Detection of coronary artery disease with exercise two-dimensional echocardiography. Description of a clinically applicable method and comparison with radionuclide ventriculography.

Abstract

SUMMARY Two-dimensional echocardiography (2-D echo) was performed in 73 patients evaluated for coronary artery disease (CAD) and in four normal volunteers before and immediately after a maximal treadmill exercise test. Diagnostic images were obtained from the apical and parasternal windows. In 17 patients with normal coronary arteriograms, ejection fraction (EF) increased from 66 9 % (±4 SD) at rest to 73 8% after exercise (p < 0.001), while in 56 patients with proved CAD, EF fell from 56 13% at rest to 53 16% after exercise (p < 0.01). The sensitivity of postexercise 2-D echo for detecting CAD (based on abnormal EF response and/or regional dyssynergy) was 91% (51 of 56 patients) and the specificity was 88% (15 of 17). Sensitivity for one-, two-and three-vessel disease was 64% (seven of 11), 95% (20 of 21) and 100%, respectively. Patients with multivessel disease showed a significant fall in a wall motion score index, from 0.79 0.25 to 0.63 0.26. Exercise radionuclide ventriculography (RNV) was also performed in 41 of the subjects (17 normals and 24 CAD patients) on a bicycle ergometer. The overall sensitivity of 2-D echo in this subgroup was 92%, compared with 71% for RNV. The sensitivity of 2-D echo for one-vessel disease (n = 4) was 50%, that for two-vessel disease (n = 12) was 100% and that for three-vessel disease (n = 12) was 100%. Respective values for RNV were 0%, 80% and 90%. The specificity of 2-D echo was 88% and that of RNV was 82%. A significantly higher peak heart rate response was observed on the treadmill than on the bicycle ergometer in both CAD patients and normal subjects. MethodsThe study population consisted of 73 patients (63 males and 10 females, mean age 54 years, range 28-75 years) with suspected CAD and four normal volunteers (two males and two females, mean age 46 years, range 34-54 years). Sixty-nine patients were evaluated for chest pain, two for dyspnea and two for ventricular arrhythmias. Patients with unstable angina, recent myocardial infarction or valvular heart disease were excluded. Cardiac medications were not discontinued before exercise. Twenty-five patients were taking propranolol and five digoxin at the time of study. All 73 patients underwent coronary angiography within 1 week of the exercise study. Echocardiographic MethodThe 2-D echoes were obtained in all 77 subjects before exercise without previous echo screening. The studies were performed using a commercially available 900 mechanical sector scanner (Advanced Technology Laboratories Mark III). With the patient in the supine left lateral position, the transducer was handheld.on the patient's chest and multiple views were obtained through the left parasternal and apical windows. The acoustic windows providing the best images were marked on the patient's chest using a washable felt-tip marker for reference during the postexercise study. Twelve-lead ECG recordings were obtained at rest and at each 3-minute level of exercise with leads V4 monitored continuously during exercise. The chest electrodes were positioned so as...

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“…5,6 Because the intramyocardial compressive forces are greatest in the subendocardial area, the flow to that region of the myocardium would be entirely diastolic in the presence of increased LV systolic pressure. [7][8][9][10][11] Although transmural myocardial ischemia is commonly investigated by thallium-201 myocardial scintigraphy or stress echocardiography, [12][13][14][15][16] evaluation of the subendocardial ischemia characteristically seen in AS is not possible with those modalities.…”

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“…The ability to visualize both the right and left ventricles has proven difficult in prior studies using exercise radionuclide, echocardiographic and earlier CT imaging techniques [23][24][25]. Poor visualization of the right ventricle, a poorly defined endocardial surface, irregular right ventricular geometry, and limited reproducibility of exercise studies are important limitations of echocardiography in evaluating the left and right ventricle [26].…”

Intraoperative Stress Echocardiography

“…Its sensitivity for detecting one-, two-and threevessel disease is between 58 and 69%, 86 and 95%, and 94 and 100%, respectively [16,24,28,[37][38][39]. Stress echocardiography has a better accuracy in detecting ischemia than right heart catheterization [40] or stress ECG [10,24,25,28,37]. Its accuracy for detecting ischemia is comparable with exercise radionuclide ventriculography [37] and single-photon emission computed tomography [38,39,41], and it correlates well with coronary angiography regarding the presence, extent and location of stenoses [24,28].…”

“…In contrast, high-dose dobutamine is able to reliably induce demand ischemia in awake patients with CAD [29]. DSE has a higher accuracy for the diagnosis of multivessel CAD than of one-vessel CAD [16,24,37], and for the detection of 170% stenosis than lesser degrees of coronary stenosis [29]. In awake patients, its overall sensitivity for detecting CAD ranges from 74 to 97%, and its specificity from 64 to 100% (table 1).…”

“…In awake patients, its overall sensitivity for detecting CAD ranges from 74 to 97%, and its specificity from 64 to 100% (table 1). Its sensitivity for detecting one-, two-and threevessel disease is between 58 and 69%, 86 and 95%, and 94 and 100%, respectively [16,24,28,[37][38][39]. Stress echocardiography has a better accuracy in detecting ischemia than right heart catheterization [40] or stress ECG [10,24,25,28,37].…”