Arquivos Brasileiros de Cardiologia.docx

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