Coronary artery disease
Application of tissue doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography☆

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Abstract

The main limitation of dobutamine echocardiography (DE) is its subjective interpretation. We sought to reduce the need for expert interpretation by developing a quantitative approach to DE using myocardial Doppler velocity (MDV) in 242 patients undergoing DE. In 128 patients with a normal dobutamine echocardiogram, the normal range was designed to give a specificity of 80%. The accuracy of this range was investigated in 114 consecutive patients who underwent coronary angiography within 2 months of DE. A standard dobutamine echocardiographic protocol was used, with MDV gathered from color tissue Doppler at rest and peak stress. Wall motion at these stages was scored by experienced observers using a 16-segment model and MDV was measured off-line. Sensitivity and specificity of wall motion scoring and MDV were obtained by comparison with angiographic evidence of disease, defined as stenosis >50% of the coronary artery diameter. The normal range in tethered segments (septum, anteroseptum, and inferior) was ≥7 cm/s in the basal segments and ≥5 cm/s in the midsegments. In the free wall (anterior, lateral, and posterior), the cutoff was ≥6 cm/s in the base and ≥4 cm/s in the midventricle. Of 114 patients undergoing angiography, 84 (75%) had significant stenoses, and the sensitivity of wall motion scoring and MDV were 88% and 83%, respectively, with specificities of 81% and 72% (p = NS). The accuracy was similar overall (86% vs 80%), as well as in each vascular territory. These data suggest that a fully quantitative interpretation of DE using site-specific normal ranges of tissue Doppler, which account for regional variations of base-apex function, is feasible and equivalent in accuracy to expert wall motion scoring.

Section snippets

Patient selection

The study population of 242 patients consisted of 2 groups: 114 consecutive patients who underwent DE for assessment of known or suspected coronary artery disease who also came to coronary angiography within 2 months as a result of clinical decision making, and 128 patients with a normal dobutamine echocardiogram without angiography, including 57 patients with a low (<20%) probability of coronary disease.10 Patients with severe valvular regurgitation or stenosis, complex atrial or ventricular

Dobutamine echocardiography

The hemodynamic responses to dobutamine stress are summarized in Table 2. The age-predicted maximum heart rate was achieved in 185 patients (76%). The protocol was terminated at a submaximal heart rate due to symptomatic, electrocardiographic, or echocardiographic evidence of severe ischemia in 5 patients (2%), hypertension or hypotension in 15 patients (6%), arrhythmias in 2 patients (1%), and intolerable adverse effects in 12 patients (5%). Symptoms suggestive of myocardial ischemia were

Discussion

This and previous studies have shown that measurements of base-apex systolic MDV are clearly related to the severity of abnormal wall motion during DE. The findings of this study are that MDV may be designated as normal or abnormal using criteria that account for regional variations of LV function. These normal cutoffs may used to obtain an accurate, fully quantitative interpretation for DE. This work also indicates that the measurement of peak systolic MDV at peak stress is a robust tool for

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☆

This study was supported in part by Grants in Aid from the National Health and Medical Research Council, National Heart Foundation, and the Clive and Vera Ramaciotti Foundation, Sydney, Australia

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