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CLINICAL STUDIES

Prognostic value of myocardial viability and ischemia detected by dobutamine stress echocardiography early after acute myocardial infarction treated with thrombolysis

^a Department of Cardiology and Biometry Unit, IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy

Manuscript received November 18, 1997; revised manuscript received March 30, 1998, accepted April 16, 1998.

Address for correspondence: Dr. Mario Previtali, Department of Cardiology, IRCCS Policlinico San Matteo, 27100 Pavia Italy
marprevi{at}tin.it

Objectives. The aim of the study was to assess the prognostic value of myocardial viability and ischemia detected by dobutamine stress echocardiography (DSE) in patients with acute myocardial infarction (AMI) treated with thrombolysis.

Background. DSE can detect myocardial viability and ischemia early after AMI, but the prognostic importance of viability and ischemia in these patients has yet to be assessed.

Methods. DSE was performed in 152 patients at a mean of 9 ± 5 days after a first AMI treated with thrombolysis to evaluate myocardial viability and ischemia. The patients were followed up for 15 ± 19 months.

Results. On the basis of DSE results three groups of patients were identified: group 1 (95 patients, 62.5%) with myocardial viability and ischemia, group 2 with myocardial viability without ischemia (32 patients, 21%) and group 3 (25 patients, 16.5%) with no myocardial viability. During follow-up 10 patients (6.5%) had hard events, 53 (35%) developed unstable angina and 67 (44%) underwent myocardial revascularization. The rate of hard events was 10% in group 1 and 0% in group 2 and 3 patients (p < 0.05 group 1 versus group 2); group 1 patients with viability and ischemia showed a significantly higher rate of recurrence of unstable angina and myocardial revascularization procedures (40% and 60%) compared to group 2 (22% and 16%) and group 3 patients (20% and 20%). Using the Cox multivariate stepwise model, only the extent of ischemic myocardium (hazard ratio (HR) = 21.7, p = 0.02) and angina during DSE (HR = 4.45, p = 0.03) were significant predictors of hard events; an ischemic response to DSE (HR = 2.92, p = 0.001) was the most important predictor of spontaneous events, followed by ST-segment depression during DSE (HR = 1.71, p = 0.04), angina during DSE (HR = 1.53, p = 0.19) and age (HR = 0.96, p = 0.05).

Conclusions. In patients with a first AMI treated with thrombolysis the presence and extent of myocardial ischemia during DSE is the most important predictor of both hard and spontaneous cardiac events, whereas myocardial viability does not have an independent prognostic value.

Abbreviations and Acronyms   AMI = acute myocardial infarction   CI = confidence intervals   DSE = dobutamine stress echocardiography   HR = hazard ratio   LV = left ventricular   WMSI = wall motion score index

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