Long-term prognosis after normal dobutamine stress echocardiography

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101 Prediction of mortality by modified myocardial jeopardy score: a strategy for combination with stress echocardiography.

103 Prognostic value of left ventricular filling pattern at peak dobutamine stress in patients with ischaemic cardiomyopathy.

I.P. Nedeljkovic 1 , M. Ostojic 2 , N. Milic 2 , B. Beleslin 2 , A. Djordjevic-Dikic 2 , M. Nedeljkovic 2 , J. Stepanovic 2 , S. Stojkovic 2 , V. Vukcevic 2 , G. Stankovic 2 . 1 University Institute for CVD, Cardiology, Belgrade, Yugoslavia; 2 Univ.Institute for CVD, Cardiology Dept., Belgrade, Yugoslavia

A. Duncan, C. Porter, D. Gibson, M. Henein. The Royal Brompton Hospital, Echocardiography Department, London, United Kingdom

102 Dipyridamole stress echocardiography and ultrasonic myocardial tissue characterization in predicting myocardial ischemia, in comparison with dipyridamole stress Tc-99m MIBI SPECT myocardial imaging. A. onbasili 1 , S. Erdogan 2 , T. Tekten 1 , C. Ceyhan 1 , Y. Yurekli 1 . 1 Adnan Menderes University, Cardiology, Aydin, Turkey; 2 Adnan Menderes University, Nuclear Medicine, Aydin, Turkey Continuous two-dimentional echocardiographic monitoring in conjunction with dipyridamol infusion has been employed for detection of myocardial ischemia. Abnormal test is usually defined as one demonstrating transient asynergy of contraction. However, sensitivity for ischemia detection is less than dipyridamol stress scintigaphy. Ultrasonic tissue characterization with cyclic variation of integrated backscatter (CVIBS) has been shown to be decreased when the myocardium is ischemic even before myocardial contraction has decreased. The purpose of this study was to validate whether ultrasonic tissue characterizaton combined with dipyridamole stress echocardiography compared with dipiridamole stress Tc-99m MIBI SPECT myocardial imaging could predict myocardial ischemia in patients with chronic coronary artery disease. Method: Twenty patients (16 M, 4 F) who had coronary angiography for stable angina pectoris were included. Mean age was 62±8 years. Left ventricle was divided into 16 segments. Regional wall motion analysis and CVIBS measurements were obtained from 16 myocardial segments at rest. Dipyridamole (0,84 mg/kg) was infused intravenously for 4 minutes. Regional wall motion analysis and CVIBS measurements were completed within 10 minutes after infusion from same myocardial segments. After 10 minutes, Tc-99m MIBI (20 mCi) was injected and SPECT myocardial imaging was performed. After 1 hours, 8 mCi Tc-99m MIBI was reinjected and rest images were obtained. Results: Tc-99m MIBI SPECT showed abnormal distribution in 176 segments and normal distribution in 144 segments after dipyridamole stress. Transient regional wall motion abnormality was detected in 92 segments with 2D echo after dipyridamol stress. Sensitivity and specificity of dipyridamol stress echocardiography were 62% and 97%, respectively. At rest, no significant difference was seen in CVIBS in the segments with normal (5.8±0.6 db) or abnormal distribution (6.1±0.5 db) on Tc-99m MIBI SPECT imaging. But, in the regions showing abnormal distribution after stress, CVIBS decreased significantly (6.1±0.5 vs 3.8±0.6 db, p=2,0 db) after dipyridamole stress was detected in 184 segments. Sensitivity and specificity of abnormal CVIBS were 85% and 84%, respectively. Conclusion: Dipyridamol stress ultrasonic tissue characterization with CVIBS may provide more sensitive detection of myocardial ischemia than dipyridamol stress echocardiography.

Eur J Echocardiography Abstracts Supplement, December 2003

104 Long-term prognosis after a normal Dobutamine stress echocardiography. F.B. Sozzi 1 , A. Elhendy 2 , V. Rizzello 2 , E.C. Vourvouri 2, A.F.L. Schinkel 2 , J.J. Bax 2 , S. Romano 1 , R.T. Van Domburg 2 , D. Poldermans 2 . 1 Ospedale Maggiore, IRCCS, Cardiology, Milan, Italy; 2 Thoraxcentre, Erasmus Medical Centre, Rotterdam, Netherlands Patients with a normal Dobutamine stress echocardiography (DSE) were shown to have a favourable outcome at an intermediate term follow-up. However, there are scarce data regarding long-term survival after a normal DSE. This study sought to assess the long-term outcome after a normal DSE. We studied 401 patients (age 62 ± 10 years, 264 men) who had normal echocardiogram at rest and with high dose dobutamine stress. End-points during a mean follow-up period of 5 ± 1.7 (minimum 3.5) years were all causes of mortality and hard cardiac events (cardiac death and non-fatal myocardial infarction). During follow-up, 45 patients (11%) died of various causes (cardiac death in 10 patients). Thirteen patients had non-fatal myocardial infarction (a total of 23 hard cardiac events). The annualized mortality rate was 2% in the first 3 years and 2.4% between the fourth and sixth years. The annualized hard cardiac event rate was 0.8% in the first 3 years and 1.7% between the forth and sixth years. Predictors of mortality in a multivariate analysis model were age (HR 1.2 [CI = 1.1-1.4]) and resting heart rate (HR 0.92 [CI = 0.85-0.99]. There was no difference between patients with and without history of coronary artery disease (CAD) regarding the annual hard cardiac event rate (1.3% vs 1% respectively, p = 0.7) or the annual death rate (1.4% vs 2.3% respectively, p = 0.4) (figure 1).

Event free survival

Revascularisation procedures were more frequently performed during follow-up in patients with than without a history of CAD (3.7% vs 1.8%, p = 0.0001). Patients with a normal DSE have an excellent outcome during the 3 years following the study. The cardiac event rate is higher between the fourth and sixth year, and therefore, it may be useful to repeat the study after 3 years to re-update the risk status.

Downloaded from ejechocard.oxfordjournals.org at University of Portland on May 24, 2011

Background: In studies involving a prediction of survival during interventional procedures, jeopardy score has been shown to predict fatal end pionts, but its impact on long-term mortality rates in the presence of various clinical, angiographic and stress echocardiographic variables is unclear. Objective: We sought to study the prediction of mortality with modified myocardial jeopardy score in combination with Dobutamine-Atropine (DobAtro), DipyridamoleAtropine (DipAtro) and Exercise (Ex) stress echocardiography. Methods: From existing database of stress echo laboratory, 166 patients were identified who all underwent DobAtro (up to 40 mcg/kg/min i.v. Dob with addition of 1 mg of atropine), DipAtro (up to 0.84 mg/kg Dip with addition of 1mg of atropine), Ex (Bruce) and coronary arteriography (analysed by quantitative arteriography). Coronary artery disease (CAD) was present in 114 pts: 91 one-, 23 multi-vessel CAD. Myocardial jeopardy score is calculated for each vessel as a sum of all significant lesions represented as a product of: (1) myocardial kinetic status (0 for akinetic, 0.5 for hypokinetic, and 1 for each normokinetic myocardial segment subserved by the vessel with equal or more than 50% diameter stenosis), (2) diameter stenosis of significantly stenosed coronary vessel (scored from 3-5), and (3) weighting flow factor for particular localisation. Results: Among clinical, demographical, stress echocardiographic and angiographycal variables, factors strongly associated with high mortality rates were: myocardial jeopardy score >7 (p=0.0003), positive DobAtro (p=0.016), positive DipAtro (p=0.0215) and the number of diseased vessels (p=0.005), while other variables and the results ox Ex stress echocardiography didn’t show significant influence on long-term risk of cardiac death (p=ns). Variable most strongly associated with cardiac death was myocardial jeopardy score (RR 1.05; p=0.00054). Conclusion: Patients with high amount of potentially ischemic myocardium and positive DipAtro and DobAtro stress echocardiography are at high risk for subsequent cardiac death. Myocardial jeopardy score is the strongest predictor of longterm outcome in patents with stress induced myocardial ischemia.

Background: Patients with late stage heart failure and restrictive filling at rest have a poor prognosis. The outcome of patients that remain restrictive at peak stress is unclear. Aim: To assess the prognostic value of stress-related left ventricular (LV) filling pattern in a group of patients with heart failure secondary to ischaemic cardiomyopathy. Methods: 47 patients with ischaemic cardiomyopathy (aged 67±8 years) were studied during dobutamine stress. All were in NYHA class III-IV with an ejection fraction 70% stenosis). LV filling velocities, early (E) and late (A), were measured using pulsed wave Doppler echocardiography at rest and at peak stress. Restrictive filling was defined as E:A ratio >2 and E wave deceleration time
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