European Journal of Cardiovascular Medicine

Perioperative cardiac complications account for a significant proportion of adverse outcomes following noncardiac surgery. Identifying patients at increased cardiovascular risk remains a cornerstone of preoperative evaluation.

Stress echocardiography is a well-established noninvasive imaging modality that detects inducible myocardial ischemia through assessment of regional wall motion abnormalities. It offers superior diagnostic accuracy compared to exercise electrocardiography by identifying early changes in the ischemic cascade before electrocardiographic alterations occur.

Dobutamine stress echocardiography (DSE) is particularly valuable in patients unable to perform exercise testing. Current guidelines recommend its use in patients with poor functional capacity (<4 metabolic equivalents) and intermediate or high clinical risk when results are expected to influence management decisions.

Despite strong evidence, DSE remains underutilized in many clinical settings. This study evaluates its role in preoperative cardiac risk assessment in a tertiary care population.

Study Design and Population This retrospective observational study included consecutive patients referred for preoperative cardiac risk assessment prior to noncardiac surgery who underwent DSE. Clinical Evaluation Baseline clinical data, including demographics, comorbidities, and surgical risk, were recorded. Risk stratification was performed using standard clinical criteria. DSE Protocol Dobutamine was administered in incremental doses (5–40 μg/kg/min) at 3-minute intervals. Atropine was administered when target heart rate was not achieved. Continuous electrocardiographic and blood pressure monitoring were performed. Target heart rate was defined as ≥85% of age-predicted maximum. Image Acquisition and Interpretation Standard echocardiographic views were obtained at baseline, intermediate, peak stress, and recovery phases. Studies were interpreted for inducible regional wall motion abnormalities. Definitions ● Positive DSE: New or worsening regional wall motion abnormality ● Negative DSE: No inducible ischemia ● Inconclusive DSE: Failure to achieve target heart rate or suboptimal imaging Outcome Measures Primary outcomes: ● Perioperative myocardial infarction ● Arrhythmia ● Cardiac death Secondary outcomes: ● Coronary angiography findings ● Need for revascularization Statistical Analysis Descriptive statistics were used to summarize data. Continuous variables are presented as mean ± standard deviation, and categorical variables as percentages. Diagnostic performance was assessed using negative predictive value.

Baseline Characteristics

A total of 200 patients were included:

• Male: 129 (64.5%)
• Female: 71 (35.5%)
• Approximately 50% aged >50 years
• Preserved left ventricular ejection fraction in 99.5%

DSE Findings

• Negative: 193 (96.5%)
• Positive: 3 (1.5%)
• Inconclusive: 5 (2.5%)
• Target heart rate achieved: 197 (98.5%)

Coronary Angiography

Six patients underwent coronary angiography:

• Significant CAD: 2
• Mild CAD: 2
• Normal coronaries: 2

Perioperative Outcomes

• Fatal myocardial infarction: 1
• Arrhythmia: 1 (medically managed)
• Noncardiac deaths: 2
• No cardiac events in majority of negative DSE patients

Diagnostic Performance

The negative predictive value of DSE was approximately 99%, indicating excellent prognostic utility.

This study demonstrates that DSE is a highly effective modality for preoperative cardiac risk stratification. The high negative predictive value observed confirms that a negative DSE reliably predicts low perioperative cardiac risk.

These findings are consistent with previous studies showing that patients with a negative stress echocardiogram have a very low incidence of cardiac events, typically less than 1% per year.

Clinical Implications

DSE is particularly useful in:

• Patients with poor functional capacity
• Intermediate-risk surgical candidates
• Patients with multiple cardiovascular risk factors

It allows:

• Safe surgical clearance
• Avoidance of unnecessary invasive procedures
• Identification of patients requiring further evaluation

Comparison With Existing Literature

Our findings align with published data demonstrating high negative predictive value and low complication rates associated with stress echocardiography.

Safety

DSE was well tolerated in this cohort, with minimal adverse events. Rare complications such as arrhythmias or stress-induced cardiomyopathy have been reported but were not significant in this study.

Limitations

• Retrospective design
• Single-center study
• Limited sample size
• Lack of long-term follow-up

Not all patients underwent coronary angiography

Dobutamine stress echocardiography is a safe, reliable, and clinically valuable tool for preoperative cardiac risk assessment in patients undergoing noncardiac surgery. A negative DSE is strongly predictive of favorable perioperative outcomes and may reduce the need for invasive investigations. Acknowledgments We acknowledge the contributions of the clinical and technical staff involved in data collection and patient care.

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