Gilmar Reis

Usefulness of dobutamine stress echocardiography in detecting coronary artery disease in end-stage renal disease

The cardiovascular evaluation of patients with end-stage renal disease (ESRD) has been hampered by the suboptimal sensitivity and specificity of currently employed diagnostic tests. Dobutamine stress echocardiography (DSE) is a recently developed technique which is accurate for the diagnosis of coronary artery disease (CAD) in general populations. The purpose of this study was to assess its diagnostic accuracy and prognostic implications in patients with ESRD. Patients with ESRD (n = 97) underwent DSE as part of a preoperative evaluation before being listed for renal transplantation. Patients were followed for 12 +/- 6 months (range 1 to 24) after the study. Rest and dobutamine stress echocardiograms were analyzed for regional and global function. Coronary angiography was performed in 30 patients, and 25 underwent renal transplantation in the follow-up period. DSE had a sensitivity of 95% (92% for 1-vessel, 100% for > or = 2-vessel disease), specificity of 86%, and accuracy of 90% for the detection of CAD. During the follow-up period, 6 patients died; DSE revealed inducible ischemia in 4, and catheterization before death revealed multivessel CAD in 2. Conversely, a normal DSE identified a very low risk population, with a 97% probability of being free of cardiac complications or death during the follow-up period. We conclude that DSE accurately identifies CAD in patients with ESRD and identifies a cohort of patients at low risk for cardiac complications.

Percutaneous revascularization and long term clinical outcomes of diabetic patients randomized in the Occluded Artery Trial (OAT).

BACKGROUND Percutaneous coronary intervention (PCI) of a persistently totally occluded infarct-related artery (IRA) in stable high-risk patients >24h after myocardial infarction (MI) does not reduce the occurrence of death, re-infarction, or heart failure. Diabetic patients are at higher risk for cardiovascular events; we examined their outcomes overall with PCI and optimal medical therapy alone (MED). METHODS The long-term (7-year) outcomes of 454 diabetic patients (20.6%) randomized to PCI or MED in the Occluded Artery Trial (OAT) were assessed for the composite primary endpoint of death, re-MI, or New York Heart Association class IV heart failure. Diabetics and non-diabetics were compared and outcomes assessed by treatment strategy. RESULTS The 7-year cumulative primary event rate for diabetic patients was 35.0% vs. 19.4% in the non-diabetic cohort (p<0.001). Multivariable analyses revealed diabetes to be an independent predictor (p<0.01) for the primary outcome, fatal or nonfatal recurrent MI, Class IV Heart Failure (HF), and death. The 7-year cumulative primary event rates were 35.3% in the PCI group vs. 34.5% in the medical therapy group in diabetic patients (p=0.19) and 19.3% in the PCI group vs. 19.5% in the medical therapy group in patients without diabetes (p=0.60). CONCLUSIONS Despite the higher overall risk conferred by the presence of diabetes, PCI did not improve clinical outcomes in this subpopulation, and is not indicated in otherwise stable patients with a totally occluded infarct-related artery in the sub-acute phase after MI.

Dobutamine-stress echocardiography in asymptomatic patients with aortic regurgitation

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

Ecocardiograma sob estresse com dobutamina em pacientes assintomáticos com regurgitação aórtica

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.

Ecocardiografía bajo estrés con dobutamina en pacientes asintomáticos con regurgitación aórtica

BACKGROUND Decreased contractile reserve may already be present in asymptomatic patients with aortic regurgitation and normal ejection fraction (EF), thus indicating the need for frequent and accurate assessments of the left ventricular function for the early detection of systolic dysfunction. OBJECTIVE To analyze if increments in EF with low dose dobutamine could predict surgery and/or death in patients with aortic regurgitation. METHODS Dobutamine-stress echocardiography was performed in 24 patients with aortic regurgitation in order to analyze whether EF increments at low dobutamine doses could predict the need for surgery and/or death in this group of patients. RESULTS Mean age was 37.8+/-16.8 years and 16 patients (66%) were male. EF increased from a mean baseline value of 62.3+/-7.9% to 71.5+/-10.5% at a dobutamine dose of 20 microg/kg/min (p<0.001). The patients were followed-up for 36.6+/-20.1 months; two patients died (one of cardiovascular death) and five underwent cardiac surgery. Baseline EF was correlated with surgery and death in the follow-up of patients. CONCLUSION Baseline EF was correlated with surgery or death in the follow-up of young patients with aortic regurgitation. However, the percentage increase in EF at low dobutamine doses did not allow us to predict events in these patients.FUNDAMENTO: La reserva contractil disminuida puede ya estar presente en pacientes portadores de regurgitacion aortica, asintomaticos con fraccion de eyeccion (FE) normal, indicando la necesidad de evaluaciones frecuentes y cuidadosas de la funcion ventricular izquierda para detectar disfuncion sistolica incipiente. OBJETIVO: Analizar se incrementos en la FE en dosis bajas de dobutamina pueden predecir cirugia y/o muerte en pacientes con regurgitacion aortica. METODOS: Eco de estres con dobutamina se realizo en 24 pacientes portadores de regurgitacion aortica para verificar se incrementos de la FE en dosis bajas de dobutamina serian capaces de predecir la necesidad de cirugia y/o muerte en ese grupo de pacientes. RESULTADOS: La edad promedio fue de 37,8±16,8, y 16 (66%) eran varones. La FE aumento de un valor basal promedio de 62,3±7,9% para 71,5±10,5%, en la dosis de 20 µg/kg/min de dobutamina (p < 0,001). Los pacientes se siguieron por 36,6±20,1 meses: dos pacientes murieron (uno de muerte cardiovascular) y cinco se sometieron a cirugia cardiaca. La FE basal se correlaciono con cirugia y muerte en el seguimiento de pacientes. CONCLUSION: La fe basal se correlaciono con cirugia o muerte en el seguimiento de pacientes jovenes con regurgitacion aortica. Sin embargo, el incremento porcentual en la FE con dosis baja de dobutamina no fue capaz de predecir eventos en esos pacientes.