Mechanisms of regional wall motion abnormalities in contrast-enhanced dobutamine stress echocardiography
N Heinicke1, B Benesch, T Kaiser
1Klinik und Poliklinik für Innere Medizin II, University of Regensburg, 93042, Regensburg, Germany. norbert.heinicke@klinik.uni-regensburg.de
Insights
Regional wall motion abnormalities (RWMA) in Dobutamine Stress Echocardiography (DSE) often indicate perfusion deficits. However, pre-existing conditions can affect DSE accuracy for diagnosing coronary artery disease (CAD).
Area of Science:
- Cardiology
- Diagnostic Imaging
- Nuclear Medicine
Background:
- Dobutamine Stress Echocardiography (DSE) is used to diagnose coronary artery disease (CAD).
- Regional wall motion abnormalities (RWMA) on DSE are typically assumed to represent perfusion deficits.
Purpose of the Study:
- To compare echo-contrast enhanced DSE with myocardial perfusion imaging (MiBi-SPECT).
- To evaluate the diagnostic accuracy of DSE for significant coronary artery stenosis.
Main Methods:
- Prospective, double-blinded study of 69 non-selected patients.
- Simultaneous DSE with echo-contrast and MiBi-SPECT, with coronary angiography as gold standard.
- Analysis of regional wall motion abnormalities (RWMA) and perfusion deficits.
Main Results:
- DSE showed 78% sensitivity and 66% specificity for significant CAD.
- 78% of true positive DSE findings correlated with perfusion deficits on MiBi-SPECT.
- False positive DSE results were associated with left ventricular hypertrophy, resting ECG, or resting RWMA.
Conclusions:
- Most RWMAs in DSE correspond to perfusion deficits seen on nuclear imaging.
- Pre-existing cardiac conditions (e.g., LV hypertrophy, bundle branch block) can limit DSE predictive value.
- Careful interpretation of DSE is needed in patients with confounding cardiac abnormalities.
Background:
In the diagnosis of coronary artery disease (CAD) with Dobutamine Stress Echocardiography (DSE), regional wall motion abnormalities (RWMA) are assumed to indicate a perfusion deficit.
Methods And Results:
For a more particular examination of RWMAs, we compared simultaneous echo-contrast (Optisone)-enhanced DSE (0-40 microg/kg Dobutamine, 16-segment- model) and MiBi-SPECT in a prospective double-blinded study design in 69 non-selected consecutive patients (44 male, 25 female, age 64+/-12 years). Additionally, all patients were examined by coronary-angiography. The prevalence of significant CAD (stenosis >50% lumen diameter) was 52%. DSE had a sensitivity of 78% and a specificity of 66% for the detection of significant CAD with a positive and negative predictive value of 72 and 73%, respectively. Among 28 patients with significant CAD and positive DSE study (true positive), 78% displayed a corresponding perfusion deficit in MiBi-SPECT. Among 11 patients with a positive DSE study but no current significant coronary stenosis (false positive), 82% showed stress-induced RWMAs in the inferior/posterior region, 73% displayed left ventricular hypertrophy, 54% resting-ECG abnormalities and 45% resting-RWMA (3 previous MI, 2 previous CABG surgery). Among 8 patients with negative DSE study but significant coronary stenosis (false negative), 75% had a stenosis of the LCX, 63% displayed resting- WMA, 63% displayed left bundle branch block or ST-segment depression, 50% displayed only peripheral coronary stenosis, and DSE visualization was suboptimal in 38%.
Conclusion:
This prospective study in non-selected patients shows that the majority of RWMAs in DSE are matched to a perfusion deficit detectable by nuclear imaging. Nevertheless, pre-existing cardiac abnormalities may also lead to stress-induced RWMA not associated with a perfusion deficit or mask a perfusion deficit upon DSE. Particularly in patients with LV hypertrophy, resting-RWMA, bundle branch block or ST segment depression, the predictive value of DSE may, therefore, be limited.
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