Pellikka.qxp 16/7/08 02:18 Page 30
Imaging
Table 3: Accuracy of Dobutamine Stress Echocardiography for
promising techniques may provide additional sensitivity and quantitation.
Detection of Coronary Artery Disease
Contrast echocardiography improves myocardial border detection and is
useful for the assessment of myocardial perfusion. Opacification of LV cavity
Study Year n Sensitivity % Specificity % Accuracy %
by injection of commercially available contrast agents improves visualization of
Cohen et al.
33
1991 70 86 86 85
the endocardium, leading to a more complete assessment of wall motion. This
Sawada et al.
34
1991 96 85 88 78
offers the potential to increase the sensitivity and specificity of the stress test.
Marcovitz et al.
35
1992 141 96 66 89
McNeill et al.
36
1992 80 70 88 78
Recent studies have confirmed the feasibility, accuracy, and prognostic value
Takeuchi et al.
37
1993 120 85 93 72
of contrast stress echocardiography. Tsutsui et al. demonstrated the
Previtali et al.
38
1993 80 79 83 80
incremental value of perfusion information obtained by realtime contrast
Elhendy et al.
39
1996 132 78 86 80
echocardiography during dobutamine stress to wall motion assessment, as
Ling et al.
40
1996 183 95 51 64 well as the prognostic value of perfusion detects in predicting cardiac events.
20
Wu et al.
41
1996 104 81 94 86 However, the clinical implications of contrast stress echocardiography are
Bigi et al.
42
1997 121 80 93 82
limited due to the lack of a standardized technique. Strain and strain rate
Hennessy et al.
43
1997 219 82 65 78
imaging are novel parameters derived from tissue Doppler imaging and offer
Smart et al.
44
1997 206 82 80 82
a more quantitative approach to regional LV function. Recent studies have
Elhendy et al.
45
1997 306 74 85 76
documented the value of strain rate analysis during dobutamine infusion for
Hennessy et al.
46
1997 199 90 50 85
the assessment of myocardial viability.
21,22
Strain rate analysis provides an
n = number of patients.
incremental value to wall motion assessment and increases sensitivity for the
Table 4: Accuracy of Dobutamine versus Dipyridamole Stress
detection of viable segments. The limitations of strain and strain rate imaging
Echocardiography for Detection of Coronary Artery Disease
in stress echocardiography are the lack of standardized methodology and
consensus on the most appropriate parameters. Data regarding the use of
Sensitivity % Specificity % Accuracy % 3D echocardiography in stress echocardiography are limited. Theoretically,
Dipy Dobu Dipy Dobu Dipy Dobu
stress echocardiography with realtime 3D echocardiography has some
Salustri et al.
47
64 57 89 78 74 65
additional advantages, such as a higher sensitivity in detecting small areas of
Previtali et al.
38
60 79 96 83 70 80
wall motion abnormalities and a shortened time for image acquisition. Recent
Beleslin et al.
30
74 82 94 76 76 82
studies have reported the ability of realtime 3D echocardiography to assess
Dagianti et al.
48
52 72 97 97 78 87
wall motion abnormalities at rest
23
and during dobutamine stress with and
Pingitore et al.
49
82 84 84 89 84 84
without contrast agents.
24,25
Further technical advances in realtime 3D stress
Minardi et al.
50
73 75 67 67 72 74
Santoro et al.
51
55 60 96 96 73 77
echocardiography are expected to result in its ultimate widespread use in
Loimaala et al.
52
93 95 75 63 63 87
routine clinical practice.
Dipy = dipyridamole; Dobu = dobutamine.
Conclusions
How Far Can We Go? Stress echocardiography has become a mainstay in the diagnosis of CAD,
Despite the variety of useful information obtained by stress echocardiography and its prognostic value is evident in a broad range of patient subsets.
that is applicable for clinical practice, there are still limitations such as a Newer techniques in echocardiography such as myocardial contrast
relatively subjective interpretation and the dependence on image quality. echocardiography for the assessment of myocardial perfusion, detailed
Recognition of ischemia may be challenging in the setting of extensive resting evaluation of myocardial mechanics using strain rate imaging, and 3D
wall motion abnormalities. Technical developments in echocardiography such imaging show great promise in the field of stress echocardiography. As we
as contrast echocardiography, myocardial Doppler imaging, and 3D seek ways to more efficiently, safely, accurately, and cost-effectively evaluate
echocardiography may play an important complementary role. These new, our patients, the future of stress echocardiography is bright. ■
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30 US CARDIOLOGY
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