CLINICAL RESEARCH: HYPERTROPHIC AND DILATED CARDIOMYOPATHY
Effect of Dobutamine Stress on Left Ventricular Filling in Ischemic Dilated Cardiomyopathy
Pathophysiology and Prognostic Implications
Alison M. Duncan, MRCP, PhD*,*, ,
Eric Lim, MSc, MRCS*,,
Derek G. Gibson, FRCP*, and
Michael Y. Henein, MD, PhD, FACC*,
* Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
Imperial College, London, United Kingdom.
Manuscript received December 20, 2004;
revised manuscript received March 31, 2005,
accepted April 5, 2005.
* Reprint requests and correspondence: Dr. Alison Duncan, Echocardiography Department, The Royal Brompton Hospital, Sydney Street, London, SW3 6NP, United Kingdom. (Email: a.duncan{at}imperial.ac.uk).
OBJECTIVES: The purpose of this research was to study the effect of dobutamine on left ventricular (LV) filling in ischemic cardiomyopathy (ICM) and to determine whether restrictive filling pattern (RFP) at peak stress has prognostic value.
BACKGROUND: The prognostic value of RFP at peak stress in ICM is unknown.
METHODS: A total of 69 patients with ICM were studied by Doppler echocardiography at rest and stress; RFP was defined as transmitral E:A ratio  1.0, isovolumic relaxation time (IVRT) <80 ms, and E-wave deceleration time (EDT) <120 ms.
RESULTS: A total of 42 of 69 had RFP at rest, which reverted to non-RFP at stress in 24 (EA), but persisted in 18 (EE); 27 of 69 had non-RFP at rest and peak stress (AA). In EA, IVRT and EDT lengthened (by 43 ms and 46 ms), and tricuspid regurgitation (TR) decreased (by 26 mm Hg, p < 0.01), suggesting a fall in left atrial (LA) pressure. The stress response in AA was similar to EA. In EE, IVRT and EDT shortened (by 21 ms) and TR increased (by 13 mm Hg, p < 0.01), suggesting a rise in LA pressure. Peak aortic acceleration (LV inotropy) increased by 0.8 g in EA but only by 0.2 g in EE (difference p < 0.001). Median follow-up (interquartile range) was 34 (20 to 57) months. Three-year survival for EE, EA, and AA was 49%, 79%, and 89%, respectively (p < 0.001). Compared with AA, the hazard ratio for EE was 9.5 (p < 0.001) and for EA was 1.9 (p = 0.30).
CONCLUSIONS: In ischemic cardiomyopathy, persistence of restrictive filling during stress implies a striking rise in LA pressure, greatly attenuated LV inotropic response, and markedly reduced survival. Stress echocardiography uniquely identifies these high-risk patients.
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Abbreviations and Acronyms
| | CAD = coronary artery disease | | CI = confidence interval | | EDT = E-wave deceleration time | | E:A ratio = ratio of early transmitral flow velocity to atrial flow velocity | | group AA = non-restrictive at rest, remained non-restrictive at stress | | group EA = restrictive at rest, became non-restrictive at peak stress | | group EE = restrictive at rest, remained restrictive at peak stress | | ICM = ischemic cardiomyopathy | | IVRT = isovolumic relaxation time | | LV = left ventricle/ventricular | | MR = mitral regurgitation | | PAA = peak aortic acceleration rate | | PES = post-ejection shortening | | PMEA = peak mitral E-wave acceleration rate | | SA = systolic amplitude | | SV = stroke volume | | TR = tricuspid regurgitation |
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