Relation between contractile response of akinetic segments during dobutamine stress echocardiography and myocardial ischemia assessed by simultaneous thallium-201 single-photon emission computed tomography

doi:10.1016/S0002-9149(96)00009-4

The American Journal of Cardiology

Volume 77, Issue 11, 1 May 1996, Pages 955-959

https://doi.org/10.1016/S0002-9149(96)00009-4 Get rights and content

Abstract

There are no standard criteria for the diagnosis of myocardial ischemia in akinetic segments during dobutamine stress echocardiography (DSE). The aim of the study was to assess the relation between different responses of akinetic segments during DSE and ischemia assessed by thallium-201 single-photon emission computed tomography (SPECT). Dobutamine-atropine stress echocardiography with simultaneous stress-reinjection thallium-201 SPECT was performed in 67 patients with old myocardial infarction significant and coronary artery stenosis. Fourteen myocardial segments were matched for both DSE and SPECT. Ischemia on SPECT was defined as reversible thallium defects. In 257 akinetic segments, 4 patterns during DSE were identified: (1) biphasic response in 41 segments (16%), defined as improvement at low dose (5 to 10 μg/kg/min) followed by worsening at high dose; (2) persistent akinesia in 155 segments (60%); (3) akinesia becoming dyskinesia in 39 segments (15%); and (4) sustained improvement in 22 segments (9%). Reversible thallium defects were detected in 21 segments (51%) in group 1, in 20 segments (13%) in group 2, none in group 3, and in 2 segments in group 4 (9%). The prevalence of reversible defects in biphasic segments was higher compared with other patterns (p < 0.00001 vs groups 2 and 3, p < 0.005 vs group 4). The ischemic perfusion defect score was significantly higher in group 1 than group 2. The positive predictive value of biphasic response for reversible thallium defects was similar to that of stress-induced dyssynergia in normal segments at rest (51% vs 58%). It is concluded that of the various responses of akinetic segments to dobutamine infusion, the biphasic response is associated with the highest prevalence and greatest severity of ischemia on thallium SPECT. Observation of contractile response at both low- and high-dose DSE is a valuable approach for the diagnosis of myocardial ischemia in akinetic segments.

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Cited by (49)

Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
In the presence of left main coronary artery or multivessel obstruction, a stress-induced decrease in ejection fraction (EF) or increase in end-systolic cavity size are more commonly seen with exercise than with dobutamine or vasodilator stress (Video 15, available online at www.onlinejase.com).61 It should be noted that akinesis becoming dyskinesis is generally considered to represent a mechanical response of an infarcted segment rather than ischemia.75,76 Recommendations for reporting are shown in Table 4.
Factors Affecting Sensitivity and Specificity of Diagnostic Testing: Dobutamine Stress Echocardiography
2009, Journal of the American Society of Echocardiography
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).
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.
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).
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.
American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography
2007, Journal of the American Society of Echocardiography
Citation Excerpt :
In addition to baseline LV dysfunction, variables associated with adverse outcome include extensive ischemia,65,160-162poor EF response or failure to reduce end-systolic volume with exercise,150wall-motion abnormalities in multivessel distribution,163a low ischemic threshold,61LV hypertrophy,155and location of wall-motion abnormalities in left anterior descending coronary artery distribution.164 Akinesis becoming dyskinesis is associated with more extensive LV dysfunction, absence of reversible perfusion defects,165 and very low probability of regional improvement after revascularization.166 In the presence of concomitant anti-ischemic therapy, a positive test result is more prognostically malignant, and a negative test result less prognostically benign.167
Prognostic Significance of Myocardial Ischemia During Dobutamine Stress Echocardiography in Asymptomatic Patients With Diabetes Mellitus and No Prior History of Coronary Events
2007, American Journal of Cardiology
The prognostic significance of myocardial ischemia assessed by dobutamine stress echocardiography in asymptomatic patients with diabetes mellitus who have no previous coronary artery disease remains unclear. We assessed the value of dobutamine stress echocardiography for risk stratification in 161 asymptomatic patients with type 2 diabetes (mean 62 ± 12 years of age; 96 men) who had no previous myocardial infarction or revascularization. End point during follow-up was hard cardiac events (cardiac death and nonfatal myocardial infarction). Ischemia was detected in 45 patients (28%). During a median follow-up of 5 years, 40 patients (25%) died (18 cardiac deaths) and 7 patients had nonfatal myocardial infarction (25 hard cardiac events). An abnormal dobutamine stress echocardiogram was associated with a higher mortality compared with a normal dobutamine stress echocardiogram (p = 0.03). In an incremental multivariate analysis model, clinical predictors of hard cardiac events were age and hypercholesterolemia. Ischemia was incremental to the clinical parameters. In conclusion, myocardial ischemia is an independent predictor of cardiac events in asymptomatic diabetic patients with no previous coronary artery disease.
Prognostic Significance of Akinesis Becoming Dyskinesis During Dobutamine Stress Echocardiography
2007, Journal of the American Society of Echocardiography
Citation Excerpt :
In this setting, the development of dyskinesia in segments that are akinetic at rest appeared to represent a mechanical phenomenon, related to the increased motion of adjacent tissue. It was suggested that the affected segments are nonperfused, infarcted, and unlikely to recover after revascularization.3-5 Although AKBD has been considered a mechanical phenomenon unrelated to myocardial ischemia, the current study has demonstrated that this pattern is independently predictive of cardiac events.
Akinesis becoming dyskinesis (AKBD) at high-dose dobutamine stress echocardiography (DSE) has been disregarded as a marker of myocardial ischemia. However, its prognostic significance is unknown.
We sought to assess the long-term outcome of patients with AKBD during DSE.
A total of 731 patients (age 62 ± 15 years, 628 men) with two or more akinetic left ventricular segments at rest underwent DSE and were followed up for a mean period of 5 ± 2.7 years. The end points considered during follow-up were hard cardiac events (cardiac death and nonfatal myocardial infarction) and heart failure.
Dyskinesis in two or more segments at peak stress developed in 60 patients (8%). Resting wall-motion score index was 2.6 ± 0.56 in patients with AKBD versus 2.3 ± 0.55 in patients without AKBD (P = .0002). Ischemia occurred in 197 patients (27%). During follow-up, 254 patients (35%) developed hard cardiac events and 204 patients (28%) developed heart failure. In all, 226 patients (31%) died of various causes (cardiac death in 172 patients). The annualized hard cardiac event rate was 11% in patients with AKBD and 6% in patients without (P = .03). The incidence of heart failure was significantly higher in patients with AKBD than without (47% vs 26%, P < .001). Independent predictors of hard cardiac events were age (hazard ratio [HR] 1.03 [confidence interval {CI} = 1.01-1.04]), previous myocardial infarction (HR 1.4 [CI = 1.1-1.9]), diabetes mellitus (HR 1.8 [CI = 1.3-2.5]), resting wall-motion score index (HR 1.11 [CI = 1.01-1.04]), and AKBD (HR 1.6 [CI = 1.1-2.4]).
AKBD at peak DSE is associated with increased risk of cardiac events in patients with akinetic segments at baseline echocardiogram.
Association of myocardial ischemia with mortality and implantable cardioverter-defibrillator therapy in patients with coronary artery disease at risk of arrhythmic death
2005, Journal of the American College of Cardiology
Citation Excerpt :
Biphasic response to dobutamine in a dyssynergic segment was considered as an ischemic response. Akinesis becoming dyskinesis was not considered an ischemic response (22). Follow-up was obtained by scheduled clinic visit to the electrophysiology (EP) clinic of our institute.
We sought to assess the relation between myocardial ischemia during stress echocardiography and major events in patients with implantable cardioverter-defibrillator (ICD).
The association of myocardial ischemia with subsequent ICD therapy and mortality is unknown.
We studied 90 patients (age 65 ± 13 years, 27 women) with history of coronary heart disease who received ICD for primary (53 patients) or secondary (37 patients) prevention of sudden cardiac death. Sixty-five (72%) patients had a previous coronary artery bypass surgery. Patients underwent exercise treadmill or dobutamine stress echocardiography. Ischemia was defined as new or worsening wall motion abnormalities. End points were death and appropriate ICD therapy.
Mean ejection fraction was 34 ± 12%. During a mean follow-up of 2.8 ± 1.5 years, 5 patients died and 19 patients had ICD therapy. Ischemia was detected in 20 of 24 patients with subsequent events and in 24 of 66 patients without (83% vs. 36%, p < 0.001). Events occurred in 17 of the 32 patients (53%) with both ischemia and inducible ventricular tachycardia (VT) on electrophysiologic (EP) studies. None of the 16 patients without ischemia or inducible VT on EP studies had events. In a Cox multivariate analysis model, independent predictors of events were a history of spontaneous sustained VT (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.3 to 3.8), inducible VT on EP studies (HR 1.7, 95% CI 1.2 to 4.5), and ischemia (HR 2.1, 95% CI 1.2 to 3.5).
Ischemia during stress echocardiography is an independent predictor of death and ICD therapy in patients with coronary heart disease at high risk of arrhythmic death. Patients without inducible ischemia or VT on a previous EP study have a very low risk of events. A combination of ischemia and a positive EP study is associated with a very high risk of events.

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^☆: This study was supported in part by the Department of Cardiology, Cairo University Hospital, Cairo, Egypt.

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Relation between contractile response of akinetic segments during dobutamine stress echocardiography and myocardial ischemia assessed by simultaneous thallium-201 single-photon emission computed tomography☆

Abstract

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