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CLINCAL STUDY: STRESS ECHOCARDIOGRAPHY

Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative cardiac troponin T

Radha Bholasingh, MD^*, Jan Hein Cornel, MD, PhD, Otto Kamp, MD, PhD, Jan P. van Straalen, Gerard T. Sanders, PhD, Jan G. P. Tijssen, PhD^*, Victor A. W. M. Umans, MD, PhD, Cees A. Visser, MD, PhD and Robbert J. de Winter, MD, PhD^*,*

^* Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
Department of Cardiology, Medical Center Alkmaar, Alkmaar, the Netherlands
Department of Cardiology, VU Medical Center, Amsterdam, the Netherlands
Department of Clinical Chemistry, Academic Medical Center, Amsterdam, the Netherlands

Manuscript received May 7, 2002; revised manuscript received August 4, 2002, accepted September 6, 2002.

^* Reprint requests and correspondence: Dr. Robbert J. de Winter, Academic Medical Center, Department of Cardiology, Room B2-137, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
r.j.dewinter{at}amc.uva.nl

OBJECTIVES: We prospectively studied the prognostic value of predischarge dobutamine stress echocardiography (DSE) in low-risk chest pain patients with a normal or nondiagnostic electrocardiogram (ECG) and a negative serial troponin T.

BACKGROUND: Noninvasive stress testing is recommended before discharge or within 72 h in patients with low-risk chest pain. The prognostic value of immediate DSE has not been studied in a blinded, prospective fashion.

METHODS: Patients presenting at the emergency room within 6 h of symptom onset and a normal or nondiagnostic ECG were eligible. Dobutamine stress echocardiography was performed after unstable coronary artery disease was ruled out by a standard rule-out protocol and a negative serial troponin T; the occurrence of any new wall motion abnormality was considered positive. Results were kept blinded. End points were cardiac death, myocardial infarction, rehospitalization for unstable angina or revascularization.

RESULTS: In total, 377 patients were included. There were 2 deaths, 2 myocardial infarctions, 8 rehospitalization for unstable angina, and 10 revascularizations at six-month follow-up. The end points occurred in 8/26 (30.8%) patients with a positive versus 14/351 (4.0%) patients with a negative DSE (odds ratio, 10.7; 95% confidence interval, 4.0 to 28.8; p < 0.0001). By multivariate analysis, DSE remained a predictor of end points (p < 0.0001).

CONCLUSIONS: A predischarge DSE had important, independent prognostic value in low-risk, troponin negative, chest pain patients.

Abbreviations and Acronyms   AMI   acute myocardial infarction   CI   confidence interval   DSE   dobutamine stress echocardiography or echocardiogram   UA   unstable angina

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