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Heart 1998;80:370-376; doi:10.1136/hrt.80.4.370
Copyright © 1998 BMJ Publishing Group Ltd & British Cardiovascular Society

Heart 1998;80:370-376 ( October )

Selection of the optimal stress test for the diagnosis of coronary artery disease

J A San Román,a I Vilacosta,b J A Castillo,d M J Rollán,e M Hernández,c V Peral,f I Garcimartín,a M del Mar de la Torre,a F Fernández-Avilésa

a Department of Cardiology, Hospital Universitario, Valladolid, Spain, b Department of Cardiology, Hospital Universitario San Carlos, Madrid, Spain, c Department of Nuclear Medicine, Hospital Universitario San Carlos, d Department of Cardiology, Hospital del Rosell, Cartagena, Spain, e Department of Cardiology, Hospital Río Hortega, Valladolid, Spain, f Department of Cardiology, Hospital Son Dureta, Palma de Mallorca, Spain

Correspondence to: Dr J A San Román, Servicio de Cardiología, Hospital Universitario, C/ Ramón y Cajal 3, 47011 Valladolid, Spain.

Accepted for publication 22 June 1998

Objective---To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease.
Design---The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography.
Setting---Two tertiary care and university centres.
Patients---102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results.
Results---MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa  = 0.72; regional analysis 93%, kappa  = 0.72; diagnosis of the "culprit" vessel 95%, kappa  = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa  = 0.84 with dobutamine and 92%, kappa  = 0.85 with dipyridamole).
Conclusions---Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.

Keywords: coronary artery disease;  dipyridamole;  dobutamine;  scintigraphy

© 1998 by Heart
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