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.
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.


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 (</=10 microg x kg-1 x min-1) dobutamine for the detection of myocardial viability and high-dose dobutamine for the detection of myocardial ischemia (</=40 microg x kg-1 x 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).


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.
Picano
E
E
From the CNR Institute of Clinical Physiology, Pisa, Italy. picano@nsifc.ifc.pi.cnr.it
Sicari
R
R
Landi
P
P
Cortigiani
L
L
Bigi
R
R
Coletta
C
C
Galati
A
A
Heyman
J
J
Mattioli
R
R
Previtali
M
M
Mathias
W
W
Dodi
C
C
Minardi
G
G
Lowenstein
J
J
Seveso
G
G
Pingitore
A
A
Salustri
A
A
Raciti
M
M
D000368:Aged; D000789:Angina, Unstable / Q000000981:diagnostic imaging / Q000401:mortality; D001285:Atropine; D004280:Dobutamine; D004452:Echocardiography; D005080:Exercise Test / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000401:mortality; D010276:Parasympatholytics; D011237:Predictive Value of Tests; D011379:Prognosis; D016019:Survival Analysis; D013566:Sympathomimetics; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000401:mortality
D010276:Parasympatholytics; D013566:Sympathomimetics; D004280:Dobutamine; D001285:Atropine