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

Coronary artery spasm following dobutamine stress echocardiogram

A 53-year-old woman with atypical chest pain underwent a dobutamine stress echocardiogram (DSE) and developed a coronary spasm (CS) with severe pain and dramatic ST-segment elevation 9 min after dobutamine infusion was discontinued. The spasm resolved after sublingual nitroglycerin administration. The same-day coronary angiogram showed non-significant stenosis in the three coronary territories. Retrospectively, we found that the patient had vasospastic angina (VSA), a condition that has been strongly associated with the development of dobutamine-induced CS. Mechanisms of dobutamine-induced CS are not fully understood and include endothelial dysfunction leading to deficient nitric oxide-mediated coronary vasodilation in response to increased myocardial oxygen demand as well as imbalance between β1 and β2 adrenergic effects of dobutamine. Dobutamine-induced CS has also been much more frequently reported in patients from Asian descent with VSA. VSA should be systemically recognised in patients considered for DSE and, if present, other modalities of stress imaging should be discussed.

STEMI after Dobutamine Stress Echocardiography in Hyperthyroid State

Uncontrolled hyperthyroidism has been associated with significant changes in cardiovascular hemodynamics. We report a case of a 39-year-old male who has been recently diagnosed with severe hyperthyroidism. He was undergoing dobutamine stress echocardiography (DSE) for evaluation of symptoms suggestive of stable angina. The exam was complicated by ST-segment elevation myocardial infarction- (STEMI-) required coronary angiography that showed mild coronary artery disease.