Safety of Dobutamine-Atropine Stress Echocardiography: A Prospective Experience of 4033 Consecutive Studies

doi:10.1016/S0894-7317(99)70182-3

Journal of the American Society of Echocardiography

Volume 12, Issue 10, October 1999, Pages 785-791

https://doi.org/10.1016/S0894-7317(99)70182-3 Get rights and content

Abstract

Dobutamine-atropine stress echocardiography (DASE) is an established method and has been shown to be accurate for the detection of coronary artery disease. Still, there are few large clinical studies that analyze the safety of DASE in general or the safety of performing it on an ambulatory basis. Most studies use a target heart rate as the primary end point regardless of whether asymptomatic ischemia occurs. Such studies have shown a serious cardiac event rate of approximately 0.3%. We prospectively studied 4033 consecutive patients on an ambulatory basis and in the hospital with the use of DASE from July 1991 to December 1998. All tests were performed by an experienced physician, and all clinical and DASE data were stored in a large database organized at the beginning of the study. Dobutamine was infused in scalar doses of 5, 10, 20, 30, and 40 μg/kg per minute in 3-minute stages. Development of a new wall motion abnormality, achievement of 85% of target heart, and end of the DASE infusion protocol were used as an end point. If 85% of the target heart rate was not achieved, atropine was infused up to 1 mg in the absence of myocardial ischemia, which was used in 1280 studies. There were 3645 diagnostic tests, and 388 (10%) were found to be nondiagnostic. This result was due to poor image quality in 115 (3%), end of protocol in negative-submaximal examinations in 124 (3%), and limiting side effects in 149 (4%). Thirty-seven percent of the tests showed positive results for myocardial ischemia. Major test-related cardiac complications occurred in 10 (0.25%) patients and included 1 ventricular fibrillation, 1 case of myocardial infarction, and 8 cases of sustained ventricular tachycardia. Atropine poisoning was observed in 5 (0.12%) patients. No deaths occurred as a direct or indirect consequence of DASE. We conclude that dobutamine-atropine stress echocardiography is a reasonably safe method for detection of coronary artery disease in the hospital or in an ambulatory basis. The use of new wall motion abnormality as 1 of the end points may prevent further ischemia-related complications. (J Am Soc Echocardiogr 1999;12:785-91.)

Section snippets

Patients

From July 1991 to December 1998, a total of 4033 DASE were done on 3945 patients in a prospective and consecutive fashion and were analyzed by the same observer at Paulista School of Medicine and Exata Diagnostic Laboratory in São Paulo, Brazil. A consent form was obtained from each patient, and the study protocol was approved by the committee on human research. The DASE data were entered into a data bank containing 141 fields of information per patient organized at the beginning of the study.

RESULTS

The reasons for test termination can be found in Table 2.

. Reasons for test termination and list of limiting side effects

Reasons for termination	No.	Percentage
Diagnostic Tests	3645	90
Positive with HR >85%	428	11
Positive HR <85%	917	22
Negative with HR >85%	2300	57
Nondiagnostic tests	388	10
End protocol in negative with HR <85%	124	3
Poor image quality in negative/ HR >85%	115	3
Limiting side effects	149	4
Symptomatic hypertension	61	1.5
Nonsustained VT	41	1
Symptomatic hypotension	16	0.4
Atrial flutter/fibrillation	15	0.4

DISCUSSION

Although there is no established safety profile for the exercise echocardiogram, the safety profile for exercise electrocardiography and exercise scintigraphy can be assumed to apply. It is estimated that for each 10,000 exercise electrocardiograms, there will be 3 severe events (0.03%) and 1 test-related death.¹⁵

The largest available body of safety data on pharmacologic stress echocardiography is for dipyridamole echocardiography; the data were gathered during more than 10,000 tests done in a

Acknowledgements

We thank Sheila Beth Prochnow Mathias for the kind review of this article.

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Dobutamine stress echocardiography (DSE) is a widely used examination for assessment of coronary ischemia, but several complications have been reported. The aim of this study was to assess the incidence of atrial fibrillation (AF) during DSE, and a systematic review and meta-analysis were also performed to determine an accurate estimate of the AF incidence. Over a 16-year period, we reviewed all patients referred for DSE. We systematically analyzed all ECG performed during DSE to detect AF during the examination. DSE was completely performed in 4,818 patients (mean age: 62.1 ± 11.7 years). AF was observed in 40 patients (31 men, mean age: 79.7 ± 8.9 years). Incidence of AF during DSE was 0.83%. Regarding the meta-analysis, the combined AF incidence was 0.86%. In our study, patients with AF occurrence had more frequent previous history of paroxysmal AF (p = 0.02) were also older (p < 0.0001) and incidence of AF during DSE increased with age: 0% below 60 years, 0.45% in patients 60 to 69 years, 1.3% in patients 70 to 79 years, and 4% in patients >80 years (p < 0.0001). In multivariate analysis, the factors significantly associated with an increased risk of AF were age (adjusted odds ratio (aOR) = 2.4, 95% confidence interval: 1.5 to 3.3, p = 0.003) and previous history of paroxysmal AF (aOR = 1.5, 95% confidence interval: 1.1 to 1.9; p = 0.04). In conclusion, AF is uncommon during DSE, and elderly patients and patients with previous history of paroxysmal AF are at risk of AF during DSE.
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The prognostic value of dobutamine stress echocardiography (DSE) at >10-year follow-up is unknown. The aim of this study was to assess the very long-term prognostic value of DSE in a high-risk cohort of patients with known or suspected coronary artery disease. This prospective, single-center study included 3,381 patients who underwent DSE from January 1990 to January 2003. Two-dimensional echocardiographic images were acquired at rest, during dobutamine stress, and during recovery. Follow-up events were collected and included overall mortality, cardiac death, nonfatal myocardial infarction, and revascularization. The incremental value of DSE in the prediction of selected end points was evaluated using multivariate Cox proportional hazard analysis. During a mean follow-up of 13 ± 3.2 years (range 7.3 to 20.5 years), there were 1,725 deaths (51%), of which 1,128 (33%) were attributed to cardiac causes. Patients with an abnormal DSE had a higher mortality rate (44% vs 35% at 15-year follow-up, p <0.001) than those with a normal DSE. When comparing echocardiographic variables at rest to variables at maximum dose dobutamine, the chi-square of the test improved from 842 to 870 (p <0.0001) and from 684 to 740 (p <0.0001) for all-cause mortality and cardiac death, respectively. DSE provided incremental value in predicting all-cause mortality, cardiac death, and hard cardiac events. There seems, however, to be a “warranty period” of approximately 7 years, when the survival curves of a normal and abnormal DSE no longer diverge.
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Citation Excerpt :
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^☆: Reprint requests: Wilson Mathias, Jr, MD, Rua Itapeva, 500 - 5 andar, Bela Vista, São Paulo-S.P., 01332-902, Brazil (e-mail: [email protected]).

^☆☆: 0894-7317/99 $8.00 + 0 27/1/101247

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Safety of Dobutamine-Atropine Stress Echocardiography: A Prospective Experience of 4033 Consecutive Studies☆,☆☆

Abstract

Section snippets

Patients

RESULTS

DISCUSSION

Acknowledgements

J Am Coll Cardiol

Am J Cardiol

J Emerg Med

Chest

Am J Cardiol

Am J Cardiol

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

Heart Facts

Utilization of short hospital stays, United States, 1987

Vital Health Stat

A simple exercise tolerance test for circulatory efficiency with standards for normal individuals

Am J Med Sci

Coronary angiography, echocardiographic and electrocardiographic studies on a patient with variant angina due to coronary artery vasospasm

Am Heart J