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Countouris ME, Catov JM, Zhu J, de Jong N, Brands J, Chen X, Parks WT, Berlacher KL, Gandley RE, Straub AC, Villanueva FS. Association of Hypertensive Disorders of Pregnancy With Coronary Microvascular Dysfunction 8 to 10 Years After Delivery. Circ Cardiovasc Imaging 2024; 17:e016561. [PMID: 38771901 PMCID: PMC11115371 DOI: 10.1161/circimaging.124.016561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/17/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are associated with subsequent adverse cardiac remodeling and cardiovascular disease. The role of myocardial microvascular disease among individuals with HDP and left ventricular (LV) remodeling as a potential link to cardiovascular disease is unknown. We aimed to determine whether individuals with HDP history have coronary microvascular dysfunction measured by coronary flow reserve 8 to 10 years after delivery and whether microvascular dysfunction correlates with LV remodeling. METHODS Individuals with pregnancies delivered from 2008 to 2010 underwent burst-replenishment myocardial contrast echocardiography (2017-2020) to quantify myocardial perfusion at rest and during dobutamine stress. Video intensity versus time data were used to derive β, the rate of rise of video intensity, a correlate for myocardial blood flow. Coronary flow reserve was calculated as the ratio of β at peak stress to β at rest, averaged across LV myocardial regions of interest. RESULTS We studied 91 individuals (aged 38±6 and 9.1±0.9 years postdelivery) and 19 with a history of HDP. Individuals with coronary microvascular dysfunction (coronary flow reserve <2.0; n=13) had a higher proportion of HDP (46.2% versus 16.7%; P=0.026) and higher prepregnancy body mass index, baseline heart rate, and hemoglobin A1c compared with those without microvascular dysfunction. The association of coronary flow reserve and HDP was attenuated after adjusting for cardiometabolic factors (P=0.133). In exploratory subgroup analyses, individuals with both LV remodeling (relative wall thickness >0.42) and HDP (n=12) had the highest proportion of microvascular dysfunction (41.7% versus +HDP-LV remodeling [n=7] 14.3%; -HDP+LV remodeling [n=26] 7.7%; P=0.0498). CONCLUSIONS In this small study, HDP history is associated with coronary microvascular dysfunction 1 decade after delivery, findings that may, in part, be driven by metabolic factors including obesity and diabetes. Microvascular dysfunction may contribute to cardiovascular disease among individuals with a history of HDP.
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Affiliation(s)
- Malamo E Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Janet M Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences (J.M.C., R.E.G.), University of Pittsburgh, PA
- Department of Epidemiology (J.M.C.), University of Pittsburgh, PA
| | - Jianhui Zhu
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Nikki de Jong
- Division of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands (N.d.J.)
| | - Judith Brands
- Department of Library, Information and Communication Technologies Services and Archive, Enschede, the Netherlands (J.B.)
| | - Xucai Chen
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - W Tony Parks
- Department of Laboratory Medicine and Pathobiology, University of Toronto, ON, Canada (W.T.P.)
| | - Kathryn L Berlacher
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
| | - Robin E Gandley
- Department of Obstetrics, Gynecology, and Reproductive Sciences (J.M.C., R.E.G.), University of Pittsburgh, PA
| | - Adam C Straub
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
- Department of Pharmacology and Chemical Biology (A.C.S.), University of Pittsburgh, PA
| | - Flordeliza S Villanueva
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, PA (M.E.C., J.Z., X.C., K.L.B., A.C.S., F.S.V.)
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Soulis D, Papaioannou TG, Zozolou M, Daskalopoulou S, Vlachopoulos C, Bethanis D, Triantafyllou D. The effect of atropine used in dobutamine stress echocardiography on pupil diameter. Eur J Ophthalmol 2022; 32:3685-3692. [PMID: 35088615 DOI: 10.1177/11206721221076310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of atropine during dobutamine stress echocardiography (DSE) is contraindicated in persons with narrow angle glaucoma though there is limited evidence that low doses of intravenous atropine do not cause pupillary dilation. OBJECTIVE The aim of this study is to investigate whether atropine when administered in persons without glaucoma during dobutamine stress echocardiography causes pupillary dilation. METHODS AND RESULTS Out of 144 patients without a history of glaucoma referred for DSE for clinical indications, 105 patients received intravenous atropine doses ranging from 0.1 mg to 1.25 mg (most patients received 0.25-0.75 mg). Pupil diameter of both eyes was measured under the same light conditions before and after the DSE using a CP-30 Optical Digital PD Ruler. For the total of 210 examined eyes pupil diameter remained unaltered after each DSE test (3.65 ± 0.799 mm before vs 3.63 ± 0.766 mm after, p = .737). Similarly, pupil diameter remained unchanged when left and right eyes were assessed separately (right eye: 3.770 ± 0.812 before vs 3.752 ± 0.745 mm after, p = .821 and left eye: 3.521 ± 0.770 before vs 3.499 ± 0.770 mm after, p = .806). Diameter of right and left pupil were also unaltered after grouping patients by sex and iris pigmentation. Age, weight, atropine dose and propranolol dose were not correlated with changes in pupil diameter. CONCLUSION Intravenous atropine in usual doses administered in DSE does not cause mydriasis in adults without glaucoma. Future studies need to confirm our findings and expand the investigation regarding safety of atropine use during DSE in patients with narrow angle glaucoma.
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Affiliation(s)
| | - Theodore G Papaioannou
- First Department of Cardiology, Hippokration Hospital, Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | | | - Stella Daskalopoulou
- Division of Internal Medicine, Department of Medicine, 5620McGill University and Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Charalampos Vlachopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Steeds RP, Wheeler R, Bhattacharyya S, Reiken J, Nihoyannopoulos P, Senior R, Monaghan MJ, Sharma V. Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2019; 6:G17-G33. [PMID: 30921767 PMCID: PMC6477657 DOI: 10.1530/erp-18-0068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, Institute of Cardiovascular Science, University Hospital Birmingham, Birmingham, UK
| | - Richard Wheeler
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | | | - Joseph Reiken
- Department of Cardiology, Kings College Hospital, London, UK
| | - Petros Nihoyannopoulos
- Department of Cardiology, National Heart Lung Institute, Hammersmith Hospital, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Mark J Monaghan
- Department of Cardiology, Kings College Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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Abram S, Arruda-Olson AM, Scott CG, Pellikka PA, Nkomo VT, Oh JK, Milan A, Abidian MM, McCully RB. Frequency, Predictors, and Implications of Abnormal Blood Pressure Responses During Dobutamine Stress Echocardiography. Circ Cardiovasc Imaging 2017; 10:e005444. [PMID: 28351907 PMCID: PMC5408460 DOI: 10.1161/circimaging.116.005444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/15/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND It is not known whether abnormal blood pressure (BP) responses during dobutamine stress echocardiography (DSE) are associated with abnormal test results, nor if such results indicate obstructive coronary artery disease (CAD). We sought to define the frequency of abnormal BP responses during DSE and their impact on accuracy of test results. METHODS AND RESULTS We studied 21 949 patients who underwent DSE at Mayo Clinic, Rochester, MN, grouped by peak systolic BP achieved during the test. We also analyzed a subgroup who underwent coronary angiography within 30 days after positive DSE. The positive predictive value of DSE was calculated for each BP group. Patients with hypertensive response (n=1905; 9%) were more likely to have positive DSE than those with normal (n=19 770; 90%) or hypotensive (n=274; 1%) BP responses (32% versus 21% versus 23%, respectively; P<0.0001). Angiography, performed in 1126 patients, showed obstructive CAD (≥50% stenosis) in 814 patients and severe CAD (≥70% stenosis) in 708 patients. Positive predictive value of DSE was similar for patients who had hypertensive and normal BP responses (69% versus 73%; P=0.3), considering 50% stenosis cut point. The proportion of severe CAD (≥70% stenosis) was lower in patients who had hypertensive response compared with those who had normal BP response (54% versus 65%; P=0.005). CONCLUSIONS Patients with hypertensive response during DSE are more likely to have stress-induced myocardial ischemia compared with those with normal or hypotensive BP responses but are not more likely to have false-positive DSE results. They are, however, less likely to have higher grade or multivessel CAD.
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Affiliation(s)
- Sara Abram
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Adelaide M Arruda-Olson
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Christopher G Scott
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Patricia A Pellikka
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Vuyisile T Nkomo
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Jae K Oh
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Alberto Milan
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Mohamed M Abidian
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Robert B McCully
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.).
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Abram S, Arruda-Olson AM, Scott CG, Pellikka PA, Nkomo VT, Oh JK, Milan A, McCully RB. Typical blood pressure response during dobutamine stress echocardiography of patients without known cardiovascular disease who have normal stress echocardiograms. Eur Heart J Cardiovasc Imaging 2015. [PMID: 26206464 DOI: 10.1093/ehjci/jev165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Blood pressure (BP) responses during dobutamine stress echocardiography (DSE) have not been systematically studied. Consequently, it is not known what constitutes a normal or an abnormal BP response to dobutamine stress. We sought to define the typical BP response during DSE of patients not known to have cardiovascular disease. METHODS AND RESULTS Of 24 134 patients who underwent DSE from November 2003 to December 2012 at Mayo Clinic, Rochester, MN, 2968 were selected for inclusion in this retrospective study. Excluded were patients with a history of hypertension, diabetes, or coronary artery disease, and those taking vasoactive medications. Patients who had baseline and/or stress-induced wall motion abnormalities were also excluded. The distribution of the study population's BP responses during DSE was Gaussian; we defined cut-point values for normative BP responses at 2 SD for each decade of age and for the whole study population. During DSE, systolic BP (SBP) increased from baseline to peak stress (Δ +2.9 ± 24 mmHg, P < 0.0001) and diastolic BP (DBP) decreased (Δ -7.4 ± 14 mmHg). BP changes were age and sex dependent; men and younger patients had greater ΔSBP and lesser ΔDBP, compared with women and older patients. Patients who received atropine had higher peak BP values than patients who did not receive atropine, due to greater ΔSBP (+7.4 ± 26 vs. -0.5 ± 22 mmHg, P < 0.0001) and lesser ΔDBP (-4 ± 14 vs. -9.7 ± 12 mmHg, P < 0.0001). This atropine effect was present in men and women, and was more pronounced in younger patients. The normative peak SBP values ranged from 82 to 182 mmHg. CONCLUSION BP responses during DSE vary and depend on patients' age, gender, and the use of atropine. We describe the typical BP responses seen during DSE and report normative reference values, which can be used for defining normal and abnormal BP responses to dobutamine stress.
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Affiliation(s)
- Sara Abram
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Department of Medical Sciences, University Hospital S. Giovanni Battista, University of Torino, Turin, Italy
| | - Adelaide M Arruda-Olson
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Jae K Oh
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Alberto Milan
- Department of Medical Sciences, University Hospital S. Giovanni Battista, University of Torino, Turin, Italy
| | - Robert B McCully
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Shehata M. Accelerated dobutamine stress testing: Feasibility and safety in patients with moderate aortic stenosis. Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Echocardiographic Evaluation of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Mieres JH, Gulati M, Bairey Merz N, Berman DS, Gerber TC, Hayes SN, Kramer CM, Min JK, Newby LK, Nixon JVI, Srichai MB, Pellikka PA, Redberg RF, Wenger NK, Shaw LJ. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350-79. [PMID: 25047587 DOI: 10.1161/cir.0000000000000061] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Shehata M. Atropine first is safer than conventional atropine administration in older people undergoing dobutamine stress echocardiography. Ther Adv Cardiovasc Dis 2014; 8:176-84. [PMID: 24906705 DOI: 10.1177/1753944714538112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Early injection of atropine during dobutamine stress echocardiography (DSE) has been demonstrated in retrospective analyses to reduce the duration and dose of dobutamine infusion, while preserving a similar diagnostic accuracy with a lower incidence of adverse effects. This study explores the safety of using atropine as a start drug before dobutamine infusion (ADSE protocol) in comparison with the conventional protocol (DASE protocol) in older patients undergoing DSE for ischemia evaluation. METHODS One hundred consecutive older patients were prospectively enrolled. When eligible, they were randomly assigned to undergo either the DASE protocol (group A, 50 patients) or the ADSE protocol (group B, 50 patients) when atropine (1.0 mg) was first administered 3 min before dobutamine infusion followed by 0.5 mg increments (maximum 1.0 mg) thereafter. Patients were monitored for adverse drug effects. Test duration was calculated. RESULTS The mean age of the whole study cohort was 67.8±4.3 years and 58 (58%) were men. Patients in group A had longer test duration (21.8±1.3 versus 13.7±0.77 min, p<0.001) and higher mean dobutamine infusion rate (39±8.2 versus 28.2±9.5 μg/kg/min, p<0.001). The two groups received a similar total dose of atropine. Group A patients showed significantly higher incidence of extrasystoles, nonsustained ventricular tachycardia and severe hypotension (p<0.05). CONCLUSION In older patients undergoing DSE, using atropine as a start drug, that is, adopting the ADSE protocol, is associated with shorter test duration, lower mean dobutamine infusion rate and consequently fewer adverse effects.
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Affiliation(s)
- Mohamed Shehata
- Department of Cardiology, Faculty of Medicine, Ain Shams University Hospital, Abbasia Square, PO 11741, Cairo, Egypt
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Chandraratna PAN, Kuznetsov VA, Mohar DS, Sidarous PF, Scheutz J, Krinochkin DV, Pak YA, Mohar P, Arawgoda U. Comparison of Squatting Stress Echocardiography and Dobutamine Stress Echocardiography for the Diagnosis of Coronary Artery Disease. Echocardiography 2012; 29:695-9. [DOI: 10.1111/j.1540-8175.2012.01687.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Usefulness of atropine in patients with chronotropic incompetence and poor exercise capacity during treadmill stress testing. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2011.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Fine NM, Pellikka PA. Stress echocardiography for the detection and assessment of coronary artery disease. J Nucl Cardiol 2011; 18:501-15. [PMID: 21431999 DOI: 10.1007/s12350-011-9365-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Nowell M Fine
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Wuthiwaropas P, Wiste JA, McCully RB, Kane GC, Scott CG, Pellikka PA. Neuropsychiatric Symptoms During 24 Hours after Dobutamine-Atropine Stress Testing: A Prospective Study in 1,006 Patients. J Am Soc Echocardiogr 2011; 24:367-73. [DOI: 10.1016/j.echo.2010.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Indexed: 10/18/2022]
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Ohara T, Hashimoto Y, Suzuki M, Matsumura A, Isobe M. Early Diastolic Flow Propagation Velocity Detects Induced Diastolic Dysfunction during Dobutamine Stress Echocardiography. Echocardiography 2011; 28:335-41. [DOI: 10.1111/j.1540-8175.2010.01328.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Durando MM, Slack J, Reef VB, Birks EK. Right ventricular pressure dynamics and stress echocardiography in pharmacological and exercise stress testing. Equine Vet J 2010:183-92. [PMID: 17402416 DOI: 10.1111/j.2042-3306.2006.tb05537.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
REASONS FOR PERFORMING STUDY There is interest in using pharmacological stress testing (PST) as a substitute for exercise stress testing (EST) to evaluate cardiac function in horses. OBJECTIVES To compare the effect of PST and EST on right ventricular pressure dynamics and stress echocardiography. METHODS Five horses completed a PST and EST in a randomised crossover design. High fidelity pressure transducers were placed in the right ventricle. Continuous pressure signals were digitally collected and stored, and dP/dtmax, dP/dtmin and tau calculated from these measurements. ECGs were recorded continuously for 20 h. Echocardiography was performed prior to EST and PST, during and after PST, and immediately post EST. Plasma cardiac troponin I concentrations were measured pre- and 3-4 h post stress testing. For PST, 5 microg/kg bwt glycopyrrolate i.v. followed after 10 min by 5 microg/kg bwt/min dobutamine infusion over 10 min was given. EST consisted of a 2 min gallop at 110% speed required to elicit VO2max. RESULTS Both EST and PST resulted in a significant increase in right-ventricular dP/dtmax and dP/dtmin over baseline (P<0.05) and a significant decrease in tau compared with baseline (P<0.05). EST dP/dtmax and dP/dtmin were significantly greater than PST dP/dtmax and dP/dtmin (P<0.05) and EST tau was significantly less than PST tau (P<0.05). Two minutes post EST and 5 min post PST dP/dtmax were not significantly different, but were significantly less than end-EST and during PST. Tau was also not significantly different between post EST and post PST, but was significantly decreased end-EST compared with during PST. FS were not significantly different between PST and post EST, but during PST and post EST all FS were significantly higher than baseline. Cardiac troponin I concentrations were significantly elevated post PST and were greater than post EST. The clinical relevance of this is unknown. CONCLUSIONS PST had a similar, although less marked effect on the cardiac parameters related to right-ventricular pressure dynamics and a similar effect on echocardiography as exercise stress testing. POTENTIAL RELEVANCE PST deserves further evaluation in normal horses and those with cardiac disease, and may be complementary to EST to better identify exercise-induced cardiac dysfunction.
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Affiliation(s)
- M M Durando
- Department of Clinical Studies, School of Veterinary Medicine, New Bolton Center, University of Pennsylvania, 382 W Street Road, Kennett Square, Pennsylvania 19348, USA
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Krenning BJ, Geleijnse ML, Poldermans D, Roelandt JRTC. Methodological Analysis of Diagnostic Dobutamine Stress Echocardiography Studies. Echocardiography 2009; 21:725-36. [PMID: 15546374 DOI: 10.1111/j.0742-2822.2004.03161.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dobutamine stress echocardiography (DSE) is an accepted test for the diagnosis of coronary artery disease (CAD), despite its wide diagnostic accuracy. AIM Which factors cause test variability of DSE for the diagnosis of CAD. METHODS 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. RESULTS 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. CONCLUSION 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.
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Geleijnse ML, Krenning BJ, van Dalen BM, Nemes A, Soliman OII, Bosch JG, Galema TW, ten Cate FJ, Boersma E. Factors affecting sensitivity and specificity of diagnostic testing: dobutamine stress echocardiography. J Am Soc Echocardiogr 2009; 22:1199-208. [PMID: 19766453 DOI: 10.1016/j.echo.2009.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Clinical characteristics of patients, angiographic referral bias, and several technical factors may all affect the reported diagnostic accuracy of tests. The aim of this study was to assess their influence on the diagnostic accuracy of dobutamine stress echocardiography (DSE). METHODS The medical literature from 1991 to 2006 was searched for diagnostic studies using DSE and meta-analysis was applied to the 62 studies thus retrieved, including 6881 patients. These studies were analyzed for patient characteristics, angiographic referral bias, and several technical factors. RESULTS The sensitivity of DSE was significantly related to the inclusion of patients with prior myocardial infarctions (0.834 vs 0.740, P < .01) and defining the results of DSE as already positive in case of resting wall motion abnormalities rather than obligatory myocardial ischemia (0.786 vs 0.864, P < .01). Specificity tended to be lower when patients with resting wall motion abnormalities were included in a study (0.812 vs 0.877, P < .10). The presence of referral bias adversely affected the specificity of DSE (0.771 vs 0.842, P < .01). CONCLUSION This analysis suggests that the reported sensitivity of DSE is likely higher and the specificity lower than expected in routine clinical practice because of the inappropriate inclusion of patients with prior myocardial infarctions, the definition of positive results on DSE, and the negative influence of referral bias. However, in the patient subset that will be sent to coronary angiography, the opposite results can be expected.
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Lu D, Greenberg MD, Little R, Malik Q, Fernicola DJ, Weissman NJ. Accelerated dobutamine stress testing: safety and feasibility in patients with known or suspected coronary artery disease. Clin Cardiol 2009; 24:141-5. [PMID: 11214744 PMCID: PMC6654775 DOI: 10.1002/clc.4960240208] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Dobutamine pharmodynamics require approximately 10 min to reach steady state. Despite this, standard dobutamine stress echo typically uses 3-min stages of advancing dobutamine doses because of safety concerns. HYPOTHESIS In patients with a high pretest probability of coronary artery disease (CAD), a continuous infusion of high-dose dobutamine is a feasible and safe method for performing a dobutamine stress test. METHODS Forty-seven consecutive patients (mean age 64 +/- 11 years) with 3.0 +/- 1.4 cardiac risk factors underwent dobutamine stress testing utilizing a single, high-dose (40 mcg/kg/min), continuous dobutamine infusion. The 40 mcg/kg/min infusion was continued for up to 10 min or until a test endpoint had been reached. If a test endpoint was not achieved, atropine (up to 1.0 mg) was added. RESULTS Heart rate rose from 71 +/- 12 to 137 +/- 18 beats/min at peak (p<0.0001) with a concomitant change in systolic blood pressure (143 +/- 35 vs. 167 +/- 38 mmHg; p = 0.001) but no change in diastolic blood pressure (74 +/- 19 vs. 75 +/- 18 mmHg; p = NS). Target heart rate was achieved in 20 of 47 (43%) patients with accelerated dobutamine alone and in 34 of 47 (72%) with the addition of atropine. An average of 11.6 +/- 3.7 min was required to obtain target heart rate. Subjective sensations from the dobutamine occurred in 49% of patients (palpitations 21%, nausea 6%, chest pain 6%, headache 6%, dizziness 13%), mild arrhythmia in 48% of patients (ventricular premature beats 38%, supraventricular tachycardia 10%), and one patient had nonsustained ventricular tachycardia. CONCLUSION A single, high-dose (40 mcg/kg/min) dobutamine-atropine protocol provides an efficient means of performing dobutamine stress echocardiography with a similar symptom profile as conventional dobutamine infusion protocols in patients with a high pretest probability of CAD. Randomized, controlled studies will be necessary to assess the sensitivity and specificity of this accelerated dobutamine echo protocol.
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Affiliation(s)
- D Lu
- Washington V.A. Medical Center, DC, USA
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Lønnebakken MT, Bleie Ø, Strand E, Staal EM, Nygård OK, Gerdts E. Myocardial Contrast Echocardiography in Assessment of Stable Coronary Artery Disease at Intermediate Dobutamine-Induced Stress Level. Echocardiography 2009; 26:52-60. [DOI: 10.1111/j.1540-8175.2008.00738.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 9:415-37. [PMID: 18579481 DOI: 10.1093/ejechocard/jen175] [Citation(s) in RCA: 395] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding - coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.
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Affiliation(s)
- Rosa Sicari
- Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124 Pisa, Italy.
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Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 2007; 20:1021-41. [PMID: 17765820 DOI: 10.1016/j.echo.2007.07.003] [Citation(s) in RCA: 510] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Patricia A Pellikka
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA.
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Geleijnse ML, Krenning BJ, Nemes A, Soliman OII, Galema TW, ten Cate FJ. Diagnostic value of dobutamine stress echocardiography in patients with normal wall motion at rest. Echocardiography 2007; 24:553-7. [PMID: 17456075 DOI: 10.1111/j.1540-8175.2007.00427.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Modi SA, Siegel RJ, Birnbaum Y, Atar S. Systematic overview and clinical applications of pacing atrial stress echocardiography. Am J Cardiol 2006; 98:549-56. [PMID: 16893716 DOI: 10.1016/j.amjcard.2006.02.067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2005] [Revised: 02/27/2006] [Accepted: 02/27/2006] [Indexed: 11/23/2022]
Abstract
Pacing atrial stress echocardiography (PASE) has been studied over the past 3 decades for the evaluation of myocardial ischemia. Published studies suggest that PASE may be used as an alternative to exercise or pharmacologic stress imaging. The recent introduction of improved pacing electrodes, together with use of accelerated and shortened pacing protocols and improvements in transthoracic echocardiographic imaging techniques, makes PASE an appealing stress imaging method. A critical analysis of the diagnostic accuracy of PASE shows equivalence with other imaging stress modalities. PASE has been found to be highly feasible and accurate technique that may expedite the diagnosis and risk stratification of patients with coronary artery disease. This review addresses the history, hemodynamics, protocols, accuracy, clinical utility, and cost-effectiveness of PASE as well as elucidating its place among other stress modalities.
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Affiliation(s)
- Shreyas A Modi
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA
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Feringa HHH, Bax JJ, Elhendy A, van Domburg RT, Schouten O, Krenning B, Poldermans D. Hemodynamic responses and long-term follow-up results in patients using chronic beta 1-selective and nonselective beta-blockers during dobutamine stress echocardiography. Coron Artery Dis 2006; 17:447-53. [PMID: 16845253 DOI: 10.1097/00019501-200608000-00008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was undertaken to determine to what extent hemodynamic responses to dobutamine infusion between patients using concomitant beta1-selective or nonselective beta-blockers differ and whether this difference affects the long-term prognostic value of dobutamine stress echocardiography with respect to cardiac events. DESIGN Single center, observational study. METHODS A total of 1234 patients using chronic beta-blockers underwent dobutamine stress echocardiography and were prospectively included in the study. Heart rate and blood pressure responses were measured during the dobutamine stress echocardiography protocol. During a median follow-up time of 4 years (range: 0.5-14 years), overall and cardiac mortality and nonfatal myocardial infarction were noted. RESULTS A total of 954 and 280 patients were using beta1-selective and nonselective beta-blockers, respectively. During dobutamine stress echocardiography, the heart rate response was significantly higher, systolic and diastolic blood pressure responses were significantly lower and the double product of heart rate and systolic blood pressure was similar in patients using beta1-selective than in patients using nonselective beta-blockers. In patients with and without new wall motion abnormalities during dobutamine stress echocardiography, a similar cardiac event-free survival was observed irrespective of the selectivity of beta-blockers (P=0.9 and 0.3, respectively). CONCLUSION During dobutamine stress echocardiography, heart rate and blood pressure response was different, but the double product was similar in patients using beta1-selective or nonselective beta-blockers, which may explain why the long-term prognostic value of dobutamine stress echocardiography is similar in these two groups.
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Affiliation(s)
- Harm H H Feringa
- Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Camarozano AC, Resende P, Siqueira-Filho AG, Weitzel LH, Noe R. The effects of beta-blockers on dobutamine-atropine stress echocardiography: early protocol versus standard protocol. Cardiovasc Ultrasound 2006; 4:30. [PMID: 16848911 PMCID: PMC1578590 DOI: 10.1186/1476-7120-4-30] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Accepted: 07/19/2006] [Indexed: 11/23/2022] Open
Abstract
Background To study the effects of Beta-blockers during Dobutamine Stress Echocardiography (DSE) comparing the hemodynamic benefits of an early administration of atropine in patients taking or not Beta-blockers. Methods One hundred and twenty-one patients were submitted to dobutamine stress echocardiography for the investigation of myocardial ischemia. The administration of atropine was randomized into two groups: A or B (early protocol when atropine was administered at 10 and 20 mcg/kg/min of dobutamine, respectively) and C (standard protocol with atropine at 40 mcg/kg/min of dobutamine). Analysis of the effects of Beta-blockers was done regarding the behavior pattern of heart rate and blood pressure, test time, number of conclusive and inconclusive (negative sub-maximum test) results, total doses of atropine and dobutamine, and general complications. Results Beta-blocked patients who received early atropine (Group A&B) had a significantly lower double product (p = 0.008), a higher mean test time (p = 0.010) and required a higher dose of atropine (p = 0.0005) when compared to the patients in this group who were not Beta-blocked. The same findings occurred in the standard protocol (Group C), however the early administration of atropine reduced test time both in the presence and absence of this therapy (p = 0.0001). The patients with Beta-blockers in Group A&B had a lower rate of inconclusive tests (26%) compared to those in Group C (40%). Complications were similar in both groups. Conclusion The chronotropic response during dobutamine stress echocardiography was significantly reduced with the use of Beta-blockers. The early administration of atropine optimized the hemodynamic response, reduced test time in patients with or without Beta-blockers and reduced the number of inconclusive tests in the early protocol.
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Affiliation(s)
- Ana C Camarozano
- Cardiology Department, Barra D'or Hospital, Rio de Janeiro, Brazil, National Heart Institute, Rio de Janeiro, Brazil
| | - Plínio Resende
- Cardiology Department, Barra D'or Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Aristarco G Siqueira-Filho
- Internal Medicine Department, University Hospital, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Luis H Weitzel
- Cardiology Department, National Heart Institute, Rio de Janeiro, Brazil
| | - Rosangela Noe
- Statistical Department, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Strach K, Meyer C, Schild H, Sommer T. Cardiac stress MR imaging with dobutamine. Eur Radiol 2006; 16:2728-38. [PMID: 16715237 DOI: 10.1007/s00330-006-0295-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2005] [Revised: 03/14/2006] [Accepted: 03/28/2006] [Indexed: 10/24/2022]
Abstract
Stress testing for detection of ischemia-induced wall-motion abnormalities has become a mainstay for noninvasive diagnosis and risk stratification of patients with suspected coronary artery disease (CAD). Recent technical developments in magnetic resonance imaging (MRI), including the adoption of balanced steady-state free precession (b-SSFP) sequences-preferentially in combination with parallel imaging techniques-have led to a significant reduction of imaging time and improved patient safety. The stress protocol includes application of high-dose dobutamine (up to 40 microg/kg/min) combined with fractionated atropine (up to a maximal dose of 1.0 mg). High-dose dobutamine stress MRI revealed good sensitivity (83-96%) and specificity (80-100%) for detection of significant CAD. Myocardial tagging methods have been shown to further increase sensitivity for CAD detection. Severe complications (sustained tachycardia, ventricular fibrillation, myocardial infarction, cardiogenic shock) are rare but may be expected in 0.1-0.3% of patients. Dobutamine stress MRI has emerged as a reliable and safe clinical alternative for noninvasive assessment of CAD. New pulse sequences, such as real-time imaging, might obviate the need for breath holding and electrocardiogram (ECG) triggering in patients with severe dyspnoea and cardiac arrhythmias, which may further improve the clinical impact and acceptance of stress MRI in the future.
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Affiliation(s)
- K Strach
- Department of Radiology, University of Bonn, Sigmund-Freud Str. 25, 53105, Bonn, Germany
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Nedeljkovic I, Ostojic M, Beleslin B, Djordjevic-Dikic A, Stepanovic J, Nedeljkovic M, Stojkovic S, Stankovic G, Saponjski J, Petrasinovic Z, Giga V, Mitrovic P. Comparison of exercise, dobutamine-atropine and dipyridamole-atropine stress echocardiography in detecting coronary artery disease. Cardiovasc Ultrasound 2006; 4:22. [PMID: 16672046 PMCID: PMC1475887 DOI: 10.1186/1476-7120-4-22] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Accepted: 05/03/2006] [Indexed: 11/25/2022] Open
Abstract
Background Dipyridamole 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. Methods Dipyridamole-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. Results Significant 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). Conclusion When 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.
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Affiliation(s)
- Ivana Nedeljkovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Miodrag Ostojic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Branko Beleslin
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Ana Djordjevic-Dikic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Jelena Stepanovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Milan Nedeljkovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Sinisa Stojkovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Goran Stankovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Jovica Saponjski
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Zorica Petrasinovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Vojislav Giga
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
| | - Predrag Mitrovic
- University Institute for Cardiovascular Diseases, Department for Diagnostic and Catheterization Laboratories, Clinical Center of Serbia, Serbia and Montenegro
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Camarozano AC, Siqueira-Filho AG, Weitzel LH, Resende P, Noé RA. The effects of early administration of atropine during dobutamine stress echocardiography: advantages and disadvantages of early dobutamine-atropine protocol. Cardiovasc Ultrasound 2006; 4:17. [PMID: 16569248 PMCID: PMC1524987 DOI: 10.1186/1476-7120-4-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Accepted: 03/29/2006] [Indexed: 11/10/2022] Open
Abstract
Background The conventional dobutamine protocol for the investigation of induced myocardial ischemia is well established. Our objective was to evaluate the effects of early administration of atropine during the dobutamine stress echocardiogram, as compared to its conventional use. Methods One hundred and twenty-one patients were referred to the dobutamine stress echocardiogram, for the investigation of myocardial ischemia and the administration of atropine was randomized into three groups (A, B, C at 10, 20 and 40 mcg/kg/min of dobutamine, respectively). Results The mean level of the double product was significantly lower in the group C patients when compared to group B patients (p = 0.002). The mean test time (12.8 ± 3.1 and 18.7 ± 3.4 p= 0.0001) and the mean total dose of dobutamine (14 × 18 × 25 mg p = 0.008) were significantly higher in group C patients than in group A & B patients. The mean test time was reduced in 6 minutes (31%) with the early administration of atropine in relation to the standard protocol. The atropine dose used in the different groups was similar. Complications were uniform in all cases. Conclusion The early administration of atropine during the dobutamine-atropine stress echocardiography significantly reduces duration of the test and the dose of amine without increasing the number of complications, the total dose of atropine or the number of diagnostic tests.
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Affiliation(s)
- Ana Cristina Camarozano
- Cardiology Department, Barra D'or Hospital, Rio de Janeiro, Brazil
- National Heart Institute, Rio de Janeiro, Brazil
| | - Aristarco G Siqueira-Filho
- Internal Medicine Department, University Hospital, Federal University of Rio de Janeiro (UFRJ), Rio de, Janeiro, Brazil
| | | | - Plínio Resende
- Cardiology Department, Barra D'or Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Arruda ALM, Barretto RBM, Shub C, Chandrasekaran K, Pellikka PA. Prognostic significance of ST-segment elevation during dobutamine stress echocardiography. Am Heart J 2006; 151:744.e1-744.e6. [PMID: 16504644 DOI: 10.1016/j.ahj.2005.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Accepted: 10/20/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Limited data are available concerning the significance of ST-segment elevation during dobutamine stress echocardiography (DSE). The purpose of this study was to assess the prognostic significance of new ST-segment elevation during DSE and its relationship to angiographic severity of coronary artery disease (CAD). METHODS From 4240 consecutive patients who had DSE, we identified 134 (3%) patients with new stress-induced ST-segment elevation > or =1 mm in at least two contiguous electrocardiographic leads. Significant CAD was considered as > or =50% diameter obstruction by angiography. Follow-up was obtained for cardiac events. RESULTS Age was 69 +/- 10 years; 84 (63%) were men. ST-segment elevation developed in the anterior leads in 55 (41%), inferior leads in 100 (75%), and lateral leads in 54 (40%); 56 (42%) had ST elevation in more than one region. Dobutamine stress echocardiography was abnormal in all patients; 115 (86%) had ischemia. Coronary angiography was obtained in 69 (51%) patients. Stenosis was > or =70% diameter in 68 (99%) patients and multivessel in 53 (77%). Follow-up (2.6 +/- 2.8 years) was obtained in all 134 patients. Events occurred in 103 (77%) patients, including death in 53, coronary revascularization in 33, myocardial infarction in 12, and unstable angina in 5. Event-free survival was 55% at 2 years, 38% at 4 years, and 28% at 5 years. CONCLUSIONS Patients with stress-induced ST-segment elevation during DSE commonly have severe CAD and are at high risk for events during follow-up. These patients should be considered for coronary angiography.
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Affiliation(s)
- Ana Lucia M Arruda
- Division of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN, USA
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Hanzal D, Ducharme A. Noninvasive assessment of coronary artery disease in diabetic patients: The role of stress echocardiography. Can J Cardiol 2006; 22 Suppl A:26A-33A. [PMID: 16485057 DOI: 10.1016/s0828-282x(06)70976-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Diabetes mellitus is a frequently occurring disease, and its prognosis is essentially related to cardiac complications. Some have suggested that these patients should be considered as coronary artery disease (CAD)-equivalent and treated aggressively, accordingly. In addition, CAD in diabetes patients at the time of diagnosis is often more advanced, and is frequently associated with more extensive disease, a greater incidence of left ventricular dysfunction and higher rates of cardiac events. Unfortunately, the standard exercise treadmill stress test has important limitations, with a poor sensitivity for CAD detection if the patient has limited exercise capacity, which is the case for more than one-half of the diabetic patients in some series. The detection of regional wall motion abnormality with echocardiography permits the identification of the coronary territory involved. It can be used for CAD diagnosis, evaluation of myocardial viability, risk stratification following a myocardial infarction and assessment of preoperative risk before noncardiac surgery. The risk of CAD in patients with diabetes mellitus is reviewed, and the role of noninvasive testing with stress echocardiography in the diagnosis and risk stratification of these patients is discussed.
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Sabbath A, Pack M, Markiewicz R, John J, Gaballa M, Goldman S, Thai H. Dobutamine Stress Echo Is Superior to Exercise Stress Testing in Achieving Target Heart Rate among Patients on Beta Blockers. Cardiology 2005; 104:138-42. [PMID: 16118492 DOI: 10.1159/000087634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 03/15/2005] [Indexed: 11/19/2022]
Abstract
Published guidelines recommend continuing beta-adrenergic receptor blockade in patients undergoing stress testing. We evaluated the role of pharmacological versus exercise stress testing in achieving target heart rate (THR) among patients on beta-adrenergic blockade. We compared data from 140 patients who underwent dobutamine stress echo (DSE) and 143 patients who underwent exercise treadmill testing (ETT). In both groups, beta-adrenergic blocker was continued at the time of stress testing. Overall, patients undergoing DSE achieved THR more frequently than ETT. With beta-adrenergic blockade, DSE patients met THR more frequently than ETT patients (p < 0.001). Without beta-adrenergic blockade, there was no difference between either modality in achieving THR. In both DSE and ETT patients, absence of beta-adrenergic blockade increased the odds of achieving THR [odds ratio (OR): 2.46, p = 0.042 and OR: 7.44, p < 0.001, respectively]. Atropine use with DSE increased the odds of achieving THR (OR: 3.76, p = 0.006). In conclusion, pharmacological stress testing appears to be superior to exercise stress testing in achieving THR among patients on beta-adrenergic blockade.
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Affiliation(s)
- Adam Sabbath
- Southern Arizona VA Health Care System, University of Arizona, Sarver Heart Center Tucson, 85723, USA.
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Abstract
PURPOSE OF REVIEW This review highlights recent progress in the quantitative approach to the interpretation of stress echocardiograms. Recent literature regarding the application of tissue Doppler and strain rate imaging for the diagnosis of coronary artery disease is summarized. RECENT FINDINGS The high temporal and spatial resolution of tissue Doppler and strain rate imaging permit recognition of regional myocardial dysfunction. These techniques have been performed during low- and high-dose dobutamine stress echocardiography and have been applied to exercise echocardiography. During stress, the peak systolic velocity and early diastolic velocity increased to a greater degree in normal segments compared to ischemic segments. With tissue Doppler imaging, viable segments show increases in systolic velocities in contrast to infarcted segments. Presently, the feasibility of strain rate imaging is slightly less than that of conventional wall motion assessment. However, in preliminary studies, tissue Doppler parameters and especially strain rate parameters appear to offer advantages in accuracy compared to conventional wall motion assessment. SUMMARY Tissue Doppler and strain rate imaging offer great promise for the accurate, reproducible quantification of regional myocardial function. Further studies are indicated to prove their accuracy, efficiency, and superiority over existing methods.
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Affiliation(s)
- Patricia A Pellikka
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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Elhendy A, O'Leary EL, Xie F, McGrain AC, Anderson JR, Porter TR. Comparative accuracy of real-time myocardial contrast perfusion imaging and wall motion analysis during dobutamine stress echocardiography for the diagnosis of coronary artery disease. J Am Coll Cardiol 2004; 44:2185-91. [PMID: 15582317 DOI: 10.1016/j.jacc.2004.08.059] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Accepted: 08/25/2004] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study sought to compare the accuracy of myocardial contrast echocardiography (MCE) and wall motion analysis (WMA) during submaximal and peak dobutamine stress echocardiography (DSE) for the diagnosis of coronary artery disease (CAD). BACKGROUND The relative merits of MCE and WMA for the detection of CAD during DSE have not been studied in a large number of patients. METHODS We studied 170 patients who underwent dobutamine (up to 50 microg/kg/min)-atropine stress testing and coronary angiography. The WMA and MCE (using repeated boluses of Optison [Mallinckrodt, St. Louis, Missouri] or Definity [Bristol-Myers Squibb, New York, New York]) were performed at rest, at intermediate stress (65% to 75% of maximal heart rate), and at peak stress. The diagnosis of CAD (>/=50% stenosis in >/=1 coronary artery) was based on reversible wall motion and perfusion abnormalities. RESULTS Coronary artery disease was detected in 127 (75%) patients. Sensitivity of MCE was higher than that of WMA at maximal stress (91% vs. 70%; p = 0.001) and at intermediate stress (84% vs. 20%; p = 0.0001). Specificity was lower for MCE compared with WMA (51% vs. 74%; p = 0.01). Overall accuracy was higher for MCE than for WMA (81% vs. 71%; p = 0.01). Sensitivity for detection of CAD based on abnormalities in >/=2 vascular regions was higher for MCE than for WMA (67% vs. 28%; p < 0.01). CONCLUSIONS The majority of inducible perfusion abnormalities occur at an intermediate phase of the stress test, without wall motion abnormalities. Myocardial contrast echocardiography provides better sensitivity than WMA, particularly in patients with submaximal stress and in identifying patients with multivessel CAD.
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Affiliation(s)
- Abdou Elhendy
- Department of Internal Medicine, Section of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Tsutsui JM, Osório AFF, Lario FAC, Fernandes DRA, Sodre G, Andrade JL, Ramires JAF, Mathias W. Comparison of safety and efficacy of the early injection of atropine during dobutamine stress echocardiography with the conventional protocol. Am J Cardiol 2004; 94:1367-72. [PMID: 15566905 DOI: 10.1016/j.amjcard.2004.07.141] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Revised: 07/27/2004] [Accepted: 07/27/2004] [Indexed: 11/16/2022]
Abstract
Although dobutamine-atropine stress echocardiography (DASE) is an established method for evaluating patients who have coronary artery disease (CAD), it can increase test duration and a patient's exposure to large doses of dobutamine. New protocols, including the early injection of atropine during dobutamine stress echocardiography (EA-DSE), have been proposed to decrease test duration. This study compared the safety, efficacy, and accuracy of EA-DSE with those of DASE. We retrospectively evaluated 3,163 patients who underwent DASE and 1,664 patients who underwent EA-DSE over a period of 12 years. In EA-DSE, atropine at a dose </=2 mg was started with 20 microg/kg/min of dobutamine if heart rate was <100 beats/min. Diagnostic accuracy for detecting CAD (>50% stenosis) was assessed in patients who underwent quantitative angiography </=3 months of stress testing. The dobutamine dose used in EA-DSE was smaller than that used in DASE (31 +/- 6 vs 36 +/- 6 microg/kg/min, p <0.0001), although the atropine dose was larger (0.8 +/- 0.5 vs 0.5 +/- 0.25 mg, p <0.0001). EA-DSE resulted in a significantly shorter duration of dobutamine infusion (12.4 +/- 2.0 vs 14.6 +/- 2.5 minutes, p <0.0001), more diagnostic studies (88% vs 81%, p <0.0001), and a lower incidence of minor adverse effects than did DASE. The rate of major adverse effects was similar in the 2 protocols. Sensitivities, specificities, positive predictive values, negative predictive values, and accuracies for detecting CAD were 84%, 90%, 93%, 76%, and 86% for EA-DSE and 86%, 78%, 84%, 79%, and 82% for DASE, respectively (p = NS). Therefore, EA-DSE is a safe and effective alternative to DASE and had a similar accuracy for the detection of CAD.
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Affiliation(s)
- Jeane M Tsutsui
- Laboratory of Echocardiography, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil.
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Wahl A, Paetsch I, Roethemeyer S, Klein C, Fleck E, Nagel E. High-Dose Dobutamine-Atropine Stress Cardiovascular MR Imaging after Coronary Revascularization in Patients with Wall Motion Abnormalities at Rest. Radiology 2004; 233:210-6. [PMID: 15304662 DOI: 10.1148/radiol.2331030463] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the value of high-dose dobutamine-atropine stress cardiovascular magnetic resonance (MR) imaging for diagnosis of ischemia in patients with coronary artery disease (CAD) who had undergone revascularization and have wall motion abnormalities at rest, with quantitative invasive coronary angiography serving as reference standard. MATERIALS AND METHODS One hundred sixty consecutive patients (mean age, 59 years +/- 8 [standard deviation]) who had undergone revascularization for CAD and have wall motion abnormalities at rest underwent stress cardiovascular MR imaging prior to clinically indicated invasive coronary angiography. Turbo gradient-echo MR images were acquired at rest and during a standardized high-dose dobutamine-atropine protocol with three short-axis and two long-axis views. Regional wall motion was assessed by a blinded observer by using a 16-segment model and a four-point scoring system. New or worsening wall motion abnormality in at least one segment was considered positive for myocardial ischemia. RESULTS Significant CAD (stenoses of at least 50% diameter at angiography) was found in 119 patients (74%). Target heart rate was not reached in nine patients (6%). Overall sensitivity and specificity for detection of significant CAD were 89% and 84%, respectively. Diagnostic accuracy was 88%, and positive and negative predictive values were 94% and 73%, respectively. Overall sensitivity for detection of significant CAD in patients with single-, double-, and triple-vessel disease was 87%, 88%, and 100%, respectively. CONCLUSION High-dose stress cardiovascular MR imaging can be used for follow-up of patients after coronary revascularization procedures. Diagnostic accuracy is similar to stress cardiovascular MR imaging data for patients suspected of having CAD and compares favorably with that of other established noninvasive techniques.
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Affiliation(s)
- Andreas Wahl
- Department of Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
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38
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ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article. J Am Soc Echocardiogr 2003. [DOI: 10.1016/j.echo.2003.08.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, Douglas PS, Faxon DP, Gillam LD, Kimball TR, Kussmaul WG, Pearlman AS, Philbrick JT, Rakowski H, Thys DM. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Coll Cardiol 2003; 42:954-70. [PMID: 12957449 DOI: 10.1016/s0735-1097(03)01065-9] [Citation(s) in RCA: 341] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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40
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Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, Douglas PS, Faxon DP, Gillam LD, Kimball TR, Kussmaul WG, Pearlman AS, Philbrick JT, Rakowski H, Thys DM, Antman EM, Smith SC, Alpert JS, Gregoratos G, Anderson JL, Hiratzka LF, Hunt SA, Fuster V, Jacobs AK, Gibbons RJ, Russell RO. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146-62. [PMID: 12952829 DOI: 10.1161/01.cir.0000073597.57414.a9] [Citation(s) in RCA: 517] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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41
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Attenhofer Jost CH, Pellikka PA. Atropine for inconclusive exercise tests: a beautiful solution or just cosmetics? Am Heart J 2003; 145:938-40. [PMID: 12796746 DOI: 10.1016/s0002-8703(02)94702-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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42
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Munagala VK, Guduguntla V, Kasravi B, Cummings G, Gardin JM. Use of atropine in patients with chronotropic incompetence and poor exercise capacity during treadmill stress testing. Am Heart J 2003; 145:1046-50. [PMID: 12796761 DOI: 10.1016/s0002-8703(02)94703-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treadmill stress testing (TMST) is a valuable diagnostic test for ischemic heart disease. However, the inability to achieve the target heart rate because of either chronotropic incompetence or poor exercise capacity is a major limitation to its utility. We evaluated the usefulness of atropine in decreasing the number of tests with inconclusive results in patients with a poor chronotropic response or exercise capacity during TMST. METHODS The study comprised 126 patients undergoing TMST. In subjects experiencing fatigue at submaximal exercise, atropine was administered in doses of 0.5 mg per minute until the test conclusion (positive test results or target heart rate achieved) or until a maximum dose of 2 mg was administered. RESULTS Thirty-three of the 126 patients (26%) required atropine (mean dose, 1 mg) during the study; 23 of the 33 patients (70%) proceeded to achieve their target heart rate (n = 17) or positive test results (n = 6). The mean increase in heart rate after atropine administration was 25 beats/min (range 3-53 beats/min). Atropine was required in 39% of patients receiving beta-blockers, versus 21% of patients not receiving beta-blockers (P =.02). Among patients receiving atropine, a conclusive test was achieved significantly more often in patients not receiving beta-blockers (94% vs 46%, P =.01). No adverse events were associated with the use of atropine. Atropine administration resulted in conclusive tests more often in subjects with poor chronotropic response than in subjects with poor exercise capacity (78% vs33%, P = <.001). CONCLUSION The use of atropine as an adjunct to standard TMST can help decrease the number of inconclusive tests, even in patients taking beta-blockers. Larger studies are warranted to further define the role of atropine in diagnostic TMST.
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Affiliation(s)
- Vijaya K Munagala
- Division of Cardiology, St. John Hospital and Medical Center, Detroit, MI 48236, USA
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Humma LM, Richardson HE, Lewis JF, McGorray SP, Pepine CJ, Johnson JA. Dobutamine pharmacodynamics during dobutamine stress echocardiography and the impact of beta-blocker withdrawal: a report from the Women's Ischemic Syndrome Evaluation Study. Pharmacotherapy 2002; 22:939-46. [PMID: 12173796 DOI: 10.1592/phco.22.12.939.33605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES To determine the pharmacodynamic parameters of dobutamine during dobutamine stress echocardiography (DSE) and to determine how beta-blocker withdrawal the evening before DSE affects responses to dobutamine during DSE. DESIGN Retrospective analysis. SETTING University medical center. PATIENTS One hundred thirty-six women who had chest pain or other symptoms suggestive of myocardial ischemia and were considered to have a clinical indication for coronary angiography MEASUREMENTS AND MAIN RESULTS Patients underwent DSE with dobutamine dosages titrated from 5 to 40 microg/kg/minute. The infusion was terminated if the patient reached target heart rate or symptoms developed. Those taking beta-blockers withheld their doses the evening before DSE. Traditional pharmacodynamic modeling revealed a wide range in responses to dobutamine. Data for 62% of patients not taking beta-blockers were described by the Emax (maximum heart rate response to dobutamine) model, whereas data for only 39% of patients taking beta-blockers were best described by this model (p = 0.01). Patients taking beta-blockers also had a smaller mean increment in left ventricular ejection fraction (10.8% +/- 4.2% vs 14.1% +/- 9.3%, p < 0.01), a trend toward a higher ED50 (dobutamine dosage rate causing half the maximum heart-rate response; median 16.8 microg/kg/min, p = 0.12) and a lower sigmoidicity factor determining the shape of the curve (median 2.1, p = 0.03). CONCLUSION The response to dobutamine exhibits wide interpatient variability, even in the absence of beta-blockade. Nonetheless, in the absence of beta-blockers, in most patients the dobutamine response reaches a plateau by the time the maximum infusion rate (40 microg/kg/min) is reached. Withdrawal of beta-blockers the evening before DSE may be inadequate time for elimination of beta-blocker effect, requiring the addition of atropine to achieve the desired response during DSE.
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Affiliation(s)
- Larisa M Humma
- Department of Pharmacy Practice, University of Florida, Gainesville 32610-0486, USA
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44
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Poldermans D, Sozzi FB, Bax JJ, Boersma E, Duncker DJ, Vourvouri E, Elhendy A, Valkema R, Roelandt JR. Influence of continuation of beta blockers during dobutamine stress echocardiography for the assessment of myocardial viability in patients with severe ischemic left ventricular dysfunction. Am J Cardiol 2001; 88:A7, 68-70. [PMID: 11423062 DOI: 10.1016/s0002-9149(01)01591-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- D Poldermans
- Department of Cardiology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
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Tadamura E, Iida H, Matsumoto K, Mamede M, Kubo S, Toyoda H, Shiozaki T, Mukai T, Magata Y, Konishi J. Comparison of myocardial blood flow during dobutamine-atropine infusion with that after dipyridamole administration in normal men. J Am Coll Cardiol 2001; 37:130-6. [PMID: 11153727 DOI: 10.1016/s0735-1097(00)01043-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The present study was designed to compare the absolute myocardial blood flow (MBF) after intravenous dipyridamole infusion with that during dobutamine-atropine administration in normal healthy male volunteers. BACKGROUND Both safety and usefulness of dobutamine-atropine stress in myocardial perfusion imaging have been reported. However, no information exists on whether the magnitude ofhyperemia achieved with dipyridamole and dobutamine-atropine is comparable. METHODS Myocardial blood flow was measured with positron emission tomography and 15O-labeled water in 20 healthy young men (23 +/- 3 years) 1) at baseline, 2) after dipyridamole infusion (0.56 mg/kg over 4 min), and 3) during dobutamine (40 microg/kg/min) and atropine (0.25 to 1.0 mg) infusion. RESULTS The MBF was significantly increased during dipyridamole infusion and during dobutamine-atropine stress compared with at rest (4.33 +/- 1.23 and 5.89 +/- 1.58 vs. 0.67 +/- 0.16 ml/min/g, respectively, p < 0.0001). Moreover, dobutamine-atropine infusion produced greater MBF compared with dipyridamole (p = 0.0011), while coronary vascular resistance did not differ significantly after dipyridamole administration and during dobutamine-atropine infusion (17.6 +/- 7.9 vs. 18.6 +/- 5.6 mm Hg/[ml/min/g], respectively). CONCLUSIONS Near maximal coronary vasodilatation caused by dipyridamole is attainable using dobutamine and atropine in young healthy volunteers. Dobutamine in conjunction with atropine is no less effective than dipyridamole in producing myocardial hyperemia.
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Affiliation(s)
- E Tadamura
- Department of Nuclear Medicine and Diagnostic Imaging, Kyoto University Graduate School of Medicine, Japan.
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Abstract
Stress echocardiography has evolved into a widely practiced and accepted method for the noninvasive assessment of the status of the coronary anatomy. Furthermore, this modality incorporates the ability to assess left ventricular function, valvular structure and function, intracardiac masses, the pericardium, and hemodynamics. The extent to which this tool can reliably provide useful clinical information is dependent, in part, on optimal performance. The purpose of this report is to provide an overview of those technical considerations that can contribute to the successful operation of a stress echocardiography laboratory. Consideration is given to personnel qualifications, functional requirements of the digital acquisition/storage/replay system, functional integration of the various hardware components, characteristics of the software, physical layout of the facility, and alternatives to treadmill exercise as the stressor. A thorough understanding of the physiologic basis of stress echocardiography, coupled with optimization of resources used in its performance, enable this tool to be an extraordinarily useful and cost-efficient method for comprehensive cardiovascular assessment.
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Affiliation(s)
- L J Crouse
- Mid-Atlantic Heart Institute, St Luke's Hospital of Kansas City, MO 64111, USA
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Atar S, Nagai T, Cercek B, Naqvi TZ, Luo H, Siegel RJ. Pacing stress echocardiography: an alternative to pharmacologic stress testing. J Am Coll Cardiol 2000; 36:1935-41. [PMID: 11092667 DOI: 10.1016/s0735-1097(00)00964-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to evaluate the diagnostic accuracy and feasibility of bedside pacing stress echocardiography (PASE) as a potential substitute for pharmacologic stress echocardiography in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris. BACKGROUND Accurate and rapid noninvasive identification and evaluation of the extent of coronary artery disease (CAD) is essential for optimal management of these patients. METHODS Bedside transthoracic stress echocardiography was performed in 54 consecutive patients admitted to a community hospital with new-onset chest pain, after acute myocardial infarction had been excluded. We used 10F transesophageal pacing catheters and a rapid and modified pacing protocol. The PASE results were validated in all patients by coronary angiography performed within 24 h of the test. Significant CAD was defined as > or =75% stenosis in at least one major epicardial coronary artery. RESULTS The sensitivity of PASE for identifying patients with significant CAD was 95%, specificity was 87% and accuracy was 92%. The extent of significant CAD (single- or multivessel disease) was highly concordant with coronary angiography (kappa = 0.73, p<0.001). Pacing stress echocardiography was well tolerated, and only 4% of the patients had minor adverse events. The mean rate-pressure product at peak pacing was 22,313+/-5,357 beats/min per mm Hg, and heart rate >85% of the age-predicted target was achieved in 94% of patients. The average duration of the bedside PASE test, including image interpretation, was 38+/-6 min. CONCLUSIONS Bedside PASE is rapid, tolerable and accurate for identification of significant CAD in patients admitted to the hospital with new-onset chest pain or worsening angina pectoris.
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Affiliation(s)
- S Atar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Arruda AM, Pellikka PA, Mahoney DW, Joseph A, Mathias W, Seward JB. Transthoracic Doppler echocardiographic comparison of left internal mammary grafts to left anterior descending coronary artery with ungrafted right internal mammary arteries in patients with and without myocardial ischemia by dobutamine stress echocardiography. Am J Cardiol 2000; 86:919-22. [PMID: 11053699 DOI: 10.1016/s0002-9149(00)01122-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
To characterize Doppler flow patterns of the grafted left internal mammary artery (LIMA) in patients with and without dobutamine stress induced wall motion abnormalities in the graft distribution, we studied 29 patients who underwent coronary artery bypass surgery using LIMA grafts to the left anterior descending coronary artery (LAD). The ungrafted right internal mammary artery (RIMA) was used as a control. RIMA Doppler flow pattern was predominantly systolic in all patients. In patients without ischemia in the LAD distribution, LIMA flow was predominantly diastolic. In patients with ischemia, LIMA flow was predominantly systolic. In the grafted LIMA, a ratio of diastolic to systolic time-velocity integral of > 1.5 best showed absence of ischemia in the graft distribution. In summary, characterization of the Doppler flow pattern in the internal mammary arteries is feasible. In the grafted LIMA, ratios of diastolic to systolic flow are less in patients with an ischemic response in the subtended vascular bed than in those without ischemia.
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Affiliation(s)
- A M Arruda
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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49
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Wu CC, Liu YB, Lin LC, Ho YL, Liau CS, Lee YT. Ultrasonic tissue characterization with integrated backscatter during inotropic stimulation. ULTRASOUND IN MEDICINE & BIOLOGY 2000; 26:1413-1420. [PMID: 11179615 DOI: 10.1016/s0301-5629(00)00272-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Ultrasonic tissue characterization with integrated backscatter is an objective method to quantitatively define the physical state of the myocardium. To determine if backscatter imaging during inotropic stimulation could be used objectively to determine the myocardial viability and ischemia in patients with ischemic heart disease, the backscatter changes were examined in 23 patients with myocardial infarction during dobutamine stress two-dimensional (2-D) echocardiography. Coronary angiography was performed within 1 to 2 days after the stress test. The results of this study demonstrated that changes in backscatter variability correlated significantly with the wall motion changes in stress echocardiography during dobutamine infusion (p < 0.0001). In addition, it was shown that the backscatter changes were significantly different in various types of myocardial tissue. In 23 healthy control segments, the ultrasonic backscatter variability was preserved and unchanged during inotropic stimulation (p = NS). In 15 viable infarct zones, restoration or an increase in backscatter variability during low-dose dobutamine infusion was noted, this being lost when ischemia developing during high-dose dobutamine infusion (p < 0.01). In 9 nonviable infarct zones, the phase-weighted variation was usually < or = 0 and did not change significantly during inotropic stimulation, regardless of the patency of the infarct-related arteries. In 15 remote ischemic myocardial zones, the backscatter variability was preserved at the baseline level, did not change during low-dose dobutamine infusion, but decreased significantly during high-dose dobutamine stress (p < 0.01). In conclusion, dobutamine stress tissue characterization could offer an objective approach for the detection of myocardial viability and ischemia, and might be a useful adjunct to the conventional stress echocardiography.
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Affiliation(s)
- C C Wu
- Section of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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50
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Abstract
Stress echocardiography is an effective diagnostic and prognostic technique in stable patients with known or suspected coronary artery disease (CAD), myocardial infarction, or chronic left ventricular dysfunction and those undergoing noncardiac surgery. Stress echocardiography is sensitive and specific for the detection and extent of CAD. Negative tests confer a high negative predictive value for cardiac events regardless of the clinical risk. Positive studies confer a high positive predictive value for ischemic events in patients with intermediate to high clinical risk. Stress echocardiography provides incremental prognostic information relative to clinical, resting echocardiographic, and angiographic data. Meta-analysis studies have shown that the diagnostic and prognostic information provided by stress echocardiography is comparable to that from radionuclide scintigraphic stress tests. Stress echocardiography may be more specific for the detection and extent of CAD, whereas radionuclide scintigraphy may be more sensitive for one-vessel disease. Sensitivities are similar for the detection and extent of disease in patients with multivessel CAD.
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Affiliation(s)
- S C Smart
- Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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