Dobutamine stress echocardiography in the evaluation of hibernating myocardium
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Impaired left ventricular (LV) systolic function in patients with coronary heart disease is often a partially reversible process (table 1). As an example, left ventricular function may improve markedly, and even normalize, in subsets of patients following successful revascularization (figure 1) [1-3].
Since many studies have established a relation between LV systolic function and cardiovascular prognosis, it is reasonable to speculate that improved LV systolic function following revascularization would be associated with a favorable effect on outcome. The superiority of revascularization compared to medical management in selected patients with coronary disease and LV dysfunction is compatible with this hypothesis [4,5]. The myocardium that recovers function after revascularization has been called "hibernating." To the extent that improvement in regional or global LV systolic function is a significant goal in such patients, the ability to accurately assess regional myocardial viability in a dysfunctional territory prior to revascularization becomes an important component of the decision making process (table 2 and algorithm 1 and algorithm 2). (See "Ischemic cardiomyopathy: Treatment and prognosis", section on 'Coronary artery revascularization' and "Clinical syndromes of stunned or hibernating myocardium".)
Dobutamine stress echocardiography has emerged as an important noninvasive clinical tool for the detection of hibernating myocardium [6,7]. The role of dobutamine stress echocardiography in the evaluation of myocardial viability in the setting of hibernation will be reviewed here. The use of other modalities in conjunction with dobutamine stress, such as Doppler studies, the relative efficacy of other imaging modalities (eg, radionuclide imaging, magnetic resonance imaging) for the detection of hibernating myocardium, and protocols for dobutamine stress echocardiography are discussed separately. (See "Evaluation of hibernating myocardium" and "Overview of stress echocardiography", section on 'Dobutamine stress echocardiography'.)
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
Pharmacologic stress echocardiography examines the "inotropic reserve" of dysfunctional but viable myocardium at rest by the administration of an inotropic agent, with dobutamine being the most frequently used agent. Viable myocardium shows improved global or regional contractile function (inotropic reserve), as assessed by simultaneous transthoracic echocardiography, in response to inotrope administration . The prevalence of contractile reserve in patients with CHD and LV dysfunction is independent of the angiographic extent and severity of coronary artery disease, and the improvement in contractility in hypoperfused viable myocardium does not require an increase in regional myocardial perfusion [9,10].
A contractile response to dobutamine appears to require that at least 50 percent of the myocytes in a given segment are viable; the contractile response also correlates inversely with the extent of interstitial fibrosis on myocardial biopsy . In comparison, radionuclide myocardial perfusion imaging identifies segments with fewer viable myocytes. In one series, for example, dobutamine stress echocardiography and thallium imaging showed equivalent sensitivity among segments with more than 75 percent viable myocytes (78 versus 87 percent) but dobutamine stress echocardiography was much less sensitive among segments with 25 to 50 percent viable myocytes (15 versus 82 percent) .
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- DOBUTAMINE STRESS ECHOCARDIOGRAPHY
- Improvement in LV function after CABG
- Improvement in LV systolic function after percutaneous revascularization
- Improvement in survival after revascularization
- Use after MI
- Use in LV dysfunction after MI
- Use in the elderly
- Comparison with perfusion imaging
- Comparison with CMR
- Role in idiopathic dilated cardiomyopathy
- ENOXIMONE STRESS ECHOCARDIOGRAPHY
- INFORMATION FOR PATIENTS