Arquivos Brasileiros de Cardiologia.docx
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ArquivosBrasileirosdeCardiologia
ArquivosBrasileirosdeCardiologia
version ISSN0066-782X
Arq.Bras.Cardiol.,aheadofprint Epub Nov 26,2010
doi:
10.1590/S0066-782X2010005000156
Prognosticvalueofdipyridamolestressechocardiographyinwomen
MariaCelitadeAlmeidaI;BrivaldoMarkmanFilhoI,II
IProcárdioDiagnósticos
IIUniversidadeFederaldePernambuco,Recife,PE-Brazil
Mailingaddress
ABSTRACT
BACKGROUND:
Stressechocardiographyisanimportantdiagnosticandprognostictoolinischemicheartdisease.
OBJECTIVE:
Toevaluatetheroleofdipyridamolestressechocardiography(DSE)intheinvestigationofmyocardialischemiainwomenanditsabilitytopredictcombinedevents(cardiovasculardeath,acutemyocardialinfarction[AMI],unstableangina,coronaryarterybypassgrafting[surgeryorpercutaneousintervention]atanaveragefollow-upof16months.
METHODS:
Aprospectivestudyusingtheprotocolofdipyridamoleat0.84mgin10minutes,associatedwithatropine(0.25mg/minupto1.0mg).
RESULTS:
Thisstudyevaluated147women.DSEwaspositivein14patients(9.5%),negativein128(87.1%)andinconclusivein5(3.4%).Eventsoccurredin8patients,7hadpositiveDSE.Theother138didnotpresentanyevents.Ourofthese,128hadnegativeDSE.Thesensitivity,specificity,accuracy,thepositiveandnegativepredictivevaluesofthetestbeforetheeventswererespectively:
83%,95%,94%,42%and99%.Theevent-freesurvivalforpatientswithnegativeDSEwas99.2%comparedwith58%forpositiveDSE(p<0.001).UnivariateanalysisidentifiedtheDSEresult,basalelectrocardiogram(ECG),LVejectionfraction,dyslipidemia,wallmotionscoreindexatrestandpeak,historyofAMI,coronaryarterybypassgrafting,asprognosticpredictorsrelatedtooutcomes.TheresultsofDSEandECGremainedsignificantlyassociatedwithoutcomesinthemultivariateanalysis(p<0.001).
CONCLUSION:
ThebaselineECGandpositiveDSEwereindependentvariablesfortheoccurrenceofoutcomes.TheDSEshowedexcellentnegativepredictivevalue,confirmingitsusefulnessinevaluatingprognosisinsuchpatients.
Keywords:
Echocardiography,stress;myocardialischemia;diagnostictechniquesandprocedures;dipyridamole;prognostic;women.
Introduction
Indevelopedcountries,atherothromboticdisease,includingcoronaryarterydisease(CAD)andcerebrovascularaccident(CVA),istheleadingcauseofdeathamongwomen1.However,inwomen,CADispresenteddifferentlyrelatedtomen.Theonsetofsymptomsislate(5-10years),thegroupofsymptomsismoreatypicalandthereisagreaterprevalenceofcomorbiditiessuchashypertension(HBP),diabetesmellitus(DM)anddyslipidemia(DLP).Besidesthis,thereisapoorspecificityofroutinediagnostictests,andincreasedmortalityduringpercutaneouscoronaryintervention(PCI)andcoronaryarterybypassgrafting(CABG)2.
Thetreadmilltest(TT)isassociatedwithahighrateoffalse-positiveresultsandahugenumberofvariablesmaychangetheaccuracyofsuchtestinwomen.ThecombinationofimagingtestssignificantlyincreasesthediagnosticaccuracyforCADandseveralauthorshaveusedstressechocardiography(EE)inthissubgrouppatients3-5.
Indipyridamolestressechocardiography(DSE),thisdrugworksbycausingmyocardialischemiathroughthemechanismofcoronary"flowsteal",aspreviouslyexplained6,7.Concomitantadministrationofatropine,increasingheartrate,enhancestheeffectsdescribed.
ThisstudywasintendedtoevaluatetheprognosticvalueofDSEinwomenwithsuspectedmyocardialischemia.
Methods
ProspectiveobservationalstudyconductedfromMar/2005-Jun/2007inwomenwithsomecontraindicationtoETorETpositiveforST-segmentalterationwithoutclinicalmanifestationofCADorinconclusiveET,whounderwentDSEforevaluationofmyocardialischemia.TheDSEwasperformedwithoutdiscontinuationofdrugtherapy.
ThestudywasapprovedbytheEthicsCommitteeonClinicalResearchofthesaidcenterandthepatientssignedaninformedconsent.
Patientswithimproperechocardiographicwindow,previouslyknowncontraindicationtodipyridamoleorthosewhohadusedxanthineproductsinthe24hoursprecedingtheexaminationwereexcluded.
Theprotocolusedconsistedofintravenousadministrationofatotaldipyridamoledoseof0.84mg/kgin10minutes,asfollows:
0.56mg/kginfourminutes,fourminutesofobservation,andifnocriterionofpositivitywasevidenced,anadditionaldoseof0.28mg/kgwereinfusedintwominutes8.Ifnocriteriafortestinterruptionarouse,atropinewasadministeredatadoseof0.25mgeveryminute,totaling1.0mg.Thetestwascompletedwiththeinfusionofaminophylline,toreversetheeffectsofdipyridamole(maximumdoseof240mgforthreeminutes)inthe16thminute.
Duringtheprocedure,bloodpressureandechocardiographicimageswererecordedateachstage.Criteriafortestinterruptionwere:
onsetofsegmentalabnormalitiesinleftventricularcontraction,chestpainofatleastmoderateintensity,ventriculararrhythmiasorsideeffectsdeemedimportantbythephysicianwhoperformedtheexamination.
TheequipmentusedwasaVivid3Pro-GEMedicalSystemsâ.Accordingtocurrentrecommendations,theleftventricle(LV)wasdividedinto17segments9.Ascoreof4pointswasgivenforeachsegment,asfollows:
1=normal,2=hypokinesia,3=akinesia,4=dyskinesia7,10.
Then,theLVwallmotionscoreindex(LVWMSI)wascalculated,consideringthesumofthepointsofthe17LVsegmentsdividedbythenumberofsegmentsanalyzed.Valuesgreaterthanonewereconsideredabnormal.Foreachpatient,thescoresatrest(pre)andatthepeakofdruginfusionweredetermined.
ThetestwasconsideredpositiveforischemiawiththeonsetofachangeintheLVsegmentalcontractility(hypokinesia,akinesiaordyskinesia)orworseningofapre-existingcontractilechange.Thestudieswereevaluatedoff-linebytwoindependentexaminers.
Follow-upwasthroughmedicalrecords,telephoneintervieworaninterviewwiththeattendingphysician.
Theclinicaleventsassessedduringfollow-upwere:
deathofcardiacorigin,acutemyocardialinfarction(AMI),unstableangina(UA)andcoronaryarterybypasssurgery(CABG)orpercutaneousintervention(PCI),occurringthreemonthsaftertheDSE.
Deathwasattributedtocardiacoriginwhenthefollowingwasdocumented:
significantarrhythmia,congestiveheartfailure(CHF)orAMI11.ThediagnosisofAMIandUAfollowedthediagnosticcriteriadefinedbycurrentguidelines12,13.
Clinicalfollow-upofeachpatientwasclosedaftertheoccurrenceofanyevent.Therefore,onlythefirsteventwasconsidered.
Statisticalanalysis
Theresultswereexpressedasmean,medianandstandarddeviationforquantitativevariables.Qualitativevariableswereexpressedinabsoluteandrelativefrequencies.Facedwithclinicaloutcomes,wecalculatedthesensitivity,specificity,accuracy,positivepredictivevalue(PPV)andnegativepredictivevalue(NPV)oftheDSE.
ThecumulativeprobabilitiesofeventswereestimatedbytheKaplan-Meiercurvesandthepresenceofdifferencesbythelogranktest.TheCOXproportionalhazardsmodelwasusedtodeterminethevariableswithindependentprognosticvalueforoccurrenceofevents.Forthemodel,weconsideredallvariablesthat,intheunivariateanalysis,showedstatisticalsignificance(p<0.20).
Thesignificancelevelwas0.05.DatawereanalyzedwithSPSS(StatisticalPackageforSocialScience)-IBMTMforWindowsversion12.0.
Results
Atotalof147patientswhosemeanagewas62years(37-87years)wasassessedbyDSE.Fivetestswerestoppedearlyduetodisablingsymptoms(twocasesofintensedyspnea,twocasesofimportantchestpainwithnosignificantalterationofmyocardialcontractilityandonecaseofbronchospasm),whichwereexcludedfromtheanalysisofresults.ClinicalcharacteristicsofpatientsareshowninTable1.Noteworthyisthehighnumberofpatientswithhypertensionanddyslipidemia.Ontheotherhand,thenumberofcoronaryeventscharacterizedbyhistoryofAMIwaslow,aswellasthenumberofcoronaryrevascularisationprocedures.
Outof147women,66.0%hadatypicalchestpain,7.5%typicalchestpain(angina)and26.8%wereasymptomatic,ofwhich51.3%withTTcharacterizedby:
ischemicST-Tsegmentchangesorangina.Inthissample,72.8%presentednormalbasalelectrocardiogram(ECG)and27.2%,ECGwithabnormalities.Abnormalitieswereconsidered:
changesinleftventricularrepolarization,leftbundlebranchblock(LBBB),electricallyinactiveareaandleftventricularhypertrophy.Regardingventricularfunction,only08patients(5%)hadloweredEF(<0.56)atbaselineDopplerechocardiography.HistoryofCAD,previousAMI,CABGorPCI,orpriorcoronaryangiographyindicatingthepresenceofobstructivecoronaryarterylesionofatleast50.0%ofthevessellumenwaspresentin27patients.
Asformedications,42.0%wereusingbeta-blockers,22%usedcalciumblocker,16%nitrate,39%angiotensin-convertingenzymeinhibitors,35%aspirinand32%statins.Therewere5.0%ofpatientsusingbeta-blockerandnitratecombination,5%withbeta-blockerandcalciumblockerandonly3%undercombineduseofbeta-blocker,calciumblockerandnitrate.
Theaveragefollow-upforeventswas16months(minimumoftwomonthsandamaximumof27months).
TheDSEshowedmyocardialischemiain14(9.5%)patients.Theresultwasnegativein128(87.1%)andinconclusivein5(3.4%)patients.Outof147patientsanalyzed,eight(5.4%)hadcardiaceventsduringfollow-upperiod.Outofthe8events,7occurredamongthe14positivetestsformyocardialischemia,ofwhichtwoeventsoccurredearlierthanthreemonthsofthe
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