The effects of beta-blockers on dobutamine-atropine stress echocardiography: early protocol versus standard protocol

BACKGROUND: To study the effects of Beta-blockers during Dobutamine Stress Echocardiography (DSE) comparing the hemodynamic benefits of an early administration of atropine in patients taking or not Beta-blockers. METHODS: One hundred and twenty-one patients were submitted to dobutamine stress echocardiography for the investigation of myocardial ischemia. The administration of atropine was randomized into two groups: A or B (early protocol when atropine was administered at 10 and 20 mcg/kg/min of dobutamine, respectively) and C (standard protocol with atropine at 40 mcg/kg/min of dobutamine). Analysis of the effects of Beta-blockers was done regarding the behavior pattern of heart rate and blood pressure, test time, number of conclusive and inconclusive (negative sub-maximum test) results, total doses of atropine and dobutamine, and general complications. RESULTS: Beta-blocked patients who received early atropine (Group A&B) had a significantly lower double product (p = 0.008), a higher mean test time (p = 0.010) and required a higher dose of atropine (p = 0.0005) when compared to the patients in this group who were not Beta-blocked. The same findings occurred in the standard protocol (Group C), however the early administration of atropine reduced test time both in the presence and absence of this therapy (p = 0.0001). The patients with Beta-blockers in Group A&B had a lower rate of inconclusive tests (26%) compared to those in Group C (40%). Complications were similar in both groups. CONCLUSION: The chronotropic response during dobutamine stress echocardiography was significantly reduced with the use of Beta-blockers. The early administration of atropine optimized the hemodynamic response, reduced test time in patients with or without Beta-blockers and reduced the number of inconclusive tests in the early protocol

Wartość diagnostyczna echokardiografii obciążeniowej z dobutaminą u chorych na cukrzycę

INTRODUCTION. The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. MATERIAL AND METHODS. We studied 396 diabetic patients (mean age 61 &plusmn; 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all causes of mortality. RESULTS. During a median follow-up of 3 years, 97 patients (24%) died (55 cardiac deaths), and 27 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were history of congestive heart failure, previous myocardial infarction, hypercholesterolemia, and ejection fraction at rest. The percentage of ischemic segments was incremental to the clinical model in the prediction of hard cardiac events (c2 = 37 vs. 18, P < 0.05). Clinical predictors of all causes of mortality were history of congestive heart failure, age, hypercholesterolemia, and ejection fraction at rest. Wall motion score index at peak stress was incremental to the clinical model in the prediction of mortality (c2 = 52 vs. 43, P < 0.05). CONCLUSIONS. DSE provides incremental data for the prediction of mortality and hard cardiac events in patients with diabetes who are unable to perform an adequate exercise stress test.WSTĘP. Celem badania była ocena rosnącej wartości echokardiografii obciążeniowej z dobutaminą (DSE, dobutamine stress echocardiography) dla stratyfikacji ryzyka chorych na cukrzycę, którzy nie są w stanie wykonać odpowiedniego, wysiłkowego testu obciążeniowego. Wydolność fizyczna chorych na cukrzycę jest często zmniejszona. Dotychczas nie określono dobrze roli farmakologicznej echokardiografii obciążeniowej w stratyfikacji ryzyka u chorych na cukrzycę. MATERIAŁ I METODY. Przebadano 396 chorych na cukrzycę (średnia wieku 61 &plusmn; 11 lat, 252 mężczyzn &#8212; 64%) z ograniczoną wydolnością wysiłkową, u których wykonano DSE, by ocenić rozpoznaną lub podejrzewaną chorobę wieńcową (CAD, coronary artery disease). Kryteriami oceny badania były ciężkie epizody kardiologiczne (śmierć sercowa i zawał serca niezakończony zgonem) oraz zgon bez względu na przyczynę. WYNIKI. Podczas badania trwającego średnio 3 lata zmarło 97 pacjentów (24%) (55 zgonów z powodu śmierci sercowej), a u 27 chorych stwierdzono zawał serca niezakończony zgonem. W analizowanym, przyrostowym, wielozmiennym modelu, predyktorami klinicznymi ciężkich epizodów sercowych były: zastoinowa niewydolność serca w wywiadzie, wcześniejszy zawał serca, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Odsetek niedokrwionych odcinków serca przyrastał w stosunku do modelu klinicznego w prognozowaniu ciężkich epizodów sercowych (c2 = 37 vs. 18, p < 0,05). Klinicznymi predyktorami zgonów bez względu na przyczynę były: zastoinowa niewydolność serca w przeszłości, wiek, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Wskaźnik punktowy ruchomości ściany serca na szczycie obciążenia przyrastał w stosunku do modelu klinicznego w prognozowaniu umieralności (c2 = 52 vs. 43, p < 0,05). WNIOSKI. Echokardiografia obciążeniowa z dobutaminą dostarcza istotnych danych dotyczących prognozowania umieralności oraz ciężkich epizodów sercowych u chorych na cukrzycę, u których nie można przeprowadzić odpowiedniego testu stresowego

Prognostic value of dobutamine stress echocardiography in patients with diabetes

WSTĘP. Celem badania była ocena rosnącej wartości echokardiografii obciążeniowej z dobutaminą (DSE, dobutamine stress echocardiography) dla stratyfikacji ryzyka chorych na cukrzycę, którzy nie są w stanie wykonać odpowiedniego, wysiłkowego testu obciążeniowego. Wydolność fizyczna chorych na cukrzycę jest często zmniejszona. Dotychczas nie określono dobrze roli farmakologicznej echokardiografii obciążeniowej w stratyfikacji ryzyka u chorych na cukrzycę. MATERIAŁ I METODY. Przebadano 396 chorych na cukrzycę (średnia wieku 61 &plusmn; 11 lat, 252 mężczyzn &#8212; 64%) z ograniczoną wydolnością wysiłkową, u których wykonano DSE, by ocenić rozpoznaną lub podejrzewaną chorobę wieńcową (CAD, coronary artery disease). Kryteriami oceny badania były ciężkie epizody kardiologiczne (śmierć sercowa i zawał serca niezakończony zgonem) oraz zgon bez względu na przyczynę. WYNIKI. Podczas badania trwającego średnio 3 lata zmarło 97 pacjentów (24%) (55 zgonów z powodu śmierci sercowej), a u 27 chorych stwierdzono zawał serca niezakończony zgonem. W analizowanym, przyrostowym, wielozmiennym modelu, predyktorami klinicznymi ciężkich epizodów sercowych były: zastoinowa niewydolność serca w wywiadzie, wcześniejszy zawał serca, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Odsetek niedokrwionych odcinków serca przyrastał w stosunku do modelu klinicznego w prognozowaniu ciężkich epizodów sercowych (c2 = 37 vs. 18, p < 0,05). Klinicznymi predyktorami zgonów bez względu na przyczynę były: zastoinowa niewydolność serca w przeszłości, wiek, hipercholesterolemia oraz frakcja wyrzutowa w spoczynku. Wskaźnik punktowy ruchomości ściany serca na szczycie obciążenia przyrastał w stosunku do modelu klinicznego w prognozowaniu umieralności (c2 = 52 vs. 43, p < 0,05). WNIOSKI. Echokardiografia obciążeniowa z dobutaminą dostarcza istotnych danych dotyczących prognozowania umieralności oraz ciężkich epizodów sercowych u chorych na cukrzycę, u których nie można przeprowadzić odpowiedniego testu stresowego.INTRODUCTION. The aim of this study was to assess the incremental value of dobutamine stress echocardiography (DSE) for the risk stratification of diabetic patients who are unable to perform an adequate exercise stress test. Exercise capacity is frequently impaired in patients with diabetes. The role of pharmacologic stress echocardiography in the risk stratification of diabetic patients has not been well defined. MATERIAL AND METHODS. We studied 396 diabetic patients (mean age 61 &plusmn; 11 years, 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of known or suspected coronary artery disease (CAD). End points were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all causes of mortality. RESULTS. During a median follow-up of 3 years, 97 patients (24%) died (55 cardiac deaths), and 27 patients had nonfatal myocardial infarction. In an incremental multivariate analysis model, clinical predictors of hard cardiac events were history of congestive heart failure, previous myocardial infarction, hypercholesterolemia, and ejection fraction at rest. The percentage of ischemic segments was incremental to the clinical model in the prediction of hard cardiac events (c2 = 37 vs. 18, P < 0.05). Clinical predictors of all causes of mortality were history of congestive heart failure, age, hypercholesterolemia, and ejection fraction at rest. Wall motion score index at peak stress was incremental to the clinical model in the prediction of mortality (c2 = 52 vs. 43, P < 0.05). CONCLUSIONS. DSE provides incremental data for the prediction of mortality and hard cardiac events in patients with diabetes who are unable to perform an adequate exercise stress test

Early and long-term outcome of elective stenting of the infarct-related artery in patients with viability in the infarct-area: Rationale and design of the Viability-guided Angioplasty after acute Myocardial Infarction-trial (The VIAMI-trial)

BACKGROUND: Although percutaneous coronary intervention (PCI) is becoming the standard therapy in ST-segment elevation myocardial infarction (STEMI), to date most patients, even in developed countries, are reperfused with intravenous thrombolysis or do not receive a reperfusion therapy at all. In the post-lysis period these patients are at high risk for recurrent ischemic events. Early identification of these patients is mandatory as this subgroup could possibly benefit from an angioplasty of the infarct-related artery. Since viability seems to be related to ischemic adverse events, we initiated a clinical trial to investigate the benefits of PCI with stenting of the infarct-related artery in patients with viability detected early after acute myocardial infarction. METHODS: The VIAMI-study is designed as a prospective, multicenter, randomized, controlled clinical trial. Patients who are hospitalized with an acute myocardial infarction and who did not have primary or rescue PCI, undergo viability testing by low-dose dobutamine echocardiography (LDDE) within 3 days of admission. Consequently, patients with demonstrated viability are randomized to an invasive or conservative strategy. In the invasive strategy patients undergo coronary angiography with the intention to perform PCI with stenting of the infarct-related coronary artery and concomitant use of abciximab. In the conservative group an ischemia-guided approach is adopted (standard optimal care). The primary end point is the composite of death from any cause, reinfarction and unstable angina during a follow-up period of three years. CONCLUSION: The primary objective of the VIAMI-trial is to demonstrate that angioplasty of the infarct-related coronary artery with stenting and concomitant use of abciximab results in a clinically important risk reduction of future cardiac events in patients with viability in the infarct-area, detected early after myocardial infarction

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI