Prognostic Significance of Systolic Blood Pressure Changes During Dobutamine-Atropine Stress Technetium-99m Sestamibi Perfusion Scintigraphy in Patients With Chest Pain and Known or Suspected Coronary Artery Disease

Abstract

To investigate the prognostic value of dobutamine stressinduced changes in systolic blood pressure (BP) 418 patients (mean age 60 years, 238 men) with chest pain and known or suspected coronary artery disease, who underwent a dobutamine-atropine stress technetium99m sestamibi myocardial perfusion scintigraphic study, were followed up for 25 { 15 months. Blood pressure was measured by automatic sphygmomanometry every 3 minutes. A marked decrease and increase in systolic BP from rest to peak were defined as changes of ¢20 mm Hg, and ¢30 mm Hg, respectively. Worst outcome events were cardiac death (n Å 30), nonfatal myocardial infarction (n Å 17), and hospitalization for congestive heart failure (n Å 8). A decrease in systolic BP (prevalence 16%) was associated with older age and higher baseline systolic BP. Fixed and reversible sestamibi perfusion defects and follow-up results were similar to patients without a systolic BP decrease. In contrast, an increase in systolic BP (prevalence 24%) was associated with younger age, lower baseline systolic BP, and with absence of a history of prior congestive heart failure or treatment with angiotensin-converting enzyme inhibitors. Furthermore, these patients had fewer fixed perfusion defects and tended to have fewer annual event rates (3.5% vs 7.5%, p õ0.10). In a multivariate model, an increase in systolic BP was not an independent predictor for subsequent events. In conclusion, a dobutamine-induced decrease in systolic BP is not associated with fixed or reversible sestamibi defects or adverse prognosis. An increase in systolic BP, however, is associated with less fixed sestamibi defects and a tendency toward less annual event rates. ᮊ1997 by Excerpta Medica, Inc.(Am J Cardiol 1997;79:1031-1035) D obutamine stress technetium-99m sestamibi myocardial perfusion scintigraphy is a pharmacologic stress modality with diagnostic 1-5 and prognostic 6 properties comparable to dobutamine stress echocardiography. Previous dobutamine stress echocardiographic studies have reported that dobutamine stress-induced hypotension is -unlike exercise -induced hypotension 7 -10 not related to new or worsening wall motion abnormalities 11 -14 and the presence or extent of coronary artery disease. 11,12Furthermore, a relatively small echocardiographic study 12 has supported these results with prognostic data that were similar for the hypotensive and the nonhypotensive group. To date, however, these findings were not confirmed by myocardial perfusion scintigraphic data. Also, it is not known whether a substantial increase in systolic blood pressure (BP)From the Thoraxcentre and the Department of Nuclear Medicine, University Hospital, Rotterdam-Dijkzigt and Erasmus University, Rotterdam, The Netherlands. This study was supported in part by funds from the Dutch Heart Foundation (Grant NHS 94.135), The Hague, The Netherlands, and Cairo University Hospital, Cairo, Egypt. Manuscript received July 16, 1996; revised manuscript received and accepted December 12, 1996.Address for reprints: Marcel L. Geleijn...

Incidence, Pathophysiology, and Treatment of Complications During Dobutamine-Atropine Stress Echocardiography

“…101,104 -106 The second mechanism, a disproportionate decrease in systemic vascular resistance, may be due to the aforementioned Bezold-Jarisch reflex or, rarely, an allergic reaction to dobutamine (see later section on dobutamine hypersensitivity). The consistent absence of histories of prior MI or congestive heart failure, 98,99 ischemia, 17,98 -102 or CAD 17,98,99,102 in studies with heterogeneous patients is indirect evidence of a dobutamine-induced hypotension mechanism that is based primarily on an excessive decrease in systemic vascular resistance instead of a mechanism principally involving inadequate cardiac output in most patients. In patients with impaired LV function (and thus a lesser role for the Bezold-Jarisch reflex), there is some evidence that contractile reserve plays a more important role in the pathogenesis of hypotension 72,107,108 and that hypotension has adverse prognostic value.…”

“…Dependent on definition, the overall incidence is much higher; a decrease of Ͼ20 mm Hg is noted in Ϸ20% of patients. 98,99 Complication-specific publications are available. 98 -106 Pathophysiology Hypotension may result from an inadequate increase in cardiac output to compensate for an expected decrease in systemic vascular resistance and/or a disproportionate decrease in systemic vascular resistance.…”

“…Selon la définition retenue, l'incidence globale de ce trouble est beaucoup plus élevée ; une chute tensionnelle de plus de 20 mmHg est observée chez environ 20 % des patients. 98,99 Des publications traitant spécifiquement de cette complication sont disponibles.…”

“…L'oblitération dynamique de la cavité VG causée par une forte stimulation inotrope avait été proposée comme étant un important facteur de diminution du débit cardiaque et d'hypotension, 103 mais les travaux menés par la suite ont abouti à des résultats contradictoires quant à la réelle implication de ce mécanisme en tant que cause majeure d'hypotension. 101,[104][105][106] Le second mécanisme, à savoir la diminution excessive des résistances vasculaires périphériques, pourrait avoir pour origine un réflexe de Bezold-Jarisch, dont il a été précédemment fait mention, ou, plus rarement, une réaction allergique à la dobutamine (voir ci-après la rubrique traitant de l'hypersensibilité à la dobutamine 17,98,99,102 dans les études ayant porté sur des populations de patients hétérogènes constitue une preuve indirecte de ce que, chez la plupart des patients, l'hypotension induite par la dobutamine a pour cause essentielle la diminution trop importante des résistances vasculaires péri-phériques et non l'inadéquation du débit cardiaque. Chez les patients dont la fonction VG est altérée (et chez lesquels le réflexe de Bezold-Jarisch joue donc un rôle moindre), certaines données confirment que la réserve contractile intervient de manière plus importante dans la pathogenèse de l'hypotension 72,107,108 et que celle-ci a une valeur pronostique défavorable.…”

Paradoxical Hypotension during Dobutamine Infusion for Myocardial Perfusion Scintigraphy

“…Hypotension during stress exercise testing indicates severe CAD and poor prognosis, but hypotension during dobutamine stress echocardiography is not an indicator of severity of coronary disease (7-9, 11, 12). On the other hand, reports on the significance of paradoxical hypotension during dobutamine infusion for myocardial perfusion scintigraphy are limited (2). Therefore, in a prospective study, we investigated the frequency of dobutamine induced paradoxical hypotension as well as the relationship between such hypotension and scintigraphic findings.…”