ABSTRACT
Although dobutamine-atropine stress echocardiography (DASE) is an established method for evaluating patients who have coronary artery disease (CAD), it can increase test duration and a patient's exposure to large doses of dobutamine. New protocols, including the early injection of atropine during dobutamine stress echocardiography (EA-DSE), have been proposed to decrease test duration. This study compared the safety, efficacy, and accuracy of EA-DSE with those of DASE. We retrospectively evaluated 3,163 patients who underwent DASE and 1,664 patients who underwent EA-DSE over a period of 12 years. In EA-DSE, atropine at a dose =2 mg was started with 20 microg/kg/min of dobutamine if heart rate was <100 beats/min. Diagnostic accuracy for detecting CAD (>50% stenosis) was assessed in patients who underwent quantitative angiography =3 months of stress testing. The dobutamine dose used in EA-DSE was smaller than that used in DASE (31 +/- 6 vs 36 +/- 6 microg/kg/min, p <0.0001), although the atropine dose was larger (0.8 +/- 0.5 vs 0.5 +/- 0.25 mg, p <0.0001). EA-DSE resulted in a significantly shorter duration of dobutamine infusion (12.4 +/- 2.0 vs 14.6 +/- 2.5 minutes, p <0.0001), more diagnostic studies (88% vs 81%, p <0.0001), and a lower incidence of minor adverse effects than did DASE. The rate of major adverse effects was similar in the 2 protocols. Sensitivities, specificities, positive predictive values, negative predictive values, and accuracies for detecting CAD were 84%, 90%, 93%, 76%, and 86% for EA-DSE and 86%, 78%, 84%, 79%, and 82% for DASE, respectively (p = NS). Therefore, EA-DSE is a safe and effective alternative to DASE and had a similar accuracy for the detection of CAD.
Subject(s)
Anti-Arrhythmia Agents/administration & dosage , Anti-Arrhythmia Agents/adverse effects , Atropine/administration & dosage , Atropine/adverse effects , Coronary Artery Disease/diagnostic imaging , Echocardiography, Stress/methods , Aged , Anti-Arrhythmia Agents/therapeutic use , Atropine/therapeutic use , Drug Administration Schedule , Female , Heart Rate/drug effects , Humans , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , Sensitivity and SpecificityABSTRACT
RESUMO: Objetivo: Determinar a segurança, eficácia, e acurácia diagnóstica da infusão precoce de atropina durante a ecocardiografia sob estresse peladobutamina (AP-EED), em comparação com o protocolo convencional de dobutamina-atropina (EEDA), em pacientes com doença arterial coronariana (DAC) conhecida ou suspeita. Introdução: Embora a EEDA seja um método bem estabelecido para avaliar pacientes com DAC, pode resultar em longa duração do teste e exposição dos pacientes a altas doses de dobutamina. Novos protocolos, incluindo AP-EED, têm sido propostos para reduzir aduração do teste. Métodos: Estudamos retrospectivamente 3163 pacientes submetidos a EEDA e 1664 pacientes submetidos a AP-EED, em um período de 12 anos. No protocolo EEDA, atropina foi injetada apenas na dose máxima de dobutamina, enquanto na AP-EED atropina foi iniciada com 20mcg/Kg/min de dobutamina se a freqüência cardíaca estivesse <100 bpm, até 2mg. A acurácia diagnóstica para detecção de DAC (estenose >50 por cento em >_1 artéria coronariana) foi avaliada em pacientes que realizaram angiografia quantitativa dentro de três meses após o ecocardiograma sob estresse. Resultados: A dose total de dobutamina utilizada na AP-EED foi menor que na EEDA (31+- 6 verso 36 +- 6 mcg/Kg/min;p<0,OOO1), enquanto a dose de atropina foi maior (0,8+-0,5 verso 0,5+-0,25 mg; p<0,0001). Com AP-EED houve redução significativa da duração do teste (12,4+-2,0 verso 14,6+-2,5 minutos;p<0,OO01), maior porcentagem de testes eficazes (88 por cento verso 81 por cento;pSubject(s)
Humans
, Male
, Atropine/adverse effects
, Atropine/therapeutic use
, Echocardiography, Stress/adverse effects
, Echocardiography, Stress/methods
, Coronary Angiography/methods
, Myocardial Ischemia/diagnosis
, Myocardial Ischemia/therapy
ABSTRACT
Humoral response emerges as an important component in acute graft rejection and a new challenge to clinicians in posttransplant care. Management of recurrent episodes and persistent activation of the humoral component of the immune system, despite the usual therapeutic approach to rejection, remains unknown. This article describes the successful use of methotrexate as an option for rescuing a graft in this worrisome situation.