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Dobutamine stress echo protocol
Dobutamine stress echocardiography (DSE) increases heart rate and contractility in steps while the same echo views are recorded at rest, low dose, peak and recovery. The test looks for segments that fail to augment or deteriorate with stress (ischaemia), and for contractile reserve in dysfunctional segments (viability).
Indications
- Detection of inducible ischaemia when exercise is not possible or not adequate.
- Risk stratification, including before major non-cardiac surgery.
- Myocardial viability in patients with LV systolic dysfunction and coronary disease.
Common contraindications include an unstable acute coronary syndrome, uncontrolled hypertension or arrhythmia, and significant dynamic LVOT obstruction. Follow your local protocol.
Stages
| Stage | Typical dose | What you record |
|---|---|---|
| Rest | — | All views: PLAX, PSAX (mid), apical 4-, 2- and 3-chamber |
| Low dose | 5–10 µg/kg/min | Same views: contractile reserve (viability), early ischaemia |
| Intermediate | 20–30 µg/kg/min | Monitoring; increments usually every 3 minutes |
| Peak | Up to 40 µg/kg/min ± atropine | Same views at or near the target heart rate |
| Recovery | Infusion stopped | Same views as the heart rate falls |
If the target heart rate is not reached at the maximum dobutamine dose, atropine is usually given in small divided doses up to the local maximum. For a viability study the low-dose steps are smaller (for example 2.5, 5 and 10 µg/kg/min) with images at each step.
Target heart rate
The usual target is 85% of the age-predicted maximum heart rate (220 − age). A 60-year-old has a predicted maximum of 160 bpm and a target of 136 bpm. A test that stops below the target without ischaemia is non-diagnostic (submaximal): it cannot be reported as negative. Beta-blockers are the most common reason the target is not reached.
Image acquisition
Record the same views at every stage and compare them side by side on a quad screen, ideally systole-aligned, so that each segment can be followed from rest to peak and into recovery. Peak images must be acquired quickly: ischaemic wall motion abnormalities can resolve within a minute or two once the heart rate falls. Use contrast when two or more contiguous segments are not seen.
End-points
- Target heart rate reached and peak images complete.
- A new or worsening wall motion abnormality, particularly in two or more contiguous segments.
- Severe chest pain, significant arrhythmia (for example sustained ventricular tachycardia or new atrial fibrillation).
- A marked fall in blood pressure, especially with symptoms, or a hypertensive response (for example systolic pressure above 220 mmHg).
- ST elevation in leads without Q waves.
- Intolerable side effects.
Side effects
Palpitations, ventricular ectopics, nausea, tremor, headache and anxiety are common. A fall in blood pressure is usually caused by vasodilatation or dynamic LVOT obstruction rather than ischaemia. Atropine can cause a dry mouth, urinary retention and confusion in older patients. Serious complications are rare when patients are selected and monitored properly.
Practise it
Every case in the simulator includes the dobutamine dose, heart rate (% of maximum), blood pressure and symptoms for each stage, so you can practise deciding whether the target was reached and whether the test is diagnostic.
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