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

Am J Cardiol. 2010; 105(6):767-772

de Graaf FR, Schuijf JD, van Velzen JE, Kroft LJ, de Roos A, Sieders A, Jukema JW, Schalij MJ, van der Wall EE, Bax JJ

OBJECTIVES: 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.

METHODS: 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.

RESULTS: 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).

CONCLUSIONS: 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.

PMID: 20211317

One Response

  1. Ronen Rubinshtein, MD  on March 10th, 2010

    A slower heart rate yields better image quality (even with newer scanners).
    Practically, I think that a combination of Beta blockers pre-treatment PO, and short acting IV beta-blockers which can be used in most patients on the CT suite by experienced personnel who are not rushing anywhere… and a more frequent use of retrospective gating (sometime without ECG-based dose modulation to allow several reconstructions) may be the optimal solution for patients with higher heart rate.

    We should remember the “ALARA” principal: It is very important to reduce radiation dose, but it is only reasonable to perform coronary CTA if you are expecting a reasonable image quality.


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