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

Computerized assessment of coronary lumen and atherosclerotic plaque dimensions in three-dimensional intravascular ultrasound correlated with histomorphometry.

Intravascular ultrasound (IVUS), which depicts both lumen and plaque, offers the potential to improve on the limitations of angiography for the assessment of the natural history of atherosclerosis and progression or regression of the disease. To facilitate measurements and increase the reproducibility of quantitative IVUS analyses, a computerized contour detection system was developed that detects both the luminal and external vessel boundaries in 3-dimensional sets of IVUS images. To validate this system, atherosclerotic human coronary segments (n = 13) with an area obstruction ≥40% (40% to 61%) were studied in vitro by IVUS. The computerized IVUS measurements (areas and volumes) of the lumen, total vessel, plaque-media complex, and percent obstruction were compared with findings by manual tracing of the IVUS images and of the corresponding histologic cross sections obtained at 2-mm increments (n = 100). Both area and volume measurements by the contour detection system agreed well with the results obtained by manual tracing, showing low mean between-method differences (−3.7% to 0.3%) with SDs not exceeding 6% and high correlation coefficients (r = 0.97 to 0.99). Measurements of the lumen, total vessel, plaque-media complex, and percent obstruction by the contour detection system correlated well with histomorphometry of areas (r = 0.94, 0.88, 0.80, and 0.88) and volumes (r = 0.98, 0.91, 0.83, and 0.91). Systematic differences between the results by the contour detection system and histomorphometry (29%, 13%, −9%, and −22%, respectively) were found, most likely resulting from shrinkage during tissue fixation. The result

Dobutamine stress myocardial perfusion imaging

AbstractIn patients with limited exercise capacity and (relative) contraindications to direct vasodilators such as dipyridamole or adenosine, dobutamine stress nuclear myocardial perfusion imaging (DSMPI) represents an alternative, exercise-independent stress modality for the detection of coronary artery disease (CAD). Nondiagnostic test results (absence of reversible perfusion defects with submaximal stress) do occur in approximately 10% of patients. Serious side effects during DSMPI are rare, with no death, myocardial infarction or ventricular fibrillation reported in three DSMPI safety reports for a total of 2,574 patients. On the basis of a total number of 1,014 patients reported in 20 studies, the sensitivity, specificity and accuracy of the test for the detection of CAD were 88%, 74% and 84%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 84%, 95% and 100%, respectively. The sensitivity for detection of left circumflex CAD (50%) was lower, compared with that for left anterior descending CAD (68%) and right CAD (88%). The sensitivity of predicting multivessel disease by multiregion perfusion abnormalities varied widely, from 44% to 89%, although specificity was excellent in all studies (89% to 94%). In direct diagnostic comparisons, DSMPI was more sensitive, but less specific, than dobutamine stress echocardiography and comparable with direct vasodilator myocardial perfusion imaging. In the largest prognostic study, patients with a normal DSMPI study had an annual hard event rate less than 1%. An ischemic scan pattern provided independent prognostic value, with a direct relationship between the extent and severity of the perfusion defects and prognosis. In conclusion, DSMPI seems a safe and useful nonexercise-dependent stress modality to detect CAD and assess prognosis

The significance of stress-induced ST segment depression in patients with inferior Q wave myocardial infarction

AbstractOBJECTIVESThis study was conducted to evaluate the relationship between ST segment depression (STD) during dobutamine stress tests in different electrocardiogram (ECG) leads and myocardial ischemia assessed by simultaneous single photon emission computed tomography (SPECT) imaging in patients with inferior Q wave myocardial infarction.BACKGROUNDSTD is a standard electrocardiographic sign of myocardial ischemia. Although STD may represent reciprocal changes in patients with previous myocardial infarction, studies of reciprocal changes during stress tests are scarce.METHODSDobutamine (up to 40 μg/kg/min) stress and rest myocardial perfusion scintigraphy using technetium SPECT imaging was performed in 125 patients >3 months after Q wave inferior myocardial infarction. The location of STD at the ECG was defined as anterior (V1–4), high lateral (I, aVL) and lateral (V5,6). Ischemia was defined as reversible perfusion abnormalities.RESULTSSTD occurred in the high lateral leads in 20 patients, in the anterior leads in 12 patients and in the lateral leads in 2 patients. ST segment elevation occurred in 25 patients in the inferior leads. High lateral STD was associated with inferior ST elevation in 16 patients (80%). There was a significant inverse linear correlation between the magnitude of ST segment shift from rest to peak stress in the inferior and the high lateral leads (r = −0.8, p < 0.0005), whereas no significant correlation was found between ST segment shift in the inferior and the anterior leads (r = −0.1, p = NS) or between the inferior and the lateral leads (r = 0.15, p = NS). Ischemia was detected in 45% of patients with and in 42% of patients without high lateral STD (p = NS). Patients with high lateral STD had a higher prevalence of fixed perfusion defects in the inferior wall (100% vs. 70%) and in the posterolateral wall (55% vs. 29%) compared with other patients (both p < 0.05). Ischemia was more prevalent in patients with anterior STD than without (75% vs. 39%, p < 0.05).CONCLUSIONSIn patients with inferior Q wave myocardial infarction, stress-induced STD in high lateral leads should be recognized as a reciprocal change for ST elevation in the inferior leads, and therefore, should be interpreted with the consideration of the significance of ST elevation if present, rather than being indicative of myocardial ischemia on its own. The STD found in the anterior leads appears to be a sign of myocardial ischemia. These findings should be considered in the definition of a positive ECG stress test and in establishing the criteria for the termination of stress test

Myocardial wall thickness predicts recovery of contractile function after primary coronary intervention for acute myocardial infarction

AbstractObjectivesWe sought to determine whether end-diastolic wall thickness (EDWT) can predict recovery of regional left ventricular contractile function after percutaneous coronary intervention (PCI).BackgroundRegional contractile function does not recover in all patients after PCI for acute myocardial infarction (AMI). Prediction of functional recovery after AMI may help in clinical decision making.MethodsForty consecutive patients with AMI were studied with left ventricular contrast echocardiography for accurate wall thickness and function measurement and myocardial perfusion immediately after and two months following PCI.ResultsOut of 640 segments, 175 (27%) dysfunctional segments in the infarct territory were analyzed for EDWT, wall function, and perfusion. One hundred and three (59%) dysfunctional segments presented with an EDWT <11 mm and 72 (41%) presented with an EDWT ≥11 mm. Perfusion (partial or complete) was present in 63 segments with an EDWT <11 mm (61%) and 71 segments with an EDWT ≥11 mm (99%) (p < 0.001). At two months' follow-up, 66 of 72 segments with an EDWT ≥11 mm (92%) improved, whereas only 35 of 103 of the dysfunctional segments with an EDWT <11 mm (34%) improved (p < 0.0001).ConclusionsWall thickness is an easy parameter to predict recovery of function after revascularization. Moreover, combining EDWT and perfusion, segments with an EDWT ≥11 mm, and presence of perfusion have the highest chance of recovery; segments with an EDWT <11 mm and perfusion have an intermediate chance of recovery. In segments with an EDWT <11 mm and no perfusion, chances of recovery are very low