Methods
Standardized guidelines for the interpretation of dobutamine echocardiography reduce interinstitutional variance in interpretation

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Abstract

Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 μg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p = 0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p <0.0001), and a low peak rate-pressure product (OR 0.93, 95% CI 0.43 to 2.27, p = 0.0382) to result in a low interinstitutional agreement. Standardization of image display in cine loop format and of dobutamine stress echo interpretation criteria resulted in improvement in test result categorization as normal or abnormal, with a kappa value of 0.50, compared with 0.39 using the original subjective interpretation. In conclusion, image quality, the severity of induced wall motion abnormalities, and the obtained rate-pressure product have a significant impact on the interpretation homogeneity of dobutamine echocardiograms. Standardization of image display in cine loop format and of reading criteria results in improved interinstitutional agreement in interpretation of stress echocardiograms.

Section snippets

Patients

Thirty consecutive patients scheduled for angiography due to suspected coronary artery disease underwent DE at each of 5 experienced institutions with a high volume of stress echocardiograms. Patients with previous Q-wave myocardial infarction, congestive heart failure, severe congenital or acquired valvular heart disease, or documented cardiomyopathy were excluded from the study. No patient was excluded on the basis of poor echocardiographic image quality. Thus, a total of 150 dobutamine

Results

Pharmacologic stress included a maximal dobutamine dosage of 35 ± 8 μg/kg/min and additional atropine administration in 53 patients. The maximal obtained RPP was 20,136 ± 5,245 mm Hg/min. Concordant interpretation of DE was obtained in 109 studies.

Discussion

Differences in interpretation are a well known limitation of most diagnostic procedures in cardiology. Low levels of interobserver agreement have been reported for exercise electrocardiography12, 13 and perfusion scintigraphy14 as well as coronary angiography.15, 16 Recently we reported a relatively moderate agreement between readers of 5 institutions on interpretation of DE.3 Reasons for the moderate agreement on DE interpretation between readers of different institutions were analyzed in this

Acknowledgements

We gratefully acknowledge the expert statistical analysis of Thorsten Reineke.

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