Dobutamine stress echocardiography is considered a relatively well-tolerated diagnostic modality, effective in the management of patients with known or suspected
coronary artery disease. Adverse effects during testing are relatively frequent, precluding the achievement of a diagnostic end-point in about 5 to 10% of tests. These adverse effects, mostly
tachyarrhythmias and arterial
hypotension, are usually minor and self limiting. However, severe life-threatening complications, as well as death, also occur. By analysing Medline-quoted literature up to March 1999, we found 35 original studies from a single institution with more than 100 patients, as well
as 2 multicentre studies, concerning the feasibility and safety of
dobutamine stress echocardiography. In a cumulative total of 26438 tests performed, 79 life-threatening complications (such as acute
myocardial infarction,
asystole,
ventricular fibrillation, sustained
ventricular tachycardia or severe symptomatic
hypotension) have been reported, giving an incidence of 1 severe adverse reaction per every 335 examinations. In addition, 29 isolated case reports have been published describing life-threatening complications during
dobutamine echocardiography. In case reports, 2 deaths have been described, both due to acute
cardiac rupture in patients with recent
inferior myocardial infarction. Severe adverse reactions during
dobutamine echocardiography can be ischaemia independent, and are independent of operator experience and are unpredictable; some complications can be late occurring and long lasting. As a consequence, the procedure must be clearly indicated, written informed consent has to be obtained from the patient, an attending physician must be present during testing, and long term observation of outpatients is useful in order to manage late complications. In conclusion, while the safety of
dobutamine stress echocardiography was reported to be outstanding in early reports, further experience presents a substantially more worrying picture. This must be taken into account by both physicians and patients when assessing the risk-benefit profile of the procedure.