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The Cardiac Society of Australia and New Zealand Pharmacologic Stress Testing in Conjunction with
This document has been prepared conjointly by a committee representing both the Cardiac
Society of Australia and New Zealand (CSANZ) and the Australia and New Zealand
Association of Physicians in Nuclear Medicine (ANZAPNM). It complements the previously
published “Safety and Performance Guidelines for Clinical Exercise Stress Testing.”
Committee Members
Kevin Allman (ANZAPNM/CSANZ/) (chair)
Nathan Better (ANZAPNM/ CSANZ)
John O’Shea (CSANZ)
Henry Krum (CSANZ)
1. Introduction
These guidelines complement those previously published for clinical exercise stress testing.
Whilst the general principles underlying the safe and effective performance of stress testing
are common to both exercise and pharmacologic approaches, this document addresses issues
specific to the use of pharmacologic agents for cardiac stress testing in conjunction with
clinical imaging procedures. Such procedures include perfusion imaging (scintigraphy) and
imaging of left ventricular function (echocardiography and gated cardiac blood pool
Exercise testing remains the preferred method of stress employed for routine cardiac stress
examinations whenever possible. However, pharmacologic stress testing in combination with
cardiac imaging has emerged as an alternative method for the evaluation of known or
suspected coronary artery disease in patients unable to achieve a diagnostic endpoint during
exercise testing.
Clinical stress protocols for both vasodilators (dipyridamole and adenosine) as well as the
synthetic catecholamine dobutamine (in combination with atropine) are presented.
The stress testing protocols for diagnostic imaging are most widely employed for the
diagnosis and/or characterisation of patterns of coronary artery disease in patients with
suspected or known CAD. They may also be employed where appropriate for the evaluation
of myocardial viability. However in this setting there may be limitations to the use of
maximal exercise or inotropic stimulation protocols in the presence of advanced left
ventricular dysfunction or associated rhythm disorders. While vasodilator stress can usually
be employed to image the results of flow heterogeneity short of inducing ischaemia, in a
minority of patients they can induce ischaemia which may acutely worsen already impaired
left ventricular function in such patients. For radionuclide studies with both SPECT and PET
tracers, viability studies can be performed at rest, with no need for a stress test.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
The efficacy of these pharmacologic approaches in regard to the diagnostic information
obtained from the associated imaging procedures has been documented as similar to those
using maximal exercise stress studies. There are also some specific instances where
pharmacologic stress may be the initial preferred method of stress testing for imaging
procedures e.g. perfusion imaging using dipyridamole stress in patients with left bundle
branch block or low-dose dobutamine echocardiography for myocardial viability assessment.
Personnel should be experienced in the selection of appropriate stress agents for the
individual patient and the clinical question being asked.
The risks associated with pharmacologic stress testing are also similar to those documented
for exercise stress. Thus, death can occur once in every 2000 to 3000 patients tested,
depending on the patient population being tested. Non fatal infarction is reported to occur
once every 1000 to 2000 patients tested. Unstable angina pectoris, systemic hypotension,
heart failure, and serious arrhythmias can also occur during testing and the skills and facilities
to promptly recognise and treat such complications are essential in every laboratory. In view
of these risks the medical practitioner responsible for stress testing should obtain informed
consent prior to pharmacologic stress testing.
Individual pharmacologic stress agents also have well documented contraindications.
Personnel should be experienced in excluding patients from the use of a particular
pharmacologic stress agent in the presence of such a contraindication.
2. Stress Testing

Physical Environment
Sufficient physical space is required for the safe and comfortable conduct of the stress
protocol and the timely treatment of any complications. Pharmacologic studies are usually
performed with the patient lying supine on a bed. Resuscitation equipment must be located in
the same room with sufficient space for cardiopulmonary resuscitation to be effectively
performed. Equipment for the use of supplemental exercise with dipyridamole or adenosine
(treadmill or cycle ergometer) should also be in the same room.
Stress Equipment
The intravenous use of the short-acting receptor agonists adenosine and dobutamine requires
the use of a controlled delivery infusion device. Individual devices require Therapeutic Goods
Administration approval and must conform to Australian Standard AS3201.1 for electrical
safety. All such devices should be periodically checked for accurate volume delivery
Exercise devices used in conjunction with pharmacologic stress (motorised treadmills or
braked cycle ergometers) should comply with the description given in paragraph 2b) of the
Safety and Performance Guidelines for Clinical Exercise Stress Testing.
All equipment should be well maintained and checked for performance and safety regularly.

Recording of Stress Parameters
With dobutamine stress target heart rate may be calculated from an appropriate nomogram (or
as below under “Dobutamine”)
and recorded on a patient worksheet prior to protocol
commencement. With vasodilator stress this is required only if supplemental exercise is to be
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
A permanent medical record of the test details (including patient’s name, date, test indication,
relevant history including medications and prior drug reactions, recent caffeine consumption,
heart rate and blood pressure measurements during stress, symptoms during and post-stress,
presence and quality of any chest pain, any side effects, any untoward effects, ECG
interpretation for ischaemia and arrhythmias, total doses of all drugs administered and copies
of the electrocardiographic recordings) should be made.
Electrocardiographic Monitoring

Adequate skin preparation and electrode fixation (whether adhesive or suction based) is
required to ensure good skin contact and artifact-free signal quality. This requires alcohol
cleaning to remove oil and skin preparation with a disposable abrasive device to remove dead
horny layer cells. The applied electrodes should be tested for good skin contact by
performing an ECG tracing and making adjustments prior to the stress test.
Baseline Electrocardiogram
A standard 12 lead electrocardiogram should be obtained and printed out with the patient
supine using a 3 channel ECG machine with appropriate low frequency filters and phase
response for accurate recording. An additional modified trace with the limb leads
repositioned on the torso should also be recorded if supplemental exercise is to be used. An
upright trace should be obtained prior to commencing supplemental exercise. Before
proceeding with the stress study the physician should compare the baseline ECG with any
previous ECG when possible.
Recordings During Pharmacologic Stress
The 12 lead ECG should be continuously monitored on a video display screen during the
stress protocol to detect ischaemia and arrhythmias. Continuous display of three leads
including an inferior lead, V5 and V1 or V2 is required to adequately detect ECG changes of
ischaemia. Further 12 lead print out should be obtained during each stage of the stress
protocol or at least every three minutes. Additional 12 lead print outs should be obtained at
the end of the stress protocol.
ECG monitors should have memory to enable capture and later print out of abnormal cardiac
Computerised ECG systems which have signal averaging included still require the raw trace
to be printed out and visually interpreted to avoid incorrect computer interpretation of heart
rate or ST segments due to either noise or artifact.
ECG Recordings During Recovery Period
12 lead hard copy should be obtained twice during the recovery period which should routinely
last at least five minutes, unless the imaging protocol necessitates a shorter period (as is the
case with thallium-201 imaging). Additional recordings in recovery should be obtained to
document recovery from ischaemia or arrhythmia as necessary. Should imaging need to be
performed prior to the ECG reverting to the pre test configuration then a delayed trace
following imaging is required.
Blood Pressure Measurement
A sphygmomanometer is required to record baseline systolic/diastolic blood pressure as well
as measurements during each stage of the stress protocol or at least once every three minutes.
Measurements should be made at least twice following stress and for longer periods as
required to document return of blood pressure to the pre test level. Repeat measurement
following completion of scintigraphy may be required as for “ECG Recordings During
Recovery Period”
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures

Recording of Symptoms and Documentation
The presence, quality and severity of chest pain, breathlessness, dizziness, fatigue and other
symptoms including those related to the pharmacologic stress agent (e.g. burning, flushing,
light-headedness, apprehension) should be recorded by the physician based on direct
questioning during the stress period. Recovery and any treatment required should also be

Resuscitation Equipment
All laboratories using pharmacologic stress testing must be able to provide advanced cardiac
life support on-site. Equipment required for this must be maintained and checked regularly
and includes:

i) Defibrillator:
Must comply with Australia/New Zealand standard A/NZS 3204 and maintained/tested
regularly as specified in A/NZS 3551 “Procurement, acceptance, safety and functional
testing of active medical devices.”
Conductive gel or gel pads must be available and
the defibrillator able to be manoeuvred into place for effective patient treatment in the
stress room.
ii) Suction:
Motor or gas driven suction with extension tubing and attachable suckers for clearing
the airway of the patient must be available in the laboratory.
iii) Airway plus self-inflating bag:
Plastic or rubber self-inflating bag and patient airways for the ventilation of a patient
during cardiac arrest are required in the laboratory and must be regularly checked and
iv) Oxygen:
Cylinder or wall-mounted oxygen supply with appropriate tubing and masks for
delivery to the patient are required.
v) Drugs and intravenous administration equipment:
Equipment for the sterile placement and maintenance of intravenous lines is required.
Together with the pharmacologic stress agents, other drugs and intravenous fluids must
be kept in the laboratory. These include: atropine, lignocaine, adrenaline and sotalol or
amiodarone, together with sublingual nitroglycerin tablets and/or spray. Salbutamol or
other beta-2-agonist metered aerosol for bronchospasm is required. Aminophylline is
needed to antagonise the effects of dipyridamole. Esmolol is a short acting beta
adrenergic receptor blocker which has been used to antagonise the effects of
dobutamine. Intravenous 0.9% saline or 5% glucose may be required to treat
hypotension associated with pharmacologic stress. All supplies must be checked
regularly and in date.

Communications and Alarm
All laboratories require an alarm system to raise the help of nearby personnel promptly and a
telephone for contacting an intensive care ambulance in an emergency.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
3. Imaging Equipment
The imaging equipment and protocols for its use should be well maintained and capable of
providing diagnostic imaging information in keeping with any clinical practice guidelines
currently in place.
In the case of nuclear imaging the gamma camera used should have gated SPECT capability
and the capacity to provide diagnostic quality images for the radiotracer being used, either
thallium-201 or a technetium-99m flow tracer. Camera performance should be monitored
with a regular quality control testing programme.
For echocardiography there should be the capacity for image frame-grabbing and
simultaneous loop display of images at rest and multiple levels of stress. Such simultaneous
display of cine loops facilitates accurate assessment of wall motion abnormalities and changes
developing at different phases of the study. The assessment of wall motion abnormalities can
be facilitated by a number of improvements in technology, including harmonic imaging,
administration of contrast agents, strain rate imaging, etc.
4. Personnel
Two persons trained in cardiopulmonary resuscitation should be present in the stress
room at all times for patient safety
. They should be trained in recognition of the major
arrhythmias and ischaemic patterns on the electrocardiogram. At least one should be a
suitably qualified medical practitioner registered in the state in which the laboratory is

Medical Practitioner
The medical practitioner responsible for overseeing the pharmacologic stress test must have a
medical qualification and be currently registered by the appropriate medical board. The
medical practitioner must be in attendance in the room during pharmacologic stress and
during the immediate post-stress period. The medical practitioner must have competence and
abilities in the following specific areas:

Indications and Contraindications for Pharmacologic Stress
The medical practitioner through obtaining an appropriate history and physical examination in
conjunction with information from the referring medical practitioner must be able to
determine that pharmacologic stress using a particular stress agent is appropriate for the
individual patient to assist in answering the clinical question being asked and that there are no
contraindications to the use of that agent. The medical practitioner must further be able to
take into account any individual circumstances which may indicate the need for special
precautions to be taken in the use of a particular agent in a given patient.
ECG Interpretation
The medical practitioner must be able to interpret all the major abnormalities which can be
detected on 12 lead electrocardiography, in particular those related to ischaemic heart disease.
This includes abnormalities on the resting trace likely to preclude the interpretation of the
stress ECG, and those which might determine that testing be cancelled or deferred. The
practitioner should also be able to recognise all the major arrhythmias and ECG patterns
indicating myocardial ischaemia during testing and to interpret the ECG traces for the
presence or absence of ischaemia at the completion of testing.
Interpretation of Symptoms
The practitioner should be able to recognise the significance of all symptoms occurring during
pharmacologic stress testing and to differentiate ischaemic from non-ischaemic symptoms.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Basic and Advanced Life Support
The supervising medical practitioner must be fully versed in the techniques of basic and
advanced life support (as defined by the Australian Resuscitation Council or in the New
Zealand Standards and Guidelines on Basic Life Support) and be able to perform these skills
in an emergency. These skills include ability to diagnose the cause of the underlying problem
and to apply early rapid defibrillation to the patient, to perform external cardiac massage, to
ventilate the patient using airway and bag with mask, to cannulate the patient and administer
the drugs detailed above appropriately.
The practitioner should be able to demonstrate continuing competence in resuscitation for
example by second annual attendance at retraining courses.
Experience in clinical pharmacologic stress testing
The practitioner should have sufficient knowledge to safely conduct and accurately interpret
the pharmacologic stress studies. This includes knowledge regarding selection of agent,
contraindications, pharmacologic and clinical effects of the agent, administration protocols,
adverse effects, reversal of pharmacologic effect, drug interactions, and when to terminate the
pharmacologic stress period.
Assistant for Pharmacologic Stress testing
The second person should be a health professional from a background including the
following: nurses, technologists or their equivalent, other suitably qualified health
professionals. The minimum required skills include:
• ability to perform cardiopulmonary resuscitation; • ability to obtain a high quality ECG trace at rest and during stress; • ability to recognise the major arrhythmias and ischaemic ECG changes and clinical manifestations likely to occur during pharmacologic stress testing.
Further details are included in the “Safety and Performance Guidelines for Clinical Exercise
Stress Testing”.

Withholding of medication
As with exercise testing, ideally anti-anginal medication, particularly beta-blockers, should be
withheld for up to 48 hours prior to the test to maximise test sensitivity and avoid potential
underestimation of true extent of ischaemia. There is a small clinical risk of acute coronary
syndrome associated with abrupt withdrawal of beta blockers in patients with coronary artery
disease so this needs to be modified according to each individual patient, and in certain cases,
the test can be performed on anti-anginal medications. Also, PDE 5 inhibitors (e.g. sildenafil,
vardenafil and tadalafil), used for erectile dysfunction and also for pulmonary arterial
hypertension, should be withheld for 48 hours prior to the test, in case nitrates are required
during the study. Ideally, the opinion of the referring Doctor should be sought in regard to
cessation of therapy in these situations.
5. Pharmacologic Stress Protocols

Details of the commonly employed clinical protocols for the conduct of pharmacologic stress
testing together with appropriate background information follow. The techniques are most
commonly employed in the diagnosis or evaluation of coronary artery disease. Special
protocols are also in use to evaluate myocardial viability in some patients.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Vasodilator Stress
Vasodilators are the most widely studied and currently preferred agents for use in conjunction
with perfusion imaging. They increase blood flow (and hence the degree of flow
heterogeneity during induced hyperaemia in patients with coronary artery disease) more than
dobutamine. They are however considered second line agents after dobutamine for imaging
of LV function (as they induce fewer abnormalities of regional wall motion and thickening).
Electrocardiographic evidence of myocardial ischaemia is produced in a relatively small
proportion of patients with this form of stress (usually those with severe multivessel coronary
artery disease dependent on collateral flow).
Whilst adenosine may have some theoretical advantages over dipyridamole by virtue of its
direct action, current data suggest similar safety and efficacy profiles overall for both
dipyridamole and adenosine in clinical use.

i) Dipyridamole
Rationale for Use
This agent creates regional heterogeneity in coronary artery flow reserve in patients with
coronary artery disease. This heterogeneity can be imaged as a stress-induced perfusion
defect on scintigraphic images. It can also be used for echocardiography or blood pool
imaging in patients unsuited to dobutamine stress. Dipyridamole stress-induced regional wall
motion abnormalities are imaged in order to detect the presence of coronary artery disease
with this approach. As with other pharmacological agents, it can be used in patients unable to
exercise and in those clinically stable at least 48 hours post myocardial infarction.
Dipyridamole and adenosine should also be considered in patients with left bundle branch
block as vasodilator stress is associated with fewer septal artefacts than exercise stress.

Mechanism of Action
Dipyridamole is a lipophilic pyrimidine. Its administration leads to arteriolar vasodilatation
through inhibition of phosphodiesterase which in turn inhibits reuptake of endogenously
produced adenosine into endothelial and red blood cells. This increases coronary arterial flow
to approximately three times resting values in normal subjects. Hyperaemic flow is
attenuated in tissue supplied by a stenosed coronary artery. This leads to heterogeneity of
tracer uptake on perfusion images or new regional wall motion abnormalities on imaging of
left ventricular function.
There is usually a modest reflex increase in heart rate secondary to a mild decrease in systolic
blood pressure. 15% of patients can exhibit a rise in blood pressure however.
Maximal vasodilatation is achieved approximately three minutes following completion of the
four minute infusion. Effects on the circulation peak from 7 to 12 minutes and then gradually
dissipate over the next 10 to 15 minutes. Symptoms and/or haemodynamic effects can still be
evident at 30 minutes in a very small proportion of patients.
Dipyridamole is administered intravenously at a standard dose of 0.56mg/kg over 4 minutes.
An infusion delivery device is not required. Tracer is injected during peak hyperaemia at 7
minutes from commencement of injection. Higher doses up to 0.84mg/kg have been
employed with echocardiography to achieve a small diagnostic gain. There are more minor
side effects but no substantial difference in safety profile. Higher doses have been less widely
studied with perfusion imaging.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Supplemental exercise (used with perfusion imaging to increase relative cardiac vs. hepatic
uptake of flow tracer to enhance image quality) is performed immediately following
dipyridamole administration and should be completed within 8 minutes so tracer injection is
performed during the period of peak hyperaemia.
Dipyridamole may increase the effects of antihypertensive drugs. Dehydration should be
avoided in patients scheduled for dipyridamole stress studies.
Adverse Effects
In 3911 patients studied with 0.56mg/kg/min 47% experienced one or more side effects:
Fatal MI in multicentre registries, adenosine and dipyridamole administration are associated
with a 0.0001% acute cardiac death rate
Nonfatal MI 0.05%
Bronchospasm 0.15%
Chest pain 20%
Dizziness 12%
Dyspnoea 3%
Flushing 3%
Nausea 5%
Headache 12%
Hypotension 5%
Palpitation 3%
ST segment changes 8%
Transient ischaemic attack has been reported in one patient with cerebrovascular disease.
Transient asystole has been reported in subjects without coronary artery disease not receiving
beta adrenergic blockers during administration of intravenous dipyridamole performed
concurrently with erect bicycle exercise.

Reversal of Effects
The effects of dipyridamole may be antagonised by intravenous aminophylline in incremental
doses of 25mgs by intravenous injection up to 250mgs as required. Aminophylline is a
competitive inhibitor of phosphodiesterase. It has a shorter half-life than dipyridamole so
later repeat injection of aminophylline is sometimes required. There are no data to
demonstrate a benefit of routine vs. selected administration for effects such as ischaemia,
hypotension, rhythm disturbance (atrioventricular block rarely) or symptoms of discomfort
(usual reason).
Ischaemia is usually relieved by aminophylline and oxygen, with other agents if required
Specific contraindications
Within 48 hours of acute myocardial infarction
Unstable angina with rest pain within last 48 hours
Severe lung disease or asthma
Heart failure/severe LV systolic dysfunction
Second or Third Degree Atrioventricular block without a pacemaker
Resting hypotension
Prior adverse reaction to dipyridamole
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Drug interactions
False negative dipyridamole stress perfusion studies have been clearly demonstrated in
patients with coronary artery disease who have had recent intake of caffeine. Caffeine and
other methylxanthines (aminophylline, theophylline) should be ceased for an adequate period
prior to testing (most laboratories require a minimum period of at least 24 hours and many 48
hours). In patients not exhibiting a haemodynamic response to the standard dose of
dipyridamole, caffeine consumption prior to testing may have occurred. Such patients may
require repeat testing after abstinence from caffeine or the use of an alternate method of
cardiac stress testing.
Beta adrenergic blockers: Marked bradycardia has been reported with vasodilator
administration in patients on background beta adrenergic blocker therapy.
Patients receiving chronic oral dipyridamole may fail to show an acute haemodynamic
response to intravenous dipyridamole: In this situation, cessation of oral dipyridamole for 48-
72 hours prior to testing is recommended.
ii) Adenosine

Rational for Use
see above for Dipyridamole

Mechanism of Action
Adenosine is an endogenous nucleoside produced within the arterial vascular bed. It acts via
specific G-protein-coupled adenosine receptors. The resulting vasodilatation is more potent
and consistent than with dipyridamole.
It is a receptor agonist with a rapid onset of action (within seconds). Its elimination half-life
is a few seconds. This is by carrier-mediated uptake and subsequent metabolism by
adenosine deaminase.
Adenosine is very potent and requires the use of a controlled delivery infusion system. It is
usually given as a constant infusion at a dose of 140mcg/kg/minute. It is helpful to prepare a
chart converting the adenosine dose into the infusion rate required, according to the patient's
A graded infusion commencing at 70mcg/kg/minute increasing to 100 and then
140mcg/kg/minute each minute to the maximum tolerated dose rate has been advocated for
higher risk patients. However lower peak infusion rates are likely to reduce test diagnostic
For perfusion imaging the recommended duration of administration is six minutes with tracer
injection at 3 minutes into the infusion. There is less evidence available concerning
diagnostic accuracy with a 4 minute infusion protocol. A separate intravenous line or T-piece
system is required for tracer injection to avoid an adenosine bolus effect which has been
demonstrated to sometimes result in acute transient high-grade atrioventricular block.

Adenosine can be combined with an exercise protocol to improve image quality.
Adverse Effects
Overall these are similar to dipyridamole. There is a higher proportion of symptoms (81%)
but they terminate rapidly on cessation of the infusion. Atrioventricular block is more
common than with dipyridamole but is usually asymptomatic and reversible.
In 9256 patients 81% experienced one or more side effects:

Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures

Fatal MI 0%
Nonfatal MI 0.01% (highlighted in case reports)
Bronchospasm 0.07%

Palpitation 7.6% (atrioventricular block, usually asymptomatic)
Chest pain 35%
Flushing 37%
Headache 14%
Shortness of breath 35%
Epigastric discomfort 9%
Nausea 15%
Dizziness 9%
ST segment changes 6%
Reversal of Effects
Due to its very short half-life the effects of adenosine are usually rapidly reversible upon
cessation of infusion. Aminophylline injection is rarely if ever required. Ischaemia is treated
with nitroglycerine and oxygen.
Specific contraindications
Resting hypotension
Heart failure
Second or Third Degree Atrioventricular block without pacemaker
Atrial fibrillation with uncontrolled ventricular rate
Prior adverse reaction to adenosine
Caution should be exhibited in liver transplant candidates with advanced hepatic dysfunction
and/or anaemia and liver transplant recipients with graft failure due to an increased incidence
of sinus arrest related to impaired adenosine metabolism.

Drug Interactions
as for dipyridamole above

Dobutamine Stress

Rationale for Use
Dobutamine is a synthetic catecholamine. This is the preferred pharmacologic stress agent
when imaging of cardiac function (echo, blood pool scintigraphy) is being performed. By
way of comparison, dobutamine is more effective in producing stress-induced regional wall
motion abnormalities, while vasodilator stress results in greater increase and regional
heterogeneity of blood flow.
Dobutamine produces myocardial ischaemia by increasing determinants of myocardial
oxygen demand including heart rate, blood pressure and contractility. In myocardium
supplied by a stenosed coronary artery, the increase in oxygen demand cannot be met by an
adequate increase in blood flow, leading to regional wall motion abnormalities or flow
Compared with exercise, dobutamine produces a greater increase in inotropic state and less
increase in heart rate, with a variable effect on blood pressure. Dobutamine produces
ischaemia at a lower rate-pressure product than exercise, indicating the contribution of
increased contractility.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Candidates for dobutamine stress with perfusion imaging represent a higher risk group as they
are likely to have significant co-morbidities which have ruled them out for exercise or
vasodilator stress. The imaging findings available with echocardiography together with
dobutamine stress which may lead to early test termination (see below) are not available with
radionuclide perfusion imaging.
Mechanism of Action
Dobutamine is a short-acting synthetic catecholamine with beta-1 agonist and some beta-2
agonist and alpha effects. Dobutamine is positively inotropic, increasing stroke volume and
cardiac output at clinical doses. It also exerts a chronotropic effect but this is variable
between patients and is in any case less than that of other catecholamines (e.g. isoprenaline).
At higher doses hypotension is frequently observed during clinical stress testing presumably
related to the alpha-1 and beta-2 receptor mediated vasodilatation.
Since the heart rate increase with dobutamine is modest, atropine supplementation is
frequently utilised during stress testing (see below).
It is metabolised via methylation and conjugation and eliminated by both renal and biliary
Dobutamine has a half life of two minutes. Steady state is achieved after ten minutes. Plasma
concentrations appear to be linearly related to infusion rates over the range studied clinically.
The elimination half life of dobutamine is less than three minutes.
Target heart rate is determined from a nomogram or calculated as (220-age in years).
Dobutamine is administered in diluted form as a continuous intravenous infusion via a
programmable controlled infusion delivery device capable of accurate volume delivery and
prompt stepwise increments in rate of administration during infusion. The patient intravenous
tubing should have the minimum possible dead space to avoid any lag effect following dose
increments. It is helpful to prepare a chart converting the -dobutamine dose at various stages
into the infusion rate required at each stage, according to the patient's weight.
The infusion protocol consists of 3 minute stages at incremental doses of 5, 10, 20, 30, 40 and
if necessary 50 mcg/kg/minute. If 85% predicted heart rate response is not achieved with this
protocol and a diagnostic ECG or echocardiographic endpoint has not been reached then
atropine may be added (see below). Conversely, the infusion may be terminated early upon
attaining such a diagnostic endpoint at a lower dose rate.

The infusion should be terminated at any time if there is clinical, ECG or echocardiographic
evidence of moderate to severe ischaemia, or if major adverse effects occur.
For nuclear studies tracer injection is performed at least one minute prior to infusion
termination. Care to avoid a bolus effect (see “Adenosine,” above) is important and usually
requires use of a separate intravenous line or at least 2 ports or three-way taps.
Particular care should be taken to avoid dobutamine extravasation into tissues (see below
under “Reversal of Effects”)
which requires termination of infusion, withdrawal of
intravenous cannula, limb elevation, and consideration of phentolamine administration (5-10
mg, diluted in 10 ml saline injected with a fine needle into the region of extravasation).

Adverse Effects
The main adverse effects are hypotension and arrhythmias. Both are dose related. Non-
cardiac adverse effects are common but rarely require interruption of the test. These effects
include nausea, anxiety, headache, tremor, palpitation, presyncope, urgency and chills.
In 1118 patients 35% had one or more side effects:
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
Major Nonfatal MI 0.1% Other Palpitation 35% (tachyarrhythmias) Anxiety 6% Chest pain 19% Dyspnoea 5% Headache 4% Hypotension 3% Nausea 8% Tremor 4% ST segment changes 9% (coronary artery spasm with ST segment elevation can occasionally occur, for which nitrate therapy may be preferable to beta-blockade) Serious Arrhythmias in 5817 patients in 4 studies Ventricular Fibrillation 0.05% Sustained ventricular tachycardia 0.2% Non sustained ventricular tachycardia 4% Supraventricular arrhythmias 3% Death: two deaths have been reported with dobutamine stress imaging studies in 1997 Hypotension In contrast to exercise testing, hypotension during dobutamine infusion is not usually a marker of severe ischaemia or severe left ventricular dysfunction. Possible mechanisms of dobutamine induced hypotension include ischaemic left ventricular dysfunction, systemic vasodilator effect of dobutamine, dynamic left ventricular outflow tract dysfunction, and vasodepressor reflex (Bezold-Jarisch). The latter two mechanisms are supported by the finding that hypotension occurs less frequently in patients taking beta-blockers and more frequently in patients with high resting left ventricular ejection fraction or with high resting systolic blood pressure. Left ventricular dysfunction and dynamic left ventricular outflow tract dysfunction can be diagnosed by two-dimensional and Doppler echocardiography during the dobutamine infusion. Dobutamine infusion should be ceased if hypotension is severe, e.g. < 80-100 mm Hg systolic or >40 mm Hg decline, or if hypotension is progressive, symptomatic or associated with evidence of severe ischaemia. Infusion should also be stopped if echocardiographic imaging demonstrates intracardiac gradients >3-3.5 m/s, often associated with LV cavity obliteration or marked systolic anterior motion of the mitral valve. If left ventricular function appears hyperdynamic and the ventricle appears hypovolaemic at baseline, infusion of normal saline (e.g. 500 ml) prior to commencement of dobutamine may be considered. Arrhythmias Arrhythmias during dobutamine infusion reflect the development of ischaemia, the beta-1 receptor stimulation, and perhaps dobutamine-induced reduction in plasma potassium. Arrhythmias are more frequent in patients with previous ventricular arrhythmia or resting left ventricular dysfunction, but are not increased by atropine. Cessation of infusion due to arrhythmia must be individualised. Isolated ectopic beats are common and do not generally required cessation. Infusion should be stopped and other treatment considered if arrhythmia is sustained, severe or symptomatic. Termination of infusion may be sufficient to end arrhythmias. Intravenous beta-blockers such as esmolol may also be required, particularly if the arrhythmia is prolonged, there is delayed return to baseline heart rate after dobutamine cessation, or there is evidence of extensive ischaemia. Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures

Reversal of Effects
The effects of dobutamine itself are reversible soon after cessation of infusion. However the
effects of stress-induced ischaemia or arrhythmias may persist. Intravenous beta-blockers
should be available, such as metoprolol or atenolol or preferably, the short acting beta-blocker
esmolol. Esmolol is given as 0.5 mg/kg over 1 minute to reverse the effects of dobutamine.
This group of patients may have received dobutamine rather than dipyridamole due to a
history of asthma; hence beta-blockers, if required, may need to be administered with caution.
Phentolamine injection should also be available for the treatment of dobutamine

Specific contraindications
These are similar to contraindications to exercise stress, with particular emphasis on unstable
angina, severe hypertension or uncontrolled arrhythmia. Prior adverse reaction to dobutamine
should also be noted.
Drug interactions
Background oral beta adrenergic blocker therapy will attenuate the response to dobutamine.
See above re cessation of beta adrenergic blockers for stress testing.

Rationale for Use
Atropine is an anticholinergic agent frequently used in conjunction with dobutamine to
further increase heart rate and therefore increase myocardial oxygen demand resulting in
ischaemia. Atropine is more frequently required in patients receiving beta-blockers or with a
low resting heart rate. Atropine increases the sensitivity of the dobutamine stress imaging test
to detect coronary artery disease, without loss of specificity. It can also be used safely as an
adjunct to exercise testing in patients with chronotropic incompetence.
Mechanism of Action
Atropine is an anticholinergic drug which exerts a vagolytic effect on the cardiac conduction
system, particularly on the sinoatrial and to a lesser degree the atrioventricular node. This
leads to an increase in heart rate.

Duration of Action
The increase in heart rate is observed usually within one minute of injection. Effects on heart
rate can persist for a number of minutes and are dose-related.
Atropine is given by intravenous bolus in 0.3 - 0.6 mg aliquots, given at 1 minute intervals
until the target heart rate is reached or to a maximal dose of 1.2 mg.

Adverse Effects
Adverse reactions to atropine include urinary retention, xerostomia, cycloplegia, mydriasis,
dry skin, flushing, constipation, nausea and central nervous system disturbance.

Reversal of Effects
Specific reversal is not usually required for cardiac effects as the action is observed to
dissipate in the minutes following administration. Urinary retention and cycloplegia require
consideration of specific management. In 4 series of 5,717 patients, neurologic
manifestations of atropine poisoning developed in 5 patients (0.09%), manifested by stupor
and hallucinations, with no permanent sequelae. Management includes supportive measures
and consideration of physostigmine.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures

Narrow angle glaucoma
Obstructive uropathy including bladder neck obstruction from prostatic hypertrophy
Obstructive gastrointestinal disease or paralytic ileus
Atrial fibrillation with uncontrolled ventricular rate
Prior adverse reaction to administration
Due to a risk of hyperpyrexia, atropine should be avoided during a high ambient temperature.
Atropine should also be used with caution in patients with chronic pulmonary disease, due to
possible reduction in bronchial secretions.

Drug Interactions
The anticholinergic activity of atropine may be increased by other anticholinergic
medications, including antihistamines, butyrophenones, phenothiazines and tricyclic
Combined Stresses

Combining vasodilator stress with exercise or combining multiple pharmacologic agents have
both been employed in efforts to increase the diagnostic performance of pharmacologic stress
imaging techniques.

Vasodilator Stress plus Exercise
Unlike exercise, vasodilators indiscriminately increase blood flow in all vascular beds. The
relative increase in hepatic/splanchnic flow is an undesirable consequence for perfusion
imaging, affecting evaluation of the inferior wall of the left ventricle for perfusion defects.
The addition of a short (up to six minutes) exercise test (treadmill or bicycle) has been used
immediately following completion of dipyridamole or during adenosine infusion. This can
improve image quality by decreasing splanchnic relative to cardiac blood flow. Tracer
injection during the physiologic action of both stresses is required. For this reason, care
should be taken to complete exercise testing within the expected period of drug-induced
hyperaemic flow.

Multiple Pharmacologic Stresses
As detailed above, atropine stress can be routinely used if required in conjunction with
dobutamine stress to achieve a diagnostic heart rate response. Atropine can be administered
early at the 20 mcg/kg/min stage of the dobutamine protocol if the heart rate is lees than
100/minute. This can shorten the test duration, with a similar safety profile and accuracy of
the test. This technique has not, as yet, been studied as extensively as the standard protocol of
using atropine at peak dobutamine dose.
Atropine can also be combined with the vasodilators although information on the diagnostic
efficacy of this technique is less abundant than for the dobutamine/atropine combination.
Dobutamine/Vasodilator Stress
Low dose dobutamine combined with dipyridamole stress has been reported in the assessment
of myocardial viability but only in preliminary studies.
Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
Clinical Cardiac Imaging Procedures
6. Bibliography
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Pingitore A, Picano E, Colosso M, et al. The Atropine Factor in Pharmacologic Stress Echocardiography. Echo Persantine (EPIC) and Echo Dobutamine International Cooperative (EDIC) Study Groups. J Am Coll Cardiol 1996;27(5):1164-1170. Poldermans D, Fioretti P, Boersma E, et al. Safety of Dobutamine-Atropine Stress Echocardiography in Patients with Suspected or Proven Coronary Artery Disease. Am J Cardiol 1994;73:456-459. Rahimtoola S. Hibernating Myocardium has reduced Blood Flow at Rest That Increases with Low-Dose Dobutamine (Editorial). Circulation 1996;94(12):3055-3061. Ritchie J, Bateman T, Bonow R, et al. Guidelines for Clinical Use of Cardiac Radionuclide Imaging. A Report of the American Heart Association/American College of Cardiology Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Committee on Radionuclide Imaging), Developed in Collaboration with the American Society of Nuclear Cardiology. Circulation 1995;91(4):1278-1303. Secknus M, Marwick T. Evolution of Dobutamine Echocardiography Protocols and Indications: Safety and Side Effects in 3011 Studies over 5 Years. J Am Coll Cardiol 1997;29:1234-1240. Tsutsui JM, Osorio AF, Lario FA, Fernandes DR, Sodre G, Andrade Jl et al. Comparison of safety and efficiency of the early injection of atropine during dobutamine stress echocardiography with the conventional protocol. Am J Cardiol 2004;94(11):1367-72. Patel AD, Lerakis S, Zacharoulis A, Martin RP. Coronary artery vasospasm during dobutamine stress echocardiography. J Am Soc Echocardiogr Holly TA, Satran A, Bromet DS, Mieres JH, Frey MJ, Elliott MD et al. The impact of adjunctive adenosine infusion during exercise myocardial perfusion imaging: Results of the Both Exercise and Adenosine Stress Test (BEAST) trial. J Nucl Cardiol 2003;10 (3) 291-6. Munagala VK, Guduguntla V, Kasravi B, Cummings G, Gardin JM. Use of atropine in patients with chronotropic incompetence and poor exercise capacity during treadmill stress testing. Am Heart J 2003;145(6):938-40. Kulhanek J, Sorrell VL, Ershadi RE, Cabarrus BR, Short DB, Movahed A. Adenosine myocardial perfusion single photon computed tomographic stress testing 24-72 h after uncomplicated myocardial infarction. Int J Cardiovasc Imaging 2002;18(4):269-72. Taillefer R, Ahlberg AW, Masood Y, White CM, Lamargese I, Mather JF et al. Acute beta-blockade reduces the extent and severity of myocardial perfusion defects with dipyridamole Tc-99m sestamibi SPECT imaging. J Am Coll Cardiol 2003;42(8):1475-83. Giedd KN, Bokhari S, Daniele TP, Johnson LL. Sinus arrest during adenosine stress testing in liver transplant recipients with graft failure: three case reports and a review of the literature. J Nucl Cardiol 2005; 12(6):696-702. Polad JE, Wilson LM. Myocardial infarction during adenosine stress test. Heart Miller DD. Impact of selective Adenosine A2A receptor agonists on cardiac imaging. Feeling the lightning, waiting on the thunder. J Am Coll Cardiol 2005;46(11):2076-8. Safety and Performance Guidelines for Pharmacologic Stress Testing in Conjunction with
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Brown KA, Heller GV, Landin RS, Shaw LJ, Beller GA, Pasquale MJ, et al. Early dipyridamole (99m)Tc-sestamibi single photon emission computed tomographic imaging 2 to 4 days after acute myocardial infarction predicts in-hospital and postdischarge cardiac events: comparison with submaximal exercise imaging. Circulation. 1999;100(20):2060-6. Smart SC, Knickelbine T, Stoiber TR, Carlos M, Wynsen JC, Sagar KB. Safety and accuracy of dobutamine-atropine stress echocardiography for the detection of residual stenosis of the infarct-related artery and multivessel disease during the first week after acute myocardial infarction. Circulation. 1997;95(6):1394-401. Calnon, D. A., P. D. McGrath, et al. (2001). "Prognostic value of dobutamine stress
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