A meta-analytic comparison of echocardiographic stressors
Yoshinori Noguchi1, Shizuko Nagata-Kobayashi, James E Stahl
1Division of General Internal Medicine, Department of Medicine, Fujita Health University School of Medicine, Toyoake, Japan. yoshi-noguchi@umin.ac.jp
Insights
Transesophageal atrial pacing (Tap-TEE) is highly accurate for diagnosing coronary artery disease (CAD), while exercise stress echocardiography is a satisfactory option, especially for younger patients. Adenosine is the least effective stressor.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Medical Technology
Background:
- The diagnostic accuracy of various stress agents used in echocardiography for coronary artery disease (CAD) remains unclear.
- Establishing the relative performance of these stressors is crucial for optimal clinical decision-making.
Purpose of the Study:
- To compare the diagnostic performance of different pharmacological and physiological stressors used in stress echocardiography for CAD.
- To identify the most effective stressor for diagnosing coronary artery disease.
Main Methods:
- A systematic review and meta-analysis of studies published between 1981 and 2001.
- Summary receiver operator characteristic (SROC) analysis was employed to assess diagnostic accuracy.
- Covariate analysis using meta-regression identified factors influencing test performance.
Main Results:
- Transesophageal atrial pacing (Tap-TEE) demonstrated the highest diagnostic discrimination, followed by exercise stress echocardiography.
- Sensitivity and specificity varied significantly, with Tap-TEE (86.2%/91.3%) and trans-thoracic atrial pacing (Tap-TTE) (90.7%/86.1%) showing high accuracy.
- Exercise stress echocardiography performance decreased in older individuals.
Conclusions:
- Tap-TEE is a highly accurate method for diagnosing CAD, though its invasiveness may limit widespread use.
- Exercise stress echocardiography provides a balanced approach for CAD diagnosis and is suitable for most patients, with considerations for the elderly.
- Dobutamine offers a viable alternative to exercise, while dipyridamole is better for ruling in than ruling out CAD. Adenosine showed the lowest diagnostic utility.
Background:
The relative performance of alternative stressors for stress echocardiography for the diagnosis of coronary artery disease (CAD) is not well established.
Methods:
All studies published between 1981 to December 2001 who met inclusion criteria were included in this analysis. We performed a summary receiver operator characteristic (SROC) analysis and calculated weighted mean of the likelihood ratio and sensitivity/specificity. A covariate analysis using meta-regression methods was also performed.
Results:
Forty-four studies presented data on Exercise, 11 on Adenosine, 80 on Dobutamine, 40 on Dipyridamole, 16 on transatrial pacing transesophageal echocardiography (Tap-TEE), and 7 on transatrial pacing transthorasic echocardiography (Tap-TTE). SROC analysis showed that the following order of most discriminatory to least: Tap-TEE, Exercise, Dipyridamole, Dobutamine and Adenosine. Weighted means sensitivity/specificity were Exercise: 82.6/84.4%, Adenosine: 68.4/80.9%, Dobutamine: 79.6/85.1%, Dipyridamole: 71.0/92.2%, Tap-TTE: 90.7/86.1%, and Tap-TEE: 86.2/91.3%. Covariate analysis showed that the discriminatory power of Exercise decreased with increasing mean age.
Conclusions:
Tap-TEE is a very accurate test for both ruling in and ruling out CAD although its invasiveness may limit its clinical acceptability. Exercise is a well-balanced satisfactory test for both ruling in and ruling out but performance might be lower for the elderly. Dobutamine offers a reasonable compromise for Exercise. Dipyridamole might be good for ruling in but not for ruling out CAD. The incapability in ruling-out CAD was a major problem in clinical application of the stress. Adenosine was the least useful stressor in diagnosing CAD.
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