Infra-low dose dipyridamole test. A novel dose regimen for selective assessment of myocardial viability by vasodilator stress echocardiography

Abstract

Low (0.56 mg.kg-1 over 4 min) and high (0.84 mg.kg-1 over 10 min) doses of dipyridamole can identify viable myocardium through the contractile recovery of basally dyssynergic regions; however, it also induces ischaemia in susceptible patients. The aim of this study was to assess the potential of an 'infra-low' dose of dipyridamole to selectively identify myocardial viability, independently evaluated by low dose dobutamine. Forty patients with resting dyssynergy and angiographically assessed coronary artery disease (1-vessel in 18, 2-vessel in 12, and 3-vessel in 10 patients) separately underwent a low dose dobutamine (5-10 μg.kg-1.min-1 for 3 min) echo test and an infra-low dose (0.28 mg.kg-1 over 4 min) dipyridamole echo test. Systolic blood pressure (rest: 131 ± 19 mmHg) changed slightly after dobutamine (137 ± 21, P < 0.05 vs rest) and remained stable after dipyridamole (130 ± 17, P = ns vs rest). Heart rate (rest: 68 ± 13 beats.min-1) was also unchanged after dipyridamole (69 ± 12, P = ns vs rest) and increased slightly after dobutamine (71 ± 15, P < 0.05 vs rest and vs dipyridamole). No patient developed echocardiographic or electrocardiographic signs of ischaemia after either dipyridamole or dobutamine. Of the 243 segments with baseline dyssynergy, 70 were responders (i.e. they showed an improvement of 1 grade or more, from 1 = normal/hyperkinetic to 4 = dyskinetic in a 16-segment model of the left ventricle) by both dipyridamole and dobutamine, 157 were non-responders (i.e. they showed no change) by both dipyridamole and dobutamine, and 16 showed discordant results (five responders by dipyridamole only; 11 by dobutamine only). The overall concordance of dipyridamole and dobutamine was 93%. An echocardiographic follow-up could be obtained > 6 weeks after successful revascularization (achieved with angioplasty in 17, with by pass surgery in 3) in 19 patients and showed an improvement of one grade or more in 50 segments (viable) and no improvement in 50 segments (necrotic). The sensitivity of dobutamine and dipyridamole for predicting recovery was 76 and 78% respectively (P = ns); the specificity of both tests was 94%. In conclusion, infra-low dose dipyridamole is a haemodynamically neutral stress test which does not affect either heart rate or systolic blood pressure; it allows myocardial viability to be explored selectively, without eliciting ischaemia; it shows excellent overall concordance with low dose dobutamine and has good sensitivity and excellent specificity for predicting functional recovery following successful revascularization.