European Journal of Echocardiography (2008) 9, 567–568 doi:10.1016/j.euje.2007.06.016
Transient global amnesia after dobutamine—atropine stress echocardiography Daniel Saura*, Pablo Pen ˜afiel, Ana Morales, Laura Albert, Francisco Martı´nez, ´s-Cha ´varri Gonzalo de la Morena, and Mariano Valde Hospital Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena S/N. 30120 Murcia, Spain Received 12 May 2007; accepted 20 June 2007; online publish-ahead-of-print 16 August 2007
KEYWORDS Stress echocardiography; Dobutamine; Atropine; Amnesia; Complications
Introduction Dobutamine—atropine stress echocardiography (DASE) is a useful test for coronary artery disease diagnosis and prognostics. However, in the high risk patients in real world practice, the adverse event rate can reach values as high as 1 in 557 studies.1 Therefore, possible complications of the test should be recognized. We present a case report from a patient who developed an unusual neurological complication after DASE.
Case report A 68-year-old woman with a history of systemic arterial hypertension and hypercholesterolaemia was referred from the cardiology clinic for a pharmacological stress echocardiogram after complaining about atypical chest pain. She was on bisoprolol, irbersartan, hydrochlorothiazide, atorvastatin and ranitidine. Her basal electrocardiogram was normal. She was unable to undergo a treadmill exercise stress echocardiogram due to severe osteoarthritis. Although it was demanded in her appointment letter, beta-blocker was not withdrawn. A DASE test was performed for ischaemia detection. Intravenous dobutamine was infused at a starting dose of 10 mg/
* Corresponding author. C/Puerta de Orihuela, 3 Bis, 7D, 30003 Murcia, Spain. Tel: þ34 657301239; fax: þ34 968369662. E-mail address:
[email protected] (D. Saura).
kg/min followed by increasing doses of 20 mg/kg/min and 30 mg/kg/min to a maximal dose of 40 mg/kg/min in 3-min stages. Heart rate had reached only 95 bpm with maximal dose of dobutamine. Four intravenous atropine boli of 0.25 mg each were injected with 1 min interval between each bolus while maintaining dobutamine infusion. Peak heart beat rate was 106 bpm (69% of maximal predicted heart rate). Blood pressure increased from 135/79 mm Hg to 153/95 mm Hg. The patient did not experience chest pain, and left ventricular wall motion defects were not detected throughout the test. Due to the low stress achieved, the test was considered inconclusive for ischaemia detection. At the end of the DASE test, the patient began to ask repetitively what she was doing there. She was able to dress herself and to address her husband normally. Level of consciousness and behaviour were normal, but she was astonished at being at the echo laboratory. She knew who she was and who her husband was, but could not recognize the cardiologist and the nurse who had performed the DASE test. An urgent neurology consultation was asked. The neurologist confirmed the presence of anterograde amnesia with time and place disorientation. The patient was perfectly oriented in person. There was no significant impairment of retrograde and procedural memory, and complex cognition was preserved. No headache, dizziness, seizures or other neurological symptoms or signs were present. The patient was admitted to the neurology department.
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Dobutamine—atropine stress echocardiography is a useful and relatively safe test for coronary artery disease assessment. However, possible complications should be recognized. We describe a case of transient global amnesia in a woman who underwent a standard-protocol dobutamine—atropine stress echocardiogram for coronary ischaemia detection, after having complained about chest pain. The test was not positive for coronary ischaemia, but a typical picture of transient global amnesia ensued. Symptoms shortly resolved spontaneously. Neurological work up was negative for organic disease. Transient global amnesia is a neurological syndrome of unknown origin and good prognosis. Dobutamine—atropine stress echocardiography can be added to the described precipitants of transient global amnesia. This neurological syndrome should be taken into account as a possible complication of dobutamine—atropine stress echocardiography.
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Amnesia progressively disappeared in 5 h. The patient underwent routine blood tests, cerebral CT and MRI scans, electroencephalogram and ultrasonography of supra-aortic trunks. All of them yielded normal results. After five days, the patient was discharged from hospital with the diagnosis of transient global amnesia (TGA). Three months later she visited the cardiology and neurology clinics. She remained asymptomatic and refused further tests.
Discussion
Currently, ischaemia is not thought to be the most probable cause of TGA,2,3 nevertheless TIA remains an alternative diagnostic possibility. A delirium secondary to atropine administration is another possibility, although it is unlikely as central anticholinergic syndrome should have presented with other central signs (somnolence, confusion, agitation, hallucinations, dysarthria and ataxia).4 Some of the precipitating factors2 might have coincided at the echo laboratory during DASE. Although the echo laboratory is heated, change in temperature after the patient got undressed could have precipitated the TGA. Our usual position for DASE (left lateral decubitus position with the left arm extended parallel to the neck) could have affected cerebral venous return. Both cardiovascular and psychological stresses in the setting of DASE are other candidate TGA precipitants in this case. Although transient global amnesia has a good prognosis, it should be known as one potential complication of dobutamine–atropine stress echocardiography.
References 1. Varga A, Garcia MA, Picano E. Safety of stress echocardiography (from the International Stress Echo Complication Registry). Am J Cardiol 2006;98: 541–3. 2. Sander K, Sander D. New insights into transient global amnesia: recent imaging and clinical findings. Lancet Neurol 2005; 4:437–44. 3. Larner AJ. Transient global amnesia in the district general hospital. Int J Clin Pract 2007;61:255–8. 4. Brown DV, Heller F, Barkin R. Anticholinergic syndrome after anesthesia: a case report and review. Am J Ther 2004;11:144–53.
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Transient global amnesia is a neurological syndrome characterized by sudden onset of profound anterograde memory impairment and spontaneous resolution in few hours. It has an excellent prognosis but is a traumatic event for patients, relatives and doctors. The aetiology is currently unknown. Suggested causes have included ischaemia, migraine, seizure, cerebral venous congestion and psychological disturbances. Precipitating events are frequently reported, including physical exercise, sexual intercourse, intense emotion, pain, temperature changes, cervical manipulation, Valsalva-like activities and some invasive medical interventions that do not include stress echocardiography.2 In this case, the differential diagnosis included transient ischaemic attack (TIA) and acute confusional syndrome (delirium) after atropine injection. Cryptogenic TIA cannot be excluded. The patient refused transoesophageal or saline contrast echocardiogram for embolic source detection. The clinical episode was witnessed by a neurologist and TGA rather than stroke being immediately suspected.
D. Saura et al.
