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Atropine augmentation in dobutamine stress echocardiography: role and incremental value in a clinical practice
L H Ling1, P A Pellikka, D W Mahoney
1Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
Insights
Adding atropine to dobutamine stress echocardiography modestly improved diagnostic sensitivity for coronary artery disease, especially in patients on beta-blockers or with milder disease, without compromising safety.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Pharmacology
Background:
- Atropine potentiation of dobutamine stress echocardiography is not standard practice.
- Limited data exist on the incremental value of atropine in routine clinical settings.
Purpose of the Study:
- To evaluate the role and incremental value of atropine in dobutamine stress echocardiography.
- To assess the safety and diagnostic yield of atropine augmentation.
Main Methods:
- 1,171 patients underwent dobutamine stress echocardiography.
- Atropine was administered to 299 patients (26%) who did not achieve target heart rate.
- Coronary angiography was performed in 183 patients.
Main Results:
- Sensitivity for detecting coronary artery disease increased from 90% to 95% with atropine.
- In patients with normal baseline wall motion, sensitivity improved from 65% to 84% with atropine.
- Atropine use did not reduce test specificity and was safe.
Conclusions:
- Heart rate augmentation with atropine modestly enhanced dobutamine stress echocardiography sensitivity.
- Atropine was particularly beneficial for patients on beta-blockers and those with milder coronary disease.
- The incremental diagnostic value of atropine was achieved safely.
Objectives:
This study sought to evaluate the role and incremental value of atropine in a large patient group undergoing dobutamine stress echocardiography.
Background:
The use of atropine to potentiate dobutamine stress is not standard practice. Although the utility of atropine has been described, data on its incremental value remain limited and do not exist for a routine clinical practice setting.
Methods:
Dobutamine stress echocardiography was performed in 1,171 patients with use of a standard protocol. Atropine (maximal dose 2.0 mg) was given to 299 patients (26%) who did not attain target heart rate. Coronary angiography was performed in 183 patients (46 received atropine), 148 of whom were found to have significant coronary artery disease (> or = 70% diameter stenosis in a major epicardial vessel, > or = 50% stenosis for left main coronary artery disease). All tests were reviewed independently by experienced observers.
Results:
There were no major adverse events. Patients receiving atropine had a lower rest heart rate (65 vs. 74 beats/min, p < 0.0001) and more often received beta-adrenergic blocking agents (49% vs. 14%, p < 0.0001). Of 444 patients in whom stress-induced ischemia developed, 70 (16%) required atropine before ischemia became evident. Sensitivity for detection of significant coronary artery disease was 90% with dobutamine alone and 95% after the addition of atropine. In 66 patients with normal wall motion at rest, test sensitivity was 65% before and 84% after atropine was given. Atropine use did not compromise test specificity. New diagnostic information was obtained in 20 (50%) of 40 patients with angiographic coronary artery disease given atropine. Proportionately more patients with single-vessel disease required atropine before an ischemic response was observed; this effect appeared related to the higher ischemic threshold in these patients.
Conclusions:
Augmentation of heart rate had a modest influence on the overall diagnostic sensitivity of dobutamine stress echocardiography in our study cohort. However, it was particularly helpful in patients receiving beta-blockers and those with milder coronary disease. Despite the use of > or = 1 mg of atropine in some patients, this incremental value was not achieved at the expense of safety.