DOBUTAMINE STRESS

ECHOCARDIOGRAPHY
Jerry Marisi H Marbun
Introduction
Stress echocardiography
• A procedure that allows for the dynamic evaluation of cardiac structure and function
during physical exercise or the pharmacologic simulation of exercise
• Increased heart rate, cardiac output, and myocardial oxygen demand

Stress echocardiographic imaging techniques may be used to evaluate

for myocardial ischemia, viability, and valvular dysfunction

Dobutamine stress echocardiography (DSE) avoids radiation and

enjoys relatively high sensitivity (81-85%) and specificity (79-81%) for
multiple types of cardiovascular pathophysiology
Advantage Disadvantages
• Higher sensitivity and specificity • Patient selection is very
than ETT important
• Higher accuracy 84% • Must be able to obtain imaged
within one minute
• Quicker than nuclear stress
• Interpreting physician
• Can evaluate LV function dependent
• Can localize wall motion
abnormalities
Contraindications
• Ventricular arrhythmias
• Recent myocardial infarction (within 3 days)
• Unstable angina
• Significant left ventricular outflow obstruction (resting peak late
systolic pressure gradient ≥30 mmHg)
• Aortic dissection
• Severe (resting SBP>180 mmHg or DBP>100 mmHg) or symptomatic
hypertension
Procedure and technique
• All negative chronotropic agents and nitrates should be held 8–12
hours before DSE, unless the goal is to assess the efficacy
• Dobutamine infusion is given at a starting dose of 5 μg/kg/mnt
• The dose is increased every 3–5 minutes to doses of 10, 20, and 30,
and finally to 40 μg/kg/mnt
• The goal is to achieve a heart rate 85% of the MHR for age
End points
• Achievement of the target heart rate
• Detection of moderate wall motion abnormalities in at least two
territories
• Symptomatic or sustained arrhythmias
• Hypotension or severe hypertension (typically systolic pressure 220–
240 mmHg or diastolic pressure 120 mmHg)
• Patient’s inability to tolerate the test
Safety

• Dobutamine may be more dangerous than

other form pharmacological stress
• There is risk albeit minor
• Physician should be present
Coronary Arterial Disease
Principle
• Dobutamine acts on β1-, β2- and mild effect on α1-adrenergic
receptors
• The goal of DSE is to detect myocardial ischemia early in the
progression of coronary disease by identifying RWMA under
pharmacologic stress
• Dobutamine temporarily increases myocardial oxygen consumption
and thereby can provoke ischemia
Testing interpretation
False Negative
• Inadequate stress
• Antianginal treatment
(especially beta blocker)
• Mild stenosis
• LCx disease
• Poor image quality
False Positive
• Over interpretation,
interpretation bias
• Localised basal inferior wall
abnormalities
• Abnomal septal motion (LBBB,
post CABG)
• Cardiomyophaties
• Hypertensive responses to stress
Valvular Heart Disease
Exercise echo in VHD
 Aortic Stenosis
Indication :
1. Asymptomatic pts with severe AS
2. Low flow, low gradient, LVEF <40%

Evaluate :
• AVA, transvalvular gradient
• Contractile reserve (stroke volume)
 Aortic Stenosis
• DSE is indicated in low-gradient severe aortic stenosis (AVA <1.0 cm2,
mean pressure gradient <30 mm Hg) with LV systolic dysfunction
• DSE is used to assess both the severity of aortic stenosis and the
presence of LV contractile reserve
• Contraindication: Severe symptomatic aortic stenosis

Aortic valve replacement appears to improve

outcome for patients with LV contractile reserve
AS low flow low gradien
 Mitral Stenosis
• DSE with focus on transmitral pressure gradient and pulmonary
pressure is useful for patients in the grey zone
• For detailed evaluation whenevere symptomatic status does not fit
with stenosis severity
• Measurement of systolic pulmonary pressure and transmitral
pressure gradient during stress may be used as surrogates invasive
• Exercise induced increase of PASP>60 mmHg (for surgical indication)
• Asymptomatic patient with significant lessions based on
hemodynamic lesion at rest (Class 1)
• Symptomatic patients disproportionate to resting doppler
hemodynamic (Class1)

• Evaluate: MVG , TR velocity, PASP, MVA

(caveat: AF, significant MR, tachycardia)
• Mean MVG >15 mmHg and PASP >60 mmHg
Severe Mitral Stenosis
 Mitral Regurgitation
• Asymptomatic Severe MR (to identify unrecognized symptoms or
subclinical latent LV dysfunction)
• Symptomatic mild-moderate MR
Evaluate: PASP, LVEF, dynamic MR
• DSE has value in identifying hemodynamically
significant dynamic mitral regurgitation
• Predicts poor outcome
 Aortic Regurgitation
• Still unclear
• To evaluate functional capacity, symptoms, and contractile reserve
• For asymptomatic patients or good EF
 Pulmonary hypertension
• DSE may be utilized for detecting pulmonary hypertension secondary
to left-sided valvular disease
• Detection of elevated pulmonary artery pressures during stress
predicts poorer outcomes in these patients
THANK YOU