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Prognostic implications of a normal dobutamine-atropine stress echocardiogram in patients with chest pain
M L Geleijnse1, A Elhendy, R T van Domburg
1Thoraxcentre, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands.
Insights
A normal dobutamine-atropine stress echocardiogram indicates an excellent cardiac prognosis for patients with stable chest pain. However, those with high pretest probability of coronary artery disease (CAD) and stress-induced symptoms remain at risk.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Preventive Medicine
Background:
- Coronary artery disease (CAD) remains a leading cause of morbidity and mortality worldwide.
- Stress echocardiography is a key diagnostic tool for assessing CAD in patients with chest pain.
- The prognostic value of a normal dobutamine-atropine stress echocardiogram (DASE) in relation to pretest CAD probability requires further clarification.
Purpose of the Study:
- To evaluate the prognostic significance of a normal DASE in patients presenting with stable chest pain.
- To correlate DASE findings with pretest probabilities of coronary artery disease (CAD).
- To identify subgroups of patients who may still be at risk despite a normal DASE.
Main Methods:
- A prospective follow-up study of 200 consecutive patients with stable chest pain and normal DASE.
- Patients were categorized into low, intermediate, and high pretest probability groups for CAD.
- Outcome events included cardiac death, non-fatal myocardial infarction, and coronary revascularization procedures over a mean follow-up of 21 months.
Main Results:
- The overall annual event rate was low (0.6% for cardiac death, 1.1% for revascularization).
- All cardiac events occurred in patients with a high pretest probability of CAD.
- Patients undergoing revascularization exhibited dobutamine-induced angina or ischemic electrocardiographic changes, often with submaximal stress.
Conclusions:
- A normal DASE generally confers an excellent cardiac prognosis in patients with stable chest pain syndrome.
- Patients with typical angina, high pretest CAD probability, and stress-induced symptoms despite a normal DASE may still have significant CAD.
- Careful consideration of clinical factors and stress test characteristics is crucial for risk stratification, even with a normal DASE.
Abstract:
To assess the prognostic significance of a normal dobutamine-atropine stress echocardiogram in relation to the pretest probability of coronary artery disease (CAD), 200 consecutive patients (86 men and 114 women, mean [SD] age 59 [13] years) with a stable chest pain syndrome and a normal dobutamine-atropine stress echocardiogram were followed-up for 21 +/- 16 months. Outcome events were cardiac death, non-fatal myocardial infarction, and coronary revascularization procedures. Low (<10%), intermediate (10% to 80%), and high (>80%) pretest probabilities of CAD were present in 27 (14%), 108 (54%), and 65 (33%) patients, respectively. During follow-up, 2 patients (annual event rate 0.6%) had cardiac death, none had nonfatal myocardial infarction, and 4 patients (annual event rate 1.1%) underwent a coronary revascularization procedure. All patients with cardiac events had high pretest probabilities of CAD. Patients with cardiac death (but unproven significant CAD) had maximal tests without angina or ischemic electrocardiographic changes. In contrast, all patients with subsequent coronary revascularization had dobutamine-induced angina or ischemic electrocardiographic changes, and all except one study were submaximal. We conclude that patients with a stable chest pain syndrome and normal findings on dobutamine-atropine stress echocardiograms have an excellent cardiac prognosis. However, patients with typical angina, high pre-test probabilities of CAD, and stress-induced angina or ischemic electrocardiographic changes, and in particular those with submaximal stress, still appear to be at risk for functionally important CAD despite a normal dobutamine-atropine stress echocardiogram.