Changes in the Doppler myocardial performance index during dobutamine echocardiography: association with neurohormonal activation and prognosis after acute myocardial infarction

Abstract

Objectives: To test whether an increase in Doppler myocardial performance index (MPI) during dobutamine stress echocardiography, reflecting deterioration of overall left ventricular function, is associated with increased N-terminal pro-brain natriuretic peptide (NT-pro-BNP) concentration and provides prognostic information beyond conventional systolic wall motion analysis after acute myocardial infarction (AMI). Design: Prospective, observational study. Methods: Dobutamine-atropine stress echocardiography (DASE) and NT-pro-BNP were assessed five days after AMI in 109 consecutive patients. MPI was measured at rest and at low-dose (10 mg/kg/min) and peak dobutamine infusion (( 40 mg/kg/min with or without atropine). Main outcome measures: End point was a composite of cardiac death or readmission for heart failure or reinfarction. Results: In 35 patients (32%), MPI increased at low-dose DASE. This was associated with higher NT-pro-BNP concentrations (b = 0.30, p = 0.004). During a mean follow up of 27 (SD 7) months, 8 patients died of cardiac causes and 15 patients were readmitted for heart failure or reinfarction. On Cox regression analysis, an increase in MPI at low-dose DASE (p = 0.02) was an independent predictor of cardiac events. In contrast, traditional wall motion analysis during DASE provided no additional prognostic information. Conclusions: An increase in MPI at low-dose DASE, reflecting early deterioration of overall left ventricular function, is associated with raised NT-pro-BNP concentration and provides prognostic information beyond conventional stress echocardiographic data after AMI. I nducible myocardial ischaemia may be detected and quantified by dobutamine-atropine stress echocardiography (DASE) after acute myocardial infarction (AMI). The detection of ischaemia is based on semiquantitative wall motion analysis, however, which assesses only left ventricular (LV) systolic function. The Doppler echocardiographic myocardial performance index (MPI) is a quantitative measure of combined LV systolic and diastolic function. [1][2][3] Because impaired LV diastolic function precedes LV systolic dysfunction during myocardial ischaemia, 4 quantitative assessment of changes in both systolic and diastolic LV function seems appealing and may potentially increase the clinical yield of DASE after AMI. Data on the changes in MPI during stress echocardiography are limited. Recently, MPI was found to correlate closely with invasive measures of LV systolic function during b adrenergic stimulation. 5 Furthermore, we have previously shown that MPI consistently improves, decreasing its value, during dobutamine stimulation in healthy people, 6 and MPI has been shown to increase (deteriorate) during dobutamine-induced ischaemia in patients with known or suspected coronary artery disease.

Early anthracycline‐induced cardiotoxicity monitored by echocardiographic Doppler parameters combined with serum hs‐cTnT

“…The Tei index has been validated for predicting major cardiovascular events, and its roles in the assessment of the trans‐catheter aortic valve implantation, acute myocardial infarction, and heart transplantation were well recognized. Development of the LV systolic dysfunction is widely considered as the most concerning cardiac injury due to anthracycline‐induced cardiotoxicity .…”

“…13 In a large cohort of over 280 000 cancer survivors in England and Wales, there were 2160 survivors died of cardiac disease, among whom survivors of lymphoma were found to experience the greatest number of cardiac deaths. 14 The Tei index has been validated for predicting major cardiovascular events, 17 and its roles in the assessment of the transcatheter aortic valve implantation, 18 acute myocardial infarction, 19 and heart transplantation 20 were well recognized. Development of the LV systolic dysfunction is widely considered as the most concerning cardiac injury due to anthracycline-induced cardiotoxicity.…”

Myocardial Contractile Response to Increasing Doses of Dobutamine in Patients with Reperfused Acute Myocardial Infarction by Cardiac Magnetic Resonance Imaging

“…Firstly, patients in the week after an AMI carry a higher risk of negative cardiac side effects and doses of dobutamine higher than 10 µg*kg –1 *min –1 are associated with an exponential increase of adverse events. In studies with low-dose dobutamine in patients after AMI no patient developed adverse events [8, 12] while in a study with a stepwise increase of dobutamine up to 40 µg*kg –1 *min –1 in patients with AMI, 26% of the patients developed negative side effects so that dobutamine had to be stopped early, and only 11% of the patients received the maximal dose [3]. Secondly, monitoring is more difficult in magnetic resonance imaging than in echocardiography and emergency interventions can be delayed because of the magnetic field.…”

“…In patients early after AMI, it has been examined by echocardiography [1,2,3,4], radionuclide ventriculography [5, 6] and cardiac magnetic resonance imaging (DCMR) [7,8,9]. Dosing of dobutamine ranged from 5 to 40 µg*kg –1 *min –1 .…”

“…A low contractile response of dysfunctional myocardium to dobutamine was attributed to post-infarction ischemia [5] and myocardial necrosis [4], whereas a positive contractile response was interpreted as myocardial stunning [6, 8]. The only study comparing different doses of dobutamine in AMI-patients observed different responses of an echocardiographic myocardial performance index and a wall motion score index at low- and high-dose dobutamine [3]. In some patients, both indices improved from low- to high-dose, in other patients deterioration of the indices was observed.…”