Arbutamine stress thallium-201 single-photon emission computed tomography using a computerized closed-loop delivery system. Multicenter trial for evaluation of safety and diagnostic accuracy

Objectives.: This study sought to evaluate the efficacy and safety of arbutamine when used in conjunction with thallium-201 single-photon emission computed tomography (SPECT) in a multicenter trial and to compare arbutamine stress and treadmill exercise thallium-201 SPECT for diagnostic sensitivity and myocardial perfusion pattern. Background.: Arbutamine is a potent beta-agonist developed specifically for pharmacologic stress testing. Methods.: Arbutamine was administered by a novel computerized closed-loop device that measures heart rate and adjusts arbutamine infusion to achieve a selected rate of heart rate increase toward a predetermined limit. The cohort included 184 patients who underwent arbutamine stress testing, of whom 122 (catheterization group) had angiographically defined coronary artery disease (≥50% diameter stenosis of a major coronary artery), and 62 had a low pretest likelihood of coronary artery disease (low likelihood group). A subset of 69 patients from the catheterization group underwent both arbutamine and exercise stress testing. Results.: Hemodynamic responses during arbutamine and exercise stress testing demonstrated no significant difference in percent increase in heart rate (81% vs. 76%) or systolic blood pressure (26% vs. 30%). The sensitivity for detecting coronary artery disease (≥50% stenosis) using arbutamine thallium-201 SPECT was 87% (95% for detecting ≥70% stenoses), and the normalcy rate in the low likelihood group was 90%. In patients completing both arbutamine and exercise stress testing, thallium-201 SPECT sensitivity for detecting coronary artery disease (≥50% stenosis) was 94% and 97% (p = NS), respectively. Furthermore, SPECT segmental visual score agreement (defect vs. no defect) showed a concordance of 92% between arbutamine and exercise results (kappa 0.80, p < 0.001). The stress thallium-201 SPECT segmental scores showed 83% exact agreement (kappa 0.69, p < 0.001), and analysis of the reversibility of segments with stress perfusion defects demonstrated 86% exact agreement (kappa 0.68, p < 0.001). In general, side effects associated with arbutamine were well tolerated and resolved with discontinuation of infusion. Conclusions.: Arbutamine, administered by a closed-loop feedback system was shown to be a safe and effective pharmacologic stress agent. Arbutamine stress thallium-201 SPECT appears to be accurate for the diagnosis of coronary artery disease with a diagnostic efficacy similar to that of treadmill exercise thallium-201 studies.