Is quantitative interpretation likely to increase sensitivity of dobutamine stress echocardiography? A study of false-negative results

doi:10.1016/j.echo.2004.01.001

Journal of the American Society of Echocardiography

Volume 17, Issue 5, May 2004, Pages 448-453

https://doi.org/10.1016/j.echo.2004.01.001 Get rights and content

Abstract

Background

False-negative interpretations of dobutamine stress echocardiography (DSE) may be associated with reduced wall stress. Using measurements of contraction, we sought whether these segments were actually ischemic but unrecognized or showed normal contraction.

Methods

We studied 48 patients (29 men; mean age 60 ± 10 years) with normal regional function on the basis of standard qualitative interpretation of DSE. At coronary angiography within 6 months of DSE, 32 were identified as having true-negative and 16 as having false-negative results of DSE. Three apical views were used to measure regional function with color Doppler tissue, integrated backscatter, and strain rate imaging. Cyclic variation of integrated backscatter was measured in 16 segments, and strain rate and peak systolic strain was calculated in 6 walls at rest and peak stress.

Results

Segments with false-negative results of DSE were divided into 2 groups with and without low wall stress according to previously published cut-off values. Age, sex, left ventricular mass, left ventricular geometric pattern, and peak workload were not significantly different between patients with true- and false-negative results of DSE. Importantly, no significant differences in cyclic variation and strain parameters at rest and peak stress were found among segments with true- and false-negative results of DSE with and without low wall stress. Stenosis severity had no influence on cyclic variation and strain parameters at peak stress.

Conclusions

False-negative results of DSE reflect lack of ischemia rather than underinterpretation of regional left ventricular function. Quantitative markers are unlikely to increase the sensitivity of DSE.

Section snippets

Patient population

We studied 48 patients (29 men; mean age 60 ± 10 years) who underwent color DTI and DSE to investigate chest pain or other symptoms suggestive of coronary artery disease (CAD), in whom the DSE was interpreted as normal despite a maximal stress, but who proceeded to coronary angiography within 6 months. Patients with left ventricular (LV) systolic dysfunction (ejection fraction < 50% or akinesis) at rest, a wall-motion abnormality during the DSE, or a submaximal stress test (ie, termination at

Patient characteristics

The clinical characteristics and echocardiographic parameters between patients with true- and false-negative results of DSE are summarized in Table 1. For patients with false-negative results of DSE, 4 were treated with β-blockers and 8 had single-vessel disease (left anterior descending artery disease in 4 and left circumflex artery disease in 4). Of those with single-vessel disease, 5 were classified into group 1 (2 in left anterior descending artery disease and 3 in left circumflex artery

Discussion

To our knowledge, this is the first study to show that the segments with false-negative results of DSE demonstrate no induced ischemia, rather then being overlooked by the interpreter. Further, the reduced wall stress has no influence on the parameters of regional contractility.

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Cited by (13)

Assessment of Postsystolic Shortening and Global Longitudinal Strain Improves the Sensitivity of Dobutamine Stress Echocardiography in End-Stage Liver Disease
2023, Journal of the American Society of Echocardiography
Dobutamine stress echocardiography (DSE) remains a widely used method for detection of coronary artery disease (CAD) in patients with end-stage liver disease (ESLD) despite low sensitivity. Speckle-tracking assessment of strain may enhance the sensitivity of DSE in the general population, but the value of strain analysis in ESLD is unknown.
Dobutamine stress echocardiography with two-dimensional speckle-tracking and quantitative coronary angiography were performed in 146 patients with ESLD. Thirty-six patients (25%) had CAD (≥50% diameter stenosis of a major vessel). Global longitudinal strain at rest (GLSr) and at peak stress (GLSp) and an index of postsystolic (PSSi) shortening ([maximal extent of shortening – extent of shortening in systole]/[extent of shortening in systole]) were determined. A PSSi of ≥ 0.25 was considered evidence for CAD. Receiver operating characteristic analysis was used to determine the optimal thresholds of GLSr and GLSp for CAD and to assess the diagnostic performance of visual assessment of wall motion (WMA) and strain parameters. The sensitivity and specificity of WMA, GLSr, GLSp, and PSSi were compared.
Thirty-six patients (25%) had significant CAD. The areas under the curve for WMA, GLSr, GLSp, and PSSi were 0.60, 0.72, 0.68, and 0.78, respectively. Visual assessment of wall motion had a sensitivity of 28%. The sensitivity of each of the strain parameters, GLSr (53%, P = .016), GLSp (69%, P = .004), and PSSi (78%, P < .001), exceeded the sensitivity for WMA. Visual assessment of wall motion specificity was 92%, which exceeded the specificity for each of the strain parameters (GLSr = 82%, P = .037; GLSp = 63%, P < .001; and PSSi =78%, P = .009). Of the strain parameters, PSSi had the best balance between sensitivity and specificity (both 78%).
Assessment of GLS and PSSi with DSE yields better sensitivity than WMA in ELSD patients. Index of postsystolic shortening had the best diagnostic performance of all parameters in this population with a low prevalence of CAD.
The significance of E/E' to detect coronary artery disease during dobutamine stress echocardiography
2012, Egyptian Heart Journal
Citation Excerpt :
Dobutamine stress echocardiography (DSE) is widely used as a noninvasive method to detect coronary artery disease (CAD) through the estimation of wall-motion abnormalities.1 However, the current method is limited by the artifacts as a result of image quality, the biasness being based on subjective interpretation and dependence on experience.2 To delineate the existing difficulties, the assessment of CAD calls for a method that can be both quantitative and be independent of image quality.
To determine how the left ventricular diastolic filling pressure determined by E/E′ during dobutamine stress echocardiographic (DSE) by tissue Doppler Imaging (TDI) is affected by the presence and the severity of coronary artery disease (CAD) among patients with stable angina pectoris and also its relation to inducible ischemia.
This study comprises 60 patients with suspected angina pectoris. All subjects were examined with DSE and TDI to assess resting mean E/E′ at peak stress, E/E′ change and E/E′ index. Coronary angiography was performed within 1 month.
Coronary angiography revealed CAD in 38 patients (CAD group) while the remaining 22 patients formed the non-CAD group. There is a significant decrease of peak E′, S′ and increase peak E/E′ in CAD group during stress compared to non-CAD group (P < 0.01, P < 0.05 and P < 0.001, respectively). Thirty-two patients with inducible ischemia during stress had higher peak E/E′, E/E′ index compared to 28 patients with non-inducible ischemia. Receiver operating curve analysis showed an optimal cut-off value of peak E/E′, E/E′ change, E/E′ index (>4.11, >0.9 and >0.8, respectively) for the presence of CAD (area under curve 0.91, 0.93 and 0.88, respectively P < 0.001 for all). Sensitivities for detection of CAD were 94.7%, 84.2% and 89.5% and specificity was 90.9%, 72.7% and 74.7%, respectively. Peak E/E′, E/E′ index increased proportionally with the number of stenotic vessels (r = 0.89 and 0.76, respectively, P < 0.001).
During DSE the changes of mean E/E′ ratio are associated with inducible ischemia, the presence of CAD and the extent of CAD. So, E/E′ can be used as objective evidence during DSE.
Clinical Use of Doppler Echocardiography and Doppler Tissue Imaging in the Estimation of Myocardial Ischemia During Dobutamine Stress Echocardiography
2008, Journal of the American Society of Echocardiography
The ratio of mitral inflow early diastolic velocity (E) to annulus velocity (E’) might be critical for the assessment of an abnormal filling pressure for patients with myocardial ischemia.
We sought to determine whether a quantitative estimation of E/E’ provides more reliable information for detecting coronary artery disease during dobutamine stress echocardiography.
A total of 82 patients suggested to have angina pectoris underwent Doppler studies during dobutamine stress echocardiography. The value of E and E’ were measured at baseline and peak dose of dobutamine stress. The value of E/E’ during stress over that at rest was defined as the E/E’ index.
Patients who had significant stenosis by coronary angiogram were classified as being in group A (n = 45) and those with no coronary artery disease were classified as being in group B (n = 37). Dobutamine infusion led to a significant increase of E/E’ in group A, whereas no changes were found with group B. Likewise, larger E/E’ index was also observed for patients with multivessel disease. The value of E/E’ index increased proportionally with the number of stenotic vessels, implying a direct correlation of the E/E’ value to the extent of myocardial ischemia.
E/E’ offers a quantitative estimation of myocardial ischemia during dobutamine stress echocardiography, thereby, providing a reliable and accurate method for the evaluation of coronary artery disease.
Enhanced sensitivity of Dobutamine stress echocardiography by observing wall motion abnormalities during the recovery phase after acute beta-blocker administration
2006, American Journal of Cardiology
Citation Excerpt :
However, the test has a decreased sensitivity for detection of single-vessel disease.1,2 Sensitivity of DSE for detection of single-vessel disease ranges from 40% to 92% and that for multivessel disease ranges from 65% to 83%, although specificity remains unchanged.8–10 Our study showed that wall motion abnormality assessment during recovery after long-term β blockade significantly increased sensitivity from 81% to 99% (p <0.001) for detection of single-vessel disease, whereas specificity was marginally decreased.
Dobutamine stress echocardiography (DSE) has a modest sensitivity for detecting single-vessel coronary artery disease (CAD). This study assessed the additional diagnostic value of new or worsening wall motion abnormalities during recovery after acute administration of β blockers. The study population consisted of 200 patients (mean 59 ± 11 years of age, 144 men), who underwent DSE. Images were acquired at rest, low dose, peak dose, and during recovery. Patients received intravenous metoprolol (1 to 5 mg/min). The dose was adjusted to achieve a recovery heart rate within a 10% range of heart rate at rest. Coronary angiography was performed within 2 months. Inducible new wall motion abnormalities were observed in 168 patients (84%) at peak stress. An additional 14 patients (7%) developed new or worsening wall motion abnormalities during recovery. CAD was detected in 182 patients (86 had single-vessel CAD). Sensitivity, specificity, and accuracy of DSE were 88%, 65%, and 73% at peak stress and 97%, 65%, and 74% during recovery. Sensitivity was particularly higher during recovery than during peak stress in patients with single-vessel CAD (98% vs 81%, p <0.001). In conclusion, assessment of wall motion abnormalities during the recovery phase after acute β blockade improves sensitivity of DSE, particularly in patients with single-vessel CAD.
Value of resting echocardiographic findings and dobutamine stress echocardiography for diagnosing myocardial ischemia in patients with suspected angina pectoris
2015, Echocardiography
Training in stress echocardiography
2010, Stress Echocardiography: Essential Guide and DVD

View all citing articles on Scopus

^☆: Supported in part by the National Health and Medical Research Council, Australia.

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Original articleIs quantitative interpretation likely to increase sensitivity of dobutamine stress echocardiography? A study of false-negative results☆

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patient population

Patient characteristics

Discussion

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Stress echocardiography

Dobutamine-atropine stress echocardiography for the detection of coronary artery disease in patients with left ventricular hypertrophyimportance of chamber size and systolic wall stress

Circulation

Original article
Is quantitative interpretation likely to increase sensitivity of dobutamine stress echocardiography? A study of false-negative results☆