Transesophageal assessment of coronary flow velocity reserve during “regular” and “high”-dose dipyridamole stress testing

doi:10.1016/S0002-9149(96)00156-7

The American Journal of Cardiology

Volume 77, Issue 14, 1 June 1996, Pages 1164-1168

https://doi.org/10.1016/S0002-9149(96)00156-7 Get rights and content

Abstract

To assess the effect of regular and high-dose dipyridamole on coronary flow velocity in the left anterior descending artery (LAD), and to determine whether assessment of coronary flow velocity reserve (CVFR) is more sensitive for detection of ischemia than standard echocardiographic criteria, 47 patients were studied prospectively: 16 patients with stenosis of the LAD, 18 patients with angiographically normal LADs, and 13 patients with minimal disease. Patients underwent transesophageal echocardiographic study of wall motion and LAD flow velocity at baseline and at hyperemia, and for angina and electrocardiographic changes. The mean CFVR values after 0.56 mg/kg and after 0.84 mg/kg of dipyridamole were similar: 2.52 ± 0.87 versus 2.62 ± 0.90. A CFVR <2.3 (normals mean −2 SDs) was more sensitive (88% at both doses) for the detection of underlying coronary obstruction than was wall motion monitoring (44% and 75%, respectively). The combination of CFVR <2.3 and wall motion monitoring was more sensitive than either index alone (94% at both 0.56 and 0.84 mg/kg). The rate-pressure product was not significantly different at the two doses of dipyridamole. When flow response is the end point of stress testing, as with transesophageal monitoring, the 0.56 mg/kg dose of dipyridamole is adequate, but when ischemia is the end point (as with wall motion monitoring by 2-dimensional echocardiography), the dose of 0.84 mg/kg is more sensitive.

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Cited by (28)

Additive Prognostic Value of Coronary Flow Reserve in Patients With Chest Pain Syndrome and Normal or Near-Normal Coronary Arteries
2009, American Journal of Cardiology
Citation Excerpt :
Estimated flow reserve can be accurate if the coronary functions only as a conduit, without changing in diameter during drug infusion. This assumption is reasonable with dipyridamole29,30 and less valid with dobutamine; this is an additional reason to stress CFR with vasodilators. Our study design was observational, not randomized, and the analysis was retrospective, although the data were acquired in a prospective fashion and entered into the databank at the time of initial assessment.
In patients with angiographically normal coronary arteries and chest pain, pharmacologic stress echocardiography can identify a subgroup of patients with a less benign prognosis. Coronary flow reserve (CFR) in the left anterior descending artery (LAD) can currently be combined with wall motion analysis during vasodilator stress echocardiography. The aim of this study was to assess the prognostic value of CFR response in patients with normal coronary arteries and normal wall motion during stress. We selected 394 patients (171 men, 61 ± 11 years of age) who underwent dipyridamole stress echocardiography (0.84 mg/kg over 6 minutes) with 2-dimensional echocardiography and CFR evaluation of the LAD by Doppler. All had angiographically nonsignificant (<50% quantitatively assessed) stenosis in any major vessel, normal left ventricular function (wall motion score index 1), and test negativity for conventional wall motion criteria. Images were independently read by a core laboratory for wall motion and a core laboratory for CFR. Mean CFR was 2.5 ± 0.6 and 87 patients (22%) had an abnormal CFR <2. During a median follow-up of 51 months, 31 events occurred, namely 4 deaths and 27 nonfatal myocardial infarctions (3 ST-elevated myocardial infarctions and 24 non–ST-elevated myocardial infarctions). Kaplan-Meier survival estimates for hard events showed a better outcome for those patients with a normal CFR compared with those with an abnormal CFR (96% vs 55%, p = 0.001, at 48 months of follow-up). In conclusion, in patients with angiographically normal or near-normal coronary arteries and preserved at-rest regional and global left ventricular function at baseline and during stress, CFR adds incremental value to the prognostic stratification achieved with clinical and angiographic data.
Head to Head Comparison Between Perfusion and Function During Accelerated High-Dose Dipyridamole Magnetic Resonance Stress for the Detection of Coronary Artery Disease
2008, American Journal of Cardiology
Citation Excerpt :
The challenge to the intuitive appeal of our approach is that vasodilatory stress can be suboptimal for the induction of WM. However, this is true only if low doses of vasodilators are used, which are optimal for perfusion imaging. When high doses of vasodilators are used in a short time (as in our study), the ischemic effect of brisk vasodilatation is at least as strong as that of high-dose dobutamine or maximal exercise.4,5,18–21 The pathophysiologic basis of this effect is the inappropriate excessive accumulation of endogenous adenosine, leading to vertical and horizontal steal phenomena with true subendocardial hypoperfusion.1,22
The aim of this study was to compare the diagnostic accuracy of perfusion and wall motion (WM) during dipyridamole magnetic resonance in patients with chest pain syndrome. Ninety-three patients with normal baseline left ventricular function were referred for coronary angiography. Additional dipyridamole stress magnetic resonance testing (0.84 mg/kg over 6 minutes; using a Signa Cvi scanner) was performed. Cardiac-gated fast gradient-echo train sequences with a first pass of gadolinium contrast medium were used to assess myocardial perfusion. A perfusion reserve index was calculated as the ratio of dipyridamole to rest upslope. A perfusion reserve index value <1.54 in 2 contiguous myocardial segments was the perfusion positivity criterion. The WM positivity criterion was a segmental score increase of ≥1 grade in ≥2 segments. WM and the perfusion reserve index showed similar diagnostic accuracy for >50% quantitatively assessed coronary diameter reduction (86% for both), with WM having higher specificity (96% vs 66%, p <0.01) and lower sensitivity (82% vs 93%, p <0.05) than the perfusion reserve index. Perfusion had the highest accuracy values for coronary stenoses <75% (cutoff 59%) and WM for coronary stenoses ≥75% (cutoff 84%) (p <0.001). In conclusion, during dipyridamole magnetic resonance stress testing, perfusion and WM abnormalities have similar diagnostic accuracy, with perfusion showing higher sensitivity, particularly in the detection of moderate stenoses, and WM showing higher specificity.
Simultaneous Analysis of Wall Motion and Coronary Flow Reserve of the Left Anterior Descending Coronary Artery by Transthoracic Doppler Echocardiography during Dipyridamole Stress Echocardiography
2003, Journal of the American Society of Echocardiography
Coronary flow reserve (CFR) can be measured in the left anterior descending artery (LAD) by dipyridamole transthoracic Doppler echocardiography (DTTDE). This information may critically improve the diagnostic accuracy of dipyridamole stress echocardiography, which is limited by moderate sensitivity.
We sought to assess the feasibility and accuracy of value of DTTDE.
We evaluated 752 consecutive patients (478 men; mean age, 64.7 years) referred for dipyridamole stress echocardiography. The diastolic velocity in the LAD was continuously monitored with pulsed Doppler at baseline and during hyperemia induced by the infusion of 0.84 mg/kg of dipyridamole. CFR was calculated as the ratio of maximal and basal diastolic velocity; a value < 2 was considered to indicate decreased CFR. Wall motion was assessed semiquantitatively. Coronary angiography was performed in 132 patients the week after DTTDE.
Adequate tracings were obtained in 95% of patients studied (715 of 752). In the subset of 132 patients undergoing coronary angiography, 71 patients (group A) showed a nonsignificant (<70%) and 61 patients (group B) a significant stenosis of the LAD. In group A, 65 had a normal wall-motion response (91.5% specificity) and 19 patients showed a decreased CFR (73.2% specificity; P = .1). In group B, new wall-motion abnormalities were seen in 42 patients (68.8% sensitivity), whereas CFR was decreased in 52 patients (86.8% sensitivity; P < .02).
Simultaneous assessment of wall motion and CFR of the LAD with DTTDE was highly feasible and safe. The information about CFR had a significantly higher sensitivity than the analysis of wall motion during dipyridamole stress echocardiography.
Simultaneous assessment of wall motion and coronary flow velocity in the left anterior descending coronary artery during dipyridamole stress echocardiography
2003, Journal of the American Society of Echocardiography
This study was designed to assess the feasibility and clinical meaning of simultaneous assessment of wall motion and coronary flow velocity (CFV) reserve in the left anterior descending coronary artery (LAD) by transthoracic approach for detecting LAD stenosis during dipyridamole stress echocardiography.
Coronary flow reserve plays an important role, which can be evaluated by transthoracic Doppler echocardiography during vasodilator stress.
Dipyridamole stress test was performed in 110 patients with known or suspected coronary artery disease. CFV in the distal LAD was obtained at baseline and after dipyridamole infusion, and wall motion was also assessed up to the administration of atropine, if required. All patients underwent quantitative coronary angiography within 2 days of the stress test, and significant LAD stenosis was defined as > 50% stenosis.
The success rate of both measurements was 92%. CFV reserve < 2 had a higher sensitivity (94% vs 72%, P < .01) and a lower specificity (65% vs 95%, P < .01) than wall-motion assessment for detecting significant LAD stenosis, and diagnostic accuracy between 2 methods was comparable (81% vs 82%). A total of 69 patients (73%) showed concordant results of the 2 methods, and diagnostic accuracy for detecting significant LAD stenosis was high (94%) in this subset of patients.
The simultaneous assessment of CFV and wall motion was feasible in the majority of cases during dipyridamole stress echocardiography. Although diagnostic accuracy between the 2 tests was comparable, concordant results of the 2 methods provided accurate diagnosis in detecting significant LAD stenosis.
Usefulness of coronary flow reserve over regional wall motion when added to dual-imaging dipyridamole echocardiography
2003, American Journal of Cardiology
Citation Excerpt :
Recently, extensive evidence also has been found with vasodilator imaging (with dipyridamole or adenosine), and with the simultaneous assessment of LAD CFR by transesophageal or transthoracic echocardiography. These procedures have shown excellent diagnostic results for the noninvasive prediction of angiographically assessed coronary artery disease.11–14 The main limitation of the CFR approach is that only the LAD artery can consistently be evaluated, and the specificity is low in a selected population with microvascular disease and normal coronary arteries8; these patients often undergo stress testing imaging on the basis of electrocardiographic positivity.
Vasodilator stress echocardiography allows semi-simultaneous imaging of left anterior descending (LAD) coronary flow and regional wall function. To assess the relative (and additive?) value of regional flow and function for noninvasive identification of angiographically assessed LAD disease in patients with chest pain syndrome, we studied 230 consecutive in-hospital patients (134 men, aged 63.5 ± 11 years) with chest pain syndrome and normal regional and global left ventricular function. All patients underwent stress echocardiography with dipyridamole (up to 0.84 mg/kg over 10 minutes), including wall motion analysis by 2-dimensional echocardiography and coronary flow reserve (CFR) evaluation of the LAD artery by Doppler, with or without contrast injection. A new regional wall motion abnormality in ≥2 contiguous segments was required for 2-dimensional echocardiographic positivity. CFR was evaluated as the ratio of dipyridamole to peak diastolic coronary blood flow velocity at rest. All patients underwent coronary angiography within 60 days; a quantitatively assessed diameter reduction >50% of the LAD artery was considered significant. Of the 230 patients, 70 had LAD disease. A regional wall motion abnormality in LAD territory was present in 52 patients, and reduced CFR (<1.9) in 62 patients. Sensitivity for detecting LAD disease was 74% for 2-dimensional echocardiography (95% confidence interval [CI] 64% to 84%) and 81% for CFR <1.9 (95% CI 72% to 90%); specificity was 91% (95% CI 87% to 96%) for 2-dimensional echocardiography and 84% for CFR (95% CI 79% to 90%). Accuracy was 86% for 2-dimensional echocardiography (95% CI 82% to 91%) and 83.5% for CFR (95% CI 79% to 88%). When 2-dimensional echocardiography and CFR criteria were considered, sensitivity increased to 93% (95% CI 87% to 99%), with 80.6% specificity (95% CI 74.5% to 86.7%). CFR was assessed during vasodilator stress echocardiography. Its diagnostic accuracy for detecting LAD disease was comparable to regional wall motion abnormalities. However, the data for flow and function can be complementary in terms of predicting underlying angiographic anatomy, because abnormal wall motion can include coronary artery disease, and negative CFR can exclude it.
Usefulness of the response of flow velocity in the left anterior descending coronary artery to the cold pressor test for evaluating endothelium-dependent vascular relaxation in the coronary microvasculature by transesophageal echocardiography in subjects with angiographically normal coronary arteries
1999, American Journal of Cardiology

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^☆: This study was supported in part by a Travelling Fellowship from the R. Samuel McLaughlin Foundation, Toronto, Canada.

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Transesophageal assessment of coronary flow velocity reserve during “regular” and “high”-dose dipyridamole stress testing☆

Abstract

Am J Cardiol

Chest

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Dipyridamole-echocardiography in coronary artery disease

Herz

Uses and limitations of high dose dipyridamole stress echocardiography for evaluation of coronary artery disease

Br Heart J