OBJECTIVES: This study sought to establish the prognostic implications of ischemic and viable myocardium identified by dobutamine echocardiography in patients with left ventricular dysfunction. BACKGROUND: Recent studies have suggested that in patients with viable myocardium identified by positron emission tomography, medical treatment is associated with recurrent cardiac events. Dobutamine echocardiography has been used to identify viable myocardium in patients with left ventricular dysfunction, but the prognostic significance of this test is undefined. METHODS: One hundred thirty-six consecutive patients (mean [+/- SD] age 67 +/- 7.9 years; 104 men) with moderate or severe left ventricular dysfunction (left ventricular ejection fraction 30 +/- 5%) undergoing dobutamine echocardiography were included in the study. Dobutamine was administered using a standard incremental protocol (5 to 40 micrograms/kg body weight per min intravenously in 3-min stages) with additional atropine (1 mg intravenously) as required. Standard body weight echocardiographic views were digitized on-line and compared using a side-by-side display. Viable myocardium was identified by enhancement of regional function at low dose (< 10 micrograms); scar was diagnosed by akinesia at rest or dyskinesia without change and ischemia as new or worsening dysfunction. One hundred thirty patients (95%) were followed up for 16 +/- 8 months after the original study for major cardiac events (cardiac death, myocardial infarction or severe unstable angina requiring late myocardial revascularization). RESULTS: No significant complications occurred during dobutamine echocardiography. Viable myocardium was detected in 26 patients (19%), ischemia in 23 (17%), both viability and ischemia in 13 (10%) and scar in 74 (54%). Of 108 patients treated medically, 46 had viable or ischemic myocardium, and 62 had scar only. There were no significant differences in age or other clinical characteristics, stress response, left ventricular dimensions and ejection fraction between the two groups. Cardiac events occurred in 26 medically treated patients (24%): 18 died of cardiac-related causes; 4 had a nonfatal myocardial infarction; and 4 had late revascularization because of unstable angina. The event rate was greater in patients with viable or ischemic myocardium than those with scar (43% vs. 8%, p = 0.01 by log-rank test). In a Cox regression model, the presence of viable or ischemic myocardium was found to predict subsequent events (relative risk 3.51, p = 0.02) independently of ejection fraction and age. CONCLUSIONS: Viable or ischemic myocardium detected at dobutamine echocardiography in patients with left ventricular dysfunction is associated with an adverse prognosis, independent of age and ejection fraction.