Negative Dobutamine Stress Echocardiography Research Articles

Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease.

Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings. Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and t-test or Wilcoxon rank-sum test for continuous variables. Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002]. Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.

Is dobutamine stress echocardiography a good screening tool for coronary artery disease in breast cancer patients that underwent treatment with radiotherapy?

Abstract INTRODUCTION Accelerated atherosclerosis has been described in breast cancer patients receiving cardiac exposure from adjuvant radiotherapy (RT). As a result of multidisciplinary care, breast cancer cure rates have improved in recent decades. Therefore, evaluating radiation-induced heart disease (RIHD), especially coronary artery disease (CAD), is essential. The 2022 cardio-oncology European Society of Cardiology (ESC) guidelines recommend screening patients 5 to 10 years after RT for CAD according to cardiovascular risk factors. This screening is generally recommended with exercise stress echocardiography since it can assess the physiological functional performance. Until now, it is unknown if dobutamine stress echocardiography (DSE) is an equal screening tool and if it can predict major adverse cardiovascular events (MACE) (myocardial infarction, stroke, cardiac death, revascularization). PURPOSE Evaluate if DSE is an adequate tool to stratify and predict MACE in post-radiotherapy patients. Methods A retrospective, descriptive cohort study was conducted. Patients who had chest RT for breast cancer and underwent DSE from 2000 to 2022 were included. A bivariate analysis, including Kruskal Wallis and Pearson Chi-Squared test, was done to identify variables associated with a positive DSE. A multivariable Cox Model for MACE and a time-to-event curve for MACE were also performed. Results We identified 163 patients that underwent DSE after a median time of 5.8 years from the end of RT. The median age was 74 years, 98.2% were female, 50% had left and 45% right breast cancer, 81% had hypertension, 41% diabetes mellitus, 71% dyslipidemia, 34% were smokers, and 19% had a prior myocardial infarction. The average dose of photon RT to the chest was 55Gy in the cohort, and 40% received chemotherapy before RT. Patients were divided into two groups: positive and negative DSE. A positive DSE was seen in 19.6%. The median (Q1, Q3) regional wall motion abnormalities (RWMA) of patients with a positive DSE was 1 (1, 1.015) at baseline and 1.280 (1.190, 1.520) at peak stress, and for a negative DSE, was 1 (1, 1) at baseline and peak stress. 88.2% of negative DSE and 87.5% of positive DSE achieved the target heart rate of 85%. HTN, dyslipidemia, and prior MI were significantly associated with a positive DSE (p &amp;lt;0.023). The cumulative incidence of MACE was higher in the group of positive DSE (p&amp;lt;0.001), even after adjusting for hypertension, diabetes mellitus, dyslipidemia, smoking, and prior myocardial infarction, with a hazard ratio of 2.500 (1.51 – 4.13) and a p&amp;lt; 0.001. Similar results were observed regardless of RT laterality. Conclusions In breast cancer survivors that received adjuvant radiotherapy as part of multidisciplinary care, a positive DSE was an independent predictor of MACE compared to a negative result. These results support the usefulness of dobutamine stress echocardiography as a screening tool in breast cancer survivors.Kaplan-Meier Curve for MACE

Clinical relevance of chest pain during dobutamine stress echocardiography

Introduction: Chest pain is a common presentation in emergency units in daily life. Dobutamine stress echocardiography (DSE) was considered an early non-invasive method that help stratifying the risk for development of CVD. However, many patients experience chest pain shortly after DSE. Methods: 150 patients admitted to catheter unit in Cardiology Department at Al-Azhar university Hospitals between June 2021 and June 2022 with chest pain despite negative DSE. They all underwent coronary angiography. Results: 150 patients were included in the study. Their mean age was 50.99 ± 8.29 years old. 56.7% of patients were males. 24.7% of patients were diabetic. After PCA, 15.3% of patients had severe coronary arteries stenosis. We found that 6% of patients had severe stenosis of Left anterior descending and right coronary arteries (p&lt;0.001). In addition, DM with other risk factors was significantly associated with development of severe stenosis of coronary arteries (P&lt;0.001). Conclusion: 15.3 % of patients with chest pain following DSE had significant coronary arteries stenosis on PCA. DM was associated with that stenosis. That is why, in patients with negative DSE and chest pain, further investigations are required. Special emphasis should be directed to patients with more than one risk factor including diabetes mellitus.

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

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

Real World Utility of Dobutamine Stress Echocardiography in Predicting Perioperative Cardiovascular Morbidity and Mortality after Orthotopic Liver Transplantation.

Background and ObjectivesStress echocardiography is the current standard for cardiac risk stratification of patients undergoing orthotopic liver transplantation (OLT). We aim to evaluate the role of dobutamine stress echocardiography (DSE) in predicting perioperative major adverse cardiac event (MACE) in patients undergoing OLT.MethodsThis was a single-center retrospective study including 144 OLT patients. Of 144 patients, 118 had DSE. MACE included myocardial infarction (MI), heart failure (HF), cardiovascular and all-cause death 1 year after OLT.ResultsOur study cohort included 118 patients. The mean age was 57.3±8.2 years (range, 25–72 years). There were 85 men and 33 women, male to female ratio being 2.6:1. Of 118, 15 (13%) had positive DSE and 103 (87%) had negative DSE. Perioperative MACE incidence was 5.9% (95% confidence interval [CI], 2.6–12.3%). In predicting MACE, DSE had sensitivity of 5.6% (95% CI, 0.2–29.4%), specificity 86% (95% CI, 77.3–91.9%), positive predictive value 6.7% (95% CI, 0.3–33.4%), and negative predictive value (NPV) 83.5% (95% CI, 74.6–89.8%). Eighteen patients had MACE in first year post OLT (15%, 95% CI, 9.5–23.3%). Adverse events included cardiogenic shock (2/18), systolic HF (2/18), non-ST-elevated MI (7/18), cardiac mortality (3/18), and all-cause mortality (7/18). The overall complication rate of DSE was 17% (20/118).ConclusionsIn our cohort, DSE had a low sensitivity but high NPV in predicting perioperative MACE post OLT. A similar trend was noted for DSE in predicting 1-year MACE post OLT. We reiterate the need of a better screening and risk stratification tool for OLT.

Reverse stress cardiomyopathy post-liver transplant needing mechanical circulatory support.

A 39-year-old female patient with hepatitis B-related decompensated chronic liver disease underwent living donor liver transplantation. Preoperatively, she had a normal electrocardiogram (ECG) and echocardiography, and also a negative dobutamine stress echocardiography test. Intraoperative course went uneventful. Two hours postoperatively, she developed hypotension. Initially, hypotension was treated with fluids and blood products after confirming normal echocardiography, but with time, patient's haemodynamics worsened. Repeat echocardiography showed postero-inferior regional wall motion abnormality. Troponin I was significantly elevated, but ECG was normal. Suspecting myocardial infarction coronary angiography was done which was normal. Based on Mayo's criteria, patient was diagnosed with reverse Takotsubo cardiomyopathy since postero-inferior wall was involved. Inotropic support failed to maintain haemodynamics and intra-aortic balloon pump (IABP) was placed. Inotropes were gradually tapered and IABP was removed at day 4. Twenty days later, repeat echocardiography was normal and patient was subsequently discharged.

Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease.

Although dobutamine stress echocardiography (DSE) is a well-defined tool for the diagnosis of coronary artery disease (CAD), false-negative and false-positive results still occur. This study investigated the diagnostic role of layer-specific analysis using 2-dimensional speckle-tracking echocardiography (STE) during DSE.A total of 121 patients who underwent DSE and showed normal wall motion and ejection fraction during baseline echocardiography were enrolled. All patients underwent coronary angiography after DSE within 2 weeks. The patients were divided into the following 4 groups according to DSE results and CAD status: negative DSE with no significant CAD (n = 73), positive DSE with significant CAD (n = 16), negative DSE with significant CAD (n = 17), and positive DSE with no significant CAD (n = 15). Layer-specific global longitudinal strain (GLS) was assessed in the endocardium, mid-myocardium, and epicardium by STE techniques.Patients with significant CAD were older, more male and showed higher glucose level compared to patients without CAD. But coronary risk factors and previous medications were not different between patients with and without CAD. There were no significant differences in whole myocardium or layer-specific GLS found in the baseline echocardiography. During recovery echocardiography, endocardial GLS was significantly different between patients with and without CAD, regardless of the DSE results. A receiver-operating characteristic curve analysis showed that endocardial GLS (>-16%) was superior for identifying significant CAD during the DSE recovery stage. Diagnostic accuracy was improved by applying the results of endocardial GLS compared with visual estimation of DSE.The assessment of layer-specific strain by STE during DSE was feasible, and the evaluation of poststress endocardial function is a more sensitive tool for the detection of CAD.

Global Longitudinal Strain in Patients with Unexplained Dyspnea and Normal Diastolic Function at Rest

Dyspnea is a subjective feeling of difficulty of breath and could be due to many causes. If no cause is found on clinical examination the term unexplained dyspnea is applied. Aim of the work: to evaluate patients with unexplained dyspnea with global longitudinal strain at rest and with dobutamine stress echocardiography. Methods: 43 patients with dyspnea were included in the study. They were divided into 2 groups: group one included 30 patients and group two included 13 patients. All patients have normal baseline echocardiography and negative dobutamine stress echocardiography for ischemic heart disease. Patients were then checked with global longitudinal strain (GLS) at rest and after DSE. Results: patients in group two showed reduced GLS after DSE (12 ± 1%) than in group one (19 ± 1%) p>0.05. They have also high triglyceride level, higher body mass index and lower levels of HDL as compared to patients in group one. Conclusion: GLS seems to be a good parameter to study patients with unexplained dyspnea who will develop symptoms and high filling pressure on stress.

0542: Prevalence of atrial fibrillation during dobutamine stress echocardiography

Dobutamine stress echocardiography (DSE) is a widely used echocardiographic examination for assessment of coronary ischemia, but several complications or side effects of DSE have been reported. The aim of this study was to assess the prevalence of atrial fibrillation (AF) during DSE. Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n =2,224) referred for DSE. Criteria for selection included patients >18 years old who underwent DSE. We systematically analyzed all ECG performed during DSE to detect AF during the examination. DSE was completely performed in 2,179 patients (mean age: 62.4±11.6 y.o.): 694 positive DSE and 1,485 negative DSE. AF was observed in 18 patients (14 men, mean age: 79.6±9.0 y.o.): 4 patients (22%) had a previous history of paroxysmal AF and 16 patients (89%) hypertension. Prevalence of AF during DSE was 0.8%. AF was more frequently observed in case of positive DSE (p<0.0005). Patients with AF during DSE were significantly older (p<0.0001) and prevalence of AF during DSE increased with age: 0.45% in patients 60 to 69 years, 1.3% in patients 70 to 79 years and 4% in patients >80 years. Prevalence of atrial fibrillation during DSE is 0.8% and its occurrence increases with age.

0026: Uselessness of high-sensitivity cardiac troponins to improve diagnostic accuracy of dobutamine stress echocardiography in high-risk diabetic patients

Dobutamine stress echocardiography (DSE) is a well-established noninvasive stress modality for the detection and evaluation of coronary artery disease in diabetic patients. High-sensitivity cardiac troponin T recently emerged as a highly sensitive dosage for the detection of ischemia. The aim of the study was to examine whether high-sensitivity cardiac troponin T may improve the diagnostic accuracy of silent ischemia by DSE in high-risk diabetic patients. 21 patients with long-standing (>10 years) and/or complicated type II DM but no established CAD were included. In addition to DSE, venous blood samples for measurement of hs-cTnT and were collected prior to DSE, 6H and 24 hours after the test. Troponins were deemed positive if >1.5 upper limit for normality. Patients with positive troponins underwent coronary angiography or CT scan regardless of the result of DSE. Among the 21 patients, 7 had positive troponins measured 6 hours after stress, (mean peak troponin=44.5). DSE were negative in all of them. Mean age was 64 years significantly higher than patients with negative troponins. No differences were noted between the groups in terms of epidemiological, clinical or echocardiographic characteristics. Patients with positive cardiac troponins were evaluated for the presence of coronary lesions but none of them had significant disease. After a 18 month mean follow-up, no adverse cardiac events were noted in either groups. In high risk diabetic patients, the measurement of hs-cTnT during DSE does not improve the sensitivity at least in those with negative DSE tests

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

139 The Medium Term Prognostic Value of Dobutamine Stress Echocardiogram in Patients with High Risk Scores of Coronary Artery Disease According to Nice Clinical Guideline 95

Coronary artery disease (CAD) is an important differential diagnosis of chest pain. The 2010 NICE Clinic Guideline 95 (CG95) – ‘Chest Pain of Recent Onset’, recommends investigating the complaint of...

Low-dose dobutamine stress echocardiography cannot predict mitral regurgitation reversibility after coronary artery bypass grafting

The ideal management of ischemic mitral regurgitation (MR) remains a clinical dilemma because of the suboptimal available therapeutic options. Recently, new concepts have emerged, pointing to the benefits of a patient selection approach when debating the management of moderate ischemic MR. We investigated the predictability of low-dose dobutamine stress echocardiography (DSE) in selecting candidates for CABG with moderate MR for valve repair. From November 2002 to May 2010, 110 candidates for first-time CABG, who were admitted to the cardiac surgery department in Day General Hospital (Tehran, Iran), were enrolled in the present cross-sectional study. DSE was performed for each case before CABG. Those with positive findings underwent CABG alone and those with negative results underwent concomitant CABG and mitral valve repair. The patients were followed up for a minimum of 60 months. Of the 110 patients, 47 (42.72%) had positive test results and underwent CABG alone and 63 (57.28%) had negative DSE results and underwent concomitant CABG and mitral valve repair. The MR degree had decreased from 2.8±0.3 preoperatively to 1.46±0.6 early during the hospital stay and 1.9±0.7 during late follow-up in the CABG group. It had decreased from 2.84±0.4 preoperatively to 0.93±0.65 postoperatively but then increased to 1.41±0.9 during late follow-up, for a significant decrease in the combined group (P<.05). Despite its utility in selecting CABG patients with moderate ischemic MR for valve repair from a short-term perspective, the use of DSE cannot predict the long-term outcomes of these patients.

Dobutamine stress cardiac magnetic resonance versus echocardiography for the assessment of outcome in patients with suspected or known coronary artery disease. Are the two imaging modalities comparable?

PurposeTo compare the value of Dobutamine stress echocardiography (DSE) with that provided by Dobutamine Cardiac Magnetic Resonance (DCMR) for the non-invasive risk stratification of patients with suspected or known coronary artery disease (CAD). MethodsPatients with suspected or known CAD underwent either DSE or DCMR using the same standardized protocol. Patient matching was then performed retrospectively for age, gender and risk factors. Outcome data including cardiac death and non-fatal myocardial infarction (defined as hard cardiac events) and ‘late’ revascularization performed >90days after the diagnostic procedures were collected during at least 6months. ResultsFollow-up data were available in 1852 patients who completed either DSE (n=884) or DCMR (n=884) during a mean follow-up duration of 4.1±2.4 and 3.9±1.9years, respectively (p=NS). Matched patients exhibited an overall high risk profile (69±9years; 69% male, 70% history of CAD and 26% diabetes mellitus in both groups). Using multivariable analysis, both modalities successfully identified patients with inducible ischemia at higher risk for subsequent hard cardiac events, surpassing the value of conventional risk factors like age, male gender and diabetes (HR=9.2; 95%CI=5.6–14.9 for DCMR versus 2.5; 95%CI=1.7–3.7 for DSE). By testing for interaction the predictive capacity of DCMR was higher than that provided by DSE (p=0.02). Patients with negative DCMR exhibited lower event rates compared to those with negative DSE (annual hard cardiac event rate of 0.8% versus 3.2%, p=0.002). ConclusionsDSE & DCMR aid the risk stratification of CAD patients. However, inducible WMA during DCMR are associated with a higher risk for subsequent cardiac events. Patients with negative DCMR on the other hand, exhibited a lower event rate compared to those with negative DSE.

Assesment of Myocardial Ischemia by Combination of Tissue Synchronisation Imaging and Dobutamine Stress Echocardiography

Background and ObjectivesDobutamine stress echocardiography (DSE) is an important non-invasive imaging method for evaluating ischemia. However, wall motion interpretation can be impaired by the experience level of the interpreter and the subjectivity of the visual assessment. In our study we aimed to combine DSE and tissue syncronisation imaging to increase sensitivity for detecting ischemia.Subjects and Methods50 patients with indications for DSE were included in the study. In 25 patients we found DSE positive for ischemia and in the other 25 patients we found it to be negative. The negative group was accepted as the control group. There was no significant difference in terms of risk factors and echocardiographic parameters between the two groups, except for wall motion scores. In both groups, left ventricular dyssychrony was accepted as the difference between time to peak systolic velocity (Ts) in the reciprocal four couple of non-apical segments at rest and during peak stress. Timings were corrected for heart rate. We compared the differences of the dyssynchronisation value at rest and during peak stress to determine the distinctions within the groups and between the groups of DSE positive and negative patients.ResultsWe found that stress and ischemia did not create any significant difference over the left intraventricular dyssynchrony with DSE, although at the segmenter level it prolonged the time to peak systolic velocity (p<0.05). These alterations did not show any significant difference between positive and negative DSE groups.ConclusionAs a result, this segmenter dyssynchrony and the time to peak systolic velocity, which is corrected for heart rate, did not enhance any new value over DSE for detecting ischemia.

Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain

Excluding obstructive coronary artery disease (CAD) as the etiology of acute chest pain in patients without diagnostic electrocardiographic changes or elevated serum cardiac biomarkers is challenging. Stress testing is a valuable risk-stratifying technique reserved for the subset of these patients with low-risk chest pain who have an intermediate clinical probability of obstructive CAD. Given the risks of radiation inherent to nuclear and computed tomography imaging, both adenosine stress cardiovascular magnetic resonance (AS-CMR) imaging and dobutamine stress echocardiography (DSE) are attractive alternative stress modalities. An essential characteristic of stress modalities is their negative prognostic value; as one must exclude clinically-relevant CAD such that patients can be discharged safely. Therefore, the aim of this study was to validate a favorable negative prognostic value for both AS-CMR and DSE in patients presenting with low-risk acute chest pain. This retrospective study included 255 patients with low-risk acute chest pain and no prior history of CAD presenting to the emergency department at our institution, with 89 patients evaluated by AS-CMR and 166 by DSE. Median follow-up was 292 days, and consisted of medical record review. The primary end-point was the composite of cardiac death, nonfatal acute myocardial infarction, obstructive CAD on invasive coronary angiography (ICA) or recurrent chest pain requiring hospital admission. Test characteristics such as sensitivity and specificity could not be evaluated as patients were not routinely evaluated with ICA. All patients completed the stress protocol without adverse events during testing. 82/89 patients (92.1%) and 164/166 patients (98.8%) had negative AS-CMR and DSE studies, respectively. Both AS-CMR and DSE had excellent negative prognostic values for the primary endpoint, 100 and 99%, respectively. Both AS-CMR and DSE are effective stress modalities for excluding clinically significant coronary artery disease in patients presenting acute low-risk chest pain. Patients without findings to suggest ischemia have an excellent intermediate-term prognosis.

The additive prognostic value of end-systolic pressure-volume relation in patients with diabetes mellitus having negative dobutamine stress echocardiography by wall motion criteria

Background/objective:The end-systolic pressure-volume relation (ESPVR) is a useful method to assess left ventricular contractility during stress providing prognostic information above and beyond regional wall motion. The aim of the study...

Late myocardial ischemia with ST-segment elevation after negative dobutamine stress echocardiography in a patient with normal coronary arteries

Late complications after pharmacological stress echocardiography are infrequent but potentially dreadful events. We report the case of a 80-year-old woman admitted to hospital for rest chest pain with trivial troponin increase, normal left ventricular function and no significant ECG changes. A dobutamine stress echocardiography was performed for diagnostic purpose, with a negative result. About 30 min after the end of dobutamine infusion, she developed ST-segment elevation in inferior leads associated with chest pain and left ventricular dyssynergy, promptly resolved by sublingual nitrates. Subsequently, angiography documented the absence of significant coronary stenoses. The following clinical course was uneventful. Transient myocardial ischemia was likely due to dobutamine-induced coronary spasm. The case emphasizes the utility of routine, long-lasting monitoring of patients after stress echocardiography, even if negative, to counteract possible late life-threatening complications.

Prognostic value of transthoracic coronary flow reserve in medically treated patients with proximal left anterior descending artery stenosis of intermediate severity

Prognostic value of transthoracic coronary flow reserve (T-CFR) is not established in patients with left anterior descending artery (LAD) stenosis of intermediate severity. Objective is to determine the prognosis value of T-CFR>2 in medically treated patients with angiographically intermediate [50-70% QCA (quantitative coronary angiography)] proximal LAD stenosis. Among 110 consecutive patients with intermediate LAD stenosis who underwent prospectively T-CFR in the distal part of the LAD after intravenous administration of adenosine to assess the functional significance of the stenosis, 80 patients had T-CFR>2 and were treated medically without revascularization (Group 1). Among the 30 patients who had T-CFR<2, an additional dobutamine stress echocardiography (DSE) was performed: 15 had a negative DSE; were treated medically and served as a comparative group (Group 2), and 15 had a positive DSE; underwent LAD revascularization, and were excluded from further analysis. All patients completed follow-up (16+/-10 months). During the follow-up period (range 6-45 months), 76 patients (95%) remained free of death or LAD-related event in Group 1, vs. 12 patients (80%) in Group 2. By Kaplan-Meier method, at 30 months the per cent estimated survival free from death or target vessel-related events was 92+/-4% in Group 1 and 44+/-22% in Group 2 (P<0.01). By multivariate analysis, T-CFR remained the only independent predictor of death or LAD-related events. In patients with proximal LAD stenosis of intermediate severity and T-CFR>2, deferral of revascularization is associated with low event rate.

Prognostic implications of negative dobutamine stress echocardiography in African Americans compared to Caucasians

BackgroundAfrican Americans (AA) have higher rates of cardiovascular morbidity and mortality than Caucasians (CA). Despite its excellent negative predictive value, the influence of race on the prognostic implications of negative dobutamine echocardiography in predicting major cardiac problems is largely unknown.MethodsWe studied 387 AA and 340 CA patients with negative dobutamine stress echocardiography (NDSE). Kaplan-Meier survival analysis was used to create freedom-from-event curves for major adverse cardiac events over a 36-month period, and a Cox proportional-hazards multivariable model to examine the influence of race on cardiac outcomes.ResultsAA patients were younger (69.4 ± 12.6 vs. 74.2 ± 10.7, p < .001), had higher incidence of diabetes mellitus (37% vs. 29%, p = .01), hypertension (91% vs. 85%, p = .006), left ventricular hypertrophy (70% vs. 49%, p < .001) and lower incidence of prior coronary artery disease (27% vs. 34%, p = .05) compared to CA patients. Ejection fraction ≥ 50% was comparable (81% vs. 82%, p = .8). At 3-years, AA patients had a lower freedom from nonfatal myocardial infarction (92% vs. 96%, p = .006) and any cardiac event (cardiac death, myocardial infarction) (91% vs. 95%, p = .005) compared to CA patients.ConclusionThis is the first study to demonstrate that AA patients have higher rates of nonfatal MI and MACE compared to CA patients with a NDSE. These patients require closer follow-up and aggressive preventive and treatment strategies should be employed to help reduce cardiovascular morbidity and mortality despite negative ischemic workup.