Transesophageal dobutamine stress echocardiography for evaluation of patients with coronary artery disease

Objectives. The present study was undertaken to determine the safety, feasibility and diagnostic accuracy of transesophageal dobutamine stress echocardiography for the evaluation of patients with known or suspected coronary artery disease.Background. Dobutamine stress echocardiography has proved to be a valuable method for detecting and prognosticating ischemic heart disease, In addition, it may provide accurate information about myocardial viability in patients with systolic dysfunction. However, in some patients the technique may be limited by poor myocardial imaging with the conventional transthoracic approach.Methods. Seventy-six patients (62 men, 14 women; mean age ± SD 60 ± 10 years) who underwent coronary angiography were included in the study. Transesophageal stress echocardiograms were performed after withdrawal of antianginal medications for ≥ 48 h. Dobutamine was infused at a starting dose of 2.5 μg/kg body weight per min and was increased by 5-μg/kg per min increments every 5 min to a maximum of 40 μg/kg per min. Two-dimensional views were acquired at each stage and digitized for subsequent analysis. The left ventricle was divided into 16 segments, and each segment was assigned to a major coronary artery with the use of a model of regional distribution of coronary perfusion.Results. Sixty-two of the 76 patients had angiographic evidence of coronary artery disease. New or worsening regional wall motion abnormalities developed during dobutamine infusion in 55 of these 62 patients and in none of the 14 patients with normal coronary arteries (sensitivity 89%, specificity 100%, overall accuracy 91%). Regional wall motion abnormalities in the distribution of more than one major coronary artery were seen in 3 of the 25 patients with single-vessel coronary artery disease and in 30 of the 37 patients with multivessel disease (p < 0.0001). The test was successfully completed in 73 (96%) of the 76 patients; it was discontinued in the remaining 3 patients because of intolerance to the probe. No major complications occurred in any patient. Minor complications developed in seven patients but did not affect the diagnostic accuracy of the test.Conclusions. Transesophageal dobutamine stress echocardiography is a safe, feasible and accurate method for assessing coronary artery disease. Its use should be considered in patients who have a suboptimal ultrasound window, and it provides an excellent tool for clinical investigations based on ultrasound imaging of the myocardium.     

Accuracy of dobutamine stress echocardiography in detecting coronary artery disease.

The diagnostic accuracy of dobutamine stress echocardiography (DSE) (incremental infused doses of 5, 10, 20 and 30 micrograms/kg/min) was evaluated in 141 patients who underwent coronary arteriography within 2 weeks of DSE. All patients were being evaluated for known or suspected coronary artery disease (CAD). DSE was interpreted blindly as normal or showing evidence of CAD, depending on the presence of resting or inducible wall motion abnormalities. Coronary arteriograms were reviewed in a blinded, quantitative fashion. DSE had a sensitivity of 96% for detecting patients with CAD, and a specificity of 66%. For the 53 patients with normal resting wall motion, sensitivity was 87% and specificity 91%. The protocol was well-tolerated by all patients. In comparison with wall motion analysis, 12-lead electrocardiograms during dobutamine infusion revealed ischemic changes in only 17% of patients with CAD. It is concluded that DSE is a clinically useful and accurate means for detecting CAD, its specificity is hindered in patients with resting wall motion abnormalities, and it can safely be used in patients with known cardiac disease.     

Comparison of squatting stress echocardiography and dobutamine stress echocardiography for the diagnosis of coronary artery disease

Background: Dobutamine stress echocardiography (DSE) is commonly used for the diagnosis for coronary artery disease (CAD). We previously demonstrated that squatting induces wall motion abnormalities (WMA) in areas subtended by stenotic coronary arteries. Objective: This study was designed to test the hypothesis that dobutamine and squatting stress echocardiography are equally useful for the diagnosis of CAD. Methods: We studied 39 patients who were scheduled to have coronary angiography for the evaluation of chest pain. Each patient had squatting stress echocardiography followed by DSE. For squatting stress echocardiography the echocardiogram in standard views was recorded in the standing position. The procedure was repeated during squatting for 2 minutes. Dobutamine echocardiography was performed using standard protocol. The squatting and dobutamine stress echocardiograms were interpreted by an observer blinded to the results of coronary angiography. Results: During squatting, new or worsening WMA developed in 20 patients. Six patients developed WMA in the left anterior descending artery territory, three in circumflex territory, three in the right coronary artery territory, and eight in multiple coronary territories. The sensitivity, specificity, and accuracy of squatting echocardiography for diagnosis of CAD were 95%, 94%, and 94%, respectively. For DSE, the sensitivity, specificity, and accuracy for the diagnosis of CAD were 85%, 94%, and 90%, respectively. There was no significant difference between squatting and dobutamine stress echocardiography for the diagnosis of CAD (P = 0.702). Conclusion: These data indicate that squatting and dobutamine echocardiography are equally useful in the diagnosis of CAD. In selected patients, squatting echocardiography may be used in place of dobutamine echocardiography for the diagnosis of CAD. (Echocardiography 2012;29:695–699)     

Tolerability and infusion time of an accelerated infusion dobutamine echocardiography protocol

OBJECTIVES: A new, accelerated dobutamine-atropine stress echocardiography (DASE) protocol (baseline 20 mcg/kg/min; 40 mcg/kg/min) was compared with a standard protocol in patients with suspected coronary artery disease (CAD) to evaluate tolerability, length of infusion, and overall test times, as well as safety. METHODS: Patients received the DASE or the standard protocol on an alternating basis (n = 164). RESULTS: Total test time, including patient recovery (HR < 100 bpm), dropped from an average of 19:23-12:12 min (p < 0.0001). Average symptom duration decreased from 5:50 to 3:17 min (p < 0.01). Women had shorter total test times in both accelerated and standard protocols compared to that of men. CONCLUSIONS: The accelerated DASE protocol is a well tolerated alternative to standard dobutamine stress testing allowing practitioners to reduce test times without increasing the incidence of arrhythmias. Patients in the accelerated arm also had shorter duration of symptoms.     

Abnormal ventricular activation and repolarisation during dobutamine stress echocardiography in coronary artery disease

Objective—To assess possible ECG changes caused by dobutamine stress and their relation to wall motion disturbances in patients with coronary artery disease.
Design—Prospective recording and analysis of 12 lead ECG at rest and during each stage of dobutamine stress echocardiography, and correlation with wall motion changes.
Setting—A tertiary referral centre for cardiac disease equipped with non-invasive facilities for pharmacological stress tests.
Subjects—27 patients, mean (SD) age 60 (8) years, with documented evidence of coronary artery disease in whom dobutamine stress echo was clinically indicated, and 17 controls of similar age.
Results—In controls, all ECG intervals shortened with increasing heart rate but in the patient group only PR and QT intervals shortened while QRS duration broadened and QTc interval prolonged progressively. In the 27 patients, 16 developed chest pain, 15 with reduced left ventricular long axis systolic excursion (p < 0.001), and all showed reduced peak lengthening rate; ST segment shift appeared in 16, 13 of whom developed chest pain, but did not correlate with reduction of either systolic long axis excursion or peak lengthening rate; QRS duration broadened in 20, 16 with reduction of long axis excursion (p < 0.02) which was more often seen at the septum (p < 0.005); QTc interval prolonged in 19, all of whom had associated reduction of peak long axis lengthening rate (p < 0.02).
Conclusions—QRS duration and QTc interval both normally shorten with dobutamine stress, while in coronary artery disease they both lengthen: changes in QRS duration correlate with systolic and QTc interval with diastolic left ventricular wall motion disturbances. ST segment shift also occurred in most patients, but without consistent correlation with wall motion abnormalities. It was thus less discriminating than the other two abnormalities in this respect.

Keywords: long axis;  QRS duration;  QTc interval;  stress echocardiography;  coronary artery disease     

Assessment of coronary artery disease by dobutamine stress echocardiography (DSE)

Background: Dobutamine stress echocardiography (DSE) is a new non-invasive imaging modality which combines two-dimensional echocardiography with cardiovascular stress induced by dobutamine infusion. Its use in patients with suspected or documented coronary artery disease (CAD) is currently under extensive investigation. Aims: To illustrate the clinical utility, safety and diagnostic value of DSE. Methods: One hundred and thirty-seven consecutive patients referred for DSE were studied. Eighty-four patients also underwent coronary angiography. Results: Eleven patients (8%) did not undergo DSE because of poor image quality. Of the remaining 126 patients, 110 (87%) achieved their target heart rate or reached a pre-determined end point during DSE. Eight patients (6%) developed non-cardiac side effects during DSE, none of which required premature termination of the procedure. Cardiac arrhythmias were documented in 15 patients (12%) but only one required intervention. In 84 patients who underwent coronary angiography, DSE showed a sensitivity and specificity of 88% and 83%, respectively, in detecting the presence of, and 75% and 75%o, respectively, in localising significant CAD. In 35 patients who underwent DSE after uncomplicated myocardial infarction, the positive and negative predictive values for cardiac events following infarction in a six-month follow up period were 74% and 62%, respectively. Conclusions: DSE is a well tolerated, safe and useful test in detecting and localising significant CAD. It can also provide useful post-infarctional prognostic information. (Aust NZ J Med 1995; 25: 707-715.) Key words: Echocardiography, dobutamine, coronary artery disease.     

Optimal criteria for the diagnosis of coronary artery disease by dobutamine stress echocardiography

The diagnosis of coronary artery disease (CAD) on the basis of inducible ischemia in ≥2, rather than ≥1, segments was suggested to improve specificity of dobutamine stress echocardiography (DSE). However, the impact of using these criteria on the sensitivity and accuracy of DSE was not studied. We studied the accuracy of DSE (up to 40 μg/kg/min) for the diagnosis of CAD in 290 patients with suspected myocardial ischemia using the criteria of ≥1 and ≥2 ischemic segments. Ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model. Among the 85 patients without previous myocardial infarction, significant CAD was detected in 51 (60%). Sensitivity, specificity, and accuracy of DSE using ≥1 ischemic segment were 73%, 85%, and 78%, respectively. Those using ≥2 segments were 67%, 94%, and 78%, respectively (p = NS). Regional specificity improved by using ≥2 segments (91% vs 96%, p <0.05) at the expense of an equivalent reduction in regional sensitivity (60% vs 44%, p <0.05), whereas the regional accuracy was similar (80% vs 79% for ≥1 and ≥2 segments, respectively). In the 205 patients with previous myocardial infarction, the criterion of ischemia in ≥1 segment had a higher sensitivity and accuracy for overall diagnosis of CAD (75% vs 64%, p <0.05; 77% vs 68%, p <0.05), infarct-related CAD (64% vs 47%, p <0.005; 70% vs 57%, p <0.01), and remote CAD (74% vs 57%, p <0.005; 78% vs 69%, p <0.05) than the criterion of ≥2 segments, respectively. It is concluded that in patients without previous myocardial infarction, the use of ≥2 ischemic segments by DSE for the diagnosis of CAD does not improve the accuracy of DSE compared with the criterion of ≥1 ischemic segment. Conversely, in patients with previous infarction the use of ≥2 segments reduces the overall and regional sensitivity and accuracy without a significant improvement in specificity.     

A rapid stress-testing protocol for the detection of coronary artery disease: comparison of two-stage transesophageal atrial pacing stress echocardiography with dobutamine stress echocardiography

OBJECTIVES: We compared a new two-stage transesophageal atrial pacing stress echocardiography (TAPSE) protocol with a standard dobutamine stress echocardiography (DSE) protocol. BACKGROUND: Transesophageal atrial pacing stress echocardiography has been proposed as an efficient alternative to DSE. METHODS: Two-stage TAPSE (85% and 100% of age-predicted maximum heart rate) and DSE (5 to 40 microg/kg/min at 3-min stages with or without atropine) were both performed, in random sequence, in each patient of a study group of 36 patients. Regional wall-motion analysis, patient acceptance (1 = low, 5 = high), hemodynamics and duration for performing and interpreting tests were compared. RESULTS: Transesophageal atrial pacing stress echocardiography was successful in 35 of the 36 patients (feasibility 97%). More TAPSE than DSE studies were called "ischemic" (37% vs. 14%; p = 0.005). Peak heart rate was higher with TAPSE (144 +/- 18 vs. 129 +/- 15 beats/min, p = 0.0001). Peak cardiac index (4.6 +/- 2.1 vs. 5.1 +/- 1.9 liters/min/m2, p = 0.14), patient acceptance score (4.2 +/- 0.7 vs. 3.8 +/- 1.3, p = 0.17) and study duration (14.2 +/- 9.3 vs. 13.3 +/- 3.3 min, p = 0.59) were similar. Recovery time (7.1 +/- 7.6 vs. 16.2 +/- 15.9 min, p = 0.0003) and interpretation time (9.1 +/- 2.8 vs. 13.5 +/- 4.4 min, p = 0.0001) were shorter for TAPSE than for DSE. CONCLUSIONS: Two-stage TAPSE permits rapid evaluation of cardiac patients. Peak cardiac index and patient acceptance scores were similar for TAPSE and DSE. Ischemia was detected more often with TAPSE; this result was attributed to the higher peak heart rate obtained with this protocol.     

Relation between the extent of coronary artery disease and tachyarrhythmias during dobutamine stress echocardiography

Despite accumulating data regarding the safety of dobutamine stress testing, the possible induction of tachyarrhythmias during the test remains a major concern for physicians, particularly in patients with extensive coronary artery disease (CAD) or left ventricular dysfunction. The aim of this study is to evaluate the clinical, echocardiographic, and angiographic predictors of arrhythmias during dobutamine stress testing. Dobutamine (up to 40 microg/kg/min)-atropine (up to 1 mg) stress echocardiography was performed in 286 patients (age 58 +/- 11 years, 200 men) with suspected myocardial ischemia who underwent coronary angiography within 3 months of the test. Wall motion score index was derived using a 16 segment/4 grade score model where 1 = normal and 4 = dyskinesia. No myocardial infarction or death occurred during the test. Ventricular and supraventricular tachycardia occurred in 16 (6%) and 21 (7%) patients, respectively. Systolic blood pressure decrease > or = 40 mm Hg occurred in 7 patients (2%). Significant CAD was detected in 220 patients (77%). There was no significant difference between patients with and without tachyarrhythmias with regard to the prevalence of CAD (78% vs 77%) or the mean number of diseased coronary arteries (1.51 +/- 0.7 vs 1.45 +/- 0.8). Independent predictors of tachyarrhythmias by multivariate analysis of clinical, angiographic, and echocardiographic characteristics were a higher resting wall motion score index (p <0.01) and mole gender (p <0.05). Independent predictors of systolic blood pressure decrease > or = 40 mm Hg were a higher baseline systolic blood pressure (p <0.0001), a history of myocardial infarction (p <0.0001), and a higher resting wall motion score index (p <0.01). It is concluded that tachyarrhythmias during dobutamine stress testing are predicted by the extent of left ventricular dysfunction but not by the presence or the extent of CAD.     

Prevalence of coronary artery spasm during dobutamine stress echocardiography

The aim of this study was to assess the prevalence of coronary artery spasm during dobutamine stress echocardiography (DSE). Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n = 2,224) referred for DSE. Criteria for selection included patients > 18 years old who underwent DSE. We systematically analyzed all electrocardiograms obtained during DSE to detect ST-segment elevation during the examination. All patients with ST-segment elevation underwent coronary angiography. DSE was performed in 2,179 patients. ST-segment elevation was observed in 21 patients, all of whom underwent emergency coronary angiography. In 13 of these 21 patients (62%) significant coronary stenosis was observed: 6 patients with critical coronary stenosis and 7 patients with chronic coronary occlusion. The remaining 8 patients (38% of patients presenting with ST-segment elevation during DSE, 7 men, mean age 67 ± 11 years) had no significant coronary stenosis. Prevalence of coronary artery spasm during DSE was 0.4%. In conclusion, physicians should be aware that, although rare, coronary artery spasm may occur during DSE.     

Diagnosis of coronary artery disease in elderly patients: safety and efficacy of dobutamine echocardiography

Coronary artery disease may be difficult to diagnose in theelderly because its clinical symptomatology is frequently atypicaland because the performance of submaximal tests makes exercisestress testing sometimes unreliable. Dobutamine stress testingmay be a useful alternative in such patients. This study comparedthe safety and accuracy of dobutamine stress echocardiographyin 73 ‘young’ (<60 years old) and 63 ‘old’( 60 years old) patients without previous myocardial infarctionundergoing diagnostic coronary angiography. The sensitivity in young patients (79%, (67–91, 95% CI))was similar to that in old patients (80% (69–91, 95% CI)).Similar levels of specificity (88% (75–101, 95% CI) vs75% (54–96, 95% CI)) were foundin the two groups. Bothgroups showed a trend to a higher sensitivity for multi-vesseldisease than for single-vessel disease. No major side effectoccurred during the entire study and peak dose (40 µg. kg^–1 . min^–1) was attained with similar frequencyin both groups (56% vs 49%). Minor side effects occurred equallyin ‘young’ and ‘old’ patients and neverpersisted more than a few minutes after ending the first infusionof dobutamine. Dobutamine echocardiography appears to be safe and accuratefor the detection of coronary artery disease regardless of age.     

Spontaneous coronary artery dissection during a dobutamine stress echocardiography

We report a case of a spontaneous dissection of the right coronary artery during a dobutamine stress echocardiography (DSE) study in a middle-aged male. Our patient experienced a severe retrosternal pain of abrupt onset during the DSE study, whereas EKG was evident of significant ST segment elevation in II, III, avF, and V5-V6 leads, followed by an accelerated idioventricular rhythm. Immediate coronary angiogram revealed a minor dissection of the distal part of the right coronary artery.     

彩色室壁动态技术在多巴酚丁胺超声心动图负荷试验诊断冠心病中的价值

目的　将彩色室壁动态 (CK)技术用于多巴酚丁胺超声心动图负荷试验 (DSE) ,并与二维超声心动图 (2 DE)目测法比较 ,评价其实用价值和优越性。方法　 30例冠心病 (CAD)患者和 2 6例正常对照组先后于冠状动脉造影后一个月内完成 DSE。(1)分别用 2 DE和 CK技术判断室壁运动状况 ,比较诊断冠心病的敏感性 ,特异性和准确性。(2 )用 SPECT作为金标准 ,采用 CK技术定量分析室壁运动。结果　 (1) CK技术诊断冠心病的敏感性和准确性分别是 89.6 %和 90 .7% ,均高于 2 DE法 ,P<0 .0 5 .尤其对单支 ,二支病变诊断敏感性更高 ,特异性无显著差异 ,分别为 92 % ,88% ,P>0 .0 5 .(2 ) DSE后冠心病非受累部位心内膜移动幅度增加 ,受累部位则明显减少。结论　 CK技术诊断冠心病的敏感性和准确性均高于 2 DE法 .CK技术定量分析法有一定价值     

Provocation of coronary spasm by dobutamine stress echocardiography in a patient with angiographically minimal coronary artery disease

Dobutamine stress echocardiography (DSE) has been widely used for the noninvasive diagnosis of obstructive coronary artery disease. The ST-segment elevation during DSE has been reported as an infrequent event, caused by old myocardial infarction and/or critical coronary narrowings. The patient presented here was a 35-year-old man with a recent history of nonexertional chest pain. He had hyperc-holesterolemia and a history of heavy smoking as risk factors. The patient developed ST-segment elevation with chest pain during 40 mcg/min dobutamine infusion for the stress echocardiographic examination. Subsequent coronary angiograms revealed only mild coronary atherosclerosis. It is speculated that coronary spasm occurred in this patient as a paradoxical response to increased coronary blood flow with dobutamine administration.     

多巴酚丁胺负荷试验中冠心病患者左室舒张功能的参数变化

目的 :探讨多巴酚丁胺负荷试验中左室舒张功能的参数变化及其在冠心病诊断中的意义。方法 :对 18例正常人和 30例冠心病患者进行多巴酚丁胺负荷超声心动图检查 ,分析比较静息状态与峰值负荷状态下两组左室舒张功能各参数的变化情况。结果 :多巴酚丁胺负荷后 ,两组心率、收缩压均明显增加 ,组间比较有明显差异 ;左室舒张早期峰值血流速度 （E）和左室舒张早期血流传播速度 （RFP）在对照组表现为增加 ,在冠心病组为减低 ;冠心病组出现局部室壁运动异常 （RWMA） 2 5例 ,对照组有 1例出现 RWMA。结论 :多巴酚丁胺负荷试验中左室舒张功能的参数变化是反映冠心病心肌缺血的敏感指标 ,可为冠心病诊断提供有力帮助。     

The diagnostic value of stress dobutamine echocardiography in stable coronary artery diseases

The relation of stress dobutamine echocardiography test results to angiographic features was assessed in 551 patients with chest pain regarded as definite or probable stable angina pectoris. The indications for catheterization in each patient were determined at the discretion of the attending physician. All patients underwent diagnostic coronary angiography (clinically important coronary artery disease was defined as > 50 per cent narrowing of the diameter of at least one major vessel or > or = 50 per cent of the left main coronary artery) and stress dobutamine echocardiography (DSE): Ischemia was defined as new or worsening wall motion abnormalities using a 16-segment model. Sensitivity and specificity of DSE was calculated: 85% and 69% respectively for the entire group, 79% and 71% in women, 87% and 66% in men and compared with diagnostic value of the electrocardiographic exercise test (EE) in the same population. Sensitivity and specificity of the EE was respectively: 93% and 21% for the entire group, 91% and 16% in women, 94% and 27% in men. CONCLUSIONS: 1. DSE has comparable sensitivity but significantly higher specificity than EE. 2. Variables determining false positive result of DSE are as follows: mean maximal heart rate, reached % of the target heart rate and wall motion abnormalities present in single segment. 3. Variables determining false negative results are: sex (male) and one vessel disease. 4. Treatment with beta-adrenolytic agents increases incidence of nondiagnostic results of DSE.