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CLINICAL RESEARCH: ECHOCARDIOGRAPHY

Cardiac events in patients with negative maximal versus negative submaximal dobutamine echocardiograms undergoing noncardiac surgery

Importance of resting wall motion abnormalities

^* Department of Cardiovascular Medicine, Lahey Clinic, Burlington, Massachusetts, USA

Manuscript received September 16, 2003; revised manuscript received February 21, 2004, accepted March 23, 2004.

^* Reprint requests and correspondence: Dr. Sherif B. Labib, Department of Cardiovascular Medicine, Lahey Clinic, 41 Mall Road, Burlington, Massachusetts 01805, USA.
sherif.b.labib{at}lahey.org

OBJECTIVES: This study sought to evaluate the negative predictive value (NPV) of preoperative dobutamine stress echocardiography (DSE) in patients who fail to achieve target heart rate (HR) and assess the influence of resting wall motion abnormalities (WMAs) without demonstrable ischemia on perioperative events.

BACKGROUND: The prognostic value of a negative-submaximal DSE study before noncardiac surgery is unknown.

METHODS: Consecutive patients (n = 429) who underwent surgery over a three-year period, preceded by DSE, were included. We compared perioperative event rates among those without inducible ischemia according to whether or not 85% age-adjusted maximum HR was achieved, and whether WMAs were present at rest.

RESULTS: Of 397 negative DSEs, peak HR was <85% maximum predicted in 62 (16%). Most were receiving beta-blockers (77%). The average dobutamine and atropine doses were 48 µg/kg/min and 1.2 mg, respectively. Average HR was 115 beats/min (74% maximum predicted). Perioperative myocardial infarctions occurred more frequently in patients with positive tests (3 of 32 [9.4%] vs. 7 of 397 [1.8%]; p = 0.03), but with similar frequency among the negative-maximal and negative-submaximal groups (6 of 335, 1.8% vs. 1 of 62, 1.6%, respectively). Accordingly, the NPV was 98% in both subgroups. Events occurred exclusively in patients with WMAs at rest: 7 of 100 (7%) versus 0 of 297 (0%) (p < 0.0001).

CONCLUSIONS: In patients undergoing preoperative DSE, failure to achieve target HR is not uncommon despite an aggressive DSE regimen. A negative DSE without resting WMAs has excellent NPV regardless of the HR achieved. Patients with resting WMAs appear to be at increased risk for perioperative events even without provokable ischemia.

Abbreviations and Acronyms   CAD = coronary artery disease   DSE = dobutamine stress echocardiography   HR = heart rate   MI = myocardial infarction   NPV = negative predictive value   WMA = wall motion abnormality

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