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[Stress echocardiography with dobutamine: the importance of adding atropine in inconclusive tests]
M Fiuza1, A Pereirinha, P Pedro
1UCIM/Medicina IV-A, Hospital de Santa Maria/FML e LA3-CCUL, Lisboa.
Insights
Adding atropine to dobutamine stress echocardiography significantly improves diagnostic accuracy for coronary artery disease. This combined approach enhances the detection of multivessel disease in patients with prior myocardial infarction.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Pharmacology
Background:
- Coronary artery disease (CAD) diagnosis often relies on stress testing.
- Dobutamine stress echocardiography (DSE) is a common non-invasive test for CAD.
- Achieving target heart rate during DSE can be challenging, especially in patients on beta-blockers.
Purpose of the Study:
- To evaluate the feasibility and efficacy of adding atropine to DSE.
- To assess if atropine improves the diagnostic yield in patients not reaching 85% of predicted maximal heart rate.
- To determine the safety and accuracy of atropine-supplemented DSE.
Main Methods:
- 219 patients with known or suspected CAD underwent DSE.
- Dobutamine was infused stepwise up to 40 mcg/kg/min.
- Atropine was administered intravenously (up to 1 mg) to patients not achieving target heart rate.
Main Results:
- Adding atropine reduced non-conclusive DSE studies from 46% to 20% (p < 0.001).
- Atropine improved sensitivity and specificity for diagnosing significant CAD (89% and 100%, respectively).
- The test's capacity to detect multivessel disease increased with atropine (85% sensitivity, 90% specificity).
Conclusions:
- Dobutamine stress echocardiography supplemented with atropine is safe and effective.
- This combined approach enhances the diagnosis of significant CAD and multivessel disease.
- It is particularly useful in patients with prior myocardial infarction and rest wall motion abnormalities.
Objectives:
To study the feasibility of adding atropine after dobutamine infusion in patients with known or suspected coronary artery disease not achieving 85% of predicted maximal heart rate.
Patients:
We studied with dobutamine stress echocardiography 219 patients (174 men e 45 women; mean age +/- SD: 58 +/- 11 years), 126 patients with a previous myocardial infarction and 93 with angor. One hundred and thirty three (61%) also performed coronariography.
Methods:
Dobutamine stress echocardiography protocol consisted of a step-wise infusion of dobutamine from 5 micrograms/kg/min to a maximal dose of 40 micrograms/kg/min or until a new or a worsening wall motion abnormality, 85% of predicted maximal heart rate or any indication for interruption. In patients not achieving any of these end points, intravenous atropine was administered up to 1 mg. Patients were divided in two groups: Group A: infusion of dobutamine alone and Group B: dobutamine plus atropine.
Results:
With this protocol the test was interrupted in 41 patients (19%) because of adverse effects that were mild and short lived and resolved with discontinuation of the test. After dobutamine infusion 46% of the tests were nonconclusive, the majority were on beta blocker therapy. After atropine administration there was a significant reduction of the nonconclusive studies to 20% (p < 0.001). In patients with a normal rest echocardiogram the sensitivity and specificity of the test to diagnose significant coronary artery disease was respectively 89% e 100% after atropine. The capacity of the test to detect multivessel disease was also increased after atropine, allowing to reach a sensitivity of 85% and a specificity of 90%.
Conclusions:
Dobutamine stress echocardiogram supplemented with atropine is a safe and accurate method to diagnose significant coronary artery disease and to detect multivessel disease in patients with a previous myocardial infarction with rest wall motion abnormalities.