Early Atropine Protocol Enhances Dobutamine Stress Echocardiography in End-Stage Liver Disease: A Practical Cardiac Risk Stratification Tool Before Liver Transplantation.

Abstract

BACKGROUND Chronotropic incompetence often prolongs dobutamine stress echocardiography (DSE) and provokes adverse events in liver-transplant (LT) candidates. We evaluated whether administering atropine 1 stage earlier than conventionally recommended improves test efficiency and tolerability. MATERIAL AND METHODS In this retrospective single-center study, 69 end-stage liver disease patients were assigned to 3 cohorts according to the protocol used: Group 1 - high-dose dobutamine alone (n=24); Group 2 - "late" atropine (1 mg at 40 µg/kg/min; n=22); Group 3 - "early" atropine (at 30 µg/kg/min; n=23). Primary endpoints were target heart rate (HR) achievement, procedure time, hypotension, and ventricular extrasystole (VES). RESULTS Target HR was reached in 83%, 86%, and 95% of Groups 1-3, respectively (P<0.001). Mean procedure duration fell from 27.82±2.06 min with late atropine to 18.48±0.95 min with early atropine (-33.6%). Hypotension dropped from 50.0% to 8.7% (relative reduction≈83%) and VES decreased from 59.1% to 13.0% (≈78%). Cumulative dobutamine exposure was halved (≈1 113→≈554 µg/kg). No early-atropine patients experienced test-terminating complications. CONCLUSIONS Introducing atropine at the preceding dobutamine stage offers a simple, cost-neutral modification that accelerates DSE, halves drug exposure, and substantially improves hemodynamic and arrhythmic safety in LT candidates. Prospective trials should confirm whether this streamlined protocol can be adopted as the new standard for chronotropically challenging patients.