S3285 The Negative Predictive Value of Dobutamine Stress Echocardiography for Identifying Coronary Artery Disease in Liver Transplant Evaluation

Abstract

INTRODUCTION: Coronary artery disease (CAD) is associated with increased morbidity and mortality in end-stage liver disease (ESLD) patients undergoing liver transplant(LT). Dobutamine stress echocardiography (DSE) has gained preference over other screening tests for detecting CAD in ESLD patients due to the chronic systemic vasodilatation, increased cardiac output, and poor exercise tolerance. This study aimed to evaluate the negative predictive value and the accuracy of DSE for the diagnosis of obstructive CAD, using coronary angiography as the reference in ESLD patients. METHODS: This is a retrospective single-center study at Methodist University Hospital, Memphis TN, which included patients with ESLD undergoing LT evaluation. We reviewed patients from three consecutive years and identified the patients who underwent DSE as part of pre-transplant evaluation along with coronary angiography within six months of DSE. A total of 94 patients were identified that had both a DSE along with coronary angiography for LT evaluation. Beta-blockers were held prior to DSE, and the target heart rate for DSE was 85% age-predicted maximum heart rate. Of the 94 patients, nine patients did not achieve a maximal heart rate despite maximal medication. An analysis was performed with the remaining 85 patients. Patients were referred for coronary angiography if DSE was abnormal or with a normal DSE in the presence of ≥1 risk factor(s) for CAD. Significant CAD was defined as ≥70% obstruction or fractional flow reserve < 0.80. RESULTS: A total of 22 patients had a DSE positive test and were referred to coronary angiography: 5/22(23%) patients had positive coronary angiography and 18/22(82%) had negative coronary angiography. The sensitivity in this group was 63% and specificity of 78%. Interestingly, 63 patients were referred for coronary angiography with a negative DSE due to CAD risk factors: 3/63(5%) patients had a positive coronary angiography, and 60/63(95%) patients had a negative coronary angiography. The negative predictive value of DSE at detecting obstructive CAD in ESLD patients is 95% (Table 1). The accuracy of DSE at detecting obstructive CAD in ESLD patients is 76%. CONCLUSION: Due to the hemodynamics of the ESLD patients, the sensitivity of DSE is limited. However, the negative predictive value is high (95%) to use DSE as a cost-effective, non-invasive screening test to rule out CAD.Table 1