PROGNOSTIC IMPLICATIONS OF A NORMAL DOBUTAMINE-ATROPINE STRESS ECHOCARDIOGRAM IN PATIENTS WITH CHEST PAIN

To assess the prognostic significance of a normal dobutamine-atropine stress echocardiogram in relation to the pretest probability of corona ry artery disease (CAD), 200 consecutive patients (86 men and 114 wome n, mean [SD] age 59 [13] years) with a stable chest pain syndrome and a normal dobutamine-atropine stress echocardiogram were followed-up fo r 21 +/- 16 months. Outcome events were cardiac death, nonfatal myocar dial infarction, and coronary revascularization procedures. Low (<10%) , intermediate (10% to 80%), and high (>80%) pretest probabilities of CAD were present in 27 (14%), 108 (54%), and 65 (33%) patients, respec tively. During follow-up, 2 patients (annual event rate 0.6%) had card iac death, none had nonfatal myocardial infarction, and 4 patients (an nual event rate 1.1%) underwent a coronary revascularization procedure . Al patients with cardiac events had high pretest probabilities of CA D. Patients with cardiac death (but unproven significant CAD) had maxi mal tests without angina or ischemic electrocardiographic changes. In contrast, all patients with subsequent coronary revascularization had dobutamine-induced angina or ischemic electrocardiographic changes, an d all except one study were submaximal. We conclude that patients with a stable chest pain syndrome and normal findings on dobutamine-atropi ne stress echocardiograms have an excellent cardiac prognosis. However , patients with typical angina, high pretest probabilities of CAD, and stress-induced angina or ischemic electrocardiographic changes, and i n particular those with submaximal stress, still appear to be at risk for functionally important CAD despite a normal dobutamine-atropine st ress echocardiogram.