Short- and long-term results of catheter balloon percutaneous transvenous mitral commissurotomy

Percutaneous transvenous mitral commissurotomy (PTMC) was performed in 219 patients with symptomatic, severe rheumatic mitral stenosis. There were 59 men and 160 women, aged 19 to 76 years (mean 43). Pliable, noncalcified valves were present in 139 (group 1), and calcified valves or severe mitral subvalvular lesions, or both, in 80 patients (group 2). Atrial fibrillation was present in 133 patients (61%) and 1+ or 2+ mitral regurgitation in 59 (27%). Technical failure occurred with 3 patients in our early experience. There was no cardiac tamponade or emergency surgery. The only in-hospital death occurred 3 days after the procedure in a group 2 premoribund patient in whom last-resort PTMC created 3+ mitral regurgitation. Mitral regurgitation appeared or increased in 72 patients (33%); 3+ mitral regurgitation resulted in 12 patients (6%). There were 3 systemic embolisms. Atrial left-to-right shunts measured by oximetry developed in 33 patients (15%). Immediately after PTMC, there were significantly reduced (p = 0.0001) left atrial pressure (24.2 +/- 5.6 to 15.1 +/- 5.1 mm Hg), mean pulmonary artery pressure (39.7 +/- 13.0 to 30.6 +/- 10.9 mm Hg) and mitral valve gradient (13.0 +/- 5.1 to 5.7 +/- 2.6 mm Hg). Mitral valve area increased from 1.0 +/- 0.3 to 2.0 +/- 0.7 cm2 (p = 0.0001) and cardiac output from 4.4 +/- 1.4 to 4.7 +/- 1.2 liters/min (p less than 0.01). The results mirrored clinical improvements in 209 patients (97%). Multivariate analysis showed an echo score greater than 8, and valvular calcification and severe subvalvular lesions as independent predictors for suboptimal hemodynamic results.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of hormone replacement therapy on cardiovascular risk factors in postmenopausal women

OBJECTIVE

To investigate changes in plasma lipoprotein profile, hemostatic factors, platelet aggregation, endothelin-1, and cardiac function during postmenopausal sequential 6-month hormone replacement therapy (HRT).

DESIGN

Open longitudinal prospective study.

SETTING

Gynecologic department of a medical center.

PATIENT(S)

Twenty-one healthy hysterectomized postmenopausal women.

INTERVENTION(S)

Oral E2 valerate (2 mg/d) combined with medroxyprogesterone acetate (MPA) (10 mg/d) during the last 10 days of each 21-day cycle. The treatment period was 6 months.

MAIN OUTCOME MEASURE(S)

Plasma lipoprotein profile, hemostatic parameters, platelet aggregation, endothelin-1, and left ventricular function.

RESULT(S)

After 6 months of treatment, total cholesterol, triglyceride, and low density lipoprotein (LDL) cholesterol were significantly progressively reduced. Atherogenic indices of total cholesterol-to-high-density lipoprotein (HDL) cholesterol and LDL-to-HDL cholesterols also showed a significant progressive decline. The concentrations of antithrombin III were significantly increased. The maximum aggregation and slope of platelet aggregation were significantly reduced, but all parameters were more pronounced at 1 month of HRT than at 3 or 6 months. The concentrations of endothelin-1 were significantly reduced (by 16.1%). In the evaluation of left ventricular function, only peak atrial diastolic velocity was significantly reduced.

CONCLUSION(S)

Combined HRT had favorable effects on lipids and lipoproteins, hemostatic factors, platelet aggregation, endothelin-1, and left ventricular function. However, further study is needed to evaluate the long-term effects of combined HRT, especially on platelet aggregation and cardiac function.

Diagnosis of coronary artery dissection following blunt chest trauma by transesophageal echocardiography

How to differentiate relevant from trivial cardiac injury in blunt chest trauma has been an ongoing debate. In a 32-year-old victim of a motorcycle crash, the electrocardiographic pattern of an acute anterior wall myocardial infarction was identified as being due to a dissection, after an intimal flap in the proximal left anterior descending artery was noted on transesophageal echocardiography.

Pedal (99m)Tc-sulfur colloid lymphoscintigraphy in primary isolated chylopericardium

Primary isolated chylopericardium is a rare disorder in which chylous fluid accumulates in the pericardial space. In this case report of a 61-year-old man with chylopericardium, pedal (99m)Tc-sulfur colloid (SC) lymphoscintigraphy was performed after emergent pericardiocentesis, and when there was a recurrent massive pericardial effusion. The results showed that (99m)Tc-SC lymphoscintigraphy can clearly reveal the lymphodynamics in patients with primary isolated chylopericardium. This noninvasive investigation is valuable and can be easily performed either before or after pericardiocentesis.

Sinus automaticity and sinoatrial conduction in severe symptomatic sick sinus syndrome

Electrophysiologic studies with recordings of sinus node electrograms were performed in 38 patients with severe symptomatic sick sinus syndrome. Thirty-two of the 38 patients had episodic tachyarrhythmias and 17 presented with syncope. The clinically documented sinus or atrial pause was 5.6 +/- 2.8 s (mean +/- SD). Patients were divided into three groups according to electrophysiologic findings. Group I consisted of nine patients with complete sinoatrial block. Sinus node electrograms were recorded during the episodes of long pauses. Seven patients had unidirectional exit block, with the atrial impulse being capable of retrograde penetration to the sinus node causing suppression of sinus automaticity; two had bidirectional sinoatrial block. Group II consisted of 22 patients with either 1:1 sinoatrial conduction (group IIa = 13 patients) or second degree sinoatrial exit block (group IIb = 9 patients) during spontaneous sinus rhythm. Sinoatrial exit block, ranging from 1 to greater than 14 sinus beats, was observed during postpacing pauses that ranged from 1,650 to 37,000 ms (mean 7,286 +/- 6,989). The maximal sinus node recovery time ranged from 770 to 5,580 ms (mean 3,004 +/- 1,686) and was normal in 5 patients and prolonged in 17. Group III consisted of seven patients with no recordable sinus node electrogram, reflecting either a technical failure or a quiescence of sinus activity. The sinus node recovery time in these seven patients ranged from 1,190 to 4,260 ms (mean 2,949 +/- 1,121). Thus, abnormalities in both sinus node automaticity and sinoatrial conduction are responsible for the long sinus or atrial pauses in the sick sinus syndrome. However, complete sinoatrial exit block can occur and cause severe bradycardia with escape rhythm; repetitive sinoatrial exit block plays a major role in producing posttachycardia pauses.

Prognostic value of dobutamine echocardiography in patients after Q-wave or non-Q-wave acute myocardial infarction

We investigated the role of dobutamine echocardiography in predicting future spontaneous events in patients with Q-wave or non-Q-wave first acute myocardial infarction (AMI). DE was performed in 168 patients with a Q-wave AMI and 105 patients with a non-Q-wave AMI. Patients were observed for hard events (cardiac death and nonfatal reinfarction) and all spontaneous events (hard events and unstable angina). When compared to patients with a Q-wave AMI, patients with non-Q-wave AMI had a higher rate of positive dobutamine echocardiographic results (51.8% vs 80.0%, p <0.0001), greater changes in wall motion score index (WMSI) (0.31+/-0.17 vs 0.42+/-0.23, p = 0.001), and more remote zone ischemia (27.9% vs 43.8%, p = 0.0072). Patients with non-Q-wave infarct had a higher all-event rate, but a similar hard-event rate. In patients with a positive dobutamine echocardiogram (DE), the rate of hard or all events was similar, regardless of different infarct patterns. Patients with a negative DE had a higher event-free survival rate for all events in both Q-wave (85.2% vs 60.9%, p <0.0001) and non-Q-wave (76.2% vs 52.4%, p = 0.0083) groups. By stepwise analysis in the Q-wave group, the most important predictors were peak stress WMSI and diabetes for hard events, and a positive DE and baseline WMSI for all events. However, in the non-Q-wave group, the strongest predictors were dobutamine time for hard events and positive DE for all events. We conclude that a positive DE is a powerful predictor of future spontaneous events in patients after either a Q-wave or non-Q-wave AMI. However, for hard events, high-risk patients with different infarct patterns were recognized with variable efficiency by different dobutamine echocardiographic variables.

Rapid fall in elevated plasma atrial natriuretic peptide levels after successful catheter balloon valvuloplasty of mitral stenosis

To determine whether an acute fall in atrial pressure decreases the secretion of atrial natriuretic peptide in man, changes in the plasma levels of this peptide were studied after catheter balloon valvuloplasty of the mitral valve. Ten patients with severe mitral stenosis were included in the study. The valvuloplasty resulted in an immediate reduction in left atrial pressure and an increase in the mitral valve area. Decreases in right atrial pressure were inconsistent and less significant. Plasma atrial natriuretic peptide levels, which were elevated before the valvuloplasty, decreased significantly in all 10 patients at 15 minutes after the valvuloplasty and reached lower plateaus at 30, 45, and 60 minutes after the procedure. In the seven patients studied for a longer period, both plasma atrial natriuretic peptide levels and the left atrial pressure remained reduced 24 hours after the valvuloplasty. Plasma atrial natriuretic peptide levels before and 30 to 60 minutes after the valvuloplasty were positively correlated to simultaneously determined left and right atrial pressures. These results indicate that atrial stretch caused by increased atrial pressure is an important stimulus for atrial natriuretic peptide release in man. "De-stretching" of the myocytes of the atria results in rapid inhibition of atrial natriuretic peptide secretion.

Coronary artery spasm-induced paroxysmal atrial fibrillation--a case report

Paroxysmal atrial fibrillation is described in a patient that was consistent with the clinical history developed after induction of coronary artery spasm. The mechanism appeared to be sinus node artery spasm inducing sinus node ischemia. Coronary artery spasm can be a cause of paroxysmal atrial fibrillation.

Pulsation, systolic thrill and murmur in femoral veins secondary to severe tricuspid regurgitation

We report on a case of pulsatile femoral veins with a systolic thrill and murmur in a 26-year-old patient who exhibited severe tricuspid regurgitation. The pulsatile nature of the veins may result from the 'ventricularization' of venous pressure with each pressure pulse. The observed systolic thrill and murmur may be due to the systolic reversal of substantial regurgitant flow in the venous system of the lower limbs. This case also demonstrates that severe tricuspid regurgitation can have far-reaching manifestations.

Effects of verapamil in normal elderly individuals with left ventricular diastolic dysfunction

Treatment with oral verapamil for 3 to 4 days has been found to enhance left ventricular (LV) diastolic filling in elderly subjects as assessed by radionuclide angiography. However, there are no Doppler echocardiographic studies to assess the long-term effect of verapamil in normal elderly subjects. Thirteen healthy elderly subjects (mean age, 64 +/- 7 years; 8 men and 5 women) with LV diastolic dysfunction underwent this placebo-controlled cross-over trial. The effect of verapamil on LV diastolic function was assessed by treadmill exercise test and Doppler echocardiography at baseline, and after each 3-month treatment period (placebo or verapamil 120 mg once daily), separated by a 1-week washout period before cross-over. Blood pressure, heart rate, LV ejection fraction, LV mass, and cardiac output were unaltered by placebo or verapamil. The exercise time was similar at baseline (11.4 +/- 2.4 min) and after placebo treatment (11.4 +/- 2.3 min) but significantly increased (P < 0.05) after verapamil treatment (12.3 +/- 2.0 min). The ratio of mitral A wave duration/pulmonary venous atrial systolic reversal duration increased after verapamil treatment (1.12 +/- 0.08) compared to placebo (0.93 +/- 0.06, P < 0.05) and baseline (0.89 +/- 0.09), which had similar durations. The isovolumic relaxation time (IVRT) was significantly decreased (P < 0.05) from 85 +/- 13 msec at baseline and 87 +/- 13 msec with placebo to 73 +/- 9 msec with verapamil. The results of this study suggest that in normal elderly patients with Doppler evidence of diastolic dysfunction, 3 months treatment with verapamil can increase exercise tolerance and improve LV diastolic function.

Effect of dobutamine-induced myocardial ischemia on Doppler echocardiography after myocardial infarction

Doppler echocardiography was performed during dobutamine stress test in 133 patients who had myocardial infarction. This investigation focused on the changes in the Doppler-derived left ventricular filling profile and hemodynamic measurements during ischemia. Patients were classified into two major groups on the basis of left ventricular ejection fraction (group 1, left ventricular ejection fraction > or = 40%, n = 66; group 2, left ventricular ejection fraction < 40%, n = 67) and then divided into the ischemic subgroup (1 A [n = 36] and 2A [n = 30]) and the scar subgroup (1 B [n = 36] and 2B [n = 31]) according to the presence or absence of dobutamine-induced myocardial ischemia. In group 1, the only Doppler echocardiographic measurement sensitive enough to differentiate ischemia was the corrected isovolumic relaxation time, which was significantly prolonged in group 1 A compared with group 1 B at peak stress (108 +/- 29 vs 82 +/- 30 msec, p = 0.005). The patients in group 2A had lower increases in stroke volume (-2% +/- 27% vs 22% +/- 33%, p = 0.002) and cardiac output (45% +/- 51 % vs 72% +/- 50%, p = 0.04) than those in group 2B, but larger increases in mitral peak early filling velocity (24% +/- 56% vs 0.9% +/- 37%, p = 0.02) and peak early to atrial velocity ratio (39% +/- 127% vs -24% +/- 38%, p = 0.01) than those in group 2B. The analysis of the changes that occurred in these parameters provides better insight into left ventricular diastolic and systolic function during dobutamine stress tests in patients after myocardial infarction.

Large right atrial thrombus with pulmonary embolism

We present the cases of two patients, aged 67 and 77 years, who were admitted for the evaluation of rapidly progressive dyspnea and syncope, respectively. Both patients developed large right atrial thrombi with pulmonary embolism. The first patient received recombinant tissue plasminogen activator and survived with an uneventful result, whereas the second patient received operative thrombectomy followed by intravenous heparin and died 15 days later of pulmonary infarction with pulseless electrical activity. Data from these limited experiences suggest that thrombolytic therapy might be considered in patients with right heart thrombi with pulmonary embolism.

Comparison of the efficacy and tolerability of telmisartan 40 mg vs. enalapril 10 mg in the treatment of mild-to-moderate hypertension: a multicentre, double-blind study in Taiwanese patients

The purpose of this randomised, double-blind, double-dummy, parallel-group study was to evaluate the efficacy and tolerability of telmisartan 40 mg once daily vs. enalapril 10 mg once daily in 147 Taiwanese patients with mild-to-moderate essential hypertension (diastolic blood pressure [DBP] 90-109 mmHg). After 6 weeks' treatment, telmisartan produced a significantly greater reduction from baseline in the primary endpoint of trough seated DBP compared with enalapril 10 mg (11.7 vs. 8.7 mmHg, respectively; p = 0.02). Numerically greater reductions compared with baseline in seated systolic blood pressure (SBP), standing DBP, and standing SBP were achieved with telmisartan compared with enalapril. Also, numerically greater proportions of patients achieved blood pressure control (DBP/systolic blood pressure [SBP] <90/140 mmHg) and responded to treatment (reduction from baseline in trough seated DBP > or = 10 mmHg and/or post-treatment DBP <90 mmHg; reduction from baseline in trough seated SBP > or = 10 mmHg and/or post-treatment SBP <140 mmHg) with telmisartan 40 mg compared with enalapril 10 mg. Although both treatments were well tolerated, the incidence of cough was markedly lower with telmisartan 40 mg (8.5%) than with enalapril 10 mg (18.4%) in this population of Taiwanese hypertensive patients.

A comparison between intravenous streptokinase and tissue plasminogen activator with early intravenous heparin in acute myocardial infarction

To compare the effects of two thrombolytic agents, streptokinase and recombinant tissue-type plasminogen activator (rTPA) with early heparinization, on left ventricular function, coronary patency and reinfarction rates, bleeding complications, and short- and long-term mortality, we studied 122 patients with acute myocardial infarction prospectively. All of them fulfilled the standard criteria for thrombolytic therapy. One group (n = 63) received 1,500,000 units of streptokinase over 1 hour, and one group (n = 59) received 100 mg of rTPA over 3 hours. Baseline data showed no significant differences between the streptokinase and rTPA groups. Results of predischarge studies 10 to 14 days after infarction revealed that there was no difference in left ventricular ejection fraction between the two groups (48.3% in the streptokinase group and 49.9% in the rTPA group; p = 0.67). The patency rate of the infarct-related artery tended to be higher in the rTPA group compared with the streptokinase group (77% vs 57%, p = 0.19). In-hospital spontaneous bleeding occurred after streptokinase in seven patients (11.1%) and after rTPA in eight (13.6%; p = 0.89). One patient had intracranial bleeding after rTPA and died 13 hours later. The early mortality rate within 30 days of acute myocardial infarction was 5 of 63 (7.9%) for the streptokinase group and 2 of 59 (3.4%) for the rTPA group (p = 0.49). During the 19.3-month follow-up period, reinfarction occurred in seven patients (11%) in the streptokinase group and in three (5%) in the rTPA group (p = 0.3). The mortality rates were 10 of 63 (16%) and 3 of 59 (5%), respectively (p = 0.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Can dobutamine stress echocardiography predict cardiac events in nonrevascularized diabetic patients following acute myocardial infarction?

STUDY OBJECTIVE

To determine whether the prognostic value of dobutamine stress echocardiography (DSE) performed early after acute myocardial infarction (AMI) is as high in diabetic patients as in nondiabetic patients.

DESIGN

Inception cohort study.

SETTING

Tertiary cardiac referral center.

PATIENTS AND INTERVENTIONS

Three hundred thirty-eight patients (116 diabetic and 222 nondiabetic) who underwent DSE after AMI were followed up for cardiac events.

MEASUREMENTS AND RESULTS

Outcome events were as follows: "hard" events consisted of cardiac death and nonfatal reinfarction, while "all events" included hard events and unstable angina. The mean follow-up duration was 21 +/- 9 months. DSE results were positive in 69 diabetic patients (59.5%) and 129 nondiabetic patients (58.1%; p = 0.817). During the follow-up period, there were 25 cardiac deaths, 16 cases of nonfatal reinfarction, and 55 cases of unstable angina. The Kaplan-Meier life table showed that a positive DSE result was associated with a lower event-free survival rate in nondiabetic but not in diabetic patients in terms of hard and all events. By multivariate analysis, a positive DSE result was the strongest independent predictor of future cardiac events in nondiabetic patients. However, in diabetics, a shorter dobutamine time, rather than a positive DSE result, independently predicted cardiac events.

CONCLUSIONS

Our preliminary data suggest that different DSE variables should be considered when assessing the likelihood of future events in diabetic and nondiabetic patients after AMI. The observation of shorter dobutamine time, instead of DSE positivity, has a higher prognostic value in diabetics. In diabetic patients, the only significant role of DSE positivity is for predicting future unstable angina; however, its predictive value is not as good as in nondiabetic patients.

Relationship between dobutamine echocardiography and the elevation of cardiac troponin I in patients with acute coronary syndromes

An elevated cardiac troponin I (cTnI) and a positive dobutamine echocardiography are powerful predictors for future cardiac events in patients with coronary artery disease. Investigating their correlation also should be helpful in understanding their clinical usefulness in evaluating patients with acute coronary syndromes (ACS). Dobutamine echocardiography and a blood sampling for cTnI were performed on 117 patients with ACS 70 +/- 2 hours after arriving at the hospital. CTnI was considered elevated when its value was greater than 2.0 ng/ml. Dobutamine echocardiography was positive in 86 (73.5%) patients, and cTnI was elevated in 37 (31.6%). The occurrence of positive dobutamine echocardiography in patients with elevated cTnI was significantly higher than in those with normal cTnI (86.5% vs. 67.5%, P = 0.042). More patients in the elevated cTnI group developed myocardial ischemia before or at the stage of dobutamine 20 microg/kg/min (43.2% vs. 15%, P = 0.002). When compared with patients with normal cTnI, patients with elevated cTnI had a lower ischemic threshold during dobutamine echocardiography, and more frequently had baseline echocardiographic wall-motion abnormalities, a history of myocardial infarction, and a positive dobutamine echocardiography. Using multivariate analysis, we found that only a lower dobutamine echocardiography ischemic threshold (P = 0.0008) and baseline wall-motion abnormalities (P = 0.0004) were associated independently with the elevation of cTnI. Our results suggest that in patients with ACS, dobutamine echocardiography can offer information regarding wall-motion abnormalities and ischemic threshold, which are suggested to have a clinical value similar to elevated cTnI.

Effects of metoprolol on left ventricular function in rats with myocardial infarction

To study the effect of beta-receptor-blocking agents in an animal model of left ventricular (LV) dysfunction, we measured LV performance in vivo and in vitro in 69 rats with or without metoprolol (M) treatment 3 wk after left coronary arterial ligation or sham operation. Rats were divided into six groups including control (C) and M noninfarct (C-N and M-N), C and M small infarct (C-S and M-S), and C and M large infarct (C-L and M-L). LV function was measured as slope of change in systolic vs. diastolic pressure (pressure-function curve) during pressor response after administration of a bolus of phenylephrine (5 micrograms/kg i.v.). Reduction of LV function was noted in C-L compared with C-N and C-S (slope of pressure-function curve 3.3 +/- 0.3 vs. 11.0 +/- 1.9 and 11.9 +/- 2.3, respectively) and in M-L compared with M-N and M-S rats (slope of 5.5 +/- 1.4 vs. 11.3 +/- 2.0 and 12.1 +/- 1.4, respectively). There was no significant difference between C and M rats, although there was a trend toward partial correction of the pressure-function curves in M-L compared with C-L rats. In muscle bath preparations the uninfarcted LV posterior papillary muscle from shams and rats with small infarcts showed a dose-related increase in peak rate of tension development with isoproterenol stimulation, but this response was lacking in both C-L and M-L. Tissue assays showed no change in beta-receptor number.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial natriuretic peptide and vasopressin during percutaneous transvenous mitral valvuloplasty and relation to renin-angiotensin-aldosterone system and renal function

To study the relation between plasma atrial natriuretic peptide (ANP) and cardiac pressure, and to assess the pathophysiologic significance of ANP in water and electrolyte metabolism, the changes in plasma levels of ANP and arginine vasopressin (AVP) were examined in 11 patients with mitral stenosis who underwent percutaneous transvenous mitral valvuloplasty, and compared with the changes in the renin-angiotensin-aldosterone system and renal function. Immediately after valvuloplasty, plasma ANP levels decreased significantly with a concomitant decrease in mean pressures in the left atrium, the pulmonary artery and the right atrium. Plasma ANP levels decreased to the normal range in 4 of the 6 patients with normal sinus rhythm, while all 5 patients with atrial fibrillation had higher levels despite a similar degree of decrease in atrial pressure. There were significant positive correlations between plasma ANP levels and the mean left atrial pressure (r = 0.61, p less than 0.01), the mean pulmonary arterial pressure (r = 0.49, p less than 0.01) and the mean right atrial pressure (r = 0.54, p less than 0.01). The mean plasma AVP levels, on the other hand, showed a transient increase after valvuloplasty from 0.5 +/- 0.1 to 1.2 +/- 0.4 pg/ml (p less than 0.05). The mean plasma renin activity (1.3 +/- 0.3 vs 2.7 +/- 0.8 ng/ml/hr, p less than 0.05) and plasma aldosterone concentration (8.6 +/- 2.3 vs 17.2 +/- 5.2 ng/dl, p less than 0.05) also increased significantly 30 minutes after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary resuscitation during coronary vasospasm induced by tilt table testing

A 65-year-old man presented to our institution with recurrent episodes of early morning chest discomfort and near syncope. An ergonovine provocation test documented a diagnosis of coronary vasospastic angina. Using our investigation of the syncope, a head-up tilt table test provoked a severe episode of coronary vasospasm that resulted in a life-threatening cardiac event. The present case reminds us that an elevation of ST segments on the electrocardiogram during tilt testing should be promptly managed as an attack of coronary vasospasm.

Dobutamine-induced hypotension is an independent predictor for mortality in patients with left ventricular dysfunction following myocardial infarction

Dobutamine echocardiography was performed on 297 patients after acute myocardial infarction to assess the prognostic value of dobutamine-induced hypotension in patients with left ventricular dysfunction. Patients were divided into two groups according to ejection fraction (group I, ejection fraction <0.45, n = 123; group II, ejection fraction > or =0.45, n = 174) and were followed for 20+/-8 months. Hypotension was defined as a decrease in systolic blood pressure > or =20 mm Hg, compared with baseline values. The incidence of hypotension was similar in groups I and II (23.6% vs. 18.4%, P = 0.28), and the hypotension was not related to positive dobutamine echocardiography. Univariate analysis showed that the development of hypotension was associated with a higher incidence of cardiac death in group I but not in group II. Multivariate analysis showed that dobutamine-induced hypotension was an independent predictor only for cardiac death in group I and was not related to any other cardiac events in either group. In conclusion, the development of hypotension during dobutamine stress can identify a subgroup with poor ventricular functional reserve and at high risk for cardiac death among patients complicated with left ventricular dysfunction.