Benefits of combined pharmacologic and submaximal exercise stress on Sub-diaphragmatic activity in myocardial perfusion scintigraphy

Document Type : Original Article


1 Research Center for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Nuclear Medicine, Vali-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran


Introduction: Myocardial perfusion imaging (MPI) is an important imaging modality in managing patients with cardiovascular disease. MPI has a significant role in diagnosis and management of cardiovascular disease; however it is subjected to different artifacts. Combining pharmacologic stress with submaximal exercise reduces side effects, improves image quality, and enhances the detection of ischemia, compared with suboptimal exercise or vasodilator stress alone.
Methods: 97 patients (62 males and 35 females) which were randomly allocated into two groups were studied using gated single-photon emission computed tomography (SPECT) imaging. The patients were randomly allocated into two different groups: dipyridamole or dipyridamole combined with submaximal exercise group. Subsequently, they were imaged at 15, 60, 120, and 180 minutes after radiotracer injection.
Results:97 patients with an average age of 57.1 were compared 15, 60, 120 and 180 minutes after radiotracer injection. Comparing dipyridamole and dipyridamole submaximal exercise group a significant difference in target areas (myocardium, inferior and lateral wall) count ratio to both liver and colon count ratio was observed (P < 0.05) up to 120 min; However 180 minutes after the injection the difference between average count ratios of the myocardium to that of the visceral activity was only significant for the colon (P < 0.05).
Conclusion: A protocol that combines submaximal exercise with dipyridamole stress is highly effective in improvingthe average count ratio of myocardial walls compared to visceral activity.


Main Subjects

  1. Roth GA, Huffman MD, Moran AE, Feigin V, Mensah GA, Naghavi M, Murray CJ. Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation. 2015 Oct 27;132(17):1667-78.
  2. Burrell S, MacDonald A. Artifacts and pitfalls in myocardial perfusion imaging. J Nucl Med Technol. 2006 Dec;34(4):193-211; quiz 212-4.
  3. Fathala A. Myocardial perfusion scintigraphy: techniques, interpretation, indications and reporting. Ann Saudi Med. 2011 Nov-Dec;31(6):625-34.
  4. Brown KA. Exercise-dipyridamole myocardial perfusion imaging: the circle is now complete. J Nucl Med. 1993 Dec;34(12):2061-3.
  5. van Dongen AJ, van Rijk PP. Minimizing liver, bowel, and gastric activity in myocardial perfusion SPECT. J Nucl Med. 2000 Aug;41(8):1315-7.
  6. Fallahi B, Beiki D, Salehi Y, Emami-Ardekani A, Fard-Esfahani A, Aghahosseini F, Haghighatafshar M, Eftekhari M. Reverse perfusion pattern in myocardial perfusion imaging using technetium-99m-sestamibi in patients with intermediate risk for coronary artery disease in relation to the time of acquisition and intensity of visceral uptake as artifactual causes. Nucl Med Commun. 2017 Jan;38(1):15-20.
  7. Samady H, Wackers FJ, Joska TM, Zaret BL, Jain D. Pharmacologic stress perfusion imaging with adenosine: role of simultaneous low-level treadmill exercise. J Nucl Cardiol. 2002 Mar-Apr;9(2):188-96.
  8. Stern S, Greenberg ID, Corne R. Effect of exercise supplementation on dipyridamole thallium-201 image quality. J Nucl Med. 1991 Aug;32(8):1559-64.
  9. Casale PN, Guiney TE, Strauss HW, Boucher CA. Simultaneous low level treadmill exercise and intravenous dipyridamole stress thallium imaging. Am J Cardiol. 1988 Oct 1;62(10 Pt 1):799-802.
  10. Thomas GS, Prill NV, Majmundar H, Fabrizi RR, Thomas JJ, Hayashida C, Kothapalli S, Payne JL, Payne MM, Miyamoto MI. Treadmill exercise during adenosine infusion is safe, results in fewer adverse reactions, and improves myocardial perfusion image quality. J Nucl Cardiol. 2000 Sep-Oct;7(5):439-46.
  11. Elliott MD, Holly TA, Leonard SM, Hendel RC. Impact of an abbreviated adenosine protocol incorporating adjunctive treadmill exercise on adverse effects and image quality in patients undergoing stress myocardial perfusion imaging. J Nucl Cardiol. 2000 Nov-Dec;7(6):584-9.
  12. Cullom SJ, Hsu B, Phillips R, Bateman TM. Very early post-stress (<6min) myocardial perfusion SPECT with Tc-99m-tetrofosmin. J Nucl Med. 2008; 49 (Suppl 1):126P.
  13. Jain D, Wackers FJ, Mattera J, McMahon M, Sinusas AJ, Zaret BL. Biokinetics of technetium-99m-tetrofosmin: myocardial perfusion imaging agent: implications for a one-day imaging protocol. J Nucl Med. 1993 Aug;34(8):1254-9.