From the CNR Institute of Clinical Physiology, Pisa, Italy.
Correspondence to Eugenio Picano, MD, PhD, FESC, CNR Institute of Clinical Physiology, Via Savi, 8, 56100 Pisa, Italy. E-mail picano{at}nsifc.ifc.pi.cnr.it
Background—Residual viable
myocardium identified by dobutamine stress
after myocardial infarction may act as an unstable substrate for
further events such as subsequent angina and reinfarction. However, in
patients with severe global left ventricular dysfunction,
viability might be protective rather than detrimental. The aim of this
study was to assess the impact on survival of
echocardiographically detected viability in medically
treated patients with global left ventricular dysfunction
evaluated after acute uncomplicated myocardial infarction.
Methods and Results—The data bank of the large-scale,
prospective, multicenter, observational Echo Dobutamine
International Cooperative (EDIC) study was interrogated to select 314
medically treated patients (271 men; age, 58±9 years) who underwent
low-dose (
Conclusions—In medically treated patients with severe global left
ventricular dysfunction early after acute uncomplicated
myocardial infarction, the presence of myocardial viability identified
as inotropic reserve after low-dose dobutamine is
associated with a higher probability of survival. The higher the number
of segments showing improvement of function, the better the impact is
of myocardial viability on survival. The presence of inducible
ischemia in this set of patients is the best predictor of
cardiac death.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Prognostic Value of Myocardial Viability in Medically Treated Patients With Global Left Ventricular Dysfunction Early After an Acute Uncomplicated Myocardial Infarction
A Dobutamine Stress Echocardiographic Study
10 µg · kg-1 ·
min-1) dobutamine for the detection of
myocardial viability and high-dose dobutamine for the
detection of myocardial ischemia (40 µg ·
kg-1 · min-1 with atropine 1 mg)
performed 12±6 days after an acute uncomplicated myocardial infarction
and showing a moderate to severe resting left ventricular
dysfunction (wall motion score index [WMSI] >1.6). Patients
were followed up for 9±7 months. Low-dose dobutamine
stress echocardiography identified myocardial
viability in 130 patients (52%). Dobutamine-atropine
stress echocardiography was positive for
ischemia in 148 patients (47%) and negative in 166 patients
(53%). During the follow-up, there were 12 cardiac deaths (3.8% of
the total population). With the use of Cox proportional hazards model,
delta low-dose WMSI (the variation between rest WMSI and
low-dose WMSI) was shown to exert a protective effect by reducing
cardiac death by 0.8 for each decrease in WMSI at low-dose
dobutamine (coefficient, -0.2; hazard ratio, 0.8;
P<0.03); WMSI at peak stress was the best predictor of
cardiac death in this set of patients (hazard ratio, 14.9;
P<0.0018).
Key Words: dobutamine • echocardiography • infarction • prognosis
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