Is exercise stress echocardiography useful in patients with suspected obstructive coronary artery disease who have
Bo Xu1, Laura Dobson1, Philip M Mottram1
1MonashHeart, Monash Health, Clayton, Victoria, Australia.
Insights
Exercise stress echocardiography (ESE) is less reliable for diagnosing obstructive coronary artery disease (OCAD) in patients with left bundle branch block (LBBB). A globally abnormal response during ESE significantly reduces its specificity for OCAD in this population.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Echocardiography
Background:
- Exercise stress echocardiography (ESE) is recommended for evaluating suspected obstructive coronary artery disease (OCAD) in patients with left bundle branch block (LBBB).
- Limited data exist on the diagnostic utility of ESE in LBBB patients.
Purpose of the Study:
- To test the hypothesis that ESE's diagnostic performance for suspected OCAD is reduced in patients with LBBB.
- To evaluate the accuracy and specificity of ESE in this specific patient group.
Main Methods:
- 191 consecutive patients with resting LBBB undergoing ESE for suspected OCAD were studied.
- ESE results were categorized as inconclusive, normal, or abnormal (regional ischemic or globally abnormal).
- Anatomic imaging was used to confirm OCAD in patients with abnormal responses.
Main Results:
- 48% of patients showed an abnormal left ventricular contractile response (LVCR) to exercise.
- Of those with abnormal responses, only 21% had significant OCAD, resulting in low specificity (21%) and accuracy (52%) for ESE.
- A regionally abnormal response had a high association with significant OCAD (89%).
Conclusions:
- ESE has significantly reduced specificity for excluding OCAD in LBBB patients with a globally abnormal LVCR.
- ESE is suboptimal for OCAD evaluation in resting LBBB due to frequent abnormal responses, often not indicative of OCAD.
- Alternative diagnostic methods should be considered for suspected OCAD in patients with resting LBBB.
Background:
Current guidelines support exercise stress echocardiography (ESE) for evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Data regarding the diagnostic utility of ESE in patients with LBBB are limited.
Hypothesis:
We hypothesized that the diagnostic performance of ESE for the assessment of suspected OCAD is reduced in the context of LBBB.
Methods:
We studied 191 consecutive patients with resting LBBB undergoing ESE for the investigation of suspected OCAD between 2008 and 2015 at our center. The studies were categorized as inconclusive, normal, or abnormal. Patients with an abnormal response were subcategorized as regional ischemic response or globally abnormal.
Results:
Eighty-two patients (43%) demonstrated a normal left ventricular contractile response (LVCR) to exercise; 92 (48%) developed an abnormal LVCR to exercise, including 70 patients with globally abnormal and 22 patients with regional ischemic responses. Of the patients with abnormal responses, 62 patients had anatomic imaging, only 29 of whom had significant OCAD, conferring an overall specificity of ESE for significant OCAD of 21% and accuracy of 52%. Of patients who developed a regionally abnormal response, 89% had significant OCAD.
Conclusions:
For patients with LBBB who develop a globally abnormal LVCR during ESE, the specificity of ESE for reliably excluding significant OCAD is significantly reduced. ESE appears to be a suboptimal test for the evaluation of OCAD in patients with resting LBBB, as about 50% of patients will have an abnormal response, the majority due to globally abnormal contraction where OCAD cannot be reliably diagnosed. Alternative testing should be considered for the investigation of suspected OCAD in patients with resting LBBB.
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01:26Exercise Stress Test
Exercise stress testing, commonly known as a treadmill test, is a noninvasive procedure used to evaluate cardiovascular function and diagnose heart conditions.
Definition
An exercise stress test measures the heart's response to exertion using a treadmill or stationary bicycle. Chest electrodes record the heart's electrical activity through an ECG, and blood pressure is monitored regularly.
Purposes