Background-Myocardial perfusion (MP) imaging with real-time contrast echocardiography (RTCE) improves the sensitivity of dobutamine stress echocardiography for detecting coronary artery disease. Its prognostic value is unknown. We sought to determine the value of MP and wall motion (WM) analysis during dobutamine stress echocardiography in predicting the outcome of patients with known or suspected coronary artery disease. Methods and Results-We retrospectively studied 788 patients with RTCE during dobutamine stress echocardiography using intravenous commercially available contrast agents. The incremental prognostic value of MP imaging over clinical risk factors and other echocardiographic data was examined through the use of a log-likelihood test (Cox model). During a median follow-up of 20 months, 75 events (9.6%) occurred (58 deaths, 17 nonfatal myocardial infarctions). Abnormal MP had significant incremental value over clinical factors, resting ejection fraction, and WM responses in predicting events (PϽ0.001). By multivariate analysis, the independent predictors of death and nonfatal myocardial infarction were resting left ventricular ejection fraction Ͻ50% (relative risk [RR], 1.9; 95% CI, 1.2 to 3.2; Pϭ0.01), hypercholesterolemia (RR, 0.5; 95% CI, 0.3 to 0.9; Pϭ0.01), and abnormal MP (RR, 5.2; 95% CI, 3.0 to 9.0; PϽ0.0001). The 3-year event free survival was 95% for patients with normal WM and MP, 82% for normal WM and abnormal MP, and 68% for abnormal WM and MP. Conclusion-MP imaging during dobutamine stress RTCE provides incremental prognostic information in patients with known or suspected coronary artery disease. Patients with normal MP have a better outcome than patients with normal WM.
The majority of inducible perfusion abnormalities occur at an intermediate phase of the stress test, without wall motion abnormalities. Myocardial contrast echocardiography provides better sensitivity than WMA, particularly in patients with submaximal stress and in identifying patients with multivessel CAD.
Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P ϭ 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of Ն65 yr (RR ϭ 2.2; 95% confidence interval (CI) ϭ 1.1-4.4; P ϭ 0.03), MELD score of Ն25 (RR ϭ 3.2; 95% CI ϭ 1.8-5.5; P Ͻ 0.0001), and abnormal MPI (RR ϭ 2.4; 95% CI ϭ 1.1-5.2; P ϭ 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P ϭ 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.
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