Prevalence of Coronary Artery Spasm During Dobutamine Stress Echocardiography




The aim of this study was to assess the prevalence of coronary artery spasm during dobutamine stress echocardiography (DSE). Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n = 2,224) referred for DSE. Criteria for selection included patients >18 years old who underwent DSE. We systematically analyzed all electrocardiograms obtained during DSE to detect ST-segment elevation during the examination. All patients with ST-segment elevation underwent coronary angiography. DSE was performed in 2,179 patients. ST-segment elevation was observed in 21 patients, all of whom underwent emergency coronary angiography. In 13 of these 21 patients (62%) significant coronary stenosis was observed: 6 patients with critical coronary stenosis and 7 patients with chronic coronary occlusion. The remaining 8 patients (38% of patients presenting with ST-segment elevation during DSE, 7 men, mean age 67 ± 11 years) had no significant coronary stenosis. Prevalence of coronary artery spasm during DSE was 0.4%. In conclusion, physicians should be aware that, although rare, coronary artery spasm may occur during DSE.


Dobutamine stress echocardiography (DSE) is a widely used echocardiographic examination for assessment of coronary ischemia because of its diagnostic and prognostic value. Several complications or side effects of DSE have been reported such as death, myocardial infarction, supraventricular or ventricular arrhythmias, hypotension, and coronary spasm. Vasospasm can be caused by an increase in coronary tone through α-adrenergic stimulation. However, coronary spasm has been described mainly in case reports and studies remain rare and the prevalence of this specific side effect of DSE is therefore uncertain. The aim of this study was to assess the prevalence of coronary spasm during DSE.


Methods


Over a 9-year period (from November 2001 to October 2010) we reviewed all consecutive patients (n = 2,224) referred for DSE. Entry criteria included an age >18 years and all patients who underwent DSE. We first distinguished patients presenting with normal dobutamine stress echocardiogram (no significant symptoms, electrocardiographic modifications, or wall motion abnormalities during examination) from patients presenting with positive dobutamine stress echocardiographic findings according to guidelines. In patients presenting with positive dobutamine stress echocardiographic findings, we systematically analyzed all electrocardiograms obtained during the echocardiographic examination, thus identifying patients with ST-segment elevation during stress testing. Coronary spasm induced during DSE was defined as a positive dobutamine stress echocardiographic finding with ST-segment elevation and wall motion abnormalities associated with normal coronary angiogram (nonsignificant coronary stenosis).


All echocardiographic examinations were performed using a Siemens/Sequoia Acuson C512 system (Acuson, Mountain View, California) equipped with multifrequency transducers and capable of low energy (0.2 to 0.3 mechanical index). For suboptimal acoustic windows, left ventricular cavity opacification was performed by peripheral venous injection of SonoVue contrast agent (Bracco Altana, Inc., Milan, Italy). Dobutamine was administered intravenously in an incremental regimen of 10, 20, 30, and 40 μg/kg/min every 3 minutes for each dose (from 2001 to 2004) and every 2 minutes after this first period. Atropine (0.25 to 1 mg) was administered at the beginning of dobutamine 20-, 30-, and 40-μg/kg/min administration and DSE was stopped when the target heart rate (85% of predicted maximal heart rate [220 minus age {years}]) was achieved. Dobutamine stress echocardiogram was interpreted according to guidelines. All patients with ST-segment elevation during DSE underwent coronary angiography. Significant coronary artery stenosis was defined as ≥50% diameter narrowing.


Statistical analysis was performed using STATA 8.0 (STATA Corp., College Station, Texas). Continuous variables are presented as mean ± SD and categorical data are presented as absolute value and percentage. Categorical variables were compared using unpaired t tests or Fisher’s exact test as appropriate.




Results


Of 2,224 patients referred for DSE in our institution, 2,179 (1,649 men, 76%) underwent complete DSE ( Figure 1 ) . Mean age was 67 ± 11 years. In the 694 patients presenting with positive dobutamine stress echocardiographic findings, we individualized 21 (1%) with ST-segment elevation during DSE. All these patients underwent emergency coronary angiography. In 13 of these 21 patients (62%), significant coronary stenosis was observed: critical coronary stenosis (i.e., lumen diameter stenosis >80%) was documented in 6 and chronic coronary artery occlusion (i.e., Thrombolysis In Myocardial Infarction grade 0 flow and spontaneously visible collaterals or known coronary occlusion on previous coronary artery angiogram) in 7. In all patients presenting with chronic coronary artery occlusion, Q waves associated with persistent ST-segment elevation were observed at baseline in leads with ST-segment elevation during DSE.




Figure 1


Flowchart of patients in study. ECG = electrocardiographic.


Eight patients ( Table 1 ) had no significant coronary stenosis despite ST-segment elevation (38% of patients presenting with ST-segment elevation) always being observed in inferior leads ( Figure 2 ) . Prevalence of coronary spasm was 0.4% and no significant difference was observed in patients included before 2005 and patients included later (p = 0.9). Dobutamine stress echocardiographic characteristics of patients presenting with coronary spasm are presented in Table 2 . Only 2 types of dobutamine stress echocardiographic indications were found for these 8 patients: preoperative risk assessment in 3 asymptomatic patients (0.14% of dobutamine stress echocardiograms) and spontaneous episodes of chest pain in 5 patients (0.23% of dobutamine stress echocardiograms). No patient presented with chest pain during exercise. Interestingly, for these 5 patients with spontaneous episodes of chest pain, the provoked chest pain during DSE was similar to the chest pain before DSE and was relieved by sublingual nitroglycerin associated with regression of ST-segment elevation. In 2 patients with spontaneous episodes of chest pain, intracoronary methyl ergometrine revealed vasospastic angina. Figure 3 presents the pattern of right coronary artery without medication, with dobutamine infusion, and with intracoronary methyl ergometrine administration in the same patient who presented with spontaneous chest pain.



Table 1

Characteristics of patients presenting with coronary artery spasm during dobutamine stress echocardiography













































































































































Patient Number Age (years)/Sex Spontaneous Chest Pain Smoker Hypertension ⁎ Diabetes Mellitus Hypercholesterolemia † Aortoiliac Occlusive Disease Previous Medical Treatment
Antiplatelet Agent Anticoagulant Beta Blockers Statins Calcium Blockers Nitrates
1 53/M + + + − + − − − − − − +
2 57/M + + − − + − + − − − − −
3 63/M − + + + + + + − − + − −
4 63/M + + + − + − + − − + − −
5 66/M + + + + + + + − + + + +
6 72/M − + + − − + − − − − − −
7 77/F + − + − + − + − + + − −
8 86/M − + + − − − − + + − − −

⁎ Defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg.


† Defined as total cholesterol >2 g/L and/or target level of low-density lipoprotein depending on number of risk factors.




Figure 2


Twelve-lead electrocardiogram in a patient presenting with coronary artery spasm during dobutamine stress echocardiography. (A) At baseline no abnormalities were detected. (B) At peak stress the patient presented with chest pain, wall motion abnormalities, and ST-segment elevation in inferior leads associated with ST-segment depression in leads DI, aVL, V 1 , and V 2 .


Table 2

Characteristics of dobutamine stress echocardiography in patients presenting with coronary artery spasm















































































































































Patient Number Age (years) Heart Rate Systolic Blood Pressure Significant Wall Motion Abnormalities
Baseline 10 μg/kg/min 20 μg/kg/min 30 μg/kg/min 40 μg/kg/min Baseline 10 μg/kg/min 20 μg/kg/min 30 μg/kg/min 40 μg/kg/min Baseline Peak stress
1 53 62 70 95 139 146 109 103 125 90 106 0 1
2 57 89 91 94 129 148 131 131 123 187 235 0 1
3 63 74 77 92 129 133 169 167 157 158 156 0 1
4 63 62 58 58 83 140 143 146 155 141 122 0 1
5 66 76 78 79 80 144 123 109 110 106 106 0 1
6 72 61 57 56 67 132 149 123 140 133 143 0 1
7 77 66 81 91 99 126 152 177 192 175 155 0 1
8 86 73 66 73 70 140 139 144 176 165 142 0 1

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Dec 15, 2016 | Posted by in CARDIOLOGY | Comments Off on Prevalence of Coronary Artery Spasm During Dobutamine Stress Echocardiography

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