Dobutamine stress echocardiography at 7.5 μg/kg/min using color tissue Doppler imaging M-mode safely predicts reversible dysfunction early after reperfusion in patients with acute myocardial infarction

doi:10.1016/S0002-9149(98)00865-0

The American Journal of Cardiology

Volume 83, Issue 3, 1 February 1999, Pages 340-344

https://doi.org/10.1016/S0002-9149(98)00865-0 Get rights and content

Abstract

Dobutamine stress echocardiography (DSE) is widely used to predict reversible left ventricular dysfunction, but evaluation by this method is subjective. The recently developed color tissue Doppler imaging (TDI) M-mode may permit objective and quantitative assessment of changes in wall motion induced by DSE. We tested the hypothesis that this new method can detect sensitively reversible dysfunction in the post–myocardial infarction setting. DSE with color TDI M-mode and conventional DSE were performed to predict reversible dysfunction in 53 patients at a mean of 3 days after infarction using 7.5 and 10 μg/kg/min of dobutamine. Follow-up regular echocardiography (4 weeks later) was used as the reference technique to define reversible dysfunction segments. To predict reversible dysfunction segments, the standard segmental wall motion score change on conventional DSE and the ratio of the segmental wall velocity difference at rest versus stress (7.5 and 10 μg/kg/min) on DSE with color TDI M-mode (7.5-TDI-M and 10-TDI-M, respectively) were used. With 7.5 μg/kg/min of dobutamine, the sensitivity for predicting reversible dysfunction using color TDI M-mode (7.5-TDI-M) was significantly higher than that of conventional DSE (89% vs 73%, p <0.05) whereas specificities and predictive values were almost identical. With a 10-μg/kg/min dose, color TDI-M mode (10-TDI-M) and conventional DSE were not significantly different in predicting reversible dysfunction. With use of color TDI-M mode, regional wall motion during DSE was analyzed objectively and quantitatively. Moreover, combined TDI-M and conventional data were slightly superior to either mode alone. There were no arrhythmias during 7.5 μg/kg/min of dobutamine, but 9 arrhythmias occurred during the 10-μg/kg/min dose in patients with acute myocardial infarction. In conclusion, color TDI M-mode permits objective and quantitative assessment of regional ventricular wall motion and gives additional information for detecting reversible dysfunction in DSE. Improvement of sensitivity at a lower dose of dobutamine with color TDI-M mode may increase the safety of DSE in the post–myocardial infarction setting.

Section snippets

Subjects

Fifty-six consecutive patients undergoing primary coronary angioplasty for a first acute myocardial infarction were admitted to our hospital. The diagnosis of acute myocardial infarction was made on the basis of prolonged chest pain, a greater than threefold increase in serum creatine kinase, ST elevation in ≥2 electrocardiographic leads, and wall motion abnormalities on baseline 2-dimensional echocardiography. Three patients were excluded from the study because of technical difficulties

Hemodynamic data

Hemodynamic measurements during DSE were as follows: heart rate at rest, 70 ± 9 beats/min, rate with 7.5 μg/kg/min of dobutamine, 75 ± 9 beats/min (p <0.01 vs rest), and rate with 10 μg/kg/min of dobutamine, 86 ± 10 beats/min (p <0.05 vs rest, p <0.01 vs 7.5-μg/kg/min dose), resting blood pressure, 118 ± 13 mm Hg, blood pressure with 7.5 μg/kg/min of dobutamine, 128 ± 14 mm Hg (p <0.01 vs rest), and blood pressure with 10 μg/kg/min of dobutamine, 138 ± 18 mm Hg (p <0.01 vs rest, p <0.01 vs

Discussion

Color TDI M-mode enables objective and quantitative assessment of ventricular wall motion and gives additional information for detecting reversible dysfunction in DSE. Moreover, improvement of sensitivity for detecting reversible dysfunction at a lower dose (7.5 μg/kg/min) of dobutamine has an excellent safety profile for DSE.

The combination of conventional and TDI data was superior to either method alone (Table I). Thus, TDI-M is useful to supplement the conventional data.

The reasons why color

Acknowledgements

We are indebted to Sinichi Fujita and Yuji Masaki for their assistance in collecting the clinical data, and we gratefully thank Nelson B. Schiller, MD, and Rita F. Redberg, MD, for their invaluable advice.

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Myocardial strain (ϵ) is a dimensionless index of change in myocardial length in response to an applied force. ϵ Rate (SR) is the rate of change of length and is usually obtained as the time derivative of the ϵ signal. In echocardiography, SR is calculated as the difference between 2 velocities normalized to the distance between the 2 velocities. SR imaging (SRI) has a theoretic advantage over Doppler tissue imaging in that SRI is relatively immune to cardiac translational motion and tethering. Therefore, SRI may be superior to Doppler tissue imaging in quantitative assessment of regional myocardial function and may find clinical application in the interrogation of coronary artery disease. The high frame rates of SRI have also renewed interest in timings of global and regional mechanical events, and their potential clinical applications. The high temporal resolution allows SRI to depict regional systolic and diastolic asynchrony. Ongoing clinical trials will determine the sensitivity, specificity, and accuracy of SRI parameters for a variety of clinical conditions. Potential clinical applications include investigation of ischemia (at rest and with stress), myocardial viability, and altered global and regional systolic and diastolic function in cardiomyopathies. Suboptimal signal quality remains a major limitation of strain imaging, and advances in data acquisition and postprocessing capabilities will help determine its future incorporation into standard regional myocardial assessment.
Usefulness of quantitative echocardiographic techniques to predict recovery of regional and global left ventricular function after acute myocardial infarction
2003, American Journal of Cardiology
Citation Excerpt :
Similarly, a significant increment in global long-axis function is concordant with the radial thickening response to low-dose dobutamine in viable segments.22 A more regional quantitative assessment of viability has been proposed in recent studies,23–25 and these approaches have been validated against single-photon26 and positron tomography.24,27 The prediction of myocardial recovery during follow-up echocardiography has been accomplished by identifying increments in segmental velocity during low-dose dobutamine using pulse-wave tissue Doppler.23,24
The left ventricular response to dobutamine may be quantified using tissue Doppler measurement of myocardial velocity or displacement or 3-dimensional echocardiography to measure ventricular volume and ejection fraction. This study sought to explore the accuracy of these methods for predicting segmental and global responses to therapy. Standard dobutamine and 3-dimensional echocardiography were performed in 92 consecutive patients with abnormal left ventricular function at rest. Recovery of function was defined by comparison with follow-up echocardiography at rest 5 months later. Segments that showed improved regional function at follow-up showed a higher increment in peak tissue Doppler velocity with dobutamine therapy than in nonviable segments (1.2 ± 0.4 vs 0.3 ± 0.2 cm/s, p = 0.001). Similarly, patients who showed a >5% improvement of ejection fraction at follow-up showed a greater displacement response to dobutamine (6.9 ± 3.2 vs 2.1 ± 2.3 mm, p = 0.001), as well as a higher rate of ejection fraction response to dobutamine (9 ± 3% vs 2 ± 2%, p = 0.001). The optimal cutoff values for predicting subsequent recovery of function at rest were an increment of peak velocity >1 cm/s, >5 mm of displacement, and a >5% improvement of ejection fraction with low-dose dobutamine.
Strain rate measurement by Doppler echocardiography allows improved assessment of myocardial viability in patients with depressed left ventricular function
2002, Journal of the American College of Cardiology
Citation Excerpt :
Several solutions have been suggested to circumvent these difficulties. Nishino et al. (18)applied M-mode TDI, in combination with dobutamine stimulation, in the post-myocardial infarction setting and reported a high sensitivity for the prediction of reversible dysfunction. They determined a velocity gradient between the endocardium and epicardium both at rest and during dobutamine stress to evaluate the functional reserve.
This study sought to evaluate whether objective assessment of the myocardial functional reserve, using strain rate imaging (SRI), allows accurate detection of viable myocardium.
Strain rate imaging is a new echocardiographic modality that allows quantitative assessment of segmental myocardial contractility.
In 37 patients (age 58 ± 9 years) with ischemic left ventricular dysfunction, myocardial viability was assessed using low-dose (10 μg/kg body weight per min) two-dimensional dobutamine stress echocardiography (DSE), tissue Doppler imaging, SRI and ¹⁸F-fluorodeoxyglucose (¹⁸FDG) positron emission tomography (PET). The peak systolic tissue Doppler velocity and peak systolic myocardial strain rate were determined at baseline and during low-dose dobutamine stress from the apical views.
A total of 192 segments with dyssynergy at rest were classified by ¹⁸FDG PET as viable in 94 and nonviable in 98. An increase of peak systolic strain rate from rest to dobutamine stimulation by more than −0.23 1/s allowed accurate discrimination of viable from nonviable myocardium, as determined by ¹⁸FDG PET with a sensitivity of 83% and a specificity of 84%. Receiver operating characteristic (ROC) curve analysis showed an area under the curve for prediction of nonviable myocardium, as determined by ¹⁸FDG PET using SRI, of 0.89 (95% confidence interval [CI] 0.88 to 0.90), whereas the area under the ROC curve using tissue Doppler imaging was 0.63 (95% CI 0.61 to 0.65).
The increase in the peak systolic strain rate during low-dose dobutamine stimulation allows accurate discrimination between different myocardial viability states. Strain rate imaging is superior to two-dimensional DSE and tissue Doppler imaging for the assessment of myocardial viability.
Early systolic mitral annular motion velocities responses to dobutamine infusion predict myocardial viability in patients with previous myocardial infarction
2002, American Heart Journal
Citation Excerpt :
The development of TDI14-17 facilitated the quantitative analysis of regional LV wall motion abnormalities. Recently, many studies have reported that myocardial viability can be evaluated with pulsed TDI27-29 or color-coded TDI30-35 during dobutamine infusion in patients with MI. The clinical usefulness of pulsed TDI is, in part, based on its excellent time resolution, which is relatively independent from the frame rate, and the simplicity of image acquisition.36,37
Objective This study was undertaken for the determination of the correlation between myocardial viability and regional systolic mitral annular motion velocity (MAV) response to dobutamine stress in patients with previous myocardial infarction (MI) with pulsed tissue Doppler scan imaging. Methods The study included 45 patients (mean age, 65 ± 12 years) with previous MI with 1 major coronary lesion and 30 healthy individuals (mean age, 61 ± 14 years). ^99mTc-methoxyisobutylisonitrile scintigraphy was performed to divide the patients into 2 groups: the viability (+) group (n = 25) and the viability (−) group (n = 20). Dobutamine was infused (at 2, 5, 10, and 20 μg/kg/min), and the peak first and second systolic MAVs (Sw₁ and Sw₂, respectively) were measured at the level of the mitral annulus corresponding to the infarct regions in the MI group and to the 6 mitral annular sites in the control group. In addition, the left ventricular wall motion score index (WMSI) was determined with 2-dimensional echocardiography. Results At baseline, the WMSI was significantly greater and the mean Sw₁ and Sw₂ were significantly lower in both the viability (+) and (−) groups than in the control group, but there were no significant differences between the viability (+) and (−) groups. After dobutamine infusion, the WMSI improved only in the viability (+) group. The mean Sw₁ and Sw₂ increased significantly with 2 μg/kg/min and 5 μg/kg/min of dobutamine, respectively, in the viability (+) group. With an increase in Sw₁ of 2.0 cm/s or more with 5 μg/kg/min of dobutamine, viable myocardium was detected, with a sensitivity of 92% and a specificity of 90%. There were no significant increases in Sw₁ or Sw₂ in the viability (−) group with dobutamine infusion. Conclusion Viable left ventricular myocardium is identified with peak early systolic MAV during dobutamine infusion. (Am Heart J 2002;143:552-8.)
Overview of stress echocardiography: Uses, advantages, and limitations
2001, Progress in Cardiovascular Diseases
Responses of the heart to changes in our environment are probably even more important than how the heart functions at rest. Accordingly, stress testing with noninvasive imaging has become important for diagnosis, prognosis, and monitoring the effects of therapy. Echocardiography at rest and with stress permits characterization of global and segmental left ventricular function as well as valvular structure and function. Moreover, echocardiography can be performed during or after a number of different physical or even mental stressors. Advantages of stress echocardiography include its ready availability, relatively low capital cost, and incremental value in that it allows characterization of cardiac anatomy as well as the myocardial response to a potentially ischemic stimulus. Moreover, echocardiography has the potential to image myocardial perfusion along with wall motion and wall thickening. Substantial literature has now been accumulated on the value of stress echocardiography for the diagnosis of ischemic disease, preoperative risk assessment, and assessment of myocardial viability. Echocardiography has compared generally well with nuclear imaging techniques for the detection of angiographic coronary artery disease. Overall sensitivity, however, has been slightly less, particularly for the detection of single-vessel coronary disease, although specificity has been on average somewhat higher than nuclear cardiology techniques. Because of the potential for variability in study acquisition as well as interpretation, careful safeguards need to be employed. Specifically, meticulous technique needs to be applied to obtain high-quality images and to assure that those images are obtained promptly after treadmill exercise stress. Only readers with specific interest and expertise should interpret stress echocardiography studies. Continuing efforts need to be made to assess and minimize variability and to assure continuing quality improvement. Advances in instrumentation, including evolving technology for real-time 3-dimensional imaging, and echocardiography contrast assessment of myocardial perfusion will likely improve the sensitivity of echocardiography and further extend its usefulness. Copyright © 2001 by W.B. Saunders Company
Guidelines of the Spanish society of cardiology for clinical practice in exercise testing
2000, Revista Espanola de Cardiologia
La mayor parte de las pruebas de esfuerzo se realizan a pacientes adultos con cardiopatía isquémica en estudio o ya conocida. En los últimos años se ha producido la incorporación de las técnicas de imagen en este campo, mejorando así la información aportada por la prueba de esfuerzo convencional. Pero cada vez existen más situaciones que escapan a esta norma general, tanto en sujetos sanos (asintomáticos, atletas, discapacitados, etc.) como en pacientes con cardiopatías diferentes de la isquémica (insuficiencia cardíaca congestiva avanzada, hipertensión, trastornos del ritmo, cardiopatías congénitas etc.). Todos estos aspectos justifican un documento de consenso en España, necesariamente multidisciplinario.
Este documento revisa en profundidad la metodología de las pruebas de esfuerzo convencionales, sin olvidar las realizadas con determinación de consumo de oxígeno. El papel de esta exploración en el manejo de la cardiopatía isquémica, así como las aplicaciones de las técnicas de imagen al campo del estrés, ocupan un lugar fundamental en esta revisión. Por último, se analiza la utilidad de las pruebas de esfuerzo en diversas cardiopatías no isquémicas y en diferentes poblaciones de sujetos sanos.
:Most exercise testing is performed in adults with known or suspected ischemic heart disease. In the last few years cardiac imaging techniques have been applied in this field, improving the information obtained with the procedure. However, the exceptions to this rule are emerging rapidly not only in healthy people (asymptomatic individuals, athletes, handicapped people) but also in cardiac patients (advanced congestive heart failure, hypertension, rhythm disorders, congenital heart disease, etc.). All these issues justify the need for a multidisciplinary consensus document in Spain.
:This paper reviews and updates the methodological aspects of the stress test, including those related to oxygen consumption measurements. The main aim of this review was to determine the role of exercise testing in the evaluation of ischemic heart disease as well as the applications of imaging stress testing. The usefulness of this test in other non-ischemic cardiac disorders and in selected subsets of healthy people is also reviewed.

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Coronary Artery DiseaseDobutamine stress echocardiography at 7.5 μg/kg/min using color tissue Doppler imaging M-mode safely predicts reversible dysfunction early after reperfusion in patients with acute myocardial infarction

Abstract

Section snippets

Subjects

Hemodynamic data

Discussion

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Coronary Artery Disease
Dobutamine stress echocardiography at 7.5 μg/kg/min using color tissue Doppler imaging M-mode safely predicts reversible dysfunction early after reperfusion in patients with acute myocardial infarction