Evaluation of Contraindications and Efficacy of Oral Beta Blockade Before Computed Tomographic Coronary Angiography

doi:10.1016/j.amjcard.2009.10.058

The American Journal of Cardiology

Volume 105, Issue 6, 15 March 2010, Pages 767-772

https://doi.org/10.1016/j.amjcard.2009.10.058 Get rights and content

Multidetector computed tomographic coronary angiography (CTA) image quality is inversely related to the heart rate (HR). As a result beta-blocking medication is routinely administered before investigation. In the present study, the use, contraindications, and efficacy of prescan beta blockade with regard to HR reduction and CTA image quality were assessed. In 537 patients referred for CTA, the baseline HR and blood pressure were measured on arrival, and contraindications for beta blockade were noted. Unless contraindicated, a single dose of metoprolol was administered orally 1 hour before data acquisition in patients with a HR of ≥65 beats/min according to a predefined medication protocol. After 1 hour, the HR was remeasured. A total of 283 patients (53%) had a HR of ≥65 beats/min. In this group, beta blockade was contraindicated in 46 patients (16%). Metoprolol was administered to the remaining 237 patients. However, 26 patients (11%) received suboptimal (lower dose than prescribed by protocol) beta blockade because of contraindications. Of the 211 patients receiving optimal beta blockade, 57 (27%) did not achieve the target HR. Of the patients with contraindications to beta blockade, 43 (60%) did not achieve the target HR. Compared to patients with optimal HR control, those receiving no or suboptimal beta blockade because of contraindications had significantly fewer examinations of good image quality (40% vs 74%, p <0.001), and significantly more examinations of poor image quality (20% vs 6%, p <0.001). In conclusion, most patients require HR reduction before CTA. Contraindications to beta blockade are present in a substantial proportion of patients. This results in suboptimal HR control and image quality, indicating the need for alternative approaches for HR reduction.

Section snippets

Methods

In consecutive patients clinically referred for CTA, information on HR before and during CTA, as well as beta-blocking medication use, were recorded. A total of 537 patients (298 men and 239 women, mean age 56 ± 18 years) were enrolled. The exclusion criteria for CTA investigation were (1) (supra)ventricular arrhythmias, (2) renal insufficiency (glomerular filtration rate <30 ml/min), (3) known allergy to iodine contrast material, (4) severe claustrophobia, and (5) pregnancy. The main clinical

Results

In the total population referred for CTA (n = 537), the mean baseline HR was 67 ± 13 beats/min. At arrival, 254 patients (47%) had a baseline HR that was less than the target HR and did not require HR reduction. In contrast, 283 patients (53%) had a baseline HR greater than the target HR and required HR reduction. In the latter group, 98 patients (35%) were already using beta blockade as a part of their baseline medication. Of the 283 patients requiring HR reduction, beta blockade was

Discussion

The present study evaluated the use and efficacy of beta blockade 1 hour before CTA in 537 consecutive patients referred for CTA. In addition, the effect on image quality was investigated. The results of our study suggest that >1/2 of the patients presenting for CTA require HR reduction before examination. The presented data suggest that oral beta-blocking administration 1 hour before CTA effectively reduces HR in most cases. However, contraindications to beta blockade are present in a

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Effectiveness of point-of-care oral ivabradine for cardiac computed tomography
2021, Journal of Cardiovascular Computed Tomography
Coronary CT angiography (CCTA) is increasing seen as a first line investigation in patients with suspected coronary artery disease. Heart-rate control improves the image quality and diagnostic accuracy of CCTA. Typically, beta-blockers are administered to induce sinus bradycardia. Sinus bradycardia may also be induced by ivabradine. We hypothesized that in a real-world population ivabradine would be an effective alternative to metoprolol at heart rate lowering for CCTA.
This was a retrospective analysis of consecutive patients who were exposed to an ivabradine-based (IB) versus a metoprolol-only (MO) protocol to achieve a target heart rate </ = 65bpm. Hemodynamic responses to both strategies were compared along with differences in cost and the time expired from medication administration to CCTA.
5955 consecutive patients were included in the analysis: 3211 were imaged during an era of a metoprolol only strategy (MO) and 2744 CCTA following an ivabradine based (IB) strategy. 2676 patients had heart rates >65 and received heart-rate lowering medication: 1958 patients had MO, and 718 received IB protocol. Target heart rate of </ = 65bpm was achieved in 77% of MO and 89% of IB patients (p < 0.01). The time from initial medication administration to CCTA was longer in the IB versus MO patients (77 versus 48 min, p < 0.01).
Introduction of a novel single dose ivabradine-based protocol to control heart rate for CCTA was more successful in achieving target heart rate than a metoprolol-only strategy. The use of ivabradine however incurred a 1.6-fold increase in the time delay from medication administration and imaging compared to a metoprolol only protocol.
Radiation Safety in Children With Congenital and Acquired Heart Disease: A Scientific Position Statement on Multimodality Dose Optimization From the Image Gently Alliance
2017, JACC: Cardiovascular Imaging
There is a need for consensus recommendations for ionizing radiation dose optimization during multimodality medical imaging in children with congenital and acquired heart disease (CAHD). These children often have complex diseases and may be exposed to a relatively high cumulative burden of ionizing radiation from medical imaging procedures, including cardiac computed tomography, nuclear cardiology studies, and fluoroscopically guided diagnostic and interventional catheterization and electrophysiology procedures. Although these imaging procedures are all essential to the care of children with CAHD and have contributed to meaningfully improved outcomes in these patients, exposure to ionizing radiation is associated with potential risks, including an increased lifetime attributable risk of cancer. The goal of these recommendations is to encourage informed imaging to achieve appropriate study quality at the lowest achievable dose. Other strategies to improve care include a patient-centered approach to imaging, emphasizing education and informed decision making and programmatic approaches to ensure appropriate dose monitoring. Looking ahead, there is a need for standardization of dose metrics across imaging modalities, so as to encourage comparative effectiveness studies across the spectrum of CAHD in children.
Impact of a motion correction algorithm on image quality in patients undergoing CT angiography: A randomized controlled trial
2017, Clinical Imaging
To investigate the motion correction algorithm Snapshot-Freeze (SSF) compared to standard reconstruction (STD) in patients randomized to receive beta-blockers (BB) or no beta-blockers (non-BB) before coronary CT, and to investigate if SSF can replace BB.
One hundred and forty patients scheduled for coronary CT were randomized. All images were reconstructed by the SSF and STD algorithms. Image quality was evaluated according to Likert score (1: excellent, 2: good, 3: adequate, 4: non-diagnostic) and presence of artifacts was noted.
Images from 64 patients in the BB group (mean HR 56 ± 4 bpm) and 51 patients in the non-BB group (mean HR 67 ± 7 bpm) were analyzed. Twenty five patients were excluded because of tachycardia, bradycardia or reconstruction errors in SSF. SSF increased the number of excellent images in both groups compared to the STD algorithm (BB: 59% vs.44%; non-BB: 25% vs. 8%), but the number of non-diagnostic images was not significantly reduced. SSF reduced motion artifacts (BB: 11% vs. 31%; non-BB: 49% vs. 75%), but despite this reduction, motion artifacts in non-BB were still more frequent compared to the BB group analyzed by STD (49% vs. 31%).
SSF improves image quality and reduces motion artifacts, but does not compensate for the absence of BB.
Bailout intravenous esmolol for heart rate control in cardiac computed tomography angiography
2016, Revista Portuguesa de Cardiologia
To evaluate the efficacy and safety of a heart rate (HR) reduction protocol using intravenous esmolol as bailout for failed oral metoprolol regimens in patients undergoing coronary computed tomography angiography (CCTA) with 64-slice multidetector computed tomography (64-MDCT).
Patients who underwent cardiac 64-MDCT in a single institution between 2011 and 2014 were analyzed. Those with HR above 60 beats per minute (bpm) on presentation received oral metoprolol (50-200 mg) at least one hour before CCTA. Intravenous esmolol 1-2 mg/kg was administered as a bolus whenever HR remained over 65 bpm just before imaging. The primary efficacy endpoint was HR <65 bpm during CCTA. The primary safety endpoint was symptomatic hypotension or bradycardia up to hospital discharge.
During the study period CCTA was performed in 947 cases. In 86% of these, oral metoprolol was the only medication required to successfully reduce HR <60 bpm. Esmolol was used in the remaining 130 patients (14%). For esmolol-treated patients mean baseline and acquisition HR were 74±14 bpm and 63±9 bpm, respectively (p<0.001). The target HR of <65 bpm was achieved in 82 of the 130 esmolol-treated patients (63%). Considering the whole population, esmolol use led to a significant increase in the primary efficacy endpoint from 86% to 95% (p<0.001). Esmolol also resulted in a statistically, but not clinically, significant reduction in systolic blood pressure (144±22 to 115±17 mmHg; p<0.001). The combined primary safety endpoint was only observed in two (1.5%) patients.
Despite optimal use of oral beta-blockers, 14% of patients needed intravenous esmolol for HR control. The pre-medication combination of oral metoprolol and on-demand administration of intravenous esmolol was safe and effective and enabled 95% of patients to be imaged with HR below 65 bpm.
Avaliar a eficácia e segurança de um protocolo de redução de frequência cardíaca (FC) utilizando esmolol endovenoso após falência de metoprolol oral, em doentes submetidos a angiografia coronária por tomografia computorizada (CCTA) de 64 cortes.
De 2011 a 2014 foram avaliados os indivíduos submetidos a CCTA num único centro. Os indivíduos com FC >60 bpm à admissão receberam 50-200 mg de metoprolol oral pelo menos uma hora antes da CCTA. Esmolol endovenoso em bólus (1-2 mg/kg) foi administrado se FC >65 bpm imediatamente antes da aquisição de imagem. O endpoint primário de eficácia foi FC <65 bpm durante a aquisição de imagem com contraste. O endpoint primário de segurança foi hipotensão ou bradicardia sintomática durante a permanência no hospital.
Foram efetuadas 947 CCTA durante o período de estudo. Em 86% dos casos, metoprolol oral foi o único fármaco utilizado. Foi necessária a administração de esmolol em 130 (14%) doentes. Nos doentes que receberam esmolol, a FC basal reduziu em média de 74±14 bpm para 63±9 bpm (p<0,001). O objetivo primário de FC <65 bpm foi alcançado em 82 desses 130 doentes (63%). Considerando toda a população, o recurso a esmolol permitiu um aumento significativo da proporção de CCTA realizados com FC <65 bpm (86% para 95% [p<0,001]). A administração de esmolol esteve associada a redução estatisticamente, mas não clinicamente, significativa da pressão arterial sistólica (144±22 para 115±17 mmHg; p<0,001). O endpoint combinado de segurança foi observado em dois (1,5%) dos doentes.
Apesar da utilização sistemática de betabloqueante oral, 14% dos casos necessitaram de esmolol endovenoso para controlo adequado de FC. Pré-medicação combinada de metoprolol oral e esmolol endovenoso quando necessária foi segura e eficaz, e permitiu que 95% dos doentes apresentassem FC <65 bpm no momento da aquisição de imagem.
Coronary Computed Tomography Angiography: Patient-related factors determining image quality using a second-generation 320-slice CT scanner
2016, International Journal of Cardiology
To investigate the diagnostic confidence of Coronary Computed Tomography Angiography (CCTA) and the effect of patient-related factors on CCTA image quality using a second-generation 320-slice scanner.
200 consecutive patients (mean age 60 ± 12 years; 109 men) prospectively underwent CCTA. The mean body mass index (BMI) was 27.1 ± 4.9 kg/m²; the median heart rate (HR) was 60.0 (interquartile range (IQR), 53.9–66.1) beats per minute (bpm). The median segment's diameter was 2.8 (IQR, 2.2–3.4) mm. For each coronary segment ≥ 1.5 mm in diameter, two readers scored: diameter narrowing as < or ≥ 50%, overall diagnostic confidence and motion-related image quality, with interobserver agreement kappa-values of 0.89, 0.91 and 0.61 respectively. Seventy-nine of the 2505 evaluated segments (3.2%) had non-diagnostic image quality because of coronary calcifications (66/79; 83.5%), stent- (6/79; 7.5%), pacemaker- (2/79; 2.5%) or motion-related artifacts (5/79; 6.5%). The effect of patient-related factors on motion-related image quality was investigated by multinomial logistic regression in 181 patients with calcium score (IQR, 0–446.5). Increasing coronary diameter was the most improving image quality factor (odds ratio (OR), 1.8637; p < 0.001), marginally followed by lower HR (OR, 0.9547; p < 0.001) and calcium score (OR, 0.9997; p = 0.04). Gender (p = 0.70), age (p = 0.24) and BMI (p = 0.45) did not affect image quality.
Using a second-generation 320-slice scanner, CCTA diagnostic confidence is predominantly affected by coronary calcifications, whereas motion-related image quality is non-diagnostic only in exceptional cases and mainly influenced by the coronary diameter. For future developments, our study findings therefore suggest greater requirements concerning spatial resolution and calcium-related artifact removal than concerning temporal resolution, especially to improve diagnostic confidence in patient groups with smaller coronary diameters.
Computed Tomography Imaging in Patients with Congenital Heart Disease Part I: Rationale and Utility. An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the Society of Pediatric Radiology (SPR) and the North American Society of Cardiac Imaging (NASCI)
2015, Journal of Cardiovascular Computed Tomography
Citation Excerpt :
Pre-procedural medication can be used to decrease the overall heart rate or the variability with respiration. Different protocols for beta blockade have been described and are effective for decreasing the heart rate and thus the required radiated interval of the cardiac cycle.366–368 Protocols specific to children have been described with effective heart rate control and excellent safety.10,369
This is an expert consensus document created to provide information about the current use of cardiovascular computed tomography (CT) in patients of all ages with proven or suspected congenital heart disease (CHD). The discussion and recommendations are based on available literature and the judgment of a diverse group of subspecialists with extensive experience in the use of CT imaging in CHD. The field of CHD CT imaging is evolving rapidly with the availability of new scanner technology. In addition, the prevalence of palliated CHD has increased with marked improvements in patient survival. We believe it is important to review the clinical indications, strengths, limitations, and risks of cardiovascular CT in this patient population. This is the first of two complementary documents. It will concentrate on the disease entities and circumstances in which CT may be used. The second document will focus on recommendations for the technical performance of cardiovascular CT in patients with CHD.
Successful cardiovascular CT imaging of CHD requires an in depth understanding of the core teaching elements of both cardiology and radiology. The ability to perform and interpret high quality congenital cardiovascular CT in a clinical context requires focused time and effort regardless of the previous background of the cardiac imager. This is reflected by a writing committee that consists of pediatric and adult radiologists and cardiologists, all whom have extensive experience in performing CT in this patient population. Cardiovascular CT is complementary to other imaging modalities and its optimal use will be in centers where all diagnostic modalities are available. The choice of modality for an individual patient should be determined by age, diagnosis, clinical condition, clinical question and patient preference.^1–4 Use of CT in CHD should be reserved for situations in which it is expected to provide unique diagnostic information for the individual patient or clinical indication, and/or less risk than other modalities. This multi-disciplinary document is intended to guide the optimal selection of CHD patients for cardiovascular CT.
The goals of this document apply to both pediatric and adult CHD patients and are to:
- 1)
  Review the current use of cardiovascular CT.
- 2)
  Assess the most up to date information on risks, benefits, as well as limitations of cardiovascular CT.
- 3)
  Provide disease-specific indications for cardiovascular CT imaging.
- 4)
  Outline a consensus opinion on the essential skills and knowledge needed to optimally perform and interpret cardiovascular CT.

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: Dr. de Graaf is co-supported by the Dutch Technology Foundation STW (Utrecht, The Netherlands), Applied Science Division of The Netherlands Organisation for Scientific Research (Den Haag, The Netherlands) and grant 10084 from the Technology Program of the Ministry of Economic Affairs. Dr. van Velzen is supported by grant 2007B223 from The Netherlands Heart Foundation (The Hague, The Netherlands). Dr. Schalij has received research grants from Boston Scientific (Natick, Massachusetts), Medtronic (Minneapolis, Minnesota), and Biotronik (Berlin, Germany). Dr. Bax has received research grants from Medtronic (Minneapolis, Minnesota), Boston Scientific (Natick, Massachusetts), Bristol-Myers Squibb Medical Imaging (New York, New York), St. Jude Medical (St. Paul, Minnesota), GE Healthcare (Chalfont St. Giles, United Kingdom), Biotronik (Berlin, Germany), and Edwards Lifesciences (Irvine, California).

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Coronary artery diseaseEvaluation of Contraindications and Efficacy of Oral Beta Blockade Before Computed Tomographic Coronary Angiography

Section snippets

Methods

Results

Discussion

Eur J Radiol

Eur J Radiol

Am J Cardiol

Eur J Radiol

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Imaging

Acad Radiol

In-plane coronary arterial motion velocity: measurement with electron-beam CT

Radiology

Noninvasive coronary angiography with 64-section CT: effect of average heart rate and heart rate variability on image quality

Radiology

Intravenous contrast material administration at 16-detector row helical CT coronary angiography: test bolus versus bolus-tracking technique

Radiology

“In-house” pharmacological management for computed tomography coronary angiography: heart rate reduction, timing and safety of different drugs used during patient preparation

Eur Radiol

Feasibility and diagnostic accuracy of 16-slice multidetector computed tomography coronary angiography in 500 consecutive patients: critical role of heart rate

Int J Cardiovasc Imaging

Improvement of image quality with beta-blocker premedication on ECG-gated 16-MDCT coronary angiography

AJR Am J Roentgenol

Coronary artery disease
Evaluation of Contraindications and Efficacy of Oral Beta Blockade Before Computed Tomographic Coronary Angiography