Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction During Dobutamine Stress Echocardiography in Women With Suspected Coronary Artery Disease

Abstract

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp intraventricular obstruction during DSE was clinically significant in patients without CAD who have unexplained reduced effort tolerance. 7 The dynamic LV cavity obliteration or LVOTO seemed to be associated with smaller LV and a greater LV wall thickness in patients who underwent DSE for the evaluation of chest pain and preoperative evaluation for non-cardiac surgery. 8 These studies, however, were performed in heterogeneous participants with different reasons for undergoing DSE, and the relationship between DLVOTO and symptoms has not been well investigated. Moreover, DLVOTO during DSE is more prevalent in female subjects, 8 and a considerable number of women have effort-induced and unexplained chest symptoms such as angina and shortness of breath with no significant evidence of angiographic CAD. obutamine stress echocardiography (DSE) is widely used as an alternative stress imaging test for the evaluation of suspected or known coronary artery disease (CAD). 1-3 The development of dynamic left ventricular outflow tract obstruction (DLVOTO) in states of hypercontractility is not infrequently observed during DSE. Although several studies investigating DLVOTO during DSE have been conducted, the clinical significance of DSE-provoked DLVOTO remains controversial. Pellikka et al suggested that the development of dynamic intraventricular obstruction leads to hypotension during DSE, 4 but this was not found in another study. 5 Furthermore, the development of DLVO gradient during DSE was not associated with dobutamine induced-chest pain or shortness of breath.

Gender differences in the presentation of chest pain in obstructive coronary artery disease: results from the Korean Women’s Chest Pain Registry

“…The Korean Women's Chest Pain Registry (KoROSE) is a nation-wide, multicenter, prospective study evaluating patients who visited outpatient clinic with chest pain. The detailed protocol of the registry has been previously published [10,11]. The registration started from January 2012.…”

Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women

“… 34) 35) Because of smaller LVOT size is prone to develop DLVOTO during increased inotopic status, smaller chamber size of women may be one reason for high incidence of DLVOTO in this study. 36) It had been reported that, development of DLVOTO is related with the exercise intolerance and ischemic symptoms 37) 38) in patient without CAS, this finding may useful to understand the patient's symptoms. But its clinical and prognostic implications need to be investigated further.…”

Usefulness of Stress Echocardiography in Assessment of Dynamic Left Ventricular Obstructions: Case Series and Review of the Literature

“…None of these 4 patients had obstructive coronary artery disease. Recent studies have indicated that in women with unexplained chest pain or shortness of breath, DSE-induced DLVOTO was not related with the presence of coronary artery disease, but to concentric LV remodeling and diastolic dysfunction [28], which both are known features of hypertensive heart disease. This highlights the importance of optimal antihypertensive treatment in patients with DLVOTO.…”

“…In one study of unselected patients referred for exercise echocardiography, the prevalence of DLVOTO was 6% [10]. By contrast, in studies including only women and at tertiary hospitals (highly selected), the prevalence of DLVOTO during DSE was reported as high as 51% [28]. In other cohorts of patients with effort angina and structurally normal hearts by conventional echocardiography and normal coronary arteries by coronary angiography, the prevalence was reported as 30–36%, detected by treadmill exercise echocardiography [9, 11].…”

“…Stress echocardiography, particularly exercise echocardiography, is considered to be the “gold standard” method for diagnosing DLVOTO or midcavity obstruction in patients with otherwise normal hearts [9-15, 19, 22, 28]. However, some patients may either not be able to exercise, or ECG may be uninterpretable, having paced-rhythm or bundle branch block, or show significant hyperventilation or rapid fall in heart rate after stopping treadmill test making image acquisition difficult, and hence not able to perform a successful exercise echocardiography.…”