Dobutamine Stress Echocardiography Test Research Articles

The Scandinavian multicenter hemodynamic evaluation of the SJM Regent aortic valve

Background112 patients who received small and medium sized St.Jude Regent heart valves (19-25 mm) at 7 Scandinavian centers were studied between January 2003 and February 2005 to obtain non-invasive data regarding the hemodynamic performance at rest and during Dobutamine stress echocardiography (DSE) testing one year after surgery.Material and methods46 woman and 66 men, aged 61.8 ± 9.7 (18-75) years, were operated on for aortic regurgitation (17), stenosis (65), or mixed dysfunction (30). Valve sizes were 19 mm (6), 21 mm (33), 23 mm (41), 25 mm (30). Two patients receiving size 27 valves were excluded from the hemodynamic evaluation. Pledgets were used in 100 patients, everted mattress in 66 and simple interrupted sutures in 21. Valve orientation varied and was dependent on the surgeons' choice. 34 patients (30.4%) underwent concomitant coronary artery surgery.ResultsThere were two early deaths (1.8%) and three late deaths, one because of pancreatic cancer. Late events during follow-up were: non structural dysfunction (1), bleeding (2), thromboembolism (2). At one year follow up 93% of the patients were in NYHA classes 1-2 versus 47.8% preoperatively.Dobutamine stress echocardiography (DSE) was performed in a total of 66 and maximal peak stress was reached in 61 patients.During DSE testing, the following statistically significant changes took place: Heart rate increased by 73.0%, cardiac output by 85.5%, left ventriclular ejection fraction by 19.6%, and maximal mean prosthetic transvalvular gradient by 133.8%, whereas the effective orifice area index did not change.Left ventricular mass fell during one year from 215 ± 63 to 197 ± 62 g (p < 0.05).ConclusionThe Dobutamine test induces a substantial stress, well suitable for echocardiographic assessment of prosthesis valve function and can be performed in the majority of the patients. The changes in pressure gradients add to the hemodynamic characteristics of the various valve sizes.In our patients the St. Jude Regent valve performed satisfactory at rest and under pharmacological stress situation.

Cardiac Allograft Vasculopathy

Cardiac allograft vasculopathy (CAV), characterized by diffuse intimal thickening and luminal narrowing in the arteries of the allograft, is the leading cause of morbidity and mortality in cardiac transplant recipients. Many transplant centers perform routine annual surveillance coronary angiography. However, angiography can underdiagnose or miss CAV due to its diffuse nature. Intravascular ultrasound (IVUS) is more sensitive than angiography. IVUS provides not only accurate information on lumen size, but also quantification of intimal thickening, vessel wall morphology, and composition. IVUS has evolved as a valuable adjunct to angiography and the optimal diagnostic tool for early detection. Noninvasive testing such as dobutamine stress echocardiography and nuclear stress test have shown considerable accuracy in diagnosing significant CAV. Computed tomographic imaging and cardiac magnetic resonance imaging are promising new modalities but require further study. This article reviews the diagnostic methods that are currently available.

Impact of Gender and Other Risk Factors on Development of Coronary Artery Disease (Comparison of Dobutamine Stress Echocardiography and Coronary Angiography)

Objectives: The aim of this Study is to examine the development of ischaemic heart disease and occurrence of segmental wall motion abnormalities in men and women during Dobutamine stresss echocardiography in order to establish the impact of gender and other risk factors in development of coronary artery disease and the role of Dobutamine stress echocardiography in detecting and assessing the degree of myocardial ischemia and coronary stenosis in patients with suspected coronary artery disease in order to justify its wider application as a non-invasive diagnostic method. Research aim and purpose: Ischemic heart disease (IHD) causes more deaths, disability and economic loss in developed and developing countries than any other disease. Cardiovascular disease is the leading cause of ddath for women in western socitew. The epidemiology of the ischemic heart disease depends on fixed risk factors, such as sex, age and genetic predisposition, and on multiple risk factors that can be addressed, such as elevated lipid levels, arterial hypertension, diabetes mellitus, obesity, lifestyle (physical inactivity and stress), smoking, and alcohol consumption. Cardiovascular diseases are the leading cause of morbidity and mortality in B&H and, considering the exposure profile of the B&H population to risk factors (unhealthy diet, ubiquitous smoking and alcohol drinking habits, inadequate physical activity, inadequate culture of health), further growing trend of cardiovascular diseases can be expected. Patients and methods: The research study covered 86 adult subjects of both sexes with cardiac risk factors, referred to dobutamine stress echocardiography test as part of their cardiological evaluation. The patients for whom invasive cardiac diagnostics was indicated following the dobutamine stress echocardiography were subjected to left heart catheterization: ventriculography and coronary angiography. The parameters obtained and results of each method applied were statistically processed. Results: The study results obtained indicate a high degree of sensitivity, specificity and accuracy of the dobutamine stress echocardiography as a non-invasive diagnostic method compared to invasive diagnostics i.e. coronary angiography, which is the gold standard for the detection and evaluation of coronary artery diseases. Dobutamine stress test, may play a key role in the optimal identification of high risk groups of patients with hypertension, diabetes mellitus, obesity, lifestyle (physical inactivity and stress), smoking, and alcohol consumption. Conslusion: Echocardiographic measures of inducible wall motion abnormalities and global and regional left ventricular function are highly accurate in detecting CAD in women and men alike. The safety and cost-effectiveness of the dobutamine stress echocardiography as a diagnostic procedure has been proved. In modern cardiology, the DSE occupies a significant place in the evaluation of patients with known or suspected coronary artery d

Silent Cardiac Comorbidity in Arthroplasty Patients: An Unusual Suspect?

We studied 109 patients who were subjected to dobutamine stress echocardiography (DSE) for preoperative cardiac risk assessment before undergoing elective primary hip and knee arthroplasty. Patients were selected for DSE based on several criteria. There were 16 patients with history of ischemic heart disease and 93 patients without. Seven of the 93 patients showed a positive DSE test result, of which 5 developed postoperative cardiac events ( P = .00). This study clearly shows that serious “silent” cardiac comorbidity can exist even in so-called healthier patients undergoing routine hip and knee arthroplasty. We believe that identifying these patients and treating them before arthroplasty can significantly improve the overall outcome of the surgery.

Prognostic Value of Exercise Stress Test and Dobutamine Stress Echo in Patients with Known Coronary Artery Disease

The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged >or=75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 +/- 1.6 METs in G1 vs. 5 +/- 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351-0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559-16.833, P = 0.007), viability (HR 3.354, CI 1.162-9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114-0.945, P = 0.039) predicted hard cardiac events. In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

Efficacy of LOw-dose DObutamine Stress-Echocardiography to predict Cardiac Resynchronization Therapy Response (LODO-CRT) multicenter prospective study—Design and rationale

Although cardiac resynchronization therapy (CRT) has a well-demonstrated therapeutic effect in selected patients with advanced heart failure on optimized drug therapy, nonresponder rate remains high. The LODO-CRT is designed to improve patient selection for CRT. Design and rationale of this study are presented herein. LODO-CRT is a multicenter prospective study, started in late 2006, that enrolls patients with conventional indications for CRT (symptomatic stable New York Heart Association class III-IV on optimized drug therapy, QRS > or =120 milliseconds, left ventricular [LV] dilatation, LV ejection fraction < or =35%). This study is designed to assess the predictive value of LV contractile reserve (LVCR), determined through dobutamine stress echocardiography (defined as an LV ejection fraction increase >5 units), in predicting CRT response during follow-up. Assessment of CRT effects will follow 2 sequential phases: in phase 1, CRT response end point is defined as LV end-systolic volume reduction > or =10% at 6 months; in phase 2, both LV end-systolic volume reduction and clinical status via a clinical composite score will be evaluated at 12 months follow-up. Predictive value of LVCR will be compared to other measures, such as LV dyssynchrony measures, through adjusted multivariable analysis. For the purpose of the study, target patient number is 270 (with 95% confidence, 80% power, alpha < or = .05). Enrollment should be complete by the end of 2008. The LODO-CRT trial is testing the hypothesis that LVCR assessment, using low-dose dobutamine stress echocardiography test, should effectively predict positive response to CRT both in terms of the reverse remodeling process as well as favorable long-term clinical outcome. Moreover, the predictive value of LVCR will be compared to that of conventional intra-LV dyssynchrony measures.

The value of fractional and coronary flow reserve in predicting myocardial recovery in patients with previous myocardial infarction

The aim of the study was to evaluate the relation between fractional flow reserve (FFR) and simultaneously evaluated coronary flow reserve by thermodilution (CFRthermo), with the improvement of left ventricular (LV) function in patients with previous myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). Study population consisted of 46 patients (mean age 53 +/- 7 years; 36 male) with previous MI and significant coronary stenosis undergoing PCI of infarct-related coronary artery. In all patients, we evaluated FFR and CFRthermo by single pressure/thermo wire during maximal hyperaemia before and immediately after PCI. We performed echocardiographic assessment of LV ejection fraction before and 6 months after PCI. Dobutamine stress echocardiography test was also performed before PCI. LV functional improvement was observed in 33/46 (72%) of patients. In patients with LV functional recovery in comparison with patients with no recovery, there was a significant difference in FFR before PCI (0.56 +/- 0.14 vs. 0.70 +/- 0.07, P < 0.001), improvement of FFR (0.35 +/- 0.14 vs. 0.21 +/- 0.07, P < 0.001), improvement of CFRthermo (1.3 +/- 0.6 vs. 0.5 +/- 0.3, P < 0.001), and CFRthermo after PCI (2.6 +/- 0.7 vs. 2.0 +/- 0.4, P < 0.001). When only parameters evaluated before PCI were taken into account, FFR before angioplasty (P = 0.001) and dobutamine-assessed viability (P = 0.006) were the most significant multivariate predictors of myocardial recovery. When all significant univariate parameters were evaluated, the most significant independent predictors for improvement in myocardial function were the improvement of CFRthermo during angioplasty (P < 0.001) and FFR before angioplasty (P = 0.002). Simultaneous evaluation of FFR and CFRthermo provide significant complementary data on the improvement in myocardial function in patients with previous MI. However, the evaluation of FFR before angioplasty identifies viable myocardium that may recover following revascularization and may be used as an alternative to non-invasive testing.

Dobutamine Stress Echocardiography in the Assessment of Cardiac Allograft Vasculopathy in Asymptomatic Recipients

Purpose Cardiac allograft vasculopathy (CAV) is the most important cause of late mortality among cardiac allograft recipients. Dobutamine stress echocardiography (DSE) is considered a safe and cost-effective method to screen these patients who remain free of angina most of the time. We evaluated DSE results in a series of cardiac allograft recipients. Methods The DSE was performed on a yearly basis. From 2004 to 2006, twelve DSEs were performed on 8 patients, including 7 men, and overall mean age of 36 ± 12 years. Dobutamine infusion begun at 5 μg/kg/min was titrated at 3-minute stages to 10, 20, 40, and 50 μg/kg/min to achieve the target heart rate. In addition, at every stage, we performed a 12-lead EKG, heart rate, and blood pressure recording. The DSE results were compared with coronary angiograms and endomyocardial biopsies. Results Two patients displayed mildly and 1 patient a severely abnormal DSE test. The severely abnormal DSE test was associated with severe coronary artery stenosis, including inexperiment of the left main coronary artery. The second patient with an abnormal DSE had contour irregularities and distal cut-off of the right coronary artery as well as 2R cellular rejection. The third patient had a normal angiogram and no rejection. None of the patients with normal DSE experienced a cardiac event, coronary lesions, or rejection. Conclusion Use of DSE appears to be a sensitive method to detect CAV in asymptomatic recipients. However, mild wall motion abnormalities can be detected in patients without stenosing coronary lesions. The value of DSE in predicting CAV must be examined in larger series with long-terms of follow-up.

Development and Validation of a Noninvasive Method to Estimate Cardiac Output Using Cuff Sphygmomanometry

Obtaining cardiac output (CO) measurements noninvasively during routine blood pressure recording can improve hypertension management. A new method has been developed that estimates cardiac output using pulse-waveform analysis (PWA) from a brachial cuff sphygmomanometer. This study evaluates the ability of PWA to track changes in CO as derived by Doppler ultrasound during dobutamine stimulation. This study aims to validate the PWA CO estimation over a wide CO range as would be obtained by dobutamine stimulation during Doppler ultrasound evaluation. A total of 48 patients undergoing standard dobutamine stress echocardiography testing for accepted clinical indications were enrolled. Among them, 44 patients (age 36-83, 18 females, 26 males) with good waveform data for analyses provided estimates of CO in this study. Noninvasive measurements of CO were performed using both Doppler ultrasound recordings and PWA techniques simultaneously at each stage of dobutamine infusion. A total of 207 simultaneous pulse-waveform analyses and Doppler measurements were taken during dobutamine stress on 44 cardiac patients. Linear regression analysis revealed good intra-patient correlation between pulse-waveform analysis and Doppler at different dobutamine-induced CO with coefficients from r = 0.69 to 0.98 (p < 0.05). Analysis of all patients yielded an overall correlation of r = 0.82 (p < 0.001, bias = 0.4 L/min, standard deviation = 1.8 L/min). The CO measured noninvasively from a sphygmomanometer using this PWA method correlates well with those of Doppler through a range of dobutamine-stimulated levels. The CO by PWA should be useful for monitoring hemodynamic changes in hypertensive and cardiac patients during routine blood pressure measurement.

Comparison of Early Dobutamine Stress Echocardiography and Exercise Electrocardiographic Testing for Management of Patients Presenting to the Emergency Department With Chest Pain

This study compared the cost-effectiveness of dobutamine-atropine stress echocardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were randomized to DASE (n = 110) or EET (n = 89) <6 hours after emergency department presentation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23 +/- 12 and 31 +/- 23 hours in the DASE and EET arms, respectively (p = 0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p = 0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026 +/- $250 vs $1,329 +/- $1,288, p = 0.03) and 2-month ($1,029 +/- 253 vs $1,684 +/- $2,149, p = 0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET.

Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery

According to previous studies, a negative dobutamine stress echocardiography (DSE) test before major vascular surgery indicates that postoperative myocardial necrosis is very unlikely. We believe that the use of new cardiac troponin assays which can detect small amounts of myocardial necrosis results in a lower DSE negative predictive value for myocardial necrosis. A total of 418 consecutive patients were screened using the ACC/AHA Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery before scheduled abdominal aortic surgery. Of these 143 met ACC/AHA criteria for non-invasive testing and underwent DSE. Patients with a negative DSE were deemed to be fit for surgery. A positive DSE led to a coronary angiogram. DSE was negative in 110 (77%) and positive in 33 (23%) patients. Myocardial necrosis was monitored up to the third postoperative day by daily cardiac troponin I (cTnI) measurement and a daily 12-lead ECG. Coronary angiography showed artery stenosis in 27 (84%) of 32 patients with a positive DSE. The negative predictive value of DSE for cTnI elevation was 92.7% (95% CI 86.2-96.8%). This was significantly lower than the lowest value of negative predictive value for myocardial necrosis assessed in previous studies. A negative DSE prescribed before scheduled aortic surgery according to ACC/AHA guidelines does not rule out postoperative myocardial necrosis.

Comparison of exercise, dobutamine-atropine and dipyridamole-atropine stress echocardiography in detecting coronary artery disease

BackgroundDipyridamole and dobutamine stress echocardiography testing are most widely utilized, but their sensitivity remained suboptimal in comparison to routine exercise stress echocardiography. The aim of our study is to compare, head-to-head, exercise, dobutamine and dipyridamole stress echocardiography tests, performed with state-of-the-art protocols in a large scale prospective group of patients.MethodsDipyridamole-atropine (Dipatro: 0.84 mg/kg over 10 min i.v. dipyridamole with addition of up to 1 mg of atropine), dobutamine-atropine (Dobatro: up to 40 mcg/kg/min i.v. dobutamine with addition of up to 1 mg of atropine) and exercise (Ex, Bruce) were performed in 166 pts. Of them, 117 pts without resting wall motion abnormalities were enrolled in study (91 male; mean age 54 ± 10 years; previous non-transmural myocardial infarction in 32 pts, angina pectoris in 69 pts and atypical chest pain in 16 pts). Tests were performed in random sequence, in 3 different days, within 5 day period under identical therapy. All patients underwent coronary angiography.ResultsSignificant coronary artery disease (CAD; ≥50% diameter stenosis) was present in 69 pts (57 pts 1-vessel CAD, 12 multivessel CAD) and absent in 48 pts. Sensitivity (Sn) was 96%, 93% and 90%, whereas specificity (Sp) was 92%, 92% and 87% for Dobatro, Dipatro and Ex, respectively (p = ns). Concomitant beta blocker therapy did not influence peak rate-pressure product and Sn of Dobatro and Dipatro (p = ns).ConclusionWhen state-of-the-art protocols are used, dipyridamole and dobutamine stress echocardiography have comparable and high diagnostic accuracy, similar to maximal post-exercise treadmill stress echocardiography.

Prospective validation of stress echocardiography as an identifier of cardiac resynchronization therapy responders

Cardiac resynchronization therapy (CRT) provides benefit for congestive heart failure (CHF), but predictors of the clinical response are debated. The aim of this prospective study was to assess the predictive role of dobutamine stress echocardiography (DSE) in identifying a suitable candidate for CRT. From March 2001 to December 2003, 71 CHF patients were prospectively enrolled on the basis of four criteria: New York Heart Association (NYHA) class III and IV; QRS > or =150 ms with a left bundle branch block pattern, and left ventricular ejection fraction (LVEF) < or =35% under optimal medical treatment. The combined endpoints were hospital readmission for class IV CHF, heart transplant (HT), and CHF-related death. The 67 patients completing the study presented with the following characteristics: age (70 +/- 10 years; 11 women); etiology (idiopathic in 44, ischemic in 23); NYHA class (40 in class III and 27 in class IV); LVEF 26% (+/-5%); QRS duration (190 +/- 28 ms); 6-minute walk test 330 m (+/-108); peak oxygen uptake 10.7 (+/-3.3 mL/kg/min); mitral insufficiency in 42 (> or =III grade); interventricular (IV) delay (62 +/- 21 ms); and intraventricular dyssynchrony in 30 patients. Over the follow-up period of 12.1 +/- 8.7 months, 20 (29.9%) of 67 patients presented with at least one hemodynamic event: hospitalization for CHF in 19 (28%) of 67, HT in 2 (3%) of 67, and CHF death in 7 (10%) 67. Univariate analysis identified NYHA class (P = .03), LVEF (P = .015), IV dyssynchrony before (P = .038) and after CRT (P = .0035), IV delay after CRT (P = .002), 6-minute walk distance (P = .01), and DSE Res+ (P = .008) as significant predictors of clinical events. A receiver operating curve established a cut-off value of 1.25 for the DSE responders (Res+: 34 patients at 10 microg/kg/min infusion rates), and the improvement at the 10 microg/kg/min level was 41% +/- 7% in Res+ and 29% +/- 8% in nonresponders (P<.0001). With a cut-off value of 1.25-fold the LVEF increase, the DSE test exhibits 70% sensitivity, 61.7% specificity, 43.8% positive predictive value, and 82.9% negative predictive value. Cox analysis identified IV dyssynchrony before CRT (P = .01) and DSE Res+ (P = .003) as independent predictive factors. Independent predictive factors of severe hemodynamic clinical outcome in patients with CRT are IV dyssynchrony and DSE.

Prognostic significance of sinus deceleration during dobutamine stress echocardiography test following acute myocardial infarction

Chronotropic incompetence during exercise stress testing after acute myocardial infarction is an indicator of ischemia or impaired left ventricular function. On the other side, infusion of dobutamine leads to a typical dose-dependent increase in heart rate. The aim of this study was to evaluate of paradoxical sinus deceleration during dobutamine stress echocardiography (DSE), as the sign of ischemia and impaired left ventricular function, or the consequence of infarction localization, and the estimation of prognostic significance after acute myocardial infarction. Our investigation comprised 81 patients hospitalized because of the acute myocardial infarction, and all of them had uncomplicated infarction. Fifty five patients were treated with thrombolytic therapy (67.9%); 53 patients (65.4%) had anterior myocardial infarction, and 28 patients (34.6%) had inferoposterior localization of myocardial infarction. After 10-12 days all of them underwent dobutamine stress echocardiography examination. During the next 3-6 months, the patients underwent coronary angiography. The average follow-up period was 36 +/- 22 months. A decrease in heart rate occurred at the dobutamine doses increasing from 15-40mcg/kg/min in 9 (11.1%) of the patients, in 1 patient with an anterior localization and in 8 patients with an inferoposterior localization. The decrease was sudden in 4 (44.4%), and gradual in 5 (55.6%) of the patients. In 3 patients (33.3%) junction rhythm was developed, and in 2 patients (22.2%) AV block II-III. Only in 2 of them, there was a worsening of regional function during a high dose dobutamine infusion, but 7 of them showed an improvement during a low dose. In 7 (77.8%) of the patients there was a simultaneous decrease in blood pressure. Coronary angiographic examination showed that in 4 (44.4%) of the patients there was a significant coronary artery disease and they underwent the revascularisation procedure. During the follow up period, there was not any significant arrhythmic disorder in that group of the patients or repeated hospitalization because of postinfarction angina, re-infarction, or heart failure. We could conclude that paradoxical sinus deceleration is not only an indicator of a significant coronary artery disease and "bad left ventricle". It also may occur as a consequence of vasodepressor reflex (Bezold-Jarisch), even after acute myocardial infarction, withont influencing a long-term prognosis.

Atrial fibrillation in dobutamine stress echocardiography

Objectives To describe the incidence of atrial fibrillation induced by dobutamine stress echocardiography and characterize patients at risk of developing atrial fibrillation, by constructing a simple validated risk score index. Design An observational study using prospectively collected data. Methods 3800 consecutive patients in sinus rhythm undergoing dobutamine stress echocardiography were randomly divided to a case (2 / 3) and test group (1 / 3). Associations of predetermined demographic, clinical, electrocardiographic and echocardiographic variables were calculated in patients with and without atrial fibrillation induced by dobutamine stress echocardiography in the case group. Logistic regression analysis determined significant independent risk predictors, a scoring index was constructed and validated on the test group. Results There was a 2% incidence of dobutamine stress echocardiography-induced atrial fibrillation in the study population. Risk predictors of atrial fibrillation included: a history of atrial fibrillation (2 points), increased left atrial diameter, right bundle branch block, decreased rest heart rate and hypertension (1 point each). The case subgroup low-risk patients (score 0–2) had a 1% risk, moderate-risk patients (score 3) a 2.7% and high-risk patients (score 4–6) a 14.5% risk of developing atrial fibrillation during dobutamine stress echocardiography. The rates in the test subgroup were 1%, 3.8% and 15.3%, respectively. Conclusion Atrial fibrillation during dobutamine stress echocardiography is not common, the risk of developing atrial fibrillation during dobutamine stress echocardiography can be predicted by using a simple risk score system comprised of clinical, electrocardiographic and rest echocardiographic variables, which may be of help when planning a dobutamine stress echocardiography test in selected cases.

Coronary flow: a new asset for the echo lab?

Non-invasive imaging of coronary blood flow by transthoracic Doppler echocardiography is an emerging diagnostic tool to study the left anterior descending (LAD)1–11 and posterior descending (PD) coronary arteries.12–15 With this new clinical application of echocardiography, we can directly measure changes in coronary flow velocity reserve (CFVR) at the very beginning of the ischaemic cascade, instead of looking at the consequences of ischaemia on myocardial contraction, as it is routinely done with dobutamine stress echocardiography and other stress tests. Since its introduction in 1997,1,2 it has been clear that transthoracic coronary Doppler ultrasound could provide useful information in the diagnosis of coronary artery disease (CAD)3–15 follow-up of percutaneous coronary interventions,16–21 coronary recanalization in acute myocardial infarction (AMI),22–26 and coronary microcirculation.27–33. The importance of measuring CFVR in routine clinical practice has been anticipated over 20 years ago by the physiologist Carl Honig: One of the principal tasks of a physician is to estimate the patient's reserves… Prognosis is an estimate of the rate at which this reserve may disappear, and therapy is designed to increase this reserve and to prevent or eliminate stresses that might compromise it.34 With this teaching in mind we have planned our seven-year work on transthoracic coronary Doppler ultrasound. In this review we will focus on the main clinical applications of transthoracic coronary Doppler ultrasound, and discuss the advantages, limitations and technical pitfalls of the method. Some basic yet simple concepts should be assimilated before beginning this new technique, in order to reduce errors and misinterpretations. ### The window Coronary blood flow velocity should be measured from an apical window by pulsed Doppler ultrasound under colour-coding guide. The best long axis view in colour flow imaging should be obtained to maintain a <30° angle between flow and the Doppler beam. Correction for …

Methodological Analysis of Diagnostic Dobutamine Stress Echocardiography Studies

Dobutamine stress echocardiography (DSE) is an accepted test for the diagnosis of coronary artery disease (CAD), despite its wide diagnostic accuracy. Which factors cause test variability of DSE for the diagnosis of CAD. In a retrospective analysis of 46 studies in 5,353 patients, the potential causes of diagnostic variability were systematically analyzed, including patient selection, definition of CAD, chest pain characteristics, confounding factors for DSE (left ventricular hypertrophy, left bundle branch block, female gender), work-up bias (present when patient's chance to undergo coronary angiography is influenced by the result of DSE), review bias (present when DSE is interpreted in relation to CAG), DSE protocol and definition of a positive DSE. Diagnostic variability was related to definition of a positive test, but not related to the definition of CAD or DSE protocol. However, only three of eight methodological standards for research design found general compliance. Differences in the selection of the study population (quality of echocardiographic window, angina pectoris), handling of confounding factors and analysis of disease in individual coronary arteries were observed. Lack of data on analysis of relevant chest pain syndromes and handling of nondiagnostic test results hampered further evaluation of these standards. Methodological problems may explain the wide range in diagnostic variability of DSE. An improvement of clinical relevance of DSE testing is possible by stronger adherence to common and new methodological standards.

1151-143 Regional wall motion abnormalities during dobutamine stress echocardiography in patients with systemic sclerosis

Background : Systemic sclerosis (SSc) is a chronic connective tissue disorder of unknown etiology, characterized by cutaneous and visceral involvement.The pathogenesis of the cardiac lesion in SSc is controversial, but the primary disorder of microvasculature with diffuse arteriolar and capillary lesions could precede any fibrosis, thus causing ischemic disorder to the heart. Dobutamine stress echocardiography (DSE) is a sensitive predictor of coronary artery disease. This study was performed to assess the value of DSE for noninvasive diagnosis of cardiac involvement in patients with SSc without clinical evidence of heart disease and to determine if abnormal responses to dobutamine can be explained by a decreased coronary flow velocity reserve (CFVR). Methods : We studied 27 patients with SSc without clinical evidence of heart disease, (15 with diffuse form and 12 with localized form of SSc), age 54±12. All patients underwent high dose DSE testing (5-40 mcg/kg/min) and evaluation of CFVR in the left anterior descending coronary artery with contrast transthoracic Doppler during adenosine infusion (140 µg/Kg/min in 5 minutes). Patients were divided into two groups based on the absence (group A; n=15) or presence ( group B; n=13) of regional wall motion abnormalities (RWMA) on DSE. Results : In 13 out of 28 pts (46%) with SSc, we found RWMA during DSE with patchy distribution. Both groups showed normal CFVR values (group A, 2.76±0.7; group B, 2.26±0.4), but CFVR in group B was statistically reduced compared to group A (p=0.03). Conclusion : This study showed that many patients with SSc, without clinical evidence of heart disease, have inducibile RWMA during DSE with patchy distribution. Furthemore, CFVR reduction suggests the role of a partial coronary microvascular dysfunction in these group of patients.

Dobutamine stress echocardiography in women with systemic lupus erythematosus: increased occurrence of left ventricular outflow gradient.

Dobutamine stress echocardiography (DSE) is an accurate noninvasive test used for the diagnosis and evaluation of patients with known or suspected coronary artery disease (CAD). The aim of this study was to determine the rate of positive findings in DSE, to define the echocardiographic and clinical characteristics of women with systemic lupus erythematosus (SLE) and to evaluate the safety of DSE in SLE patients. Thirty consecutive SLE patients were enrolled in the study and underwent DSE study. The mean age of patients was 44 years (range 20-76). Mean duration of SLE was 8.1 years and mean SLEDAI was 5.5. None of the DSE tests performed were positive for myocardial ischaemia. A left ventricular outflow gradient (LVOG) was found in 15/28 (54%) patients who completed the test, a result higher than the reported 20% prevalence of this finding in the literature. There were no significant differences in baseline characteristics between patients who developed a gradient and patients in whom a gradient was not found. There were no significant adverse effects during the study. In the general population, LVOG has been reported to be associated with an increased rate of chest discomfort and with a significantly lower prevalence of CAD. Whether this is true for SLE patients requires further study.

Predictive significance of residual ischemia detected by the dobutamine stress-echocardiography test soon after the first uncomplicated myocardial infarction

To evaluate the long-term prognostic value of dobutamine stress-echocardiography (ECG) test for new coronary events (new episodes of angina pectoris, cardiac-related deaths, and reinfarctions) early after the first uncomplicated myocardial infarction. Dobutamine stress-echocardiography tests were performed in all of 104 patients 10-20 days after the first myocardial infarction. Patients were followed-up for 36 (29 +/- 7) months. Kaplan-Meier cumulative survival curves were tested by Breslow test (Log Rank). Two cardiac deaths (1.92%), nine nonfatal myocardial infarctions (8.65%), and three cases of recurrent angina pectoris (2.88%) occurred during the prospective follow-up. Cumulative survival curves showed that in patients with negative findings of dobutamine stress-echocardiography test, survival time without significant events was 35.31 months, while in the group with positive findings of dobutamine stress-echocardiography test it was 30.91 months (log Rank 7.22; p<0.01). Prognostic value of dobutamine stress-echocardiography test was analyzed by Cox regression model and was 2.92, meaning that the risk of significant events was 2.92 times higher in the group of patients with positive findings of dobutamine stress-echocardiography test. Patients with negative findings of dobutamine stress-echocardiography test were with significantly higher possibility of surviving without significant events in comparison with the patients in whom the findings of dobutamine stress-echocardiography test were positive. In combination with clinical signs and ECG results, the results of dobutamine stress-echocardiography test improved prognostic value in the patients with the first uncomplicated myocardial infarction, and in that way influenced the strategy of their further treatment.