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Dobutamine stress echocardiography: safety in diagnosing coronary artery disease
F Lattanzi1, E Picano, E Adamo
1National Research Council, Institute of Clinical Physiology, University of Pisa, Italy.
Insights
Dobutamine stress echocardiography (DSE) is a common test for coronary artery disease. While generally safe, severe complications occur in 1 in 335 tests, necessitating careful patient selection and monitoring.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Patient Safety
Background:
- Dobutamine stress echocardiography (DSE) is widely used for diagnosing coronary artery disease.
- Early reports suggested a favorable safety profile for DSE.
- Adverse events, though infrequent, can be serious and impact test completion.
Purpose of the Study:
- To comprehensively review the safety and feasibility of dobutamine stress echocardiography.
- To determine the incidence of severe adverse events associated with DSE.
- To inform risk-benefit assessments for patients undergoing DSE.
Main Methods:
- Systematic literature review of Medline-quoted studies up to March 1999.
- Analysis of 35 single-institution studies (>100 patients) and 2 multicenter studies.
- Cumulative analysis of 26,438 DSE procedures and review of 29 case reports.
Main Results:
- A total of 79 life-threatening complications were reported across 26,438 procedures (incidence of 1 per 335).
- Severe events included myocardial infarction, asystole, ventricular fibrillation, and severe hypotension.
- Case reports documented 2 deaths, both from cardiac rupture in patients with recent myocardial infarction.
Conclusions:
- While DSE is generally well-tolerated, severe adverse reactions can occur unpredictably and independently of ischemia or operator experience.
- These severe complications, including rare fatalities, necessitate strict adherence to procedural guidelines, informed consent, and post-procedure monitoring.
- Physicians and patients must carefully consider the evolving risk-benefit profile of DSE based on cumulative safety data.
Abstract:
Dobutamine stress echocardiography is considered a relatively well-tolerated diagnostic modality, effective in the management of patients with known or suspected coronary artery disease. Adverse effects during testing are relatively frequent, precluding the achievement of a diagnostic end-point in about 5 to 10% of tests. These adverse effects, mostly tachyarrhythmias and arterial hypotension, are usually minor and self limiting. However, severe life-threatening complications, as well as death, also occur. By analysing Medline-quoted literature up to March 1999, we found 35 original studies from a single institution with more than 100 patients, as well as 2 multicentre studies, concerning the feasibility and safety of dobutamine stress echocardiography. In a cumulative total of 26438 tests performed, 79 life-threatening complications (such as acute myocardial infarction, asystole, ventricular fibrillation, sustained ventricular tachycardia or severe symptomatic hypotension) have been reported, giving an incidence of 1 severe adverse reaction per every 335 examinations. In addition, 29 isolated case reports have been published describing life-threatening complications during dobutamine echocardiography. In case reports, 2 deaths have been described, both due to acute cardiac rupture in patients with recent inferior myocardial infarction. Severe adverse reactions during dobutamine echocardiography can be ischaemia independent, and are independent of operator experience and are unpredictable; some complications can be late occurring and long lasting. As a consequence, the procedure must be clearly indicated, written informed consent has to be obtained from the patient, an attending physician must be present during testing, and long term observation of outpatients is useful in order to manage late complications. In conclusion, while the safety of dobutamine stress echocardiography was reported to be outstanding in early reports, further experience presents a substantially more worrying picture. This must be taken into account by both physicians and patients when assessing the risk-benefit profile of the procedure.