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Ismail H, Gabriels JK, Chang D, Donnelly J, Kim BS, Epstein LM, Hentz R, Fishbein J, Huang X, Kowalski M, Dasrat P, Rahyab AS, Goldner B. Site-specific effects of dobutamine on cardiac conduction and refractoriness. J Interv Card Electrophysiol 2024; 67:71-82. [PMID: 37227538 DOI: 10.1007/s10840-023-01573-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Isoproterenol, a non-specific beta agonist, is commonly used during electrophysiology studies (EPS). However, with the significant increase in the price of isoproterenol in 2015 and the increasing number of catheter ablations performed, the cost implications cannot be ignored. Dobutamine is a less expensive synthetic compound developed from isoproterenol with a similar mechanism to enhance cardiac conduction and shorten refractoriness, thus making it a feasible substitute with a lower cost. However, the use of dobutamine for EPS has not been well-reported in the literature. OBJECTIVE To determine the site-specific effects of various doses of dobutamine on cardiac conduction and refractoriness and assess its safety during EPS. METHODS From February 2020 to October 2020, 40 non-consecutive patients scheduled for elective EPS, supraventricular tachycardia, atrial fibrillation, and premature ventricular contraction ablations at a single center were consented and prospectively enrolled to assess the effect of dobutamine on the cardiac conduction system. At the end of each ablation procedure, measures of cardiac conduction and refractoriness were recorded at baseline and with incremental doses of dobutamine at 5, 10, 15, and 20 mcg/kg/min. For the primary analysis, the change per dose of dobutamine from baseline to each dosing level of dobutamine received by the patients, comparing atrioventricular node block cycle length (AVNBCL), ventricular atrial block cycle length (VABCL) and sinus cycle length (SCL), was tested using mixed-effect regression. For the secondary analysis, dobutamine dose level was tested for association with relative changes from baseline of each electrophysiologic parameter (SCL, AVNBCL, VABCL, atrioventricular node effective refractory period (AVNERP), AH, QRS, QT, QTc, atrial effective refractory period (AERP), ventricular effective refractory period (VERP), using mixed-effect regression. Changes in systolic and diastolic blood pressures were also assessed. The Holm-Bonferroni method was used to adjust for multiple testing. RESULTS For the primary analysis there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to each dose level of dobutamine. The SCL, AVNBCL, VABCL, AVNERP, AERP, VERP and the AH, and QT intervals all demonstrated a statistically significant decrease from baseline to at least one dose level with incremental dobutamine dosing. Two patients (5%) developed hypotension during the study and one patient (2.5%) received a vasopressor. Two patients (5%) had induced arrhythmias but otherwise no major adverse events were noted. CONCLUSION In this study, there was no statistically significant change of AVNBCL and VABCL relative to SCL from baseline to any dose level of dobutamine. As expected, the AH and QT intervals, and the VABCL, VERP, AERP and AVNERP all significantly decreased from baseline to at least one dose level with an escalation in dobutamine dose. Dobutamine was well-tolerated and safe to use during EPS.
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Affiliation(s)
- Haisam Ismail
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - James K Gabriels
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - David Chang
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Joseph Donnelly
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Beom Soo Kim
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Laurence M Epstein
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Roland Hentz
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New York, NY, USA
| | - Joanna Fishbein
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New York, NY, USA
| | - Xueqi Huang
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New York, NY, USA
| | - Marcin Kowalski
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Parmanand Dasrat
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Ali Seyar Rahyab
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA
| | - Bruce Goldner
- Department of Cardiac Electrophysiology, Northwell Health, New York, NY, USA.
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Lee C, Dow S, Shah K, Henkin S, Taub C. Complications of exercise and pharmacologic stress echocardiography. Front Cardiovasc Med 2023; 10:1228613. [PMID: 37600036 PMCID: PMC10435903 DOI: 10.3389/fcvm.2023.1228613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).
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Affiliation(s)
| | | | | | | | - Cynthia Taub
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, NH, United States
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Eerdekens R, Tonino P, Zelis J, Adrichem R, Ahn JM, Demandt J, Eftekhari A, El Farissi M, Freeman P, Rahman Ihdayhid A, Kakouros N, Kim DH, Lee SA, Van Mieghem NM, Qureshi W, Johnson NP. Rationale and design of SAVI-AoS: A physiologic study of patients with symptomatic moderate aortic valve stenosis and preserved left ventricular ejection fraction. IJC HEART & VASCULATURE 2022; 41:101063. [PMID: 35663622 PMCID: PMC9157233 DOI: 10.1016/j.ijcha.2022.101063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/20/2022]
Abstract
Background Moderate aortic valve stenosis occurs twice as often as severe aortic stenosis (AS) and carries a similarly poor prognosis. Current European and American guidelines offer limited insight into moderate AS (MAS) patients with unexplained symptoms. Measuring valve physiology at rest while most patients experience symptoms during exertion might represent a conceptual limitation in the current grading of AS severity. The stress aortic valve index (SAVI) may delineate hemodynamically significant AS among patients with MAS. Objectives To investigate the diagnostic value of SAVI in symptomatic MAS patients with normal left ventricular ejection fraction (LVEF ≥ 50%): aortic valve area (AVA) > 1 cm2 plus either mean valve gradient (MG) 15–39 mmHg or maximal aortic valve velocity (AOV max) 2.5–3.9 m/s. Short-term objectives include associations with symptom burden, functional capacity, and cardiac biomarkers. Long-term objectives include clinical outcomes. Methods and results Multicenter, non-blinded, observational cohort. AS severity will be graded invasively (aortic valve pressure measurements with dobutamine stress testing for SAVI) and non-invasively (echocardiography during dobutamine and exercise stress). Computed tomography (CT) of the aortic valve will be scored for calcium, and hemodynamics simulated using computational fluid dynamics. Cardiac biomarkers and functional parameters will be serially monitored. The primary objective is to see how SAVI and conventional measures (MG, AVA and Vmax) correlate with clinical parameters (quality of life survey, 6-minute walk test [6MWT], and biomarkers). Conclusions The SAVI-AoS study will extensively evaluate patients with unexplained, symptomatic MAS to determine any added value of SAVI versus traditional, resting valve parameters.
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Gianni C, Sanchez JE, Mohanty S, Trivedi C, Della Rocca DG, Al-Ahmad A, Burkhardt JD, Gallinghouse GJ, Hranitzky PM, Horton RP, Di Biase L, Natale A. High-Dose Dobutamine for Inducibility of Atrial Arrhythmias During Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2020; 6:1701-1710. [PMID: 33334450 DOI: 10.1016/j.jacep.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study sought to compare the effect of high-dose dobutamine (DBT) with that of high-dose isoproterenol (IPN) in eliciting triggers during atrial fibrillation (AF) ablation. BACKGROUND High-dose IPN is commonly used to elicit triggers during AF ablation. However, it is not available worldwide and, in the United States, its cost per dose has significantly increased. DBT is a similarly nonselective β-agonist and, as such, is a potential alternative. METHODS This was a prospective, randomized 2×2 crossover study of patients undergoing AF ablation. Patients were assigned to receive IPN (20 to 30 μg/min for 10 min) followed by DBT (40 to 50 μg/kg/min for 10 min) or vice versa in a 1:1 fashion. The type, number, and location of triggers as well as heart rate, blood pressure, and side effects were noted. RESULTS Fifty patients were included in the study. Both drugs caused a significant increase in heart rate, with a consistently lower peak for DBT. Blood pressure significantly increased with DBT, while there was a significant reduction with IPN, despite phenylephrine support. Atrial arrhythmias induced during DBT were comparable to that induced during IPN. In patients with IPN-inducible outflow tract premature ventricular contractions, a similar effect was noted with DBT. No major complications occurred during either drug challenge. CONCLUSIONS High-dose DBT is safe and comparable to high-dose IPN in respect of eliciting AF triggers, with the advantage to maintain systemic pressure without the need of additional vasopressor support. This study supports the use of high-dose DBT in electrophysiology laboratories in which IPN is not readily available and for those patients in whom hypotension is a concern.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Dell Medical School, University of Texas, Austin, Texas, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - Patrick M Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Department of Biomedical Engineering, University of Texas, Austin, Texas, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Department of Biomedical Engineering, University of Texas, Austin, Texas, USA; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; HCA National Medical Director of Cardiac Electrophysiology, Austin, Texas, USA; Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA; MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Shehata M. Accelerated dobutamine stress testing: Feasibility and safety in patients with moderate aortic stenosis. Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2014.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Bennin CLK, Ramoutar V, Velarde G. Intraparenchymal haemorrhage and uncal herniation resulting from dobutamine stress echocardiography. BMJ Case Rep 2014; 2014:bcr-2013-201891. [PMID: 24642173 DOI: 10.1136/bcr-2013-201891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Intracranial haemorrhage (ICH) resulting from dobutamine stress echocardiography (DSE) is a rare complication in an otherwise relatively safe procedure. There has been one previously reported case of ICH associated with DSE in a patient who was fully anticoagulated. The authors report a second case of ICH associated with DSE leading to a poor outcome. Unlike the previous report, this patient was not fully anticoagulated and bleeding resulted from uncontrolled hypertension. Clinicians should be attentive to the risk of ICH associated with DSE in the setting of uncontrolled hypertension.
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San Román JA, Sanz-Ruiz R, Ortega JR, Pérez-Paredes M, Rollán MJ, Muñoz AC, Segura F, Jimenez D, Carnero A, Pinedo M, Arnold R, Gómez I, Fernández-Aviles F. Safety and Predictors of Complications with a New Accelerated Dobutamine Stress Echocardiography Protocol. J Am Soc Echocardiogr 2008; 21:53-7. [PMID: 17628422 DOI: 10.1016/j.echo.2007.05.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study sought to document the safety of a new accelerated dobutamine-atropine stress echocardiography protocol and to analyze its complications. METHODS Dobutamine-atropine stress echocardiography studies were performed using an incremental dobutamine infusion protocol from 20 to 40 microg/kg/min in 3-minute stages and followed by atropine. RESULTS A total of 962 patients were included. Mean age was 64 +/- 11 years and 584 were male (61%). Mean ejection fraction was 62 +/- 10%. Complications included hypertensive responses in 66 patients (7%), arrhythmias in 26 (2.7%), and symptomatic hypotension in 16 (1.7%). No patient developed heart failure, acute myocardial infarction, ventricular fibrillation, or died. The independent predictors of hypertensive responses were age, baseline systolic blood pressure, and treatment with nitrates. The independent predictors of arrhythmias were history of hypertension, previous coronary artery disease, and baseline heart rate. CONCLUSIONS This accelerated dobutamine-atropine stress echocardiography protocol is safe in a low-risk population and has a rate of complications similar to that reported for the standard protocol.
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Affiliation(s)
- José Alberto San Román
- Institute of Heart Sciences (ICICOR), Clinic University Hospital of Valladolid, Valladolid, Spain.
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8
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Minardi G, Manzara C, Pulignano G, Pino PG, Pavaci H, Sordi M. Feasibility, safety and tolerability of accelerated dobutamine stress echocardiography. Cardiovasc Ultrasound 2007; 5:40. [PMID: 18031577 PMCID: PMC2203976 DOI: 10.1186/1476-7120-5-40] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2007] [Accepted: 11/21/2007] [Indexed: 11/20/2022] Open
Abstract
A continuous infusion of a single high dose of dobutamine has been, recently, suggested as a simple and effective protocol of stress echocardiography. The present study assesses the feasibility, safety, and tolerability of an accelerated dobutamine stress protocol performed in patients with suspected or known coronary artery disease. Two hundred sixty five consecutive patients underwent accelerated dobutamine stress echocardiography: the dobutamine was administered at a constant dose of 50 μg/kg/min for up to 10 minutes. The mean weight-adjusted cumulative dose of dobutamine used was 330 ± 105.24 μg/kg. Total duration of dobutamine infusion was 6.6 ± 2.1 min. Heart rate rose from 69.9 ± 12.1 to 123.1 ± 22.1 beats/min at peak with a concomitant change in systolic blood pressure (127.6 ± 18.1 vs. 167.6 ± 45.0 mmHg). Dobutamine administration produced a rapid increase in heart rate (9.4 ± 5.9 beats/min2). The side effects were similar to those described with the standard protocol; the most common were frequent premature ventricular complexes (21.5%), frequent premature atrial complexes (1.5%) and non sustained ventricular tachycardia (1.5%); among non cardiac symptoms the most frequent were nausea (3.4%), headache (1.1%) and symptomatic hypotension (1.1%). No major side effects were observed during the test. Our data demonstrate that a continous infusion of a single high dose of dobutamine is a safe and well tolerated method of performing stress echocardiography in patients with suspected or known coronary artery disease. This new protocol requires the administration of lower cumulative dobutamine dose than standard protocol and results in a significant reduction in test time.
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Affiliation(s)
- Giovanni Minardi
- Cardiodiagnostica non invasiva, Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy.
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Pastorius CA, Knickelbine T, Schum K, Nelson TF, Harris KM. Tolerability and infusion time of an accelerated infusion dobutamine echocardiography protocol. Echocardiography 2007; 24:393-6. [PMID: 17381648 DOI: 10.1111/j.1540-8175.2007.00401.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVES A new, accelerated dobutamine-atropine stress echocardiography (DASE) protocol (baseline 20 mcg/kg/min; 40 mcg/kg/min) was compared with a standard protocol in patients with suspected coronary artery disease (CAD) to evaluate tolerability, length of infusion, and overall test times, as well as safety. METHODS Patients received the DASE or the standard protocol on an alternating basis (n = 164). RESULTS Total test time, including patient recovery (HR < 100 bpm), dropped from an average of 19:23-12:12 min (p < 0.0001). Average symptom duration decreased from 5:50 to 3:17 min (p < 0.01). Women had shorter total test times in both accelerated and standard protocols compared to that of men. CONCLUSIONS The accelerated DASE protocol is a well tolerated alternative to standard dobutamine stress testing allowing practitioners to reduce test times without increasing the incidence of arrhythmias. Patients in the accelerated arm also had shorter duration of symptoms.
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Affiliation(s)
- Catherine A Pastorius
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota 55407, USA
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San Román JA, Serrador A, Ortega JR, Medina A, Fernández-Avilés F. Diagnostic accuracy of a new shorter dobutamine infusion protocol in stress echocardiography. Heart 2003; 89:1089-90. [PMID: 12923040 PMCID: PMC1767802 DOI: 10.1136/heart.89.9.1089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2001; 10:345-60. [PMID: 11760498 DOI: 10.1002/pds.549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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