Dobutamine stress echocardiography - Safety in diagnosing coronary artery disease

Dobutamine stress echocardiography is considered a relatively well-tolerate d diagnostic modality, effective in the management of patients with known o r suspected coronary artery disease. Adverse effects during testing are rel atively frequent, precluding the achievement of a diagnostic end-point in a bout 5 to 10% of tests. These adverse effects, mostly tachyarrhythmias and arterial hypotension, are usuary minor and self limiting. However, severe l ife-threatening complications, as well as death, also occur. By analysing Medline-quoted literature up to March 1999, we found 35 origin al studies from a single institution with more than 100 patients, as well a s 2 multicentre studies, concerning the feasibility and safety of dobutamin e stress echocardiography. In a cumulative total of 26 438 tests performed, 79 life-threatening complications (such as acute myocardial infarction, as ystole, ventricular fibrillation, sustained ventricular tachycardia or seve re symptomatic hypotension) have been reported, giving an incidence of 1 se vere adverse reaction per every 335 examinations. In addition, 29 isolated case reports have been published describing life-threatening complications during dobutamine echocardiography. In case reports, 2 deaths have been des cribed, both due to acute cardiac rupture in patients with recent inferior myocardial infarction. Severe adverse reactions during dobutamine echocardi ography can be ischaemia independent, and are independent of operator exper ience and are unpredictable; some complications can be late occurring and l ong lasting. As a consequence, the procedure must be clearly indicated, wri tten informed consent has to be obtained from the patient, an attending phy sician must be present during testing, and long term observation of outpati ents is useful in order to manage late complications. In conclusion, while the safety of dobutamine stress echocardiography was r eported to be outstanding in early reports, further experience presents a s ubstantially more worrying picture. This must be taken into account by both physicians and patients when assessing the risk-benefit profile of the pro cedure.