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Comment & Response
October 2, 2013

Therapy for Mental Stress–Induced Myocardial Ischemia—Reply

Author Affiliations
  • 1Duke University Medical Center, Durham, North Carolina
JAMA. 2013;310(13):1401-1402. doi:10.1001/jama.2013.277975

In Reply We agree that the REMIT trial cannot answer the question raised by Drs Burg and Soufer about the effect of escitalopram on vascular processes leading to MSIMI because the study was primarily designed to test whether escitalopram would improve MSIMI compared with placebo.

There were several reasons echocardiography was chosen over SPECT MPI for this study. First, mental stress–induced wall motion abnormality and significant reduction of LVEF (≥5%) are well accepted as evidence of MSIMI.1 Second, stress-induced LVEF reduction may be related to subendocardial hypoperfusion,2 which may not be optimally detected by SPECT MPI. Even though SPECT MPI represents a well-established technique, it has lower specificity compared with echocardiography for stress-induced ischemia.3 In addition, comparison studies of echocardiography and SPECT MPI on sensitivity and specificity in relation to MSIMI are limited. Third, another main disadvantage of SPECT MPI is that patients are exposed to diagnostic levels of radiation that would be considered an unacceptable risk.