Bradley Witbrodt, MD,a Abhinav Goyal, MD, MHS,a Anita A. Kelkar, MD,a Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology Prognostic significance of blood pressure response during vasodilator stress Rb-82 positron emission tomography myocardial perfusion imaging Bradley Witbrodt, MD,a Abhinav Goyal, MD, MHS,a Anita A. Kelkar, MD,a Sharmila Dorbala, MD, MPH,b Benjamin J.W. Chow, MD,c Marcelo F. Di Carli, MD,b Brent A. Williams, PhD,d Michael E. Merhige, MD,e Daniel S. Berman, MD,f Guido Germano, PhD,f Robert S. Beanlands, MD,c James K. Min MD,g Punitha Arasaratnamc, MDc; Masoud Sadreddini, MDc; Marjolein Lidwine van Velthuijsen, MDc Leslee J. Shaw, PhD,a   a Emory University School of Medicine, Atlanta, GA e Niagara Falls Memorial Medical Center, Buffalo, NY b Brigham and Women’s Hospital, Boston, MA f Cedars-Sinai Medical Center, Los Angeles, CA c Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON g Weill Cornell Medical College New York, NY d Geisinger Medical Center Danville, PA Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology BACKGROUND 1- A drop in blood pressure (BP) or blunted BP response is an established high-risk marker during exercise myocardial perfusion imaging (MPI) 2- Data are sparse regarding the prognostic value of BP response in patients undergoing vasodilator stress rubidium-82 (Rb-82) Positron Emission Tomography (PET) MPI. 3- We sought to analyze a large cohort of patents referred for vasodilator stress Rb-82 PET MPI to determine if BP and BP response provides similar additional prognostic benefit. Copyright American Society of Nuclear Cardiology

METHODS Study type: Study subjects: Study endpoints: Study variables: Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology METHODS Study type: Prospective Cohort Study Study subjects: 3,413 patients consecutively referred for pharmacologic stress Rb-82 PET MPI with either adenosine or dipyridamole. Study endpoints: Primary end point: All-cause mortality Study variables: BP variables: stress minus rest systolic BP (∆SBP), stress minus rest diastolic BP (∆DBP), resting systolic BP (rSBP), and resting diastolic BP (rDBP). Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology RESULTS Fig. 1. a b Fig. 2. a b Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology RESULTS Abbreviated Table 3***: Blood Pressure Covariates from Cox Multivariable Model   Unadjusted hazard ratio (95% confidence interval) Unadjusted P value Adjusted hazard ratio (95% confidence interval) Adjusted P value Resting DBP (mmHg) – <0.001** 0.045** <60 1.77 (1.35-2.32) <0.001 1.45 (1.08-1.96) 0.013 ≥60 to <90 Reference ≥90 1.00 (0.63-1.59) 0.99 .97 (0.59-1.59) 0.894 Resting SBP (mmHg) 0.008** 0.026** <90 1.38 (0.34-5.62) 0.650 1.52 (0.36-6.41) 0.572 ≥90 to <120 1.17 (0.86-1.61) 0.307 1.35 (0.97-1.89) 0.075 ≥120 to <140 ≥140 to <160 0.60 (0.42-0.86) 0.005 0.70 (0.49-1.01) 0.58 ≥160 1.07 (0.77-1.47) 0.696 1.10 (0.77-1.58) 0.602 Stress minus rest SBP (∆SBP) (mmHg) 0.082** 0.287** ≤ -20 1.39 (0.996-1.95) 0.053 1.38 (0.97-1.96) 0.070 >-20 to ≤ -10 1.15 (0.80-1.66) 0.45 1.10 (0.76-1.59) 0.61 >-10 to ≤ 0 > 0 0.94 (0.65-1.37) 0.75 1.15 (0.78-1.68) 0.48 * Covariates that were considered but not statistically significant (p>0.10) in univariate analysis were stress minus resting DBP (∆DBP), use of calcium channel blockers smoking history, and use of ACE inhibitors. ** These values represent overall P values for the parent categorical variables. ***This is a subset of the results from the full multivariate model found in table 3 in the full manuscript, abridged for this slide set. Copyright American Society of Nuclear Cardiology

Journal of Nuclear Cardiology | Official Journal of the American Society of Nuclear Cardiology CONCLUSIONS 1- We hypothesized that BP response (∆SBP and ∆DBP) during pharmacologic stress would be an independent predictor of all-cause mortality. 2- Our results reveled that rDBP, rSBP, and ∆SBP predicted mortality in univariable analysis, and ∆DBP did not. 3- However, when entered into a multivariable mortality model along with other clinical, hemodynamic, and MPI variables, only lower rDBP and rSBP remained independently prognostic, whereas neither BP response variables (∆SBP nor ∆DBP) were prognostic. Copyright American Society of Nuclear Cardiology