Perioperative prognostic value of dipyridamole echocardiography in vascular surgery: A large-scale multicenter study in 509 patients. EPIC (Echo Persantine International Cooperative) Study Group

[The Clinical use of Stress Echocardiography in Ischemic Heart Disease Cardiovascular Ultrasound (2017)15:7. Translation authors: Arystan A.Zh., Fettser D.V.]

Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows detecting myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependence on operator expertise, the lack of outcome data (a widespread problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.

The clinical use of stress echocardiography in ischemic heart disease

Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows to detect myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician.

The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependance on operator expertise, the lack of outcome data (a widesperad problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.

Usefulness and limitations of transthoracic echocardiography in heart transplantation recipients

Transthoracic echocardiography is a primary non-invasive modality for investigation of heart transplant recipients. It is a versatile tool which provides comprehensive information about cardiac structure and function. Echocardiographic examinations can be easily performed at the bedside and serially repeated without any patient's discomfort. This review highlights the usefulness of Doppler echocardiography in the assessment of left ventricular and right ventricular systolic and diastolic function, of left ventricular mass, valvular heart disease, pulmonary arterial hypertension and pericardial effusion in heart transplant recipients. The main experiences performed by either standard Doppler echocardiography and new high-tech ultrasound technologies are summarised, pointing out advantages and limitations of the described techniques in diagnosing acute allograft rejection and cardiac graft vasculopathy. Despite the sustained efforts of echocardiographic technique in predicting the biopsy state, endocardial myocardial biopsies are still regarded as the gold standard for detection of acute allograft rejection. Conversely, stress echocardiography is able to identify accurately cardiac graft vasculopathy and has a recognised prognostic in this clinical setting. A normal stress-echo justifies postponement of invasive studies. Another use of transthoracic echocardiography is the monitorisation and the visualisation of the catheter during the performance of endomyocardial biopsy. Bedside stress echocardiography is even useful to select appropriately heart donors with brain death. The ultrasound monitoring is simple and effective for monitoring a safe performance of biopsy procedures.

The use of stress echocardiography for prognostication in coronary artery disease: an overview

PURPOSE OF REVIEW

Stress echocardiography has a high accuracy for the detection of coronary artery disease. Additionally, it provides clinically useful prognostic information, such as resting left ventricular function, myocardial viability, stress-induced ischemia, vascular extent of wall motion abnormalities, and changes in end-systolic volume and ejection fraction with stress.

RECENT DEVELOPMENTS

The timing, extent, and severity of the stress-induced wall motion abnormalities are important determinants of long-term prognosis. Previous studies have shown the efficacy of stress echocardiography in predicting long-term cardiac events in mixed patient groups and the value of this test in selected patient subsets.

SUMMARY

This review attempts to define the role of stress echocardiography for prognostication in coronary artery disease, pointing out the ability of this technique to identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions.

Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation

AIMS

The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn).

METHODS AND RESULTS

Consecutive vascular surgery candidates (n=391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI=2.60-10.43; P<0.0001) in group 1 and 2.58 (95% CI=1.27-4.38; P=0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR=4.73, 95% CI=2.92-7.65; P<0.0001) and at 30 days (adjusted HR=5.52, 95% CI=3.23-9.42; P<0.0001).

CONCLUSION

After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.

Perioperative risk stratification in non cardiac surgery: role of pharmacological stress echocardiography

Perioperative ischemia is a frequent event in patients undergoing major non-cardiac vascular or general surgery. This is in agreement with clinical, pathophysiological, and epidemiological evidence and constitutes an additional diagnostic therapeutic factor in the assessment of these patients. Form a clinical standpoint, it is well known that multidistrict disease, especially at the coronary level, is a severe aggravation of the operative risk. From a pathophysiological point of view, however, surgery creates conditions able to unmask coronary artery disease. Prolonged hypotension, hemorrhages, and haemodynamic stresses caused by aortic clamping and unclamping during major vascular surgery are the most relevant factors endangering the coronary circulation with critical stenoses. From the epidemiological standpoint, coronary disease is known to be the leading cause of perioperative mortality and morbidity following vascular and general surgery: The diagnostic therapeutic corollary of these considerations is that coronary artery disease - and therefore the perioperative risk - in these patients has to be identified in an effective way preoperatively.

Pharmacologic stress echocardiography predicts total mortality early after acute myocardial infarction

OBJECTIVE

The aim of this multicenter, prospective, observational study was to assess the value of inducible ischemia in a large population of survivors of a first uncomplicated myocardial infarction (MI).

METHODS AND RESULTS

Pharmacologic stress echocardiography either with high-dose dipyridamole (0.84 mg/kg over 10 minutes) or high-dose dobutamine (up to 40 microg/kg over 3 minutes) (DET) was performed 9 +/- 10 days after a first acute uncomplicated MI in 1681 patients (1499 males; 57 +/- 10 years) with technically satisfactory rest echocardiographic study. Patients were followed up for a mean of 16 +/- 18 months (range: 1-122). DET was positive for myocardial ischemia in 884 (52.5%) and negative in 797 (47.5%) patients. During the follow-up there were 49 deaths for all-cause mortality (2.9% of the total population), 22 of which were cardiac; 62 (3.6%) nonfatal MIs; and 164 (9.7%) hospital readmissions for unstable angina. In all, 376 patients (22%) underwent coronary revascularization (bypass operation or angioplasty).

RESULTS

Hard events occurred in 71 of the 884 patients with positive and in 40 of the 797 patients with negative DET (8% vs 5%, P =.014). Using the Cox proportional hazards model, age (relative risk [RR] 1.07, 95% confidence interval [CI] 1.03-1.1), history of angina (RR 3.8, 95% CI 1.6-8.6), peak wall-motion score index (RR 2.2, 95% CI 1.1-4.4), and pharmacologic dose at ischemia (RR 1.5, 95% CI 1.04-2.3) were independent predictors of all-cause death.

CONCLUSIONS

In survivors of a first acute uncomplicated MI DET allows effective risk stratification on the basis of the presence, severity, and extent the induced ischemia.

A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery

OBJECTIVE

To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery.

DESIGN

Meta-analysis of published reports.

METHODS

Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests.

RESULTS

In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9).

CONCLUSIONS

On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.

Stress echo results predict mortality: a large-scale multicenter prospective international study

OBJECTIVES

The purpose of this study was to assess the long-term value of pharmacologic stress echocardiography with either dipyridamole or dobutamine (DET) for prediction of cardiac death in patients with proven or suspected coronary artery disease (CAD).

BACKGROUND

Stress echocardiography is an established, cost-effective technique for the detection of CAD.

METHODS

From the Echo Persantine International Cooperative-Echo Dobutamine International Cooperative data bank, 7,333 patients (5,452 males; 59 +/- 10 years) underwent pharmacologic stress echocardiography with either high-dose dipyridamole (0.84 mg/kg over 10 min) (n = 4,984) or high-dose dobutamine (up to 40 microg/kg/3 min) (n = 2,349) for diagnostic purposes. Patients were followed up for a mean of 2.6 years (range 1 to 206 months).

RESULTS

The DET was positive for myocardial ischemia in 2,854 (35%) patients and negative in 4,479 (61%) patients. During the follow-up there were 161 cardiac deaths (sudden death and fatal myocardial infarction) (2.1% of the total population). Kaplan-Meier survival estimates showed a significantly better outcome for those patients with a negative pharmacologic stress echocardiography test compared with those with a positive test (92 vs. 71.2%, p = 0.0000).

CONCLUSIONS

Pharmacologic stress echocardiography with either dipyridamole or dobutamine is effective in predicting cardiac death during a long-term follow-up. A negative stress echocardiography test result is related to a favorable outcome.

Which stress test is superior for perioperative cardiac risk stratification in patients undergoing major vascular surgery?

OBJECTIVE

to compare the additional prognostic value of Dobutamine Stress Echocardiography (DSE), Dipyridamole Stress Echocardiography (DiSE) and Perfusion Scintigraphy (DTS) on clinical risk factors in patients undergoing major vascular surgery.

DESIGN

retrospective analysis.

MATERIALS

2204 consecutive patients who underwent DSE (n=1093), DiSE (n=394), or DTS (n=717) testing before major vascular surgery were studied.

METHODS

primary endpoint was a composite of cardiac death and non-fatal myocardial infarction (MI). Logistic regression analysis was performed to evaluate the relation between cardiac risk factors, stress test results and the incidence of the composite endpoint.

RESULTS

there were 138 patients (6.3%) with cardiac death or MI. Patients with 0, 1-2, and 3 or more risk factors experienced respectively 3.0, 5.7 and 17.4% cardiac events. We found no statistically significant difference in the predictive value of a positive test result for DiSE and DSE (Odds ratio (OR) of 37.1 [95% CI, 8.1-170.1] vs 9.6 [95% CI, 4.9-18.4]; p=0.12), whereas a positive test result for DTS had significantly lower prognostic value (OR=1.95 [95% CI, 1.2-3.2]).

CONCLUSION

a result of stress echocardiography effectively stratified patients into low- and high-risk groups for cardiac complications, irrespective of clinical risk profile. In contrast, the prognostic value of DTS results was more likely to be dependent on patients' clinical risk profile.

[Stress echocardiography in the pre-operative evaluation of patients undergoing major vascular surgery. Are results comparable with dypiridamole versus dobutamine stress echo?]

INTRODUCTION

[corrected] Perioperative cardiovascular complications are an important cause of post-surgical morbility and mortality in patients undergoing major vascular surgery. Dobutamine Stress Echo is considered one of the methods of choice in the detection of coronary artery disease in this subgroup of patients.

OBJECTIVES

. Our aim was to analyze if dipyridamole stress echocardiography could be used as an alternative to Dobutamine Stress Echo in the perioperative evaluation of patients in need of major vascular surgery.

PATIENTS AND METHOD

The result of consecutives dypiridamole and dobutamine stress exams prior to vascular surgery were reviewed. We analyzed if those patients with a positive stress echo presented a higher number of cardiac events during and after surgery than those with negative stress echo. The negative and positive predictive values were calculated for both techniques.

RESULTS

133 stress exams were analysed: 39 with dobutamine and 94 with dipyridamole. Of the 39 dobutamine studies 2 were positive, 29 negatives and 8 non conclusive. Of the 94 dypiridamole studies 13 were positive and 81 negatives. None of the patients with a positive dobutamine echo underwent surgery. The negative predictive value for dobutamine echo was 96.5%, quite similar to that of dypiridamole stress echo (97.5%).

CONCLUSION

Dipyridamole stress echocardiography is a valid alternative to dobutamine echocardiography in the pre-surgical evaluation of patients undergoing major vascular surgery.

Long-term prognostic value of dipyridamole echocardiography in vascular surgery: a large-scale multicenter study

BACKGROUND

Late cardiac events after non-cardiac major vascular surgery are an important cause of morbidity and mortality. The aim of the present study was to assess the value of a preoperative dipyridamole echocardiography test (up to 0.84 mg/kg over 10 min) in predicting late cardiac events in survivors of major non-cardiac vascular surgery.

DESIGN

Large-scale, multicenter, prospective, observational study design.

METHODS

Two hundred and seventy-six patients (mean age 66 +/- 9 years) were studied prior to vascular surgery by dipyridamole stress echocardiography in four different centres. All patients underwent preoperative clinical risk assessment according to the American Heart Association guidelines. All underwent dipyridamole stress echocardiography according to standard high-dose protocol.

RESULTS

No major complications occurred during dipyridamole stress echocardiography. Sixty-three patients (23%) had a positive test. Patients were followed up for a median of 20 months. Cardiac events occurred in 43 patients (16%): five deaths, 18 myocardial infarctions and 20 cases of unstable angina. The difference between wall-motion score index (WMSI) at rest and peak stress (delta WMSI), using multivariate analysis, was an independent predictor of late cardiac death.

CONCLUSION

Dipyridamole stress echocardiography performed before major vascular surgery identifies patients at high risk for late cardiac events. Stress echocardiographic parameters outperformed clinical variables in the long-term risk stratification in this set of patients.