The safety and clinical usefulness of dobutamine stress echocardiography among octogenarians

Undiagnosed Chronic Obstructive Pulmonary Disease is Highly Prevalent in Patients Referred for Dobutamine Stress Echocardiography with Shortness of Breath

PURPOSE

Shortness of breath (SOB) is a common symptom referral for dobutamine stress echocardiography (DSE). Patients with SOB and a normal DSE have worse long-term outcome than the general population. This suggests multiple aetiologies are involved. The purpose of this study was to assess the prevalence and clinical significance of undiagnosed COPD amongst patients referred for a DSE with SOB.

METHODS

We prospectively studied 114 patients referred for DSE with SOB without prior evidence of lung disease (mean age 64.9 ± 18.5 years, 60 male). Respiratory function testing using spirometry was performed on all patients on the day of their DSE. The study end-points were cardiac events and total mortality.

RESULTS

Respiratory function testing and DSE was performed in all patients and COPD was highly prevalent (n = 93). Multivariate Cox regression analysis was used to estimate the effect of dyspnoea on non-fatal cardiac events (NFCE) and all-cause mortality. Over a mean follow-up of 4.5 ± 2.6 years, the composite end-point of NFCE and all-cause mortality occurred in 62.7% and 16.7% patients, respectively. COPD (HR 1.27; 95% CI 1.17-1.93), previous myocardial infarction (HR 1.84; 95% CI 1.06-3.2), myocardial ischaemia (HR 2.56; 95% CI 1.48-4.43), peak wall motion score index (HR 4.66; 95% CI 2.26-9.6), and mitral E/E' (HR 1.21; 95% CI 1.1-1.33) were significantly associated with a NFCE. Myocardial ischaemia (HR 4.43; 95% CI 1.24-15.81) was the only independent predictor of all-cause mortality.

CONCLUSION

Undiagnosed COPD is highly prevalent and independently associated with worse outcome amongst patients with SOB referred for DSE. Symptom presentation is therefore an important consideration when interpreting DSE results.

L, Rassi S. Dobutamine Stress Echocardiography Safety in Chagas Disease Patients

BACKGROUND:

A few decades ago, patients with Chagas disease were predominantly rural workers, with a low risk profile for obstructive coronary artery disease (CAD). As urbanization has increased, they became exposed to the same risk factors for CAD of uninfected individuals. Dobutamine stress echocardiography (DSE) has proven to be an important tool in CAD diagnosis. Despite being a potentially arrhythmogenic method, it is safe for coronary patients without Chagas disease. For Chagas disease patients, however, the indication of DSE in clinical practice is uncertain, because of the arrhythmogenic potential of that heart disease.

OBJECTIVES:

To assess DSE safety in Chagas disease patients with clinical suspicion of CAD, as well as the incidence of arrhythmias and adverse events during the exam.

METHODS:

Retrospective analysis of a database of patients referred for DSE from May/2012 to February/2015. This study assessed 205 consecutive patients with Chagas disease suspected of having CAD. All of them had their serology for Chagas disease confirmed.

RESULTS:

Their mean age was 64±10 years and most patients were females (65.4%). No patient had significant adverse events, such as acute myocardial infarction, ventricular fibrillation, asystole, stroke, cardiac rupture and death. Regarding arrhythmias, ventricular extrasystoles occurred in 48% of patients, and non-sustained ventricular tachycardia in 7.3%.

CONCLUSION:

DSE proved to be safe in this population of Chagas disease patients, in which no potentially life-threatening outcome was found.

FUNDAMENTO:

Até poucas décadas atrás, os pacientes chagásicos eram predominantemente trabalhadores rurais, com baixo perfil de risco para doença obstrutiva coronária. Com a crescente urbanização, passaram a ter os mesmos fatores de risco para doença aterosclerótica que indivíduos não infectados. O ecocardiograma sob estresse com dobutamina (EED) é uma importante ferramenta no diagnóstico de coronariopatia. É referido, porém, como um método potencialmente arritmogênico, mas seguro, em pacientes coronarianos não chagásicos. Entretanto, há insegurança na prática clínica de indicá-lo no paciente chagásico, devido ao potencial arritmogênico já intrínseco nesta cardiopatia.

OBJETIVOS:

Analisar a segurança do EED em uma população de chagásicos com suspeita clínica de coronariopatia.

MÉTODOS:

Análise retrospectiva de um banco de dados de pacientes encaminhados para a realização do EED entre maio/2012 e fevereiro/2015. Avaliou-se pacientes consecutivos portadores de doença de Chagas e com suspeita de coronariopatia. Confirmou-se a sorologia para doença de Chagas em todos os pacientes.

RESULTADOS:

A média etária dos 205 pacientes analisados foi de 64 ± 10 anos, sendo a maioria do sexo feminino (65,4%). Nenhum paciente apresentou eventos adversos significativos, como infarto agudo do miocárdio, fibrilação ventricular, assistolia, acidente vascular encefálico, ruptura cardíaca ou morte. Quanto às arritmias, extrassístoles ventriculares frequentes ocorreram em 48% dos pacientes, taquicardia ventricular não sustentada em 7,3%, bigeminismo em 4,4%, taquicardia supraventricular e taquicardia ventricular sustentada em 1% e fibrilação atrial em 0,5%.

CONCLUSÃO:

O EED mostrou ser um exame seguro nessa população de pacientes chagásicos, onde nenhum desfecho grave foi encontrado.