Dobutamine-atropine Stress Echocardiography Research Articles

Safety and feasibility of dopamine-atropine stress echocardiography.

Dobutamine-atropine stress echocardiography (DSE) has lower sensitivity in patients with advanced liver disease (ALD) due to vasodilation. Dopamine-atropine stress echocardiography (DopSE) may be an alternative to DSE in ALD patients by improving the blood pressure response to stress. The safety and tolerability of DSE and DopSE were compared in 10 volunteers. The safety, adverse effects, and efficacy of DopSE were then assessed in 105 patients, 98 of whom had ALD. Dopamine was infused in stepwise fashion from 5µg/kg/min to a peak dose of 40µg/kg/min. Atropine was given before and in early stages of dopamine infusion up to cumulative dose of 1.5mg. The hemodynamic responses of 98 ALD patients were compared with 102 patients with ALD who underwent standard DSE. In normal volunteers, systolic BP increased more with DopSE compared to DSE (61±19mmHg vs 39±15mmHg, P=.008). In 105 patients who underwent DopSE, none had adverse effects that required early stress termination. In the groups with ALD, the systolic BP increase (38±28mmHg vs 12±27mmHg, P<.001) and peak rate pressure product (RPP) (22861±5289 vs 17211±3848, P=<.001) were both higher in those undergoing DopSE versus DSE. The sensitivity and specificity of DopSE were 45% and 88%, respectively for coronary disease (≥70% stenosis) in 37 patients who had angiography. Dopamine-atropine stress echocardiography appears to be a safe stress modality and provides greater increases in RPP in patients with ALD compared to DSE.

Incidence and variables associated with arrhythmias during dobutamine-atropine stress echocardiography among patients with Chagas disease.

Dobutamine stress echocardiography (DSE) is an important tool in the diagnosis of coronary artery disease. However, there is hesitation in clinical practice for using it in patients with Chagas disease (CD) due to the arrhythmogenic potential of this heart condition. This study aimed to evaluate the incidence and variables associated with arrhythmias during DSE in a population of patients with CD. A population of 205 consecutive patients with CD and suspected coronary heart disease was assessed through a retrospective database analysis. CD was confirmed in all patients by serological testing. The mean age of the patients selected was 64years, and 65.4% of the patients were female. Significant arrhythmias occurred as follows: nonsustained ventricular tachycardia in 7.3% of patients; supraventricular tachycardia and sustained ventricular tachycardia in 1%; and atrial fibrillation in 0.5%. Nonsignificant arrhythmias occurred as follows: premature ventricular contractions in 48% of patients and bigeminy in 4.4%. Values for the wall-motion score index at rest greater than 1.12 and 1.18 were independently correlated with the occurrence of nonsignificant arrhythmias (odds ratio [OR]=2.90, P<0.001) and significant arrhythmias (OR=4.23, P=0.044), respectively. DSE should be considered a safe examination in patients with CD despite the known increased risk of arrhythmias in this group of patients. The occurrence of arrhythmias was low in this study. Abnormal wall-motion score index values at rest were associated with the occurrence of significant and nonsignificant arrhythmias during the test.

CLINICAL PROFILE AND SIGNIFICANCE OF SUBMAXIMAL DOBUTAMINE ATROPINE STRESS ECHOCARDIOGRAPHY: A META-ANALYSIS

Dobutamine atropine stress echocardiography (DASE) is a widely used alternative to exercise stress in evaluation of suspected or known coronary artery disease (CAD). Nearly one-fourth of adults undergoing DASE fail to reach target heart rate (≥85% predicted maximum for age). The latter has been

Analyzing the Safety and Predictors of Arrhythmias during Dobutamine-Atropine Stress Echocardiography in a Non-Hospital Setting

Analyzing the Safety and Predictors of Arrhythmias during Dobutamine-Atropine Stress Echocardiography in a Non-Hospital Setting

Effect of sex on the diagnostic efficacy of dobutamine stress echocardiography with early atropine administration in the detection of coronary artery disease

Considering a poorer diagnostic accuracy of exercise stress test in women, echocardiographic stress tests are often recommended for the diagnosis of coronary artery disease (CAD) in this patient group. The aim of the study was to compare the diagnostic value of a modified protocol of dobutamine-atropine stress echocardiography between men and women. This was a prospective study including 250 patients with symptoms suggesting CAD. Coronary anatomy was examined in 248 subjects, and 1 female patient was excluded owing to coronary anomaly. We analyzed the results of dobutamine stress echocardiography with early atropine administration separately for patients with a history of myocardial infarction (109 women and 138 men; mean age, 62 ±9 years; group A) and patients without such history (72 women and 71 men; mean age, 62 ±9 years; group B). Atropine at a dose of up to 2 mg was administered after dobutamine infusion of 20 μg/kg/min. Coronary luminal stenosis of 50% or more in diameter in the left main coronary artery and of 70% and more in the other arteries was considered significant. In group A, echocardiography had higher specificity and negative predictive value in women compared with men (84.5% vs. 64.4%, P = 0.001, and 92.3% vs. 64.4%, P <0.0001, respectively). The accuracy was 85.3% and 76.8% in women and men, respectively (P = 0.03). In group B, a higher specificity was observed in women compared with men (82.6% vs. 60%, P = 0.01), but the accuracy was similar between the sexes. Dobutamine stress echocardiography with early atropine administration offers a higher diagnostic value in women, especially with regard to specificity.

New-Onset Seizure after Perflutren Microbubble Injection during Dobutamine Stress Echocardiography

Intravenous microbubble contrast agents are frequently used during ultrasound imaging to improve endocardial border detection, enhance Doppler signals, differentiate thrombi from tumors or define vascular anatomy. Dobutamine stress echocardiography (DSE) with or without addition of atropine is a standard technique for evaluation of coronary artery disease. Noncontrast or contrast-enhanced DSE is generally considered a safe procedure. We report what appears to be the first case of new-onset seizure activity following perflutren microbubble contrast injection during dobutamine-atropine stress echocardiography. On the basis of this single occurrence, we are only able to demonstrate a temporal, but not a causal relationship between the administration of microbubble echo contrast and onset of seizure. We do not suggest withholding administration of microbubble contrast when clinically indicated. However, increased vigilance in monitoring for seizure development in patients receiving microbubble contrast seems warranted.

Central Anticholinergic Syndrome Following Dobutamine–Atropine Stress Echocardiography

We present a case of central anticholinergic syndrome following dobutamine-atropine stress echocardiography in an elderly female. Although atropine toxicity is a recognized complication of stress echocardiography, no case reports are currently available. The central nervous system side effects of atropine are varied in severity (mild cognitive impairment to severe coma) and spectrum (agitation or somnolence), and thus are often overlooked. Management includes prompt recognition, stopping the offending agent, providing supportive care, and consideration of physiostigmine. Atropine is used in up to 60% of dobutamine stress echocardiograms, and has the potential to cause morbidity.

518 Safety and feasibility of accelerated dobutamine-atropine stress echocardiography

518 Safety and feasibility of accelerated dobutamine-atropine stress echocardiography

Dynamic Changes in Microcirculatory Blood Flow during Dobutamine Stress Assessed by Quantitative Myocardial Contrast Echocardiography

Although dobutamine-atropine stress echocardiography (DASE) has been widely used for evaluating patients with coronary artery disease (CAD), dynamic changes that occur at microcirculatory level during each stage of stress have not been demonstrated in humans. We sought to determine variations in myocardial blood flow (MBF) during DASE using quantitative real time myocardial contrast echocardiography (RTMCE). We studied 45 patients who underwent coronary angiography and RTMCE. Replenishment velocity of microbubbles in the myocardium (β) and MBF reserves were obtained at baseline, intermediate stage (70% of maximal predicted heart rate), peak stress, and recovery phase. β and MBF reserves were lower in patients with than without CAD at intermediate (1.65 vs. 2.10; P=0.001 and 2.44 vs. 3.23; P=0.004) and peak (1.63 vs. 3.00; P<0.001 and 2.14 vs. 3.98; P<0.001, respectively). In patients without CAD, β, and MBF reserves increased from intermediate to peak and decreased at recovery, while in those without CAD reserves did not change significantly. Optimal cutoff values of β reserve at intermediate, peak, and recovery were 1.78, 2.09, and 1.70, with areas under the curves of 0.80 (95%CI=0.67-0.94), 0.89 (95%CI=0.79-0.99), and 0.69 (95%CI=0.53-0.85). Sensitivity, specificity and accuracy for detecting CAD at intermediate stage were 68% (95%CI=48-89), 85% (95%CI=71-98), and 78% (95%CI=66-90), at peak stress were 79% (95%CI=61-97), 96% (95%CI=89-100), and 89% (95%CI=80-98), and at recovery were 74% (95%CI=54-93), 65% (95%CI=47-84), and 69% (95%CI=55-82), respectively. RTMCE allows for quantification of dynamic changes in microcirculatory blood flow at each stage of DASE. The best parameter for detecting CAD in all stages was β reserve.

Transmural myocardial ischaemia complicating recovery after dobutamine-atropine stress echocardiography in patients with non-significant coronary artery disease: insights from invasive assessment of coronary physiology

In the proposed selection of cases, traditional imaging is integrated with contemporary diagnostic tools available in the cath-lab to navigate the potential mechanisms underlying a very rare complication occurring in the recovery phase of dobutamine-atropine stress echocardiography. The data, collected in a time frame of nearly 15 years, provide interesting elements to possibly evolve from speculative considerations to plausible confirmation of the candidate pathophysiological mechanism mediating the occurrence of transmural myocardial ischaemia after beta-blockers administration.

Incidence, Pathophysiology, and Treatment of Complications During Dobutamine-Atropine Stress Echocardiography

modality rapidly expanded from diagnosing coronary artery disease (CAD) to risk stratification of patients undergoing vascular surgery; risk stratification of patients with chronic CAD, unstable angina, acute or chronic myocardial infarction (MI), or valvular heart disease; and the assessment of myocardial viability in patients with severe left ventricular (LV) dysfunction. Thus, dobutamine stress has been applied to progressively more complex, older, and higher-risk patients. Additionally, stress protocols became more aggressive, with higher dobutamine doses and the addition of atropine. 3 Although generally regarded as a safe stress modality, serious complications do occur. In this review, we will describe the incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography (DASE). Data on incidence of complications were obtained from 26 studies including 400 patients that reported at least the major complications of mortality, acute MI, ventricular fibrillation, and sustained ventricular tachycardia, 4–29 for a total of 55 071 patients (Table 1). In addition, references are given to case reports and studies dealing specifically with a particular complication.

Abnormal spatial QRS-T angle predicts mortality in patients undergoing dobutamine stress echocardiography for suspected coronary artery disease

To investigate the association between (cardiac) mortality and spatial QRS-T angle in patients undergoing dobutamine - atropine stress echocardiography (DSE) for evaluation of known or suspected coronary disease. Between 1990 and 2003, 2347 patients underwent DSE for evaluation of coronary disease at the Erasmus Medical Center. Echocardiographic images were analyzed offline using a 16-segment, 5-point scoring model for regional function. Twelve-lead resting ECGs were analyzed and patients were grouped in three categories according to their spatial QRS-T angle: normal (0-105 degrees), borderline (105-135 degrees), and abnormal (135-180 degrees). Mean age was 61+/-13 years, 66% were male, 32% had hypertension, 26% had hypercholesterolemia, 28% were smokers, and 12% were diabetic. During a mean follow-up of 7+/-3.4 years, 26.5% (623) of the patients died; 15.3% (359) died due to a cardiac cause. Abnormal QRS-T angle (135-180 degrees ) was present in 21% of the patients. Abnormal QRS-T angle was a predictor of cardiac death [hazard ratio: 3.2 (2.6-4.1)] and all-cause mortality [hazard ratio: 2.2 (1.8-2.6)]. After multivariate analysis abnormal and borderline QRS-T angle, peak wall motion score, age, male sex, history of diabetes, history of heart failure, smoking, and hypertension were independent predictors of (cardiac) death. Abnormal QRS-T angle is an independent predictor of (cardiac) death in patients undergoing DSE. Abnormal QRS-T angle should be considered as a risk factor in stable patients evaluated for coronary disease.

Adjunctive application of handgrip exercise associated with dobutamine stress echocardiography

Stress echocardiography is today the best possible imaging choice in the field of noninvasive diagnosis of coronary artery disease. Dobutamine stress echocardiography (DSE) and Dobutamine-atropine stress echocardiography (DASE) have been studied. Handgrip (HG) exercise has been rarely studied in stress echocardiography. We present a case of the use of isometric HG exercise with DSE in a 78-year-old Italian man. This case is illustrative of the safety, feasibility and efficacy of the use of isometric HG exercise with DSE and on the fact that it improves diagnostic capacity of the test.

Handgrip exercise associated with dobutamine stress echocardiography

Background Stress echocardiography is today the best possible imaging choice in the field of noninvasive diagnosis of coronary artery disease. Dobutamine stress echocardiography (DSE) and Dobutamine-atropine stress echocardiography (DASE) have been studied. Handgrip (HG) exercise has been rarely studied in stress echocardiography. Aim of the study was to investigate the safe, feasibility and efficacy of use of HG associated with DSE and if it may lead to improved diagnostic capacity of the test. Methods DSE was performed in 96 consecutive patients. Seventy-seven patients reached their target heart rate age-adjusted and were excluded. To 19 patients who have not reached their target hr age-adjusted, HG at 50% maximum effort was applied for a minute and 16 patients reached the maximum heart rate. Results Of these 16 patients, 8 were positive for myocardial ischemia induced. Of the 3 other patients, 2 were positive for myocardial ischemia before reaching the target hr. One patient, without reaching the max hr and without being positive for myocardial ischemia, refused other investigations. Therefore, a total of 10 patients presented an inducible myocardial ischemia. Coronary angiography revealed a significant coronary artery disease in all these 10 patients (10/10 patients, 100%). Discussion Our study concludes for the safe, feasibility and efficacy of use of HG with DSE and that it may lead to improved diagnostic capacity of the test. Large studies need to be done to confirm these preliminary results but our study is very encouraging for the application and validity of this type of test mixture.

Effect on Quality of Life of Different Accelerated Diagnostic Protocols for Management of Patients Presenting to the Emergency Department With Acute Chest Pain

This study assessed the effects on quality of life (QoL) of dobutamine-atropine stress echocardiography (DASE) and electrocardiogram exercise testing (EET) accelerated diagnostic protocols for early stratification of low-risk patients with acute chest pain (ACP). A total of 290 patients with ACP, a nondiagnostic electrocardiogram, and negative biomarkers were randomly assigned to an accelerated diagnostic protocol (DASE, n = 110, or EET, n = 89) or usual care (n = 91) and followed up for 2 months. QoL was assessed at discharge and 2-month follow-up using the Nottingham Health Profile questionnaire. Baseline and 2-month follow-up answers to the Nottingham Health Profile questionnaire were available for 207 patients (71%; 55 in the usual-care, 77 in the DASE, and 75 in the ETT arm). At predischarge, patients in the usual-care arm reported higher impairment in the physical mobility and pain dimensions compared with the DASE and EET arms (p = 0.019 and p = 0.023, respectively). At 2-month follow-up, QoL improved in all groups; however, patients in the usual-care arm had significantly worse scores than patients managed using accelerated diagnostic protocols in the physical mobility, pain, social isolation, emotional reactions, and energy level dimensions (p = 0.014, p = 0.002, p = 0.04, p = 0.01, and p = 0.003, respectively). In conclusion, low-risk patients with ACP had non-negligible impairment of QoL in the acute phase. Emergency department ADPs with early DASE and EET reduced QoL impairment at both baseline and 2-month follow-up.

Death Caused by Splenic Artery Aneurysm Rupture during Dobutamine–Atropine Stress Echocardiography: Case Report and Literature Review

A 55-year-old man developed hypertension and acute epigastric pain during dobutamine-atropine stress echocardiography (DASE). Evaluation-including a helical computed tomography (CT) scan of the abdomen and pelvis, as well as surgical exploration-revealed a ruptured splenic artery aneurysm. The patient died, despite multiple surgical interventions and a massive blood product transfusion. Impressively, no deaths from DASE have been previously reported. Additionally, no adverse sequelae during DASE have been reported in patients with an unruptured abdominal aortic aneurysm >or=4 cm in diameter or with an unruptured intracranial aneurysm. We report the first case, to our knowledge, of death caused by splenic artery aneurysm rupture during DASE. Splenic artery aneurysm rupture during DASE, though rare, can lead to death.

Abstract 4230: Comparison of Dobutamine-atropine Stress Echocardiography and Magnetic Resonance for Detection of Obstructive Coronary Artery Disease by Assessing Wall Motion and Myocardial Perfusion Abnormalities

Background: The analysis of wall motion abnormalities (WMA) with dobutamine stress echocardiography or magnetic resonance is an established method for the detection of myocardial ischemia. Contrast echocardiography has been demonstrated a useful technique for evaluating myocardial perfusion (MP). We test the hypothesis that combination of MP and WMA would improve the diagnosis of coronary artery diseasen (CAD). Objective: To compare the diagnostic accuracy of dobutamine stress real-time myocardial contrast echocardiography (RTMCE) and gadolinium-enhanced magnetic resonance imaging (G-MRI) for detecting CAD by analyzing left ventricular WMA and MP. Methods: We prospectively studied 46 patients (23 males, mean age 58±8 years) referred for coronary angiography, RTMCE and MRI within a maximum interval of two weeks. Protocol used in RTMCE and G-MRI was four-stage dobutamine protocol (10 – 40 mcg/kg/min), with injection of atropine as required to reach 85% of age-adjusted target heart rate. Patients underwent first dobutamine stress RTMCE and then G-MRI using the same doses of dobutamine and atropine. RTMCE was performed using low-mechanical index imaging combined with intravenous commercially available contrast agent (Definity, Bristol-Myers Squibb). Positivity for the stress test was defined as new or worsening WMA or reversible perfusion defects in &gt;2 contiguous segments. Quantitative coronary angiography (QCA) was performed in all patients. CAD was defined as the presence of lesion &gt;50 % in at least one coronary artery territory. Results: All patients tolerated well dobutamine stress. In five patients G-MRI was not performed (2 because of claustrofobia, 1 because patient did not fit in MRI, 2 because of extensive ischemia by dobutamine RTMCE). A total of 41 patients underwent dobutamine RTMCE, G-MRI and QCA. The sensitivity, specificity, and accuracy to detect CAD by dobutamine RTMCE were 74%, 89% and 80% for the analysis of wall motion, 83%, 89% and 85% for the analysis of MP and 65%, 83% and 73% for dobutamine stress G-MRI. C onclusion: RTMCE seems to have better performance for detecting angiographically significant CAD than G-MRI using dobutamine stress. The analysis of MP increases sensitivity to RTMCE without changing specificity.

Abstract 2081: The Effect Of Left Atrial Volume On Prognostic Value Of Dobutamine-atropine Stress Echocardiography In Patients With Suspected Or Known Coronary Artery Disease.

Although dobutamine-atropine stress echocardiography (DSE) is an established technique for detecting coronary artery disease (CAD), new echocardiographic parameters have been recently described to influence the prognostic value of this test. Objective: To determine the influence of left atrial anatomical evaluation on the prognostic value of DSE in patients with known or suspected CAD. Methods: From January 2000 to October 2004 we studied 981 pts (61±12 years, 536 men) who underwent DSE with early-atropine injection protocol. Primary end-point was major cardiovascular events, defined as non-fatal myocardial infarction (MI) and cardiac death (CD). Secondary end-point was major cardiovascular events plus revascularization (surgical and percutaneous). Left atrial diameter was determined by two-dimensional echocardiography in longitudinal paraesternal view and left atrial volume in apical 4-chamber view, at rest. Abnormal DSE was defined as fixed or inducible wall motion abnormalities. Pts were followed for a mean of 18 months (6 to 47 months). Results: DSE was abnormal in 330(34%) pts. Mean left atrial diameter was 3.9±0.6 cm (2.2±0.4 cm/m2) while mean left atrial volume was 54.4±18.9 ml (30.7±11.2 ml/m2). Major cardiovascular events occurred in 39(4%) pts (29 CD and 10 non-fatal MI). A total of 120(12%) pts achieved secondary end-point. By univariate analysis the predictors of CD or non-fatal MI were left atrial diameter (p=0.0013), left atrial volume (p&lt;0.001), male sex (p=0.007), diabetes mellitus (p=0.013), previous MI (p=0.013), left ventricular ejection fraction (p&lt;0.001), and abnormal DSE (p&lt;0.001). By multivariate analysis, the independent predictors of CD and MI were left atrial volume (RR=1.02; 95%CI =1.01–1.03; p&lt;0.001) and abnormal DSE (RR=6.38; 95%CI =3.1–13.2; p&lt;0.001). When considering secondary end-point, independent predictors of combined events were left atrial volume (RR=1.01; 95%CI =1.01–1.02; p&lt;0.001), male sex (RR=1.7; 95%CI =1.1–2.5; p=0.017), and abnormal DSE (RR=4.4; 95%CI =2.9 – 6.6; p&lt;0.001). Conclusion: Resting left atrial volume is an independent predictor of major cardiovascular events and combined events and can be used as an incremental tool for prognostic evaluation of patients who underwent DSE.

Abstract 2685: Assessment of Myocardial Perfusion With Stress-Contrast Echocardiography in Diabetics

Background and purpose: The combination of myocardial contrast echocardiography with dobutamine-atropine stress echocardiography has shown promising results in the diagnostic approach of coronary heart disease (CHD). However, its diagnostic value in specific patient populations has not been clearly specified. The aim of the present study was to assess the value of stress contrast echocardiography (SCE) in diagnosing significant coronary heart disease in diabetic versus non-diabetic patients. Methods: 127 individuals (60 males, 62±9.8 years old) with no known history of CHD, among which 59 patients with Type 2 diabetes mellitus, were submitted to stress echocardiography (four-stage dobutamine protocol 10 – 40 mcg/kg/min, with use of atropine as required to reach 90% of age-adjusted target heart rate), combined with intravenous contrast use to perform myocardial contrast echocardiography. New or worsening wall motion abnormalities during stress or reversible perfusion defects in &gt;2 contiguous segments were considered as signs of ischemia. Significant CHD was defined as &gt;50% stenosis in a major epicardial artery on coronary angiography (CAG). Results: Among the 68 non-diabetic subjects and the 59 diabetics, 58 (85.3%) and 45 (76.3%) were found to have significant CHD on CAG, respectively. There were no significant differences as regards to age, sex and other major risk factors between diabetics and non-diabetics. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) in the total of 127 patients were 92%, 63%, 91%, 65% and 87%, respectively. These diagnostic parameters in non-diabetic vs. diabetic subjects were 93% vs. 91% (p= NS ), 90% vs. 43% (p&lt;0.01), 98% vs. 84% (p&lt;0.05) and 69% vs. 60% (p= NS ). Conclusions: Stress contrast echocardiography is an exceptionally reliable technique for CHD diagnosis. However, our findings suggest that in diabetic patients it appears to exhibit inferior specificity and PPV compared to non-diabetics. A possible explanation could be that microcirculation abnormalities, which are common in diabetes, may cause appearance of signs of ischemia (wall-motion abnormalities and/or perfusion defects) on SCE, without presence of angiographically significant CHD.

Transient global amnesia after dobutamine–atropine stress echocardiography

Dobutamine-atropine stress echocardiography is a useful and relatively safe test for coronary artery disease assessment. However, possible complications should be recognized. We describe a case of transient global amnesia in a woman who underwent a standard-protocol dobutamine-atropine stress echocardiogram for coronary ischaemia detection, after having complained about chest pain. The test was not positive for coronary ischaemia, but a typical picture of transient global amnesia ensued. Symptoms shortly resolved spontaneously. Neurological work up was negative for organic disease. Transient global amnesia is a neurological syndrome of unknown origin and good prognosis. Dobutamine-atropine stress echocardiography can be added to the described precipitants of transient global amnesia. This neurological syndrome should be taken into account as a possible complication of dobutamine-atropine stress echocardiography.