Patients Undergoing Dobutamine Stress Echocardiography Research Articles

Dobutamine-induced alternations in cerebral blood flow of healthy adults: a 3D pseudocontinuous arterial spin labeling study

BackgroundIt is unclear whether dobutamine, commonly used clinically in echocardiography and short-term congestive heart failure treatment for promoting increased myocardial contractility, affects brain microcirculatory behavior. Cerebral microcirculation plays an important role in ensuring adequate oxygen transport. Therefore, we investigated the effects of dobutamine on cerebral hemodynamics.MethodsForty-eight healthy volunteers without cardiovascular or cerebrovascular disease underwent MRI to obtain cerebral blood flow (CBF) maps using 3D pseudocontinuous arterial spin labeling before and during the dobutamine stress test. Additionally, cerebrovascular morphology was obtained based on 3D-time-off-light (3D-TOF) magnetic resonance angiography (MRA). Electrocardiogram, heart rate (HR), respiration rate (RR), blood pressure, and blood oxygen were simultaneously recorded before and during dobutamine injection and during recovery (not during MRI). The anatomic features of the circle of Willis and the basilar artery (BA) diameter were assessed on MRA images by two radiologists with extensive neuroimaging experience. Binary logistic regression was used to test for the independent determinants of CBF changes.ResultsHR, RR, systolic (SBP), and diastolic blood pressure (DBP) significantly increased after dobutamine infusion. Blood oxygen levels remained similar. Compared to the CBF in the resting state, the CBF values exhibited significantly lower CBF levels in both grey matter and white matter. Furthermore, compared with the CBF in the resting state, that in the stress state was decreased in the anterior circulation, mainly in the frontal lobe (voxel level P < 0.001, pixel level P < 0.05). Logistic regression showed that body mass index (BMI; odds ratio [OR] 5.80, 95% confidence interval [CI] 1.60–21.01, P = 0.008], resting SBP (OR 0.64, 95% CI 0.45–0.92, P = 0.014), and BA diameter (OR 11.04, 95% CI 1.05–116.53, P = 0.046) were significantly associated with frontal lobe CBF changes.ConclusionsDobutamine-induced stress significantly decreased CBF in the frontal lobe anterior circulation. Individuals with a high BMI and low SBP during the dobutamine stress test are more likely to have a stress-induced CBF decrease. Thus, attention should be paid to blood pressure, BMI, and cerebrovascular morphology of patients undergoing dobutamine stress echocardiography or those receiving intensive care or anesthesia.

Early ischemia identification employing 2D speckle tracking selective layers analysis during dobutamine stress echocardiography.

Two-dimensional (2D) strain derived from speckle tracking proved to be feasible and accurate in the quantitative evaluation of myocardial ischemia during stress echocardiography. We compared the accuracy in detecting myocardial ischemia of the transmural segmental analysis with an endocardial specific evaluation in 20 patients undergoing dobutamine stress echocardiography (DSE) and coronary angiography. Peak systolic global strain (G-ε) and at the subendocardial level (Endo-ε) were measured off-line at rest, a low dose, and peak stress; then, we compared the results with wall-motion analysis and significant coronary artery disease (CAD>70% diameter stenosis). Endocardial strain variation from basal to low and peak dose was computed both for global or subendocardial analysis. The utilization of the ROC curve allowed us to derive optimal cutoffs, sensibility and specificity for ischemic segments. The subendocardial analysis at high dose showed to be able to increase significantly the accuracy of the test to detect the ischemic segments (sens 90.2% vs 85.4%; spec 93.1% vs 92.2%). Moreover, at the low dose, the subendocardial analysis showed to be able to increase significantly, mostly the specificity of the test (sens 69.6% vs 68.3%; spec 92.2% vs 86.2%). Notably, the strain subendocardial analysis at low dose showed to reach a high specificity, similar to the peak dose transmural analysis. Measurement of subendocardial strain during DSE is feasible and can increase the accuracy of the test. Moreover, the subendocardial strain during DSE can reach a high specificity, even limiting the test at a low dose infusion.

P3465Inducible left ventricular outflow tract obstruction is associated with a higher incidence of perioperative cardiac arrest in liver transplantation

Abstract Background Inducible left ventricular outflow tract obstruction (LVOTO) is not infrequently encountered in liver transplant (LT) candidates undergoing cardiac workup. While the impact of LVOTO on adverse cardiovascular haemodynamics is well reported, it is unclear whether it predisposes to perioperative cardiovascular complications following LT. Purpose To investigate the effect of inducible left ventricular outflow tract obstruction on perioperative cardiovascular complications in a modern cohort of liver transplant patients. Methods Consecutive patients undergoing dobutamine stress echocardiography (DSE) were evaluated from a quaternary LT centre between 2010 and 2017. Inducible LVOTO was defined as LVOT gradient ≥36mmHg. Perioperative major adverse cardiovascular events (MACE) at 30 days and all-cause death were recorded from a prospectively maintained transplantation database and augmented by electronic medical record review. Results We evaluated 560 patients who underwent DSE as part of a workup for LT. Of these, 319 progressed to transplant. Inducible LVOTO was observed in 68 patients (21.3%). A higher baseline cardiac output (7.7 L/min vs 7.0 L/min, p=0.002) predicted for development of inducible LVOTO. Seventy-seven patients (4.1%) experienced a MACE including five deaths, 19 cases of heart failure, 11 cardiac arrests, 10 acute coronary syndromes and 46 cases of arrhythmias (VT/AF). Overall MACE occurred in 17/68 patients (25.0%) with LVOTO and 60/251 patients (23.9%) without LVOTO (p=0.85). However, there was a significantly increased risk of resuscitated perioperative cardiac arrest in patients with LVOTO (7.4% vs 2.4%, p=0.04). Patients with LVOTO also required significantly greater volumes of fluid intra-operatively (8.37L vs. 6.71L, p=0.043). Cardiac Arrest in LT Patients with LVOTO Conclusions Inducible LVOTO is a frequent finding occurring in 21.3% of LT candidates. Despite higher intraoperative fluid resuscitation, LVOTO increased the risk of a perioperative cardiac arrest. Further studies are required to confirm these findings and to assess whether patients with LVOTO undergoing liver transplantation may benefit from heightened perioperative surveillance.

The significance of electrocardiographic changes without echocardiographic evidence of segmental wall motion abnormalities in patients undergoing dobutamine stress echocardiography

Ischemic ECG changes during dobutamine stress echocardiography (DSE) have been reported to have low sensitivity and specificity for detecting myocardial ischemia in the absence of wall motion abnormalities on echocardiography. We present a case of a renal transplant candidate with severe multivessel disease who had ST depressions without any wall motion abnormalities on DSE. Certain studies have shown the sensitivity of DSE is lower in patients with left ventricular hypertrophy and/or end stage renal disease, but the significance of ischemic ECG changes with no evidence of wall motion abnormalities in these patients has not been well studied.

Incremental Value of 2-Dimensional Longitudinal Radial and Circumferential Speckle Tracking Strain Imaging to Wall Motion Analysis for Detection of Coronary Artery Disease in Patients Undergoing Dobutamine Stress Echocardiography

Background: DSE is considered one of the good options in clinical practice but due to some limitations new promising modalities like speckle tracking echocardiography (STE) was introduced. STE is a new imaging technique that allows evaluation of global and regional myocardial function independently from the angle of acquisition and from cardiac translational movements. Objectives: Determine optimal cutoff values for longitudinal, radial and circumferential strains at peak DSE for detection of significant stenosis on CA. Also investigate incremental value of combining strain measurements to wall motion analysis. Methods: The study population comprised 100 patients (age 50 ±9 years) underwent high dose DSE, STE followed by CA. DSE and STE results were compared and added to each other and finally compared to CA result. Results: GLS cutoff points (-16.75%) showed significantly higher accuracy when compared to GCS and GRS, with highest balanced sensitivity and specificity to predict CAD. GLS, GRS and GCS reduced the DSE false positivity by 83%, 72.2% and 66.6% respectively. STE also showed better Agreement with CA than DSE in detecting coronary territorial affection especially LAD (Kappa= 0.775). Conclusions: STE is feasible during DSE, it helps increasing the diagnostic accuracy of DSE and decreasing its false positivity. Both global and segmental longitudinal strain can offer accurate, feasible and non invasive assessment of CAD.

Abstract 11676: Importance of Longitudinal Dyssynchrony in Low Flow Low Gradient Severe Aortic Stenosis Patients Undergoing Dobutamine Stress Echocardiography. A Multicenter Study (on behalf of the HAVEC group)

Introduction: Patients with reduced left ventricular ejection fraction (LVEF), low-flow low-gradient aortic stenosis (LFLG AS) represent a challenging cohort with high morbidity and mortality. Low-dose dobutamine stress echocardiogram (DSE) is recommended for assessment of flow reserve (FR, defined as ≥ 20% increase in stroke volume) which is prognostically important. Hypothesis: Presence of longitudinal dyssynchrony (LD) is independently associated with no FR during DSE. Methods: 185 LFLG AS patients from 4 different institutions who underwent DSE between 1997 through 2013 were studied. Baseline LD, transverse dyssynchrony and strain analysis were performed using vendor-independent 2D CPA TomTec software using DICOM images from apical 2 and 4-chamber and feasible in 97% of patients (N=179). Multivariate logistic regression analysis of predictors of no FR was performed. Results: The mean age was 74 ± 9 yrs; LVEF 30 ± 10%; indexed AV area 0.44 ± 0.1 cm2/m2; mean AV gradient 24 ± 7 mmHg; mean QRS width 126 ± 32 msec and 28% of the cohort had a QRS width ≥ 130 msec. LD, pre-defined as maximum opposite wall delay ≥ 130 msec, was present in 83% (149/179) of study cohort, whereas FR on DSE was present in 54%. Coronary artery disease was more common in those without FR. Although baseline LVEF was not different according to FR status (p=0.23), greater LV stroke volume index (p=0.001) and longitudinal strain (p=0.004) were seen in those without FR. LD was more prevalent in patients without FR (90% vs 77%, p=0.02). On multivariate analysis (Figure 1), presence of LD (HR=4.58, p=0.01) was an independent predictor of no FR despite several adjustments. Conclusions: LD is very prevalent in patients with LFLG AS undergoing DSE. Quantification of LD provides important insights as LD is independently associated with no FR. Whether LD improves after valvular intervention and whether its correction confers a better prognosis to these patients remains to be studied.

40 Persistent ischemia in recovery predicts mortality after myocardial infarction in patients undergoing dobutamine stress echocardiography

40 Persistent ischemia in recovery predicts mortality after myocardial infarction in patients undergoing dobutamine stress echocardiography

Feasibility and Prognostic Value of Stress Echocardiography in Obese, Morbidly Obese, and Super Obese Patients Referred for Bariatric Surgery

Stress echocardiography (SE) is clinically used in the risk stratification and prognosis of patients with coronary artery disease. Due to multiple comorbidities, obese patients have increased risk of adverse cardiovascular events perioperatively in noncardiac surgery. The aim of this study was to investigate the feasibility of SE in morbidly obese patients undergoing bariatric surgery. Consecutive patients referred for SE for preoperative evaluation prior to bariatric surgery from January 2002 to July 2011 formed the study cohort. Contrast was used to define the endocardial border in patients with poor acoustic windows. All-cause mortality data were obtained from Social Security Death Index. Six hundred fifty-two patients (47 ± 10 years, 84% females) with the mean follow-up of 3.0 ± 2.7 years and mean body mass index (BMI) of 47 ± 9 kg/m² were included in this analysis. Dobutamine SE was performed in 65% of patients compared to exercise SE in 35%. Patients with higher BMI were more likely to undergo dobutamine SE (P < 0.0001). Similarly, incidence of poor acoustic windows and contrast use was higher in those with increased BMI (P < 0.001). Contrast use was higher in patients undergoing dobutamine SE (39%) versus exercise (25%), (P = 0.002). 19 patients (3%) had an abnormal SE and 8 patients (1.2%) died during the follow-up period. Stress echocardiography is feasible in the morbidly obese patients. Patients with higher BMI were more likely to undergo dobutamine SE and have higher incidence of poor acoustic windows and contrast use.

Loss of Adrenergic Augmentation of Diastolic Intra-LV Pressure Difference in Patients With Diastolic Dysfunction: Evaluation by Color M-Mode Echocardiography

The aim of this study was to evaluate the hypothesis that the adrenergic response of the intraventricular pressure difference (IVPD) is reduced in patients with preserved ejection fraction (EF) and diastolic dysfunction (DD). In early diastole, there is a progressive IVPD extending from the left atrium (LA) to the left ventricular (LV) apex. In response to adrenergic stimulation, as occurs during exercise, the IVPD increases allowing rapid filling without an abnormal increase in LA pressure. Patients with heart failure with a reduced EF have impaired adrenergic augmentation of the IVPD. We studied 166 consecutive patients undergoing dobutamine stress echocardiography who had no inducible ischemia and an EF ≥50%, of which 21 had normal diastolic function, 14 had impaired relaxation (grade 1), 80 had pseudonormal filling (grade 2), and 51 had restrictive filling (grade 3). Color M-mode Doppler (CMMD) images of mitral inflow were obtained at rest and during low (10 μg/kg/min) and peak (20 to 40 μg/kg/min) doses of dobutamine. The total IVPD from the LA to LV apex, LA to mid-LV, and mid-LV to the LV apex were calculated using the CMMD data to integrate the Euler equation. Total IVPD was not different between groups at rest. With dobutamine, the total IVPD increased by 2.20 ± 1.95 mm Hg in normal subjects and by only 0.73 ± 1.33 mm Hg, 1.84 ± 1.63 mm Hg, and 1.08 ± 1.57 mm Hg in patients with grades 1, 2, and 3 DD, respectively. This difference was due to a failure in augmentation of IVPD from the mid-LV to the LV apex, indicating reduced apical ventricular suction with DD, whereas the IVPD from the LA to the mid-LV responded similarly to dobutamine in normal subjects and those with DD. In patients with preserved EF, DD is associated with a reduced adrenergic augmentation of the IVPD from the mid-LV to the LV apex, reflecting less apical suction.

Differential Effects of Dobutamine Versus Treadmill Exercise on Left Ventricular Volume and Wall Stress

Dobutamine and exercise echocardiography are well-validated modalities used for the evaluation of patients with suspected myocardial ischemia. Patients undergoing dobutamine stress echocardiography (DSE), however, experience less angina, ST-segment depressions, and wall motion abnormalities. Other than the effect on heart rate, the physiologic and volumetric differences between pharmacologic and exercise-induced stress that affect myocardial oxygen demand are not well defined. The aim of this study was to test the hypothesis that in the absence of ischemia, dobutamine reduces left ventricular (LV) volume, wall tension (WTN), and peak systolic stress (PSS) compared with exercise. Seventy patients without ischemia were prospectively enrolled (35 underwent exercise echocardiography and 35 DSE), and various hemodynamic parameters were measured and LV volumes calculated (using the Simpson and Teichholz formulas). Systolic WTN and PSS were determined at rest and stress. LV end-diastolic volume index fell significantly more with dobutamine than with exercise (-34% vs -9%, P < .0001), as did mean end-systolic volume index (-55% vs -37%, P = .07). Systolic blood pressure increased more with exercise (41 ± 22 vs 1 ± 33 mm Hg, P < .0001), as did cardiac index (2.5 ± 0.7 vs 1.0 ± 0.8 L/min/m(2), P < .0001). Systolic WTN increased with exercise by 24% (P < .0001) but decreased with dobutamine by 18% (P < .0001). PSS increased with exercise by 21% (P < .0001) but decreased with dobutamine by 23% (P < .0001). The degree of stress achieved with DSE appears to be considerably different than with exercise. DSE produces greater reductions in LV end-diastolic and end-systolic volumes than exercise and decreases rather than increases in WTN and PSS. The lower WTN and PSS were related to both a decrease in LV volume and lower systolic blood pressure with dobutamine. These observations support recommendations favoring exercise stress testing in patients able to exercise and reinforce the notion that high-risk echocardiographic features of ischemia such as stress-induced LV dilatation may be less striking or absent with DSE.

Early atropine-dobutamine echocardiography in diabetic patients

Objective We sought to explore the effi cacy and safety of the early atropine-dobutamine stress echocardiography (EA-DSE) protocol in comparison with the conventional atropine-dobutamine stress echocardiography (CA-DSE) protocol, in diabetic patients undergoing dobutamine stress echocardiography (DSE) for suspected coronary artery disease (CAD).Methods and results We enrolled 100 consecutive diabetic patients referred to our stress echocardiography labs for suspected CAD. Patients were randomly assigned to undergo either of the following two DSE protocols: CA-DSE (group 1; 50 patients) or EA-DSE (group 2; 50 patients) where atropine was started at a dobutamine infusion rate of 20 μ g/kg/min, up to a maximum dose of 2.0 mg. Patients were monitored for adverse drug reactions. Test duration was calculated. All patients underwent coronary angiography. The mean age of the whole study population was 54.9 ± 2.8 y, 56 (56%) being males. Patients in group 1 had a longer test duration (29.7 ± 3.4 versus 14.7 ± 1.3 minutes, respectively, P < 0.05). At peak stress, group 1 had a signifi cantly lower heart rate, signifi cantly higher systolic and diastolic blood pressure, and rate-pressure product (P < 0.05 for all). Group 1 patients had a higher incidence of arrhythmias, exaggerated blood pressure response, and hypotension as compared with group 2. The EA-DSE protocol had a similar diagnostic accuracy in comparison with the CA-DSE protocol (90% versus 92% respectively).Conclusions In diabetic patients with suspected CAD undergoing DSE, adopting the EA-DSE protocol off ers shorter test duration, fewer adverse eff ects, and a diagnostic accuracy similar to that of the CA-DSE.

Dobutamine Stress Echocardiography Doppler Estimation of Cardiac Diastolic Function: A Simultaneous Catheterization Correlation Study

Doppler echocardiography using the ratio of early diastolic transmitral velocity to early diastolic mitral annular tissue velocity (E/E') is routinely used to evaluate left ventricular (LV) filling pressures at rest. We tested the hypothesis that measurement of E/E' in patients undergoing dobutamine stress echocardiography (DSE) will detect changes in LV filling pressures. In this prospective study, 16 patients with normal LV ejection fraction and normal coronary arteries by angiography underwent a standard DSE protocol with simultaneous LV filling pressure monitoring with a fluid filled pigtail catheter. Doppler echocardiographic assessment of LV diastolic function was performed using E/E' at rest and during DSE. The average age of the study participants was 57 ± 8 years. Average heart rate was 61 ± 11 bpm at baseline and 141 ± 12 bpm at peak stress. LV mean diastolic pressure decreased from 12.3 ± 2.6 mmHg at baseline to 9.0 ± 2.3 mmHg at peak stress (P = 0.0001). Baseline E/E' at the septum and lateral annulus were 8.7 ± 2.2 and 7.5 ± 1.9 and during peak stress were 8.3 ± 3.1 and 7.9 ± 3.5, respectively. There was no significant change in E/E' at either the septum or the lateral annulus (P = 0.55, P = 0.66). There was no significant correlation between LV mean diastolic pressure and E/E' with dobutamine stress. In patients with normal LV ejection fraction and no significant coronary artery disease undergoing DSE, the ratio of early diastolic transmitral velocity to early diastolic tissue velocity (E/E') at peak stress with dobutamine does not predict changes in LV filling pressures.

Left ventricular outflow tract and mid-cavity obstruction may cause false-positive dobutamine stress echocardiograms

Left ventricular (LV) outflow tract obstruction (LVOTO) occurs in up to 20% of patients undergoing dobutamine stress echocardiography (DSE). Mid-cavity LV obstruction occurs less commonly during DSE. LV regional wall motion abnormalities during DSE may occur despite normal coronaries due to hypertensive blood pressure response and takotsubo stress cardiomyopathy. We describe herein two cases of LVOTO and one case of mid-cavity LV obstruction during DSE associated with transient apical hypokinesis.

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.

Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography

Interpretation of dobutamine stress echocardiogram (DSE) is often subjective and requires expert training. The purposes of this study was to determine optimal cutoff values for longitudinal, circumferential, and radial strains at peak DSE for detection of significant stenoses on coronary angiography and to investigate incremental value of combining strain measurements to wall motion analysis. In this multicenter study, 102 patients underwent concomitant DSE and coronary angiography. Optimal cutoff values for mean global longitudinal (-20%), global circumferential (-26%), and mean radial (50%) strains at peak stress for detection of significant stenoses on coronary angiography were determined in a derivation group (n = 62) and tested in a prospectively recruited validation group (n = 40). Respective sensitivities for longitudinal, circumferential, radial strains, and expert wall motion score index (WMSI) were 84.2%, 73.9%, 78.3%, and 76%; respective specificities were 87.5%, 78.6%, 57.1%, and 92.9%; and respective accuracies were 85.2%, 75.7%, 70.3%, and 82.1%. Longitudinal strain analysis had comparable accuracy to WMSI (P = .70). However, combination longitudinal strain and WMSI had the highest sensitivity, specificity, and accuracy (100%, 87.5%, and 96.3% respectively), and its diagnostic accuracy was incremental to either longitudinal strain (P = .034) or WMSI alone (P = .008). Longitudinal strain analysis had higher diagnostic accuracy than circumferential and radial strains and was comparable to WMSI for detection of significant coronary artery disease. However, combination longitudinal strain and WMSI resulted in significant incremental increase in diagnostic accuracy.

Left ventricular transient ischemic dilation during dobutamine stress echocardiography predicts multi-vessel coronary artery disease

We sought to explore the value of stress-induced transient ischemic dilation (TID) of the left ventricle during dobutamine stress echocardiography, to predict the presence of multi-vessel coronary artery disease as seen by coronary angiography. We enrolled 60 patients referred to our stress echocardiography labs with ischemic-type chest pain or other symptoms suggestive of myocardial ischemia. All patients underwent resting and stress echocardiography employing the standard dobutamine stress protocol. TID ratio was defined as the ratio of left ventricular end-diastolic volume or end-systolic volume measured at peak stress, to that measured at rest (EDV ratio and ESV ratio, respectively). We enrolled 20 consecutive patients with normal response (control group) who were subsequently evaluated to develop normal limits for TID ratio, and 40 patients with ischemic response (study group) that comprised 20 consecutive patients without TID (group A) and 20 consecutive patients with TID (group B). Patients then underwent coronary angiography. Both EDV ratio and ESV ratio were significantly higher in groups A and B as compared to the control group (P<0.01 for both). Analysis of the receiver operating characteristic (ROC) curves identified the 1.12 cutoff value as the optimal cutoff value of TID ratio that best predicts three-vessel disease. Using this cutoff value, the ESV ratio was able to predict three-vessel disease with a sensitivity of 90%, specificity 84%, positive and negative predictive values of 85% and 89%, respectively. The mean number of vessels affected by significant stenosis was 1.8+/-0.83 in group A in comparison with 2.45+/-0.69 in group B (P<0.05). Among group B, both EDV ratio and ESV ratio were higher in female patients as compared to male ones. In patients undergoing dobutamine stress echocardiography, the occurrence of TID is both sensitive and specific to predict underlying three-vessel coronary artery disease.

Prognostic significance of renal function in patients undergoing dobutamine stress echocardiography

Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30 ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years. New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively. The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warranty period after a normal DSE is determined by the severity of renal dysfunction.

Comparison of two-dimensional speckle and tissue Doppler strain measurement during dobutamine stress echocardiography: an angiographic correlation

Two-dimensional (2D)-strain derived from speckle-tracking is an alternative to tissue velocity imaging (TVI)-based strain. We compared their feasibility and accuracy in 150 patients undergoing dobutamine stress echocardiography (DSE) and coronary angiography. 2D- and TVI-strain were obtained in three apical views at rest and peak stress. Peak systolic strain rate (SR), endsystolic strain (epsilon(end-sys)), and peak strain (epsilon(peak)) were measured off-line at rest and peak stress, and results were compared with wall motion analysis and significant coronary artery disease (CAD > or = 70% diameter stenosis). Optimal cut-offs were derived from receiver operating characteristic (ROC) curves for sentinel segments. The most feasible method was 2D-strain at rest, and TVI-strain at peak stress. The average peak SR and epsilon(end-sys) at peak stress in segments of patients with significant CAD was less than in segments of patients without CAD (P < 0.0001) and mean PSI at peak stress was higher (P < 0.0001) with both 2D- and TVI-strain. Peak systolic SR at peak stress had the best area under the ROC for both 2D- (AUC 0.67) and TVI-strain (AUC 0.71) for the diagnosis of CAD. The accuracy of WMS (75%) for diagnosis of CAD per patient was similar to 2D-SR (69%) and TVI-SR (74%). The accuracy of 2D-SR and TVI-SR at peak stress was 78 vs. 79% (P = NS) for LAD, 67 vs. 73% (P = NS) for LCX, and 59 vs. 74% (P = 0.008) for RCA disease. Measurement of speckle tracking strain during DSE is feasible and similar in accuracy to TVI-strain in the anterior, but not in the posterior circulation.

Incremental Value of Strain Rate Imaging to Wall Motion Analysis for Prediction of Outcome in Patients Undergoing Dobutamine Stress Echocardiography

Wall motion score at dobutamine stress echocardiography is an independent predictor of mortality. We sought to determine whether quantification of DSE by strain rate imaging was incremental to wall motion score for predicting outcome. In 646 patients undergoing dobutamine stress echocardiography for the evaluation of known or suspected coronary disease, customized software was used to automatically measure peak systolic strain rate (SR(s)) and end-systolic strain (S(es)) in 18 segments. Results were expressed as the number of abnormal segments and the mean SR(s) and S(es) per patient. All-cause mortality was identified over 7 years of follow-up (mean, 5.2+/-1.5 years). Contributions of clinical, wall motion, and SR(s) and S(es) data to outcome were analyzed with Cox models, which also were used to define cut points for SR(s) and S(es). Ischemia (new or worsening wall motion abnormalities) was detected in 45%, and 39% had a previous myocardial infarction. In patients with no ischemia, annualized mortality without and with previous myocardial infarction were 2% and 3% compared with 5% in patients with ischemia. Peak wall motion score index, mean SR(s), segmental S(es), and segmental SR(s) were all predictors of mortality, but only segmental SR(s) (hazard ratio, 3.6; 95% CI, 1.7 to 7.2) was independently predictive. In sequential Cox models, the model based on clinical data (overall chi2, 12.7) was improved by peak wall motion score index (18.4, P=0.002) and further increased by either segmental SR(s) (31.8, P<0.001) or mean SR(s) (25.7, P=0.009). Segmental analysis by SR(s), derived from automated strain rate imaging analysis of dobutamine stress echocardiography response, offers prognostic information that is independent and incremental to standard wall motion score index.

208 Long term mortality in patients undergoing dobutamine stress echocardiography

208 Long term mortality in patients undergoing dobutamine stress echocardiography