Secknus M A, Marwick T H
Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
J Am Coll Cardiol. 1997 May;29(6):1234-40. doi: 10.1016/s0735-1097(97)00039-9.
This study sought to document the safety of dobutamine stress echocardiography as it has evolved at a single center and to define predictors of adverse events.
The indications and protocol for dobutamine stress testing have evolved over 5 years of clinical use, but the influence of these changes on the safety and side effects of the test is undefined.
Over 5 years, 3,011 consecutive dobutamine stress studies were performed in 2,871 patients, using an incremental protocol from 5 to 40 micrograms/kg body weight per min in 3-min stages, followed by atropine or an additional stage with 50 micrograms/kg per min, if required. Clinical data were gathered prospectively, and hemodynamic and echocardiographic findings were recorded at each stage, including recovery. Dobutamine echocardiography was defined as positive for ischemia in the presence of new or worsening wall motion abnormalities; in the absence of ischemia, failure to attain 85% of age-predicted maximal heart rate was identified as a nondiagnostic result.
Studies were performed for risk assessment (70%) and symptom evaluation (30%); over the study period, there was an increment in the use of dobutamine echocardiography for preoperative evaluation. Most tests (n = 2,194 [73%]) were terminated due to attainment of peak dose with achievement of target heart rate (> 85% maximal age-predicted heart rate); 455 patients (15%) failed to achieve > 85% maximal predicted heart rate despite maximal doses of dobutamine and atropine. The protocol was stopped prematurely in 230 patients (7.6%) because of side effects, including ventricular (n = 27 [0.9%]) and supraventricular rhythm disorders (n = 22 [0.7%]), severe hypertension (n = 24 [0.8%]) and hypotension or left ventricular outflow tract obstruction (n = 112 [3.8%]). Noncardiac symptoms, such as headache, nausea or anxiety, caused early test termination in 45 patients (1.6%). The remaining tests were stopped because of severe chest pain (n = 106 [3.5%]) or severe ischemia by echocardiography (n = 26 [0.9%]). Serious complications occurred in nine patients, including sustained ventricular tachycardia in five, myocardial infarction in one and other conditions in three requiring hospital admission (sustained supraventricular tachycardia, hypotension, suspected myocardial infarction), but neither ventricular fibrillation nor death occurred. Independent predictors of serious complications could not be defined. Over 5 years, higher dose protocols and more frequent use of atropine have raised the number of diagnostic protocols from 59% to 80%, without increasing the incidence of major side effects.
Despite the use of more aggressive protocols and alterations of the indications for testing to include sicker patients, major side effects are a rare complication of dobutamine echocardiography.
本研究旨在记录多巴酚丁胺负荷超声心动图在单一中心的发展历程中的安全性，并确定不良事件的预测因素。
多巴酚丁胺负荷试验的适应证和方案在5年的临床应用中不断演变，但这些变化对该检查安全性和副作用的影响尚不清楚。
在5年期间，对2871例患者连续进行了3011次多巴酚丁胺负荷试验，采用递增方案，从每分钟5微克/千克体重开始，以3分钟为一个阶段，逐渐增加至每分钟40微克/千克体重，必要时随后使用阿托品或增加一个每分钟50微克/千克体重的阶段。前瞻性收集临床数据，并在每个阶段记录血流动力学和超声心动图检查结果，包括恢复情况。多巴酚丁胺超声心动图在出现新的或恶化的室壁运动异常时被定义为缺血阳性；在无缺血情况下，未能达到年龄预测最大心率的85%被确定为非诊断性结果。
进行这些检查的目的是风险评估（70%）和症状评估（30%）；在研究期间，多巴酚丁胺超声心动图用于术前评估的情况有所增加。大多数检查（n = 2194 [73%]）因达到目标心率（>最大年龄预测心率的85%）的峰值剂量而终止；455例患者（15%）尽管使用了最大剂量的多巴酚丁胺和阿托品，仍未达到>最大预测心率的85%。230例患者（7.6%）因副作用而提前终止检查，包括室性（n = 27 [0.9%]）和室上性心律失常（n = 22 [0.7%]）、严重高血压（n = 24 [0.8%]）以及低血压或左心室流出道梗阻（n = 112 [3.8%]）。非心脏症状，如头痛、恶心或焦虑，导致45例患者（1.6%）提前终止检查。其余检查因严重胸痛（n = 106 [3.5%]）或超声心动图显示严重缺血（n = 26 [0.9%]）而终止。9例患者发生严重并发症，包括5例持续性室性心动过速、1例心肌梗死和3例其他需要住院治疗的情况（持续性室上性心动过速、低血压、疑似心肌梗死），但未发生心室颤动或死亡。无法确定严重并发症的独立预测因素。在5年期间，更高剂量的方案和更频繁地使用阿托品使诊断性方案的比例从59%提高到80%，而未增加主要副作用的发生率。
尽管采用了更积极的方案并改变了检查适应证以纳入病情更重的患者，但主要副作用仍是多巴酚丁胺超声心动图检查罕见的并发症。
