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Cardiac scintigraphy has emerged as a key diagnostic test for transthyretin cardiac amyloidosis (ATTR-CA). However, there are potential limitations and pitfalls in the interpretation of cardiac scintigraphy for ATTR-CA that are worth noting. We present here a series of three cases which illustrate some of these important principles.

Background: Failure to achieve an adequate heart rate limits the sensitivity of exercise myocardial perfusion imaging (MPI) for the detection of coronary artery disease. In addition, it is often not possible to discontinue medications that may blunt the heart rate response to exercise, because of conditions such as hypertension or angina. However, if pharmacologic stress testing is performed, the ability to assess functional capacity is lost. Accordingly, we developed a protocol that incorporates adenosine stress with symptom-limited exercise., Methods and Results: As part of a multicenter study, 35 patients were enrolled prospectively and underwent both exercise MPI and exercise MPI with a 4-minute adenosine infusion on a separate day. Technetium 99m sestamibi was injected at or near peak exercise (exercise only) and at 2 minutes into the adenosine infusion (combined exercise and adenosine). The perfusion images were interpreted in a blinded fashion. The combined adenosine and exercise protocol was well tolerated. The summed stress scores and summed difference scores were greater in the exercise-plus-adenosine group than in the exercise-only group (10.0 vs 8.5, P =.02, and 4.9 vs 3.3, P =.002, respectively). Exercise time was slightly but significantly less with the exercise-plus-adenosine protocol (8 minutes 46 seconds vs 8 minutes 11 seconds, P =.027)., Conclusion: A protocol combining 4 minutes of adenosine infusion with symptom-limited exercise was safe and well tolerated. Furthermore, this protocol resulted in a greater amount of myocardial ischemia detected on MPI while allowing for the assessment of functional capacity. A combined exercise and adenosine protocol may be a useful test for patients undergoing MPI who are unlikely to achieve an adequate chronotropic response.