Dobutamine stress echocardiography versus computed tomography coronary angiography (PANDA trial)

Contributed by Dr. Navni Garg
Lady Hardinge Medical College
New Delhi

Dr. Navni Garg, DNB reviewing Ahn JH, Jeong YH, Park Y, Kwak CH, Jang JY, Hwang JY, Hwang SJ, Koh JS, Kim KH, Kang MG, Park JR. Head-to-head comparison of prognostic accuracy in patients undergoing noncardiac surgery of dobutamine stress echocardiography versus computed tomography coronary angiography (PANDA trial): A prospective observational study.
J Cardiovasc Comput Tomogr. 2020 Nov-Dec;14(6):471-477
doi: 10.1016/j.jcct.2020.02.001.

Study Questions: To compare the prognostic value of Dobutamine stress echocardiography (DSE) and coronary computed tomography angiography (CTA) in risk stratification of patients undergoing noncardiac surgery for occurrence of perioperative cardiovascular (CV) events.

Methodology

  • Type of study: Prospective observational study
  • Inclusion criteria: Patients undergoing non cardiac surgery in a single tertiary care hospital with one or more clinical risk factors
  • Exclusion criteria: Patients undergoing low risk minor surgery (endoscopic, superficial, and ambulatory surgery), patients who might need emergency surgery, patients who had received prophylactic PCI, active cardiac conditions (including recent myocardial infarction (MI), decompensated heart failure, more than moderate valvular heart disease, significant arrhythmia), any absolute contraindication to CTA or DSE and/or estimated glomerular filtration rate < 15 mL/min/1.73 m2.
  • Methods: Detailed clinical history was obtained and 1 point was assigned for presence of each of the six clinical risk factors – ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin therapy with diabetes mellitus, and renal dysfunction (serum creatinine level > 2.0 mg/dl) for calculation of Revised cardiac risk index score (RCRI).
  • Included patients underwent CT coronary angiography and Dobutamine stress echo.
  • CTA using 64 slice multidetector scanner and DSE were performed on the study group preoperatively. CTA was used to assess the degree of stenosis in three major epicardial arteries. Maximal diameter stenosis [DS] ≥50% was considered as significant stenosis.
  • For DSE, a baseline echocardiography was performed followed by increasing doses of dobutamine up to a peak dosage of 40 mg/kg/min, and a target heart rate of 85% of the age-predicted maximum. The images were interpreted by two experienced cardiologists for presence of inducible ischemia and/or nonviable infarction. A new or worsened wall motion abnormality during stress was considered as inducible ischemia. A biphasic response in an akinetic or severely hypokinetic segment was considered as an ischemic response.
  • The study group was observed for occurrence of perioperative CV events defined as CV death, non-fatal myocardial infarction (MI), myocardial injury, pulmonary edema, non-fatal stroke, and systemic embolism within 30 days after surgery.

Results:

    • 206 patients were included in the study
    • Mean age was 69 ± 9 years and 52.9% were male.
    • 107 patients (51.9%) had one clinical risk factor while 99 patients had more than one clinical risk factor
    • Perioperative CV events occurred in 24 (11.7%) patients (one case of cardiac death, 10 cases of nonfatal MI, 8 cases of MINS, 11 cases of pulmonary oedema with heart failure, one case of non-fatal stroke, and one case of pulmonary embolism)

     

    • DSE demonstrated abnormal results in 46 patients (24 had inducible ischemia and 26 had nonviable infarction). Patients with abnormal DSE result had more perioperative CV events compared to patients with normal result (OR: 5.88, 95% CI: 2.41 to 14.34, P < 0.001). Patients with inducible ischemia had more perioperative CV events compared to patients without ischemic region (Odds ratio [OR]: 4.00, 95% CI: 1.45 to 10.99, P = 0.007)
    • Peak wall-motion score index (PWSI) was found to be an independent and significant predictor of CV events (p-0.003)
    • Symptoms (chest pain and dyspnoea), ST-segment depression, heart rate reserve, and drops of blood pressure during DSE were not related to perioperative CV events.

     

    • CTA demonstrated significant CAD in 65 patients (32%). Patients with significant CAD had more perioperative CV events compared with those with no significant stenosis (OR, 24.05; 95% CI, 6.89 to 83.93, P < 0.001).

Limitations:

  • Study comprised small study group and was performed at a single tertiary care hospital
  • CTA is contraindicated in patients with history of allergy to iodinated contrast and those at high risk for contrast nephropathy, thus could not be performed in all patients. The results are therefore not valid for patients with chronic kidney disease and with iodine allergy.

Conclusions:

DSE and CTA are important predictive factors for occurrence of perioperative CV events in patients undergoing noncardiac surgery than clinical risk factors alone. Among them, assessment of significant CAD using CTA might show a higher prognostic value compared with DSE, before noncardiac surgery.