Chronotropic Incompetence on Dobutamine Stress Echocardiography in Candidates for a Liver Transplant

Abstract

Objectives: We evaluated dobutamine stress echocardiography as an initial screening test for a cardiac evaluation before a liver transplant. Materials and Methods: We retrospectively examined 111 liver transplant candidates who had undergone previous cardiac evaluation; 30 of whom had undergone a liver transplant. Results: Eighty patients (72.1%) completed a dobutamine stress echocardiography (41 chronotropically competent, 39 incompetent), while 31 patients (27.9%) required us to terminate early. Overall, 68 patients (61%) were on β-blockers (21 required early dobutamine stress echocardiography termination, 30 chronotropically incompetent, and 17 competent). Patient results were normal. Thirty patients underwent a liver transplant. Among candi dates requiring termination of early dobutamine stress echocardiography, posttransplant cardiac events included 1 fatal acute myocardial infarction, 1 nonfatal acute myocardial infarction, and 1 idiopathic cardiomyopathy. Among chrono tro pically incompetent patients, 2 patients had transient bradycardia, and among those who were chronotropically competent, 1 had refractory atrial fibrillation, and 1 had transient bradycardia. Conclusions: Nearly 50% of patients with end-stage liver disease may not reach the target heart rate. Early termination of dobutamine stress echocardiography because of cardiac symptoms or significant echocardiographic changes have more effect in predicting postoperative cardiac events, but further evaluation is required even if their target heart rate is close to that desired. Lower target heart rate may be acceptable in chronotropically incompetent individuals provided they are asymptomatic, have no echocardiographic changes, or cardiovascular risk factors, especially if they are on β-blockers.

Evaluation of coronary artery disease in potential liver transplant recipients

“…DSE is only reliable if at least 85% of the predicted maximum heart rate is achieved. However, 19%‐50% of patients do not achieve this due to the use of beta‐blocking agents, peripheral vasodilatation, and chronotropic incompetence . Recent data suggest that β‐blockers can be temporally discontinued without hemodynamic rebound or increased variceal bleeding .…”

“…Recent data suggest that β‐blockers can be temporally discontinued without hemodynamic rebound or increased variceal bleeding . In addition, DSE is not without complications, and early termination rate due to significant changes in blood pressure, arrhythmia, and chest pain are reported in up to 28% of patients …”

Cardiac stress testing and coronary artery disease in liver transplantation candidates: Meta-analysis

“…However, this meta-analysis found much lower sensitivity values for diagnosis of CAD in patients awaiting LT, while specificity rates did not vary so much. This could have happened because results for stress testing might be false due to modifications in hemodynamics caused by ESLD, such as high-output cardiac failure, cirrhotic cardiomyopathy, anemia and the use of beta blockers[ 36 , 37 ].…”

Low to Intermediate Dose Atropine Administration During Dobutamine Stress Echocardiography in the Pre-Liver Transplant Population

“…1,2 While much speculation has resulted in identifying the best approach to exclude clinically significant CAD, current guidelines recommend noninvasive testing, including dobutamine stress echocardiography (DSE). 1,[3][4][5][6][7][8] Although the sensitivity and specificity of this study compared to invasive angiography can be limited in the endstage liver disease (ESLD) population, its results tend to be a strong predictor of clinical outcomes. [7][8] As part of stress testing, a continuous dobutamine infusion and, frequently, atropine adjunctive therapies are administered in order to achieve a target heart rate to allow for an accurate assessment.…”

“…[4][5][6][10][11][12][13][14][15][16] These properties can make it more difficult to achieve an adequate heart rate response, requiring the use of atropine as an adjunct to dobutamine during testing. [4][5][6] Although atropine has been shown to be relatively safe in the general population, its anticholinergic effects can result in the development of adverse symptoms, including worsening encephalopathy. Wuthiwaropas et al found that in a prospective study of 1006 patients undergoing DSE with atropine use, the administration of at least 1 mg atropine resulted in a more than 5-fold increase in neuropsychiatric symptoms.…”