Prognostic implications of a normal dobutamine-atropine stress echocardiogram in patients with chest pain.

To assess the prognostic significance of a normal dobutamine-atropine stress echocardiogram in relation to the pretest probability of coronary artery disease (CAD), 200 consecutive patients (86 men and 114 women, mean [SD] age 59 [13] years) with a stable chest pain syndrome and a normal dobutamine-atropine stress echocardiogram were followed-up for 21 +/- 16 months. Outcome events were cardiac death, non-fatal myocardial infarction, and coronary revascularization procedures. Low (<10%), intermediate (10% to 80%), and high (>80%) pretest probabilities of CAD were present in 27 (14%), 108 (54%), and 65 (33%) patients, respectively. During follow-up, 2 patients (annual event rate 0.6%) had cardiac death, none had nonfatal myocardial infarction, and 4 patients (annual event rate 1.1%) underwent a coronary revascularization procedure. All patients with cardiac events had high pretest probabilities of CAD. Patients with cardiac death (but unproven significant CAD) had maximal tests without angina or ischemic electrocardiographic changes. In contrast, all patients with subsequent coronary revascularization had dobutamine-induced angina or ischemic electrocardiographic changes, and all except one study were submaximal. We conclude that patients with a stable chest pain syndrome and normal findings on dobutamine-atropine stress echocardiograms have an excellent cardiac prognosis. However, patients with typical angina, high pre-test probabilities of CAD, and stress-induced angina or ischemic electrocardiographic changes, and in particular those with submaximal stress, still appear to be at risk for functionally important CAD despite a normal dobutamine-atropine stress echocardiogram.