Dipyridamole Echocardiography Test Research Articles

P4982Blunted heart rate reserve as an imaging-independent prognostic predictor during dipyridamole-echocardiography test

Abstract Background A blunted heart rate (HR) response during dipyridamole myocardial perfusion imaging have been associated with a poor outcome. Aim To assess the value of HR response in patients undergoing high dose dipyridamole stress echocardiography (SE). Methods We retrospectively selected a consecutive sample of 1,622 patients (none with pacemakers or atrial fibrillation), mean age 66±12 years, 431 (27%) on beta-blockers. All underwent high dose (0.84 mg/kg) dipyridamole SE for known or suspected coronary artery disease and/or heart failure from January 1988 to January 2018 in our Cardiology Division. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio. All patients were followed-up. The composite end-point was made of all cause-death, non-fatal myocardial infarction and late (>3 months) symptoms-driven myocardial revascularizations. Results SE was positive for regional wall motion abnormalities (RWMA) in 192 patients (12%). HR increased (rest=70±11 beats/min vs stress= 92±17 beats/min, p<0.0001). During a median follow-up time of 904 days, 462 events occurred: 73 deaths, 57 non-fatal myocardial infarctions, 332 myocardial revascularizations. Receiver operating curve analysis identified a HRR ≤1.27 as the best cutoff. At multivariate analysis a reduced HRR was a significant predictor of hard events (Hazard Ratio, HR=2.02, 95% Confidence Intervals, CI, 1.38–2.95, P<0.0001), additive to ischemic regional wall motion abnormalities (HR=2.11, 95% CI 1.28–3.48, P=0.004), resting RWMA (HR =1.88, 95% CI 1.31–2.72, P<0.001), age (HR =1.06, 95% CI 1.04–1.08, P<0.001) and beta-blockers at the time of testing (HR =1.55, 95% CI 1.06–2.29, P=0.03). Five-year hard event-free survival increased from 6% to 26% from the highest to the lowest HRR quartile: see figure. Survival curve Conclusion A blunted HRR is a useful non-imaging predictor of adverse events during high dose dipyridamole-SE. It is additive over resting or inducible regional wall motion abnormalities, and unmasks a prognostically meaningful autonomic unbalance. Chronotropic incompetence during dipyridamole SE is a negative prognostic finding, equally important than RWMA.

AB0797 Impairment of coronary microcirculation in patients with diffuse systemic sclerosis

BackgroundAn association between systemic autoimmune diseases (SADs) and atherosclerosis has been described in many connective tissue diseases, and is known to lead to increased cardiovascular (CV) morbidity and mortality. Systemic...

Silent cardiovascular involvement in patients with diffuse systemic sclerosis: a controlled cross‐sectional study

An association between systemic autoimmune diseases and atherosclerosis has been described in many connective tissue diseases, and this association is known to lead to increased cardiovascular morbidity and mortality. Systemic sclerosis (SSc) is characterized by multisystem organ inflammation, endothelial wall damage, and vasculopathy. There are many markers of endothelial dysfunction and/or atherosclerotic risk, such as asymmetric dimethylarginine (ADMA), arterial stiffness parameters, carotid intima-media thickness (CIMT), and coronary flow reserve (CFR) assessed by transthoracic echocardiography. The aim of this pilot study was to use various endothelial and atherosclerosis markers to identify early cardiovascular involvement in a group of SSc patients. The study involved 20 patients (2 men and 18 women with a mean ± SD age of 52.96 ± 12.51 years) with diffuse SSc who had no signs or symptoms of cardiovascular disease (CVD) and 20 age- and sex-matched controls. All subjects underwent a dipyridamole echocardiographic stress test that included a determination of CFR and an evaluation of CIMT, arterial stiffness, and plasma ADMA levels. All of the arterial wall measurements of the patients with diffuse SSc were significantly different from those of the controls, and both right and left CIMT, pulse wave velocity, and stiffness index (β) were significantly elevated in the SSc patients compared to the healthy controls. Moreover, in patients with diffuse SSc, CFR was significantly lower (P = 0.0033) and plasma ADMA levels were higher (P < 0.0001) than in healthy controls. SSc patients without any clinical evidence of CVD seem to have had subclinical atherosclerosis, which was suggested by early impairment of coronary microcirculation and macrovascular involvement.

Prognostic value of dipyridamole echocardiography testing

The aim of this study was to follow the results of dipyridamole echocardiography testing (DET) in 105 patients (mean age 53.2±8.5 years) with suspected ischemic heart disease. The follow-up period was 31.4±4.2 months. Twenty-nine patients had a positive DET result, and 76 a negative one. Fifty-two of the 105 underwent coronarography, and the remainder had no heart catheterization. In the follow-up study, the patients' subjective condition and the new heart events (angina, infarction, coronary bypass surgery, and death) were registered. The new heart events were more frequent in the DET-positive group than the negative one (45% vs 22%;p<0.05). In the coronarography-positive and -negative group these values were 77% and 10%, respectively (p<0.001). In the coronarography- and DET-positive group the frequency of new cardiac events was 69%. This value was only 10% in the coronarography- and DET-negative group. The difference between the true-positive and true-negative groups was highly significant (p<0.001). Coronarography was found to be a good predictor of future cardiac events, however, the noninvasive dipyridamole echocardiography testing was also an appropriate method for follow-up.

Effects of GIK (glucose–insulin–potassium) on stress-induced myocardial ischaemia

Despite the evidence in experimental animal models that insulin, or GIK (glucose-insulin-potassium), improves left ventricular function and perfusion during both acute and chronic ischaemia, clinical studies have generated conflicting results. We tested the hypothesis that pretreatment with GIK attenuates the vascular and functional effects of stress-induced myocardial ischaemia in humans. Twenty-two patients with evidence of inducible myocardial ischaemia were enrolled; 11 patients with normal ventricular function underwent two dipyridamole echocardiography tests, and 11 with regional contractility defects from previous myocardial infarction were submitted to two ECG exercise tests combined with 201Tl myocardial perfusion scintigraphy; the tests were preceded by 60 min of either normal saline or an isoglycaemic GIK infusion. On a stress echocardiogram, a 30% reduction in the severity of ischaemia was observed. On ECG ergometry, GIK infusion slightly increased the time to ischaemia (+0.6 min, P=0.07); however, the higher workload (+8%, P=0.07) was achieved at a similar rate-pressure plateau. On scintigraphy, an increase in ischaemic segments (+48%, P<0.001) was imaged mainly at the expense of viable (but non-ischaemic) and non-viable segments, which were reduced by 60%. GIK affected stress-induced left ventricular underperfusion only marginally (GIK: 39.7+/-2.5 compared with saline: 35.4+/-2.2 units, P<0.05), but significantly improved its acute reversibility (-42+/-4 compared with -25+/-4%, P<0.001). We conclude that GIK pretreatment attenuates the effect of ischaemia on myocardial contractility, slightly improves exercise tolerance and causes a more rapid and diffuse recovery of post-ischaemic reperfusion.

The prognostic value of Doppler echocardiographic-derived coronary flow reserve is not affected by concomitant antiischemic therapy at the time of testing

When wall motion abnormality is the diagnostic end point, concomitant antiischemic therapy heavily modulates the prognostic value of dipyridamole echocardiography test (DET). A negative test result is less benign, and a positive test result is more malignant if performed under therapy. Recently, coronary flow reserve (CFR) was added to wall motion in dual imaging DET. The aim of the study was to determine whether antianginal medications affect the prognostic value of Doppler echocardiographic-derived CFR in patients with known or suspected coronary artery disease undergoing DET. In a prospective, multicenter, observational study, we evaluated 1,779 patients (1,072 males; 64 +/- 11 years) who underwent high-dose dipyridamole (0.84 mg/kg for 6 minutes) stress echo with CFR evaluation of left anterior descending (LAD) artery by Doppler. Seven hundred thirty-three (41%) patients were on antiischemic therapy at time of testing (nitrates and/or calcium antagonists and/or beta-blockers). Mean CFR was 2.3. +/- 0.6. At individual patient analysis, 1,141 patients had normal (CFR >2.0) and 638 had abnormal (CFR <or=2.0) CFR on LAD. During a median follow-up of 36 months, 263 events occurred as follows: 36 deaths and 59 ST-elevation myocardial infarctions (STEMIs) and 168 non-STEMIs (NSTEMIs). Survival was highest in patients with normal CFR and lowest in patients with abnormal CFR (87% vs 34%, P = .0001). Survival was comparable in patients with normal CFR on and off therapy and in patients with abnormal CFR on and off therapy. At multivariable analysis, hypertension (hazard ratio [HR] 1.5, 95% CI 1.0-1.9, P = .010), DET positivity for regional wall motion abnormalities (HR 5.7, 95% CI 4.3-7.4, P = .000), an abnormal CFR on LAD (HR 3.3, 95% CI 2.5-4.4, P = .000) were independent prognostic predictors of hard cardiac events. Ongoing antiischemic therapy at the time of testing does not modulate the prognostic value of Doppler echocardiographic-derived coronary flow reserve.

The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stress echo

The aim of the study was to evaluate the prognostic value of Doppler echocardiographic-derived coronary flow reserve (CFR) over regional wall motion in patients with known or suspected coronary artery disease (CAD) undergoing dipyridamole echocardiography test (DET). In a prospective, multicentre, observational study, we evaluated 1145 patients (702 males; 64 +/- 11 years) who underwent high-dose dipyridamole (0.84 mg/kg over 6 min) stress echo with CFR evaluation of LAD by Doppler. DET was positive for regional wall motion abnormalities in 291 (25%) and negative in 854 (74%) patients. Mean CFR was 2.2 +/- 0.5. At individual patient analysis 702 patients had normal (CFR > 2.0) and 443 had abnormal CFR on LAD. During a median follow-up of 27 months, 109 events occurred: 16 deaths, 17 non-fatal myocardial infarctions, 76 re-hospitalizations for unstable angina. The 30 months infarction-free survival showed the best outcome for those patients with negative DET by wall motion criteria and normal CFR and the worst outcome for patients with positive DET by wall motion and abnormal CFR (99 vs. 68%, P < 0.001). At multivariable analysis, CFR on LAD [hazard ratio (HR) 2.4, 95% CI 1.1-5.4, P = 0.030], medical therapy at time of testing (HR 2.8, 95% CI 1.2-6.6, P = 0.022), DET positivity for regional wall motion abnormalities (HR 3.6, 95% CI 1.5-8.7, P = 0.000), and angina on effort (HR 6.3, 95% CI 2.7-14.8, P = 0.000) were independent prognostic predictors of hard cardiac events. In patients with known or suspected CAD, DET result by wall motion criteria and CFR are additive and complementary for the identification of patients at risk of experiencing hard events.

Dipyridamole echocardiography test in patients with normal or near normal coronary arteries

We read with great interest the paper by Sicari et al .1 dealing with the prognostic value of dipyridamole echocardiography test in patients with chest pain syndrome and angiographically normal or near normal coronary arteries and the accompanying editorial by Marwick.2 This study, based in a large cohort with long-term follow-up, shows that …

Dipyridamole echocardiography test in patients with normal or near normal coronary arteries: reply

Dipyridamole echocardiography test in patients with normal or near normal coronary arteries: reply

Ischaemia and outcome with normal coronary arteriesThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to 'Long-term survival of patients with chest pain syndrome and angiographically normal or near-normal coronary arteries: the additional prognostic value of dipyridamole echocardiography test'dagger by R. Sicari et al., on page 2136.

Long-term survival of patients with chest pain syndrome and angiographically normal or near-normal coronary arteries: the additional prognostic value of dipyridamole echocardiography test (DET)

Patients with normal coronary arteries have a heterogeneous prognosis. Aim of this study was to assess whether dipyridamole stress echocardiography positivity identifies a prognostically less benign subset. We selected 457 patients (245 males; 56+/-10 years) who underwent stress high-dose dipyridamole echocardiography and had angiographically non-significant (<50% visually assessed) stenosis in any major vessel and preserved left ventricular function. All patients were followed up for a median of 7.1 years (first quartile 5 and third quartile 10.5). Dipyridamole echocardiography test (DET) positivity for regional dysfunction occurred in 43(9%) patients. Kaplan-Meier survival estimates showed a significant better outcome for those patients with negative dipyridamole echocardiography test compared with those with a positive test (90 vs. 75.7%, at 140 months of follow-up, P=0.0018). At multivariable analysis, mild or moderate irregularity on coronary arteriogram (HR=3.3, CI 95%=1.7-6.2), diabetes (HR=3.5, CI 95%=1.4-9.2), and wall motion score index at peak stress (HR=6.7, CI 95%=2.5-17.8) were independent predictors of all-cause death. DET adds incremental value to the prognostic stratification achieved with clinical and angiographic data in the subset of patients with normal or near-normal coronary arteries.

724 Influence of beta-blockade on results of low-dose dipyridamole echocardiography tests for myocardial viability

724 Influence of beta-blockade on results of low-dose dipyridamole echocardiography tests for myocardial viability

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography)

Prognostic value of contractile response during high-dose dipyridamole echocardiography test in heart transplant recipients

Background: Coronary allograft vasculopathy (CAV) remains a main factor limiting long-term survival after heart transplantation (HTX). The diagnosis of CAV is still based on serial coronary angiography. In this study, we evaluated the prognostic value of high-dose dipyridamole echocardiography in HTX. Methods: Sixty-eight patients underwent dipyridamole echocardiography within 48 hours of their scheduled annual coronary angiography. Coronary allograft vasculopathy was defined as CAV 1 (focal or diffuse stenosis <50%) or CAV 2 (focal or diffuse stenosis ≥50%). Wall-motion score index (WMSI) was evaluated at rest and after dipyridamole administration. Results: Results of coronary angiography were normal in 43 patients (63%), showed CAV 1 in 11 (16%), and showed CAV 2 in 14 (21%). Rest wall motion was normal in 39 patients and abnormal in 29. After dipyridamole administration, wall motion remained normal in all 39 (Group 1, no CAV in 34 and CAV 1 in 5). Of 29 patients with rest wall-motion abnormalities, all reversed to normal after dipyridamole in 8 patients (Group 2, no CAV in 7 and CAV 1 in 1) and remained or worsened in 21 (Group 3, CAV 2 in 14 and no CAV or CAV 1 in 7). During follow-up (6 ± 3 years), 15 patients had major cardiac events: 11 occurred in Group 3, whereas 4 occurred in Groups 1 and 2. Wall motion at rest and after dipyridamole administration and CAV were independent predictors for cardiac events; only dipyridamole WMSI >1 remained significant ( p < 0.0001) at multivariate analysis. Conclusions: Dipyridamole echocardiography is a simple, non-invasive test that after HTX may identify patients with altered wall motion who deserve stricter surveillance.

Usefulness of isometric handgrip during treadmill exercise stress echocardiography

Usefulness of isometric handgrip during treadmill exercise stress echocardiography

Non-invasive prediction of angiographic progression of coronary artery disease by dipyridamole-stress echocardiography.

Coronary angiography is the currently accepted standard means for assessing progression of coronary artery disease. A dipyridamole-echocardiography test (DET) might provide an alternative non-invasive functional imaging method for this purpose. To assess whether variations in results of serial DET match variations in angiographic assessments of coronary artery disease. From the Pisa Institute of Clinical Physiology stress-echocardiography data bank (1983-1998), we selected 60 patients satisfying the inclusion criteria of coronary angiography and DET having each been performed and interpreted twice independently and within 1 week. The second angiographic and stress-echocardiographic assessment was performed 45+/-31 months after the initial one. Angiographic progressors were defined a priori as patients with any progression of stenosis to occlusion and those with any stenosis > 30% with > 20% progression of stenosis measured by visual and quantitative coronary angiography. Stress-echocardiography progressors were defined as those patients who had previously had a negative test of a test having a positive result and those patients who had positive results of tests both in initial testing and in a second session of testing with the latter having a peak wall-motion-score index > 0.12 (on a scale of 1, normal to 4, dyskinetic in a 16-segment model) larger than the former. Of the 60 patients, 44 were angiographic 'progressors' and 16 were 'non progressors'. Stress-echocardiographic responses were concordant with angiographic identification for 39 of 44 progressors and 15 of 16 non-progressors, with an overall concordance of 90%. Measurement of dipyridamole-stress-echocardiographic response allows one to separate angiographic progressors and non-progressors efficiently, simply by taking into account the presence, extent and severity of stress-induced abnormalities of wall motion.

Perioperative prognostic value of dipyridamole echocardiography in vascular surgery: A large-scale multicenter study in 509 patients. EPIC (Echo Persantine International Cooperative) Study Group.

Patients undergoing major vascular surgery are at a relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for perioperative risk stratification. The aim of the current study was to evaluate the value of dipyridamole echocardiography test (up to 0.84 mg/kg over 10 minutes) in predicting cardiac events in a large-scale, multicenter, prospective, observational study design. Five hundred nine patients (mean age 66+/-10 years) were studied before vascular surgery by dipyridamole stress echocardiography in 11 different centers. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. No major complications occurred during dipyridamole stress echocardiography. Technically adequate images were obtained in all patients; however, in 4 patients only the low dipyridamole dose (0.56 mg/kg over 4 minutes) was given for limiting side effects. Eighty-eight (17.3%) had a positive test. Perioperative events occurred in 31 (6.1%) patients: 6 deaths, 11 myocardial infarctions, and 14 episodes of unstable angina. Sensitivity and specificity of dipyridamole stress echocardiography for predicting spontaneous cardiac events were 81% and 87%, respectively, with a positive predictive value of 28% and negative predictive value of 99%. By multivariate analysis, the difference between wall motion score index at rest and peak stress (Deltawall motion score index), test positivity, and ST-segment depression during dipyridamole infusion were independent predictors of any perioperative cardiac event. Dipyridamole stress echocardiography is safe and well tolerated in patients undergoing major vascular surgery and provides an effective preoperative screening test for the risk stratification of these patients, mainly because of the extremely high negative predictive value, which is a potent predictor of complication-free procedure.

Perioperative Prognostic Value of Dipyridamole Echocardiography in Vascular Surgery

Background —Patients undergoing major vascular surgery are at a relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for perioperative risk stratification. The aim of the current study was to evaluate the value of dipyridamole echocardiography test (up to 0.84 mg/kg over 10 minutes) in predicting cardiac events in a large-scale, multicenter, prospective, observational study design. Methods and Results —Five hundred nine patients (mean age 66±10 years) were studied before vascular surgery by dipyridamole stress echocardiography in 11 different centers. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. No major complications occurred during dipyridamole stress echocardiography. Technically adequate images were obtained in all patients; however, in 4 patients only the low dipyridamole dose (0.56 mg/kg over 4 minutes) was given for limiting side effects. Eighty-eight (17.3%) had a positive test. Perioperative events occurred in 31 (6.1%) patients: 6 deaths, 11 myocardial infarctions, and 14 episodes of unstable angina. Sensitivity and specificity of dipyridamole stress echocardiography for predicting spontaneous cardiac events were 81% and 87%, respectively, with a positive predictive value of 28% and negative predictive value of 99%. By multivariate analysis, the difference between wall motion score index at rest and peak stress (Δwall motion score index), test positivity, and ST-segment depression during dipyridamole infusion were independent predictors of any perioperative cardiac event. Conclusions —Dipyridamole stress echocardiography is safe and well tolerated in patients undergoing major vascular surgery and provides an effective preoperative screening test for the risk stratification of these patients, mainly because of the extremely high negative predictive value, which is a potent predictor of complication-free procedure.

Wavelet transform analysis of heart rate variability during dipyridamole-induced myocardial ischemia: relation to angiographic severity and echocardiographic dyssynergy.

Analysis of heart rate variability (HRV) is a valuable noninvasive method for quantifying autonomic cardiac control in humans and has been utilized during dipyridamole echocardiographic test to differentiate positive from negative test results. We aimed to evaluate, by means of HRV analysis, the influence of the angiographic severity of coronary artery disease on cardiac autonomic control during dipyridamole-induced myocardial ischemia. We analyzed RR interval variability changes during dipyridamole-induced myocardial ischemia in 31 selected patients (mean age 54 +/- 9 years) with available coronary angiography and positive dipyridamole echocardiographic test. Spectral components of HRV were assessed by means of wavelet transform analysis for the last 5 min before the beginning of the test (baseline) and for 5 min after the onset of ischemia-related events (peak dipyridamole effect). Patients were divided into three groups according to the number of coronary diseased vessels (Group A, single-vessel disease; Group B, double-vessel disease; Group C, triple-vessel disease). No difference was detectable at baseline among the three groups. After dipyridamole, low-frequency power, a measure of sympathetic modulation of heart rate, increased and echocardiographic wall motion score index worsened in all groups (p < 0.001). The increase in low-frequency power was more evident in Group C patients than in the other two groups (p < 0.005). Furthermore, after dipyridamole, a direct correlation was found between low-frequency power and wall motion score index (r = 0.59; p < 0.001). These data suggest that HRV analysis performed during dipyridamole echocardiographic test provides useful information to assess the severity of coronary artery disease.

Preoperative Assessment of Coronary Artery Disease in Aortic Stenosis: A Dipyridamole Echocardiographic Study

Background. The aim of this study was to establish the feasibility, safety, and diagnostic accuracy of the dipyridamole echocardiography test in patients with severe aortic valve stenosis for noninvasive detection of coexisting coronary artery disease. Methods. The high-dose dipyridamole echocardiography test was performed in 52 patients with severe aortic stenosis; all patients also underwent coronary angiography, independent of test results, before cardiac operation. Results. The dipyridamole echocardiography test was completed without major complications. One patient had transient atrial fibrillation that was reversed by aminophylline. Thirty-one patients (60%) had a negative test result; all had normal coronary arteries. Ten of the 21 patients (48%) with a positive test result had coexisting coronary artery disease. The positive predictive value of the dipyridamole echocardiography test for detection of coronary disease in patients with severe aortic stenosis was 48%. The negative predictive value was 100%. The sensitivity was 100% and the specificity was 74%. Conclusions. Dipyridamole echocardiography is a safe and feasible tool in patients with severe aortic stenosis eligible for a cardiac operation. A negative test result reliably rules out a significant stenosis, whereas a positive one is much less accurate in predicting coronary artery disease.