Document Detail

Ultra-early risk stratification after myocardial infarction via pharmacological stress echocardiography: the relative value of resting function, viability and myocardial ischemia.
MedLine Citation:
PMID:  9359049     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: Echocardiographically recognized resting function, myocardial viability (by low-dose dobutamine) and stress-induced ischemia (by high-dose dipyridamole) are potent predictors of subsequent events, but their relative value in patients evaluated very early after acute myocardial infarction remains to be established. AIM OF THE STUDY: To assess the feasibility and usefulness of an integrated approach with resting and pharmacological stress echo for risk stratification in patients evaluated very early after myocardial infarction. METHODS: Sixty acute myocardial infarction patients without contraindications to stress testing, and who were being given thrombolytic therapy, underwent resting echo (16-segment model of left ventricle, each segment scored from 1 = normo-hyperkinetic to 4 = dyskinetic), high-dose dipyridamole (up to 0.84 mg/kg over 10') and low-dose dobutamine (up to 10 mcg/kg/min) echo on the third-fourth day after drug withdrawal. The response was "ischemic" with a dipyridamole-induced increase in the regional score > 1 in segments with a resting score < 3, and "viable" with a dobutamine-induced decrease in the regional score > 1 in segments with resting score > 1. All patients underwent coronary angiography on the tenth-twelfth day after the acute event, and all of them were followed up for 15 +/- 10.04 months. RESULTS: Ischemia elicited by dipyridamole appeared in 29 patients (48%) and dobutamine-induced viability was observed in 28 (47%). Ischemic events occurred in 26 patients (43.4%), five of which during the early in-hospital period. There were three deaths (5%), one re-AMI (1.7%), 7 Canadian Class III-IV angina (12%) and 15 (25%) early revascularization procedures undertaken independently of stress echo results. Events occurred in 21 patients (72%) with dipyridamole-induced ischemia and in 5 (16%) without it (p < 0.001). Likewise, events occurred in 13 patients (46.4%) with dobutamine-induced inotropic recovery and in 13 (40.6%) without it (p = ns). Event-free survival occurred in 64% of dipyridamole-positive patients, as opposed to 90% of dipyridamole-negative patients (p = 0.025). Dipyridamole echocardiographic test sensitivity and specificity for events were 81 and 74%, respectively. Sensitivity and specificity for events of dobutamine viability were 46 and 55%, respectively. In a multivariate logistic analysis, dipyridamole-induced myocardial ischemia was the strongest predictor of subsequent events (p = 0.01). According to Cox analysis, dipyridamole positivity had a relative risk estimate of 4. CONCLUSIONS: Pharmacological stress echo is feasible even very early after acute myocardial infarction via a useful approach based on low-dose dobutamine to assess myocardial viability, and high-dose dipyridamole to assess ischemia. For risk stratification purposes, stress-induced myocardial ischemia outperforms resting function and myocardial viability, and it is independent of angiographic data. Revascularization procedures do not seem to be effective when only viability is present.
M Sclavo; E Aruta; P Presbitero
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Publication Detail:
Type:  Comparative Study; Journal Article    
Journal Detail:
Title:  Giornale italiano di cardiologia     Volume:  27     ISSN:  0046-5968     ISO Abbreviation:  G Ital Cardiol     Publication Date:  1997 Oct 
Date Detail:
Created Date:  1997-12-08     Completed Date:  1997-12-08     Revised Date:  2007-11-15    
Medline Journal Info:
Nlm Unique ID:  1270331     Medline TA:  G Ital Cardiol     Country:  ITALY    
Other Details:
Languages:  eng     Pagination:  1000-7     Citation Subset:  IM    
Divisione di Cardiologia, Ospedale Giovanni Bosco, Torino.
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MeSH Terms
Adrenergic beta-Agonists / diagnostic use*
Coronary Angiography
Data Interpretation, Statistical
Dipyridamole / administration & dosage,  diagnostic use*
Disease-Free Survival
Dobutamine / administration & dosage,  diagnostic use*
Echocardiography / methods*
Evaluation Studies as Topic
Follow-Up Studies
Logistic Models
Middle Aged
Myocardial Infarction* / mortality,  ultrasonography
Myocardial Ischemia / ultrasonography
Risk Assessment
Sensitivity and Specificity
Time Factors
Vasodilator Agents / diagnostic use*
Reg. No./Substance:
0/Adrenergic beta-Agonists; 0/Vasodilator Agents; 34368-04-2/Dobutamine; 58-32-2/Dipyridamole

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