Safety and prognostic value of early dobutamine-atropine stress echocardiography in patients with spontaneous chest pain and a non-diagnostic electrocardiogram

Aims To risk stratify;and shorten hospital stay in patients with spontaneou s (resting) chest pain and a non-diagnostic electrocardiogram (ECG). Methods and Results The study comprised 102 patients (mean age 58 +/- 12 ye ars, 67 men) with spontaneous chest pain and a non-diagnostic EGG. Forty-th ree patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwe nt serial creatine kinase enzyme measurements, continuous ECG monitoring fo r at least 12 h and early dobutamine-atropine stress echocardiography in pa tients with negative creatine kinase enzymes and normal findings at ECG mon itoring. Dobutamine-atropine stress echocardiography was considered positiv e in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine-atropine stress echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction,unstable angina, and coronary arter y bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable ang ina by ECG monitoring. In the remaining 89 patients, dobutamine-atropine st ress echocardiography was performed after a median observation period of 31 h (range 12-68 h). During dobutamine-atropine stress echocardiography no s erious complications (death, non-fatal myocardial infarction, sustained ven tricular tachycardia or ventricular fibrillation) occurred. Dobutamine-atro pine stress echocardiography results were of poor quality in three, non-dia gnostic in six, negative in 44 and positive in 36 patients. In the 80 patie nts with diagnostic dobutamine-atropine stress echocardiography, variables associated with in-hospital events (n = 7) were history of exertional angin a (P<0.005), chest pain score (P<0.005), stress-induced angina (P<0.001) an d positive dobutamine-atropine stress echocardiography (P<0.005). Variables associated with follow-up events (n = 11) were history of exertional angin a (P<0.05), chest pain score (P<0.001), stress-induced angina (P<0.01) and positive dobutamine-atropine stress echocardiography (P<0.01). At multivari ate analysis the only significant predictor of events was positive dobutami ne-atropine stress echocardiography (P<0.01). Conclusion Early dobutamine-atropine stress echocardiography may safely dis tinguish between low- and high-risk subsets for subsequent cardiac events i n patients with spontaneous chest pain and a non-diagnostic EGG. (C) 2000 T he European Society of Cardiology.