Skip Navigation


European Heart Journal Advance Access originally published online on November 28, 2006
European Heart Journal 2006 27(24):3039-3044; doi:10.1093/eurheartj/ehl393
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
27/24/3039    most recent
ehl393v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Chaowalit, N.
Right arrow Articles by Pellikka, P. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chaowalit, N.
Right arrow Articles by Pellikka, P. A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

© The European Society of Cardiology 2006. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Outcomes after normal dobutamine stress echocardiography and predictors of adverse events: long-term follow-up of 3014 patients

Nithima Chaowalit1, Robert B. McCully1, Mark J. Callahan1, Farouk Mookadam1, Kent R. Bailey2 and Patricia A. Pellikka1,*

1 Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
2 Department of Biostatistics, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA

Received 27 December 2005; revised 24 October 2006; accepted 7 November 2006; online publish-ahead-of-print 28 November 2006.

* Corresponding author. Tel: +1 507 266 0676; fax: +1 507 284 3968. E-mail address: pellikka.patricia{at}mayo.edu


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Aims Normal exercise echocardiography predicts a good prognosis. Dobutamine stress echocardiography (DSE) is generally reserved for patients with comorbidities which preclude exercise testing. We evaluated predictors of adverse events after normal DSE.

Methods and results We studied 3014 patients (1200 males, 68±12 years) with normal DSE, defined as the absence of wall motion abnormality at rest or with stress. During median follow-up of 6.3 years, all-cause mortality and cardiac events, defined as myocardial infarction and coronary revascularization, occurred in 920 (31%) and 231 (7.7%) patients, respectively. Survival and cardiac event-free probabilities were 95 and 98% at 1 year, 78 and 93% at 5 years, and 56 and 89% at 10 years, respectively. Age, diabetes mellitus, and failure to achieve 85% age-predicted maximal heart rate were independent predictors of mortality and cardiac events. Patients with all three of these characteristics had a 13% probability of cardiac events within the first year and higher risk throughout follow-up.

Conclusion Prognosis after normal DSE is not necessarily benign, but depends on patient and stress test characteristics. Careful evaluation, using clinical and stress data, is required to identify patients with normal DSE who are at increased risk of adverse outcomes during long-term follow-up.

Key Words: Dobutamine • Ischaemic heart disease • Prognosis • Stress echocardiography


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Dobutamine stress echocardiography (DSE) is an appealing alternative to exercise echocardiography in patients who are unable to exercise. Previous small studies have reported excellent short- and intermediate-term outcomes after normal DSE.1–4 However, much less is known about long-term follow-up. Previous studies of exercise echocardiography have suggested a favourable prognosis after a normal test result, even in patients with a clinically intermediate or high pretest probability of coronary artery disease (CAD).5 Given the relatively poor prognosis of patients who are unable to exercise and the comorbid conditions typically present in patients who undergo DSE, it is reasonable to postulate that outcomes after normal DSE may be less favourable. Attention has focused on those variables characterizing an abnormal stress echocardiogram, namely extent and severity of wall motion abnormalities (WMA), change in left ventricular (LV) end-systolic volume and ischaemic threshold, which characterize patients at risk of future cardiovascular events.4,6–9 In contrast, risk stratification and the identification of predictors of adverse outcomes in patients with normal DSE have gained little attention. Whether any haemodynamic or stress variables add incremental value to clinical data in predicting long-term outcomes after normal DSE has not been determined. We, therefore, sought to evaluate the prognostic significance of normal DSE, including the value of stress haemodynamic variables, for predicting long-term outcomes.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Acknowledgement
 References
 
Study population
The Mayo Clinic Institutional Review Board approved the study. Of 7165 patients referred for clinically indicated DSE from June 1992 through December 1999, we identified 3018 patients with normal DSE; of these, four (0.12%) refused to allow access of their records for research. The remaining 3014 constituted the study population.

Relevant data relating to clinical characteristics, electrocardiogram (ECG), and rest and stress echocardiography were recorded at the time of DSE into an electronic database. Diabetes mellitus was defined according to the requirement for treatment with insulin or oral hypoglycaemic agents or according to the definition by the American Diabetes Association.10 Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or the use of antihypertensive medication. Patients were considered to have hyperlipidaemia if their total cholesterol value was ≥5.17 mmol/L or if they were receiving lipid-lowering medication. Prior myocardial infarction (MI) was defined as the presence of significant Q waves on the baseline ECG or from the history. History of CAD was defined as prior MI or prior coronary revascularization. Family history of CAD was defined as the presence of premature CAD in male first-degree relative <55 years or female first-degree relative <65 years. The abnormal rest ECG was determined based on the presence of the diagnostic criteria for LV hypertrophy, bundle branch block, or significant Q waves on the baseline ECG. Risk factors considered for the evaluation of the pretest probability of CAD were hypertension, smoking, diabetes mellitus, hyperlipidaemia, defined as total cholesterol >200 mg/dL or therapy with a lipid-lowering agent, and ST-T segment wave changes (including those associated with left bundle branch block) on the rest ECG.11 The estimation of pretest probability of CAD was determined using previously described criteria which included the presence and characteristics of chest pain, age, gender, and presence of greater than or equal to three risk factors for CAD.5 Low, intermediate, and high pretest probability of CAD were defined as probability of ≤25, 26–69, and ≥70%, respectively.

Dobutamine stress echocardiography
DSE was performed according to a previously described protocol using 3 min stages and a peak dose of 40 µg/kg/min.12 Atropine, in 0.25 mg increments to a total dose of 2 mg, was administered intravenously as needed to augment the heart rate while the dobutamine infusion was continued. The 12-lead ECG was recorded at the end of each stage and the six-lead ECG continuously monitored. Blood pressure was measured non-invasively at rest and at the end of each stage. The predetermined endpoints for test termination were extensive new or worsening WMAs, the completion of the stress protocol, achievement of target heart rate, severe angina, ST-segment elevation in ECG leads without significant Q waves, haemodynamically significant arrhythmias, severe hypertension (>220/110 mmHg), hypotension or >20 mmHg reduction in systolic blood pressure from the previous stage, or intolerable symptoms. DSE was reviewed by a cardiologist experienced in interpretation of regional ventricular wall motion and blinded to clinical data. Ejection fraction (EF) was evaluated by a modification of the method of Quinones et al.13 combined with visual estimation. The reproducibility of this method and validation with biplane Simpson method have previously been described.14 Wall motion was assessed and scored 1 through 5 in each of the 16 segments, according to a previously described model.15 DSE was defined as normal if there was no WMA at rest or at peak stress. The target heart rate was defined as 85% of age-predicted maximal heart rate (220-age). The dose of dobutamine and heart rate at peak stress were recorded. The stress ECG was positive for ischaemia if there was horizontal or downsloping ST-segment depression of ≥1 mm at 80 ms after the J point.

Follow-up
Follow-up information was obtained from review of medical records, telephone interviews, mailed questionnaires, and Social Security Death Index in all patients. The endpoints of this study included all-cause mortality and cardiac events, defined as MI and coronary revascularization. For the analysis of cardiac events, in patients who experienced more than one event, only the first event was included for the analysis and the patients censored at the time of this event. For the analysis of mortality no censoring was used.

Statistical analysis
Categorical variables were summarized as percentages and continuous variables as mean±SD. Comparison between groups was based on Wilcoxon rank-sum test for continuous variables and Pearson's {chi}2 test for categorical variables. Overall survival and events-free survival were estimated by the Kaplan–Meier method. Observed survival was compared with expected survival based on an age- and gender-stratified life table data of Minnesota white population, using one-sample log-rank test. Univariable and multivariable associations of clinical, haemodynamic, and stress echocardiographic variables with the endpoint were assessed using the Cox proportional hazard model. The variables that were considered in the multivariate Cox regression for all-cause mortality were age, male sex, diabetes, known CAD, and failure to achieve target heart rate. For cardiac events, these were age, diabetes, hypertension, known CAD, pretest probability of CAD, and failure to achieve target heart rate. For these analyses, the pretest probability of CAD was classified according to a 1–3 scale (1, low; 2, intermediate; and 3, high). Variables were selected in a stepwise forward selection manner with entry and retention set at a significance level of 0.05. Results of these analyses were summarized as hazard ratios (HR) with 95% confidence intervals (CI) and associated log-likelihood ratio {chi}2 and P-values. We studied the stability of the final model under a bootstrap sampling scheme, drawing 1000 bootstrap samples of the dataset and repeating the forward stepwise selection using the same candidate variables for both endpoints. The proportional hazards assumption was tested. We also tested for non-linearity (quadratic terms) of the effects of the two continuous variables, age and pretest probability of CAD.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Acknowledgement
 References
 
Clinical data
The mean age was 68±12 years. Baseline characteristics are summarized in Table 1. The indication for DSE was for the evaluation of suspected or known CAD in 52%, for pre-operative cardiac risk assessment in 41%, and other reasons in 7%. Reasons for inability to exercise were orthopaedic limitation in 35%, peripheral vascular disease in 19%, debility in 10%, pulmonary disease in 7%, and others in 29%. Among 286 patients with prior revascularization, 138 had undergone percutaneous intervention (PCI), 112 had coronary bypass surgery, and 36 had both procedures. History of chest pain was reported in 1357 patients; among these 385 had typical angina. Among patients with typical angina, the indication for DSE was for the evaluation of suspected or known CAD in 82%, for pre-operative cardiac risk assessment in 16%, and other reasons in 2%. Twenty-six percent of patients had at least three risk factors for CAD. The pretest probability of CAD was low in 55%, intermediate in 33%, and high in 12% of patients.


View this table:
[in this window]
[in a new window]

  		Table 1 Baseline characteristics of 3014 patients with normal DSE

 
Haemodynamic and stress echocardiographic data
EF was 63±5%, range 50–80%. The peak dose of dobutamine infusion averaged 35±9 µg/kg/min. Atropine, mean dose 0.7±0.6 mg, was administered in 38% of patients. The ECG was positive for ischaemia in 166 (6%) patients. Heart rate increased from 72±12 to 132±15 b.p.m., and rate-pressure product from 10 316±2317 to 18 765±4352. The percent of age-predicted maximal heart rate attained was 87±10%. Among the 427 (14%) patients who failed to achieve target heart rate, 186 (44%) were receiving beta-blocker therapy. The reasons for test termination were achievement of target heart rate in 83%, completion of the stress protocol in 7%, intolerable adverse effects in 8%, and arrhythmias in 2%. Among those who were on beta-blockers, 26% failed to achieve target heart rate.

Outcomes
The median follow-up was 6.3 years (IQR 0.02–12 years). Cardiac events or death occurred in 1052 patients. All-cause mortality occurred in 920 patients. Cardiac events occurred in 231 patients, including as the first event, MI in 93 and coronary revascularization in 138 patients (PCI in 72 patients and coronary artery bypass surgery in 66). The estimated cardiac event-free probabilities at 1, 3, 5, 7, and 10 years were 98, 95, 93, 91, and 89%, respectively. The 1, 3, 5, 7, and 10-year survival probabilities were 95, 86, 78, 69, and 56%, respectively. Overall survival of the study population was lower than the expected survival of an age- and gender-matched population (P<0.0001), as shown in Figure 1. Survival was worse in men than in women (P=0.029), as shown in Figure 2. Survival was also worse in patients with a history of CAD (P<0.001), as shown in Figure 3. Survival probabilities of patients in the low, intermediate, and high pretest probability subgroups were similar (P=0.16).


Figure 3931
View larger version (8K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 Kaplan–Meier survival curves of patients with normal DSE(observed, n=3014) and an age- and gender-matched population obtained from life tables (expected).

 

Figure 3932
View larger version (8K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Kaplan–Meier survival curves of females vs. males with normal DSE.

 

Figure 3933
View larger version (9K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Kaplan–Meier survival curves of patients with and without a history of CAD and with normal DSE.

 
Predictors of outcomes
The univariate analysis of clinical, haemodynamic, and stress variables in predicting adverse events are listed in Tables 2 and 3, and multivariable predictors in Table 4. Neither beta-blocker therapy nor a positive stress ECG was predictive of either mortality or cardiac events. Thus, failure to achieve target heart rate was an independent predictor of both mortality (P=0.004) and cardiac events (P=0.001). In patients with normal DSE, failure to achieve target heart rate identified subjects who were at increased risk for adverse events with a 31% increased risk of mortality and a 74% increased risk of cardiac events.


View this table:
[in this window]
[in a new window]

  		Table 2 Univariate predictors of all-cause mortality

 

View this table:
[in this window]
[in a new window]

  		Table 3 Univariate predictors of cardiac events

 

View this table:
[in this window]
[in a new window]

  		Table 4 Multivariate predictors of adverse events

 
Based on the presence or absence of the variables which were most strongly predictive in the multivariate model, namely diabetes mellitus, history of CAD, and failure to achieve target heart rate, we estimated survival for patients in four categories, depending on the number of risk variables present (Figure 4). By the end of the first year, the probability of having a cardiac event for those with three risk factors was 13% and for those with no, one, or two risk factors, was 1, 3, and 6% respectively.


Figure 3934
View larger version (10K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Event-free survival is estimated for patients with normal DSE according to the number of risk factors present. Risk factors include diabetes mellitus, history of CAD, and failure to achieve target heart rate.

 
Robustness of predictive models
For the mortality model, each of the four variables in the final model appeared in the bootstrap models over 90% of the time, while the variable ‘history of CAD’ also appeared but in only 18% of the models. For the endpoint of cardiac events, diabetes, history of CAD, failure to achieve target heart rate, and age appeared in 100, 99, 93, and 85%, respectively, of the bootstrap models. Hypertension and pretest probability of CAD appeared in 57 and 56% of the bootstrap models, respectively. Table 4 also shows the average parameter estimates for the variables in the final model averaged across bootstrap samples in which the final model was, or was not, the selected model thus showing the ‘shrinkage’ that should be applied because of the use of stepwise selection.

The only variable and model in which proportional hazards was not satisfied was for the association of age with mortality. Specifically, the log (HR) per decade of age increased 0.128 for every natural logarithmic unit increase in time of follow-up in years, which implies a HR of 1.26 per decade of age at 4 months, vs. 1.45 per decade of age at 1 year, and 1.95 per decade of age at 5 years. This may represent an initial phase where the indication for the DSE plays a more important role than the age of the individual, whereas later in follow-up, age takes on its more usual role in modifying the risk of mortality. In addition, it may simply reflect the non-linear relation of age with mortality in the population. When non-linear effects were considered, only age led to statistically significant but modest quadratic effects in each of the two models.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Acknowledgement
 References
 
Data regarding the prognostic significance of abnormal DSE have been well demonstrated in several previous studies.4,7,9,16–18 On the contrary, less is known about the clinical importance and long-term outcomes after normal DSE in a large population. The present study reports a relatively high mortality after normal DSE in a large group of 3014 patients during long-term follow-up of up to 12 years. Our findings identify clinical and haemodynamic predictors of long-term adverse outcomes in the setting of normal DSE. Older age, male gender, diabetes mellitus, hypertension, history of CAD, and increased pretest probability of CAD identified a high-risk group among patients with normal DSE. Furthermore, failure to achieve target heart rate was an important haemodynamic stress variable, incremental to clinical data, for predicting long-term adverse outcomes, and identified those with a 31% increased hazard of mortality and 74% increased hazard of cardiac events.

Prognostic significance of clinical and haemodynamic variables despite normal DSE
Although data describing overall mortality and cardiac events after normal DSE are scarce, prognostic information to identify independent predictors of adverse outcomes is much less available.19 The ability to predict poor outcomes in the setting of normal study, using clinical and haemodynamic variables, is clinically meaningful. In the present study, traditional CAD risk factors, including older age, male gender, diabetes mellitus, hypertension, history of CAD were predictors of long-term adverse outcomes in patients with normal DSE. This finding emphasizes the importance of clinical data, even in the setting of a normal study, for risk stratification.

When is further testing indicated after normal DSE?
As shown in Figure 4, the survival curves of patients stratified according to the number of risk variables begin to diverge immediately, suggesting that in those with diabetes mellitus, history of CAD, and failure to reach target heart rate, despite normal DSE, further testing is indicated. Each of these variables was an independent predictor of adverse events. The association of a higher resting heart rate with an increased risk of mortality has previously been described.19,20 On the other hand, less is known about the predictive value of failure to achieving target heart rate after pharmacologic stress testing. Since inadequate chronotropy reduces the diagnostic sensitivity of DSE, some investigators may consider a non-ischaemic study in patients who failed to achieve target heart rate as a non-diagnostic,21 while others have not paid much attention to the degree of chronotropic response at the test conclusion.4,18 According to our findings, failure to achieve target heart rate was an important predictor of the patient at increased risk.

Previous studies of normal stress echocardiography
McCully et al.5 reported a favourable outcome in 1325 patients with normal exercise echocardiography. During the median follow-up of 23 months, all-cause mortality, non-fatal MI, and coronary revascularization were reported in 17, 10, and 20 patients, respectively. Survival rates free of all cardiac events (cardiac death, non-fatal MI, and coronary revascularization) at 1 and 3 years were 99.5 and 98.6%, respectively. Clinical characteristics of the patients in McCully's study and the current study were similar except patients in our study were older, underwent DSE because of the inability to exercise, and had a longer follow-up, which contributes to the higher event rate in our patient population despite the normal test result. Regarding the prognostic value of normal DSE, previous studies have reported a low event rate at short- and intermediate-term follow-up.1–4 Steinberg et al.4 described a favourable 5-year prognosis after normal DSE in the subgroup of 42 male patients with a high pretest probability of CAD. All-cause mortality and MI occurred in 9.5 and 4.8%, respectively. However, coronary revascularization was performed in a relatively high number of patients (28.5%), resulting in a high hard event rate (42.9% of combined all-cause mortality, MI, and coronary revascularization). Geleijnse et al.2 studied 200 patients with a stable chest pain syndrome and normal DSE and reported the combined events of death, MI, and coronary revascularization in 6.5% during 21±16 months of follow-up. Of note, the number of patients was relatively small with a short follow-up period. Dhond et al.1 reported a low MI and cardiac death rate (1.5 and 0.13% per patient/year, respectively) in 171 patients with normal DSE during intermediate-term follow-up. Mesa et al.3 reported a 2-year prognostic value of normal DSE in 100 women with suspected CAD, with all-cause mortality of 6% and combined death, MI and coronary revascularization of 8%. Of note, target heart rate was achieved in all patients, reflecting a low-risk population. Recently, Sozzi et al.19 demonstrated a favourable outcome during long-term follow-up in 401 patients with normal DSE. All-cause mortality and non-fatal MI occurred in 11 and 3.2%, respectively. Compared with this group, our population was older (68±12 years vs. 62±10 years), fewer of our patients achieved target heart rate (86% vs. 97%), and our follow-up was longer (6.6±2.3 years vs. 5.0±1.7 years). Biagini et al.22 recently reported outcome after DSE in 3381 patients during follow-up of 7±3.4 years. Independent predictors of cardiac events, including cardiac death and MI, were male gender, age, history of heart failure, previous MI, and diabetes mellitus. In 1170 patients with normal DSE, subgroup analysis for predictors of events was not performed. However, in this subgroup, men had less favourable outcomes than women with a two-fold greater cardiac event rate. In our population, the mean age was 7 years greater, and gender differences were less striking, although male sex was an independent predictor of mortality.

Unrecognized importance of normal DSE
To our knowledge, this is the largest study to evaluate the long-term survival and prognostic value after normal DSE. Compared with previous studies, we found a relatively high rate of adverse outcomes, probably due to the longer period of follow-up. As a result of a longer follow-up, the progression of pre-existing non-obstructive coronary lesions and the development of new, obstructive lesions may explain the observation of higher event rates. Event rate was significantly higher than that of an age and sex matched referent group, not surprising, as the patients undergoing DSE were unable to perform an exercise test. The 3-year survival and cardiac event-free probabilities in our study were 86 and 95%, respectively. We identified higher-risk subgroups of patients after normal DSE (e.g. those with advancing age, male gender, diabetes mellitus, hypertension, history of CAD, increased pretest probability of CAD, and failure to achieve target heart rate) that may need either further risk stratification or an earlier follow-up study. The low-risk guarantee of normal DSE may not be applicable to all patients during long-term follow-up. A normal dobutamine stress echocardiogram should not prevent the performance of further testing and therapeutic intervention in patients who are at increased risk of adverse outcomes during long-term follow-up.

Study limitations
The combined endpoint of MI and coronary revascularization was used in the present study. Generally, coronary revascularization has been influenced by the physician's decision and thus regarded as a soft endpoint. However, subsequent coronary revascularization can be considered an unexpected outcome after normal DSE. We, therefore, considered coronary revascularization as a cardiac event. Although it may be useful to repeat DSE after a previous normal study, an appropriate time interval has never been determined. Further studies are required to establish the appropriate timing of such a test.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Acknowledgement
 References
 
In patients undergoing clinically indicated DSE, long-term mortality is substantial, despite normal test results. Age, diabetes mellitus, and failure to achieve target heart rate identify patients at increased risk.


   Acknowledgement
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
References
 
N.C. was supported by a grant from Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Conflict of interest: none declared.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgement
 References
 

  1. Dhond M, Donnell K, Singh S, Garapati S, Whitley T, Nguyen T, Bommer W. (1999) Value of negative dobutamine stress echocardiography in predicting long-term cardiac events. J Am Soc Echocardiogr 12:471–475.[CrossRef][Web of Science][Medline]
  2. Geleijnse M, Elhendy A, van Domburg R, Cornel J, Roelandt J, Foioretti P. (1998) Prognostic implications of a normal dobutamine-atropine stress echocardiogram in patients with chest pain. J Am Soc Echocardiogr 11:606–611.[CrossRef][Web of Science][Medline]
  3. Mesa A, Falcone M, Hernandez A, Stainback R, Wilansky S. (1999) Long-term prognosis in women with normal dobutamine stress echocardiography. Am J Cardiol 83:1127–1129 A9.[CrossRef][Web of Science][Medline]
  4. Steinberg E, Madmon L, Patel C, Sedlis S, Kronzon I, Cohen J. (1997) Long-term prognostic significance of dobutamine echocardiography in patients with suspected coronary artery disease: results of a 5-year follow-up study. J Am Coll Cardiol 29:969–973.[Abstract]
  5. McCully R, Roger V, Mahoney D, Karon B, Oh J, Miller FJ, Seward J, Pellikka P. (1998) Outcome after normal exercise echocardiography and predictors of subsequent cardiac events: follow-up of 1325 patients. J Am Coll Cardiol 31:144–149.[Abstract/Free Full Text]
  6. Das M, Pellikka P, Mahoney D, Roger V, Oh J, McCully R, Seward J. (2000) Assessment of cardiac risk before nonvascular surgery: dobutamine stress echocardiography in 530 patients. J Am Coll Cardiol 35:1647–1653.[Abstract/Free Full Text]
  7. Chuah S, Pellikka P, Roger V, McCully R, Seward J. (1998) Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease. Circulation 97:1474–1480.
  8. Coletta C, Galati A, Ricci R, Sestili A, Guagnozzi G, Re F, Ceci V. (1997) Prognostic value of left ventricular volume response during dobutamine stress echocardiography. Eur Heart J 18:1599–1605.[Abstract/Free Full Text]
  9. Poldermans D, Fioretti P, Boersma E, Bax J, Thomson I, Roelandt J, Simoons M. (1999) Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: a single-center experience. Circulation 99:757–762.
  10. Report of the Expert Committee on the Diagnosis: Classification of Diabetes Mellitus. Diab Care (1997) 20:1183–1197.[Web of Science][Medline]
  11. Diamond G and Forrester J. (1979) Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Engl J Med 300:1350–1358.[Abstract]
  12. Pellikka P, Roger V, Oh J, Miller F Jr, Seward J, Tajik A. (1995) Stress echocardiography. Part II. Dobutamine stress echocardiography: techniques, implementation, clinical applications, and correlations (see comments). Mayo Clin Proc 70:16–27.[Web of Science][Medline]
  13. Quinones M, Waggoner A, Reduto L, Nelson J, Young J, Winters WJ, Ribeiro L, Miller R. (1981) A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography. Circulation 64:744–753.
  14. Arruda A, Das M, Roger V, Klarich K, Mahoney D, Pellikka P. (2001) Prognostic value of exercise echocardiography in 2632 patients ≥65 years of age. J Am Coll Cardiol 37:1036–1041.[Abstract/Free Full Text]
  15. Schiller N, Shah P, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I, Silverman N, Tajik A. (1989) Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr 2:358–367.[Medline]
  16. Marwick T, Case C, Vasey C, Allen S, Short L, Thomas J. (2001) Prediction of mortality by exercise echocardiography: A strategy for combination with the Duke treadmill score. Circulation 103:2566–2571.
  17. Sicari R, Pasanisi E, Venneri L, Landi P, Cortigiani L, Picano E. (2003) Stress echo results predict mortality: a large-scale multicenter prospective international study. J Am Coll Cardiol 41:589–595.[Abstract/Free Full Text]
  18. Mazeika P, Nadazdin A, Oakley C. (1993) Prognostic value of dobutamine echocardiography in patients with high pretest likelihood of coronary artery disease. Am J Cardiol 71:33–39.[CrossRef][Web of Science][Medline]
  19. Sozzi F, Elhendy A, Roelandt J, van Domburg R, Schinkel A, Vourvouri E, Bax J, Rizzello V, Poldermans D. (2003) Long-term prognosis after normal dobutamine stress echocardiography. Am J Cardiol 92:1267–1270.[CrossRef][Web of Science][Medline]
  20. Kristal-Boneh E, Silber H, Harari G, Froom P. (2000) The association of resting heart rate with cardiovascular, cancer and all-cause mortality. Eight year follow-up of 3527 male Israeli employees (the CORDIS Study). Eur Heart J 21:116–124.[Abstract/Free Full Text]
  21. Ballal R, Secknus M, Mehta R, Kapadia S, Lauer M, Marwick T. (1997) Cardiac outcomes in coronary patients with sub maximum dobutamine stress echocardiography. Am J Cardiol 80:725–729.[CrossRef][Web of Science][Medline]
  22. Biagini E, Elhendy A, Bax J, Rizzello V, Schinkel A, van Domburg R, Kertai M, Krenning B, Bountioukos M, Rapezzi C, Branzi A, Simoons M, Poldermans D. (2005) Seven-year follow-up after dobutamine stress echocardiography: impact of gender on prognosis. J Am Coll Cardiol 45:93–97.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur J EchocardiogrHome page
R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi
Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Eur J Echocardiogr, July 1, 2008; 9(4): 415 - 437.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
A. E. Weyman
The Year in Echocardiography
J. Am. Coll. Cardiol., March 25, 2008; 51(12): 1221 - 1229.
[Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
P. A. Pellikka and R. B. McCully
Stress Echocardiography: So Much to Do, So Little Time
J. Am. Coll. Cardiol., November 13, 2007; 50(20): 1990 - 1991.
[Full Text] [PDF]

Home page
 Nephrol Dial TransplantHome page
S. Gang, M. Dabhi, and M. M. Rajapurkar
Ischaemia imaging in type 2 diabetic kidney transplant candidates is coronary angiography essential?
Nephrol. Dial. Transplant., August 1, 2007; 22(8): 2334 - 2338.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
27/24/3039    most recent
ehl393v1
Right arrow E-letters: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when E-letters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (4)
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Chaowalit, N.
Right arrow Articles by Pellikka, P. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chaowalit, N.
Right arrow Articles by Pellikka, P. A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?