Left ventricular cavity obliteration during dobutamine stress echocardiography in diabetic patients.

Prevalence of dynamic left ventricular outflow tract obstruction (DLVO) during dobutamine stress-echo (DSE) seems disproportionally high among diabetic patients. We retrospectively identified 212 diabetic (D+) and 212 non diabetic (D-) subjects, who underwent DSE for suspected coronary artery disease (CAD); we evaluated DSE-induced DLVO prevalence and correlates. During DSE, 105 patients in D+ (50%) and 83 in D- group (39%, P = 0.032) developed a DLVO, with similar maximum gradient (94 ± 49 mmHg in D+ vs. 86 ± 49 mmHg in D-, P = NS). D+ and D- patients with DLVO showed reduced LV end-diastolic and end-systolic dimension. Compared with diabetic subjects without DLVO, diabetic patients with DLVO had higher left ventricular (LV) ejection fraction (EF), lower LV mass index; diastolic function was normal in a higher proportion of cases. Non diabetic patients with moderate or severe DLVO had higher LV EF compared with patients without DLVO. At multivariate analysis, in D+ patients, the only independent predictor was a smaller LV end-diastolic diameter (HR 0.779, CI 0.655-0.926, P = 0.005); in D- patients lower age (HR 0.878, CI 0.806-0.957, P = 0.003), higher LV EF (HR 1.087, CI 1.003-1.177, P = 0.042) and lower peak WMSI (HR 0.017, CI 0.001-0.325, P = 0.007) were associated to presence of DLVO. In D+ patients, during a median follow-up of 924 ± 134 days, we observed 11 new cardiac events, only 1 in patients with DLVO (P = 0.0041). DSE-provoked DLVO had a very high prevalence in patients evaluated for suspected CAD, especially among diabetic patients; echocardiographic predictors were a reduced LV dimension in D+ and a preserved systolic function, both at rest and at peak stress, in D- patients.

Left ventricular remodeling in the elderly with acute anterior myocardial infarction treated with primary coronary intervention.

We compared left ventricular (LV) remodeling following a first time acute anterior ST-elevation myocardial infarction (aSTEMI) treated with primary coronary intervention (pPCI) in different age groups. A total of 116 patients, 61 aged <65 and 55 aged >or=65 years, who survived after a recent aSTEMI treated with pPCI, underwent dobutamine stress-echocardiography (DSE) and non-invasive measurement of left anterior descending coronary artery flow reserve (CFR) during intravenous adenosine infusion. Baseline LV dimensions and systolic function were similar between the two groups; wall motion score indices during all DSE stages and CFR were also similar. In both groups, the LV ejection fraction was positively affected by the presence of viability in the necrosis area and by a higher CFR, but negatively influenced by viability in a remote area, an indirect sign of an extensive infarction size. This study demonstrates that PCI in the geriatric population with aSTEMI is as equally effective as in younger subjects, in terms of LV remodeling and function.

Prognostic value of dobutamine stress echocardiography in diabetic patients.

CAD is the main cause of morbidity and mortality in diabetic patients; we need reliable clinical parameters to stratify cardiovascular risk in these patients. We thus assessed prognostic value of clinical parameters, rest and stress echocardiographic data in diabetic patients, with known or suspected CAD. We studied 322 type 2 diabetic patients, who underwent dobutamine stress echocardiography (DSE) for known or suspected CAD; for prognostic assessment, end-points were all-cause mortality and hard cardiac events (cardiac death and non fatal myocardial infarction). During DSE, viability and inducible ischemia developed in 65 (20%) and 192 (60%) subjects, respectively; a severe ischemia (an asynergic area including more than 40% of all segments combined with a rate pressure product < 17,000) appeared in 88 (27%). Presence of a diabetic treatment or microvascular diabetic complications didn't influence prognosis, while a longer diabetes duration was associated with a higher all-cause mortality at univariate analysis. At multivariate analysis, an advanced age (RR = 1.108, CI: 1.039-1.182, P = 0.002), a lower left ventricular ejection fraction (RR = 0.956, CI: 0.919-0.994, P = 0.025) and, tendentially, peripheral vascular disease (RR = 2.942, CI: 0.985-8.785, P = 0.053) independently determined an increased all-cause mortality. New hard cardiac events occurred more frequently in presence of peripheral vascular disease (RR = 2.975, CI: 1.339-6.608, P = 0.007), viability (RR = 3.427, CI: 1.400-8.390, P = 0.007) and severe ischemia (RR = 3.245, CI: 1.503-7.005, P = 0.003). In diabetic patients with known or suspected CAD, presence of viability and severe ischemia during DSE are independently associated with higher occurrence of hard cardiac events.

Prognostic value of exercise stress test and dobutamine stress echo in patients with known coronary artery disease.

BACKGROUND: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). METHODS: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged >or=75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). RESULTS: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 +/- 1.6 METs in G1 vs. 5 +/- 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351-0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559-16.833, P = 0.007), viability (HR 3.354, CI 1.162-9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114-0.945, P = 0.039) predicted hard cardiac events. CONCLUSION: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

Traditional and color M-mode parameters of left ventricular diastolic function during low-dose dobutamine stress echocardiography: relations to contractility reserve.

BACKGROUND: Cross-sectional studies reported that left ventricular (LV) systolic and diastolic functions are correlated. However, whether changes in wall-motion score index (WMSI) or 2-dimensional ejection fraction (EF) predict changes of Doppler parameters of LV diastolic function is unclear. METHODS: Patients with known or suspected history of coronary artery disease underwent assessment of LV systolic function (WMSI, EF) and diastolic function at baseline and during stress echocardiography by low-dose dobutamine (LDD) (peak infusion 10 microg/kg/min). Peak velocities of early (E) and late (A) LV filling waves and E wave deceleration time were measured according to standard protocol. E wave propagation rate (EVp) was assessed by color Doppler M-mode across the mitral valve. Tei index was calculated as: (A wave to E wave time - ejection time)/ejection time. Changes at LDD were calculated as: 100 x (value at LDD - value at baseline)/baseline. RESULTS: The study group comprised 66 patients, mean age 61 +/- 10 years, 80% men. Worse LV systolic function was associated with more severely impaired LV diastolic function both at baseline and at LDD. However, percent change of WMSI and change in EF did not correlate with percent change of EVp and E/E wave propagation rate, but with percent change of Tei index. At LDD, patients with myocardial viability did not show greater percent change of LV diastolic function parameters but significantly lower Tei index. CONCLUSIONS: In patients with suspected or known coronary artery disease, assessment of diastolic function reserve by LDD stress echocardiography using traditional and color M-mode Doppler may add quantitative information on myocardial function beyond traditional assessment of contractility reserve by WMSI or EF.