The Additive Prognostic Value of End-Systolic Pressure-Volume Relationship in Diabetic Patients with Negative Dobutamine Stress Echocardiography by Wall Motion Criteria

Background/objective: The end-systolic pressurevolume relation (ESPVR) is a useful method to assess left ventricular contractility during stress providing prognostic information above and beyond regional wall motion. The aim of the study was to assess the prognostic value of ESPVR in patients with diabetes mellitus having negative dobutamine stress echocardiography by wall motion criteria. Design: We enrolled 233 patients with diabetes mellitus (140 males; mean age 67 (SD 9); mean ejection fraction 52 (SD 10)) having negative dobutamine (up to 40 mg/kg/min with atropine 1 mg) stress echocardiography. In all, ESPVR was determined at rest and at the peak of stress as the ratio of peak systolic pressure and end-systolic volume (SP/ESV) index. Setting: Adult patients with diabetes mellitus evaluated at a tertiary care centre. Main outcome measures: Death, non-fatal ST-elevation (STEMI), non-ST-elevation (NSTEMI) and late (.6 months) revascularisation. Results: During a median of 18 months, 62 events occurred: 35 deaths, 4 STEMI, 5 NSTEMI and 18 late revascularisations. Event-free survival was lower (p=0.006) in patients with peak SP/ESV index (28 mm Hg/ml/m2, chosen with a receiver-operating characteristic curve. Multivariable indicators of future events were prior angioplasty (HR 2.10, 95% CI 1.17 to 3.77; p=0.01), resting wall motion abnormality (HR 1.94, 95% CI 1.12 to 3.36; p=0.02), and peak SP/ESV index (28 mm Hg/ml/m2 (HR 2.28, 95% CI 1.08 to 4.81; p=0.03). At incremental analysis, peak SP/ESV index (28 mm Hg/ml/m2 added prognostic information to that of clinical and resting echo findings. Conclusions: Patients with diabetes mellitus having negative dobutamine stress echocardiography may still experience an adverse outcome, which can be identified by ESPRV, providing a prognostic stratification in addition to that supplied by regional wall motion abnormalities