Dobutamine stress

a) SCMR official document standardized acquisition guidelines – relevant extract

LV structure and function module
Dobutamine stimulation
a. Increase the dobutamine in increments of 10 μg/kg body weight/minute every 3 minutes starting at 10 μg/kg body weight/minute until target heart rate [85% × (220-age)] reached.
b. Add atropine in small incremental doses, if heart rate response is poor.
c. Repeat 3 short axis and 3 long axis cine views during each increment
d. Continuous ECG monitoring and BP measured during each stage.
e. View cine loops online as they are being acquired.
f. Adapt the SSFP cine sequence to optimize temporal resolution as needed as the heart rate increases.
g. Stop test for new wall motion abnormality, serious side effect, or achievement of peak heart rate.
Analysis
a. View cines in multiscreen format, reviewing rest, intermediate stress levels and peak stress at the same time in a synchronized fashion.
b. Describe wall motion as normokinetic, mild hypokinetic, severe hypokinetic, akinetic and dyskinetic for all 17 segments.
c. Report inducible wall motion abnormalities and viability.

b) SCMR official document reporting recommendations – relevant extract

For studies incorporating CV stress, prior to the procedure, the following information should be verified:
• Prior MI
• Prior coronary revascularization (PCI and/or CABG)
• Pretest Probability of CAD (none, low, medium, high)
• Is the ECG interpretable for ischemia? Yes/No
• Framingham Risk Score
• Estimate of CAD risk (<10%,10-20%, >20% over 10 years

For tests incorporating stress testing, the heart rates and rhythm, oxygen saturation, systolic and diastolic blood pressures, and the predictive heart rate response for age should all be
recorded during the following points in time:
• Before study
• At each level of stress
• In recovery
For studies utilizing cardiac active agents (i.e., stress testing), the agent, quantity,
duration, and route of administration of the agents and associated medications should be
provided.
The SCMR recommends the reporting of LV myocardial information in the format of a 17-
segment model through the use of a chart, table, or bipolar maps (so called “Bullseye” plot)
[4].

Wall motion stress:
Wall function should be designated as qualitative (wall motion) or quantitative
(referenced measure such as % wall thickening, or strain) during testing. In addition,
wall motion score index (the sum of the wall motion scores divided by the number of
segments scored) should be reported at each level of stress. Inducible ischemia or
contractile reserve should be identified in each study according to previously
published referenced methods. Identification should be made of when global LV
function does not improve or worsens during stress.

c) Standardized web based images

Case pending

d) Case of the Week example(s)

Number 10-05: Dobutamine inducible ischaemia: Case 2
History: An 48 year old male was admitted to hospital with 6 hours of crushing central chest pain.

Number 10-02: Dobutamine inducible ischaemia: Case 1
History: 62 year old asthmatic male presented to the cardiologists with worsening atypical chest pain and breathlessness on exertion.

e) Expert opinion – ‘How we do’

"How we do Dobutamine Stress CMR" (Ashraf Hamdan, Ingo Paetsch and Eike Nagel)

f) Relevant Online Talks

Free talks

The Role of Dobutamine
By Marco Gotte - Amsterdam, Netherlands
Recorded at EuroCMR 2009 Athens

The Role of DE
By Christoph Klein - Berlin, Germany
Recorded at EuroCMR 2009 Athens

Dobutamine Stress
By Christoph Klein - Berlin, Germany
Recorded at EuroCMR 2009 Athens

Members only talks - general

Myocardial Ischemia
By Raymond Kwong - Brigham and Women's Hospital
Recorded at SCMR 2009 Physician preconference

Measure regional and global LV function
By Rob van der Geest - Leiden
Recorded at SCMR2008 Physician Pre-Conference Section 2: How to �

Myocardial ischemia
By Greg Hundley - Winston-Salem
Recorded at SCMR2008 Physician Pre-Conference Section 4: Clinical Applications of CMR

Members only talks - cutting edge
(this talk relevant due to the high temporal resolution cine imaging discussed)

Exercise-stress perfusion
By Orlando Simonetti - The Ohio State University
Recorded at SCMR 2009 Novel Approaches to CMR perfusion

g) Useful documents

DOBUTAMINE & ADENOSINE ADMINISTRATION FOR STRESS MRI from Southampton General Hospital, Uk
Dobutamine Infusion Rate (4000mcg/mL) from Southampton General Hospital, UK
Stress CMR BP/pulse documentation with cannula documentation from Southampton General Hospital, UK
Stress CMR BP/pulse documentation (no cannula documentation) from Southampton General Hospital, UK
Dobutamine Flow Rates for Cardiac Stress (provided by Oxford CMR Unit)

h) Relevant papers (starting point):

Nagel E, Lehmkuhl HB, Bocksch W et al. Noninvasive diagnosis of ischemia induced wall motion abnormalities with the use of high dose dobutamine stress MRI. Comparison with dobutamine stress echocardiography. Circulation 1999;99:763–70.

Nagel E, Lorenz C, Baer F et al. Stress cardiovascular magnetic resonance: consensus panel report. J Cardiovasc Magn Reson 2001;3:267–81.

Hundley WG, Morgan TM, Neagle CM, Hamilton CA, Rerkpattanapipat P, Link KM. Magnetic resonance imaging determination of cardiac prognosis. Circulation 2002;106:2328-33

Kuijpers D, van Dijkman PR, Janssen CH, et al. Dobutamine stress MRI, Part I and Part 2: Eur Radiol. 2004;14:2046-2052

Dall'Armellina E, Morgan TM, Mandapaka S et al. Prediction of cardiac events in patients with reduced left ventricular ejection fraction with dobutamine cardiovascular magnetic resonance assessment of wall motion score index. J Am Coll Cardiol 2008;52:279-86