[en] OBJECTIVES: The aims of this study were (1) to assess the relation between ST-segment elevation and wall motion response occurring during dobutamine testing and (2) to evaluate the usefulness of stress-induced ST-segment elevation for predicting functional recovery after acute myocardial infarction. BACKGROUND: Clinical significance of stress-induced ST-segment elevation after acute myocardial infarction remains controversial. According to previous studies, it may reflect a larger infarcted area, depressed left ventricular function, left ventricular aneurysm, stress-induced dyskinesia, residual myocardial ischemia, or viability in the affected region. Whether transient ST-segment elevation occurring during dobutamine testing may predict functional recovery is unknown. METHODS AND RESULTS: We studied 38 patients who underwent dobutamine stress testing early (5 +/- 2 days) after a first acute myocardial infarction. Dobutamine was infused at increasing doses from 5 to a maximum of 40 microg/kg per minute, with the addition of up to 1 mg of atropine if the target rate could not be reached by dobutamine alone. Twelve-lead electrocardiography and cross-sectional echocardiography were continuously monitored throughout the test. Dobutamine-induced ST-segment elevation was defined as a new or worsening >/=1 mm elevation, 80 ms after J point, in >/=2 infarct-related leads. Quantitative angiography was available in all patients before hospital discharge. Follow-up resting echocardiography was recorded in all patients 12 to 18 months after the acute event. ST-segment elevation was observed in 20 of the 38 patients. There were no significant differences between patients with and those without dobutamine-induced ST-segment elevation in age, site of infarction, peak level of total creatine kinase enzyme, and use of thrombolytic therapy, angioplasty, or both. Persistent akinesis without change during dobutamine stress testing was more frequently observed in patients without ST elevation (P <. 05). A biphasic response during dobutamine testing was more frequently observed in patients with ST-segment elevation (P =.01). Multivariate analysis selected 2 independent variables associated with ST-segment elevation: a biphasic response during dobutamine stress (chi-square = 7.3; P =.007) and the minimal lumen diameter of the infarct-related vessel at quantitative angiography (chi-square = 5.5; P <.02). Functional recovery was demonstrated in 26 patients. Sensitivity of ST-segment elevation for the prediction of functional recovery was 69%, specificity 83%, positive predictive value 90%, and accuracy 74%. Two independent variables predicting functional recovery were selected: dobutamine-induced ST-segment elevation (chi-square = 9.1; P =.003) and a biphasic response during stress (chi-square = 6.15; P =.013). CONCLUSIONS: Dobutamine-induced ST-segment elevation in the infarct-related leads is an ancillary sign of viable myocardium in jeopardy. It has a high specificity and an acceptable sensitivity for the prediction of functional recovery after acute myocardial infarction.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Pierard, Luc ; Université de Liège - ULiège > Département des sciences cliniques > Cardiologie - Pathologie spéciale et réhabilitation
Lancellotti, Patrizio ; Université de Liège - ULiège > Département des sciences cliniques > Imagerie cardiaque fonctionnelle par échographie
Kulbertus, Henri ; Université de Liège - ULiège > Relations académiques et scientifiques (Médecine)
Language :
English
Title :
St-Segment Elevation During Dobutamine Stress Testing Predicts Functional Recovery after Acute Myocardial Infarction
Stiles GL, Rosati RA, Wallace AG. Clinical relevance of exercise-induced S-T segment elevation. Am J Cardiol 1980;46:931-6.
Gewirtz H, Sullivan M, O'Reilly G, et al. Role of myocardial ischemia in the genesis of stress-induced S-T segment elevation in previous anterior myocardial infarction. Am J Cardiol 1983;51:1289-93.
Chahine RA, Raizner AE, Ishimori T. The clinical significance of exercise-induced ST-segment elevation. Circulation 1976;54:209-13.
Gorlin R, Klein MD, Sullivan JM. Prospective correlation study of ventricular aneurysm: mechanistic concept and clinical recognition. Am J Med 1967;42:512-7.
Lahiri A, Balasubramanian V, Millar Craig MW, et al. Exercise-induced ST-segment elevation: electrocardiographic, angiographic, and scintigraphic evaluation. Br Heart J 1980;43:582-8.
Waters DD, Chaitman BR, Bourassa MG, et al. Clinical and angiographic correlates of exercise-induced ST-segment elevation: increased detection with multiple ECG leads. Circulation 1980;61:286-96.
Fox KM, Jonathan A, Selwyn A. Significance of exercise induced ST-segment elevation in patients with previous myocardial infarction. Br Heart J 1983;49:15-9.
Dunn RF, Bailey IK, Uren R, et al. Exercise-induced ST-segment elevation: correlation of Thallium-201 myocardial perfusion scanning and coronary arteriography. Circulation 1980;61:989-95.
Sriwattanakomen S, Ticzon AR, Zubritzky SA, et al. S-T segment elevation during exercise: electrocardiographic and arteriographic correlation in 38 patients. Am J Cardiol 1980;45:762-8.
Margonato A, Ballarotto C, Bonetti F, et al. Assessment of residual tissue viability by exercise testing in recent myocardial infarction: comparison of the electrocardiogram and myocardial perfusion scintigraphy. J Am Coll Cardiol 1992;19:948-52.
Margonato A, Chierchia SL, Xuereb RG, et al. Specificity and sensitivity of exercise-induced ST-segment elevation for detection of residual viability: comparison with fluorodeoxyglucose and positron emission tomography. J Am Coll Cardiol 1995;25:1032-8.
Piérard LA, De Landsheere CM, Berthe C, et al. Identification of viable myocardium by echocardiography during dobutamine infusion in patients with myocardial infarction after thrombolytic therapy: comparison with positron emission tomography. J Am Coll Cardiol 1990;15:1021-31.
Previtali M, Poli A, Lanzarini L, et al. Dobutamine stress echocardiography for assessment of myocardial viability and ischemia in acute myocardial infarction treated with thrombolysis. Am J Cardiol 1993;72:124G-30G.
Berthe C, Pierard LA, Hiernaux M, et al. Predicting the extent and location of coronary artery disease in acute myocardial infarction by echocardiography during dobutamine infusion. Am J Cardiol 1986;58:1167-72.
Lombardo A, Loperfido F, Pennestri F, et al. Significance of transient ST-T segment changes during dobutamine testing in Q wave myocardial infarction. J Am Coll Cardiol 1996;27:599-605.
Lanzarini L, Fetiveau R, Poli A, et al. Significance of ST-segment elevation during dobutamine-stress echocardiography in patients with acute myocardial infarction treated with thrombolysis. Eur Heart J 1996;17:1008-14.
Albert A, Anderson JA. Probit and logistic discriminant functions. Community Stat 1981;A10:641-57
Weiner DA, McCabe C, Klein MD, et al. ST-segment changes post-infarction: predictive value of multi-vessel coronary disease and left ventricular aneurysm. Circulation 1978;58:887-91.
Chahine RA, Lowery MH, Bauerlein EJ. Interpretation of the exercise-induced ST-segment elevation. Am J Cardiol 1993;72:100-2.
Elhendy A, Cornel JH, Roelandt JRTC, et al. Relation between ST-segment elevation during dobutamine stress test and myocardial viability after a recent myocardial infarction. Heart 1997;77:115-21.
Haines DE, Beller GA, Watson DD, et al. Exercise-induced ST-segment elevation 2 weeks after uncomplicated myocardial infarction: contributing factors and prognostic significance. J Am Coll Cardiol 1987;9:996-1003.
Nesto RW, Cohn LH, Wynne J, et al. Inotropic contractile reserve: a useful predictor of increased 5 year survival and improved postoperative left ventricular function in patients with coronary artery disease and reduced ejection fraction. Am J Cardiol 1982;50:39-44.
Rozanski A, Berman D, Gray R, et al. Preoperative prediction of reversible myocardial asynergy by postexercise radionuclide ventriculography. N Engl J Med 1982;307:212-6.
Popio KA, Gorlin R, Bechtel D, et al. Postextrasystolic potentiation as a predictor of potential myocardial viability: preoperative analysis compared with studies after coronary bypass surgery. Am J Cardiol 1977;39:944-53.
Dilsizian V, Rocco TP, Freedman NMT, et al. Enhanced detection of ischemic but viable myocardium by the reinjection of thallium after stress-redistribution imaging. N Engl J Med 1990;323:141-6.
Tillisch J, Brunken R, Marshall R, et al. Reversibility of cardiac wall-motion abnormalities predicted by positron tomography. N Engl J Med 1986;314:884-8.
Salustri A, Garyfallidis P, Elhendy A, et al. T-wave normalization during dobutamine echocardiography for diagnosis of viable myocardium. Am J Cardiol 1995;75:505-7
Chen C, Li L, Chen LL, et al. Incremental doses of dobutamine induce a biphasic response in dysfunctional left ventricular regions subtending coronary stenoses. Circulation 1995;92:756-66.
Shimonagata T, Nishimura T, Uehara T, et al. Exercise-induced ST-segment elevation in leads over infarcted area and residual myocardial ischemia in patients with previous myocardial infarction. Am J Physiol Imaging 1990;5:99-106.
Coma-Canella I, Gomez MV, Terol I, et al. Radionuclide studies in patients with stress-induced ST-segment elevation after acute myocardial infarction. Am Heart J 1994;128:459-65.
Prinzmetal M, Toyoshima H, Ekmekci A, et al. Myocardial ischemia: nature of ischemic electrocardiographic patterns in the mammalian ventricle as determined by intracellular electrocardiographic and metabolic changes. Am J Cardiol 1961;8:493-503.
Bayley RH. An interpretation of the injury and the ischemic effects of myocardial infarction in accordance with the laws which determine the flow of electric currents in homogeneous volume conductors and in accordance with relevant pathologic changes. Am Heart J 1942;24:514-28.
Cinca J, Bardaji A, Carreno A, et al. ST-segment elevation at the surface of a healed transmural myocardial infarction in pigs. Circulation 1995;91:1552-9.
Afridi I, Kleiman NS, Raizner AE, et al. Dobutamine echocardiography in myocardial hibernation: optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995;91:663-70.