.

It is possible that the HRR to adenosine is a

Disclosures

None.

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Clinical InvestigationDiabetes and MetabolismThe prognostic value of the heart rate response to adenosine in relation to diabetes mellitus and chronic kidney disease

Background

Methods

Results

Conclusions

Section snippets

Study population

Results

Discussion

Disclosures

American heart journal

Am J Cardiol

Am J Cardiol

J Nucl Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Nucl Cardiol

Am J Cardiol

Lancet

Clinical Investigation
Diabetes and Metabolism
The prognostic value of the heart rate response to adenosine in relation to diabetes mellitus and chronic kidney disease