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Non-invasive imaging
Advanced techniques in dobutamine stress echocardiography: focus on myocardial deformation analysis
  1. Emer Joyce,
  2. Victoria Delgado,
  3. Jeroen J Bax,
  4. Nina Ajmone Marsan
  1. Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Dr Emer Joyce, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden 2300 RC, The Netherlands; E.M.Joyce{at}

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Stress echocardiography is a well validated, cost effective and reliable tool for the diagnosis and assessment of myocardial ischaemia in patients with suspected or known coronary artery disease (CAD). The prognostic value of this technique has been demonstrated in large studies, including diabetic, female, and elderly populations, as well as in patients after myocardial infarction or coronary artery revascularisation.1 A related and equally important role of stress echocardiography is the detection of myocardial viability, or reversible dysfunctional myocardium, in patients with CAD and associated left ventricular (LV) systolic dysfunction.

Stress echocardiography may be performed with exercise (bicycle or treadmill) or pharmacological stressors (dobutamine, dipyridamole, and adenosine). Although exercise echocardiography is preferred in many cases owing to the robust prognostic power of exercise capacity, pharmacological stress testing offers the advantage of being able to minimise factors which can significantly degrade exercise image quality (hyperventilation, excessive chest wall movement) and thus lower diagnostic accuracy, in addition to being an alternative for patients who cannot exercise. Dobutamine is a widely available sympathomimetic agent that at high doses acts similarly to exercise in increasing myocardial oxygen demand, thereby precipitating ischaemia in the presence of a flow limiting coronary artery stenosis. Given the large body of evidence available for this technique, and the fact that vasodilator stress testing does not consistently produce wall thickening abnormalities even in the presence of a significantly flow limiting stenosis,2 this article will focus on dobutamine stress echocardiography (DSE).

The hallmark of induced ischaemia on DSE is the development of a new or worsening regional wall motion abnormality. At low dose, dobutamine increases myocardial perfusion—and thus myocardial contractility—if sufficient myocardial contractile reserve is present. The development of augmented myocardial contractility at low dose in segments with resting dysfunction (with subsequent deterioration at peak doses if performed—the so-called ‘biphasic …

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