Detection of coronary artery disease by digital stress echocardiography: Comparison of exercise, transesophageal atrial pacing and dipyridamole echocardiography

-

~chocardiographic rno~~tori~gof left ventricularwall

diography is planned, alternative stresses need to be used not only in patients for whom exercise is unfeasible, inadequate or contraindicated but alsc in those with poor quality echocardiographic images during exercise, making interpretation of the stress exam difficult if not impossible.

From the Institute of Cardiology, University of Bari, Bari, Italy. This study was supported in part by the Associazione per la Riccrca in Cardiologia, Rari. Dr. Marangelli is a recipient of a research doctoral grant in cardiovascular clinics and pathophysiology from the Ministry of Scientific Research and Technological Advancement of the Ralian Government, Rome, Italy. Manuscript received October 7, 1993; revised manuscript received January 28, 1994. accepted February 2. 1994. Address for aesoondw: Dr. Sabino Iliceto, Institute of Cardiology. University of Bari, Piazza Giulio Cesare, 13, 70124 Bari. Italy. QlW

by the American College of Cardiology

hageal atrial pacing (45) and high dose dipyridamole infusion (6-8) ave been proposed as alternative stress pro ures to be used in co nction with echocard’ vious studies have monstrated that bot ography. stresses are capable of inducing isch different mechanism image quality. The procedures (exercise, transes ageal atrial pacing, dipyridamole) in an actual clinical ing has still not been fully elucidated, because they have not been compared in a single ion. We hypothesized that differences in ischemiasame group of patients,

either

to address the followe role of each of t three stress procedures in a clinical context; 2) to evaluate ihe diagnostic reliability of the two alternative stresses 073s1097/94/$7.co

lld

JACC Vol. 24. No. I

MARANGELLI ET AL. EXERCISE, ATRIAL PACING AND DIPYRIDAMOLE

(transesophaged atria! pacing and dipyridamole)in a headto-head comparison; 3) to assess and compare the diagnostic role of alternative stress procedures in patients for whom exercise ech~~diog~pby is neither feasiblenor diagnostic.

The study involved 1 tive patients admitted to hospital at the Institute of Cardiov

1 infa~~t~o~or left beefing conditions as well as those wit motion. The 104 phic laboratory. Eighty-

al atria! pacing echocardiography. Our local eview Board approved the study protocol, and all patients gave written informed consent for each stress procedure and participationin the study. Di~y~damoleand transesophageaiatria)pacing ech~ardiog~phy were scheduled to be performed in a random sequence at the same time

ventricle were recorded with the patients and in the left itus position on 0.754n. videotape and in digital both apical (four-chair, two~ham~r and s) and precordial tom illary short- or long-ax the echocardiographic examination at rest, the ised on the treadmill (Del El1 and CardioExec Software, Schiller)according to the stanprotocol. A 124ead electrocardiogram (ECG) was continuously monitored, and KG and cuff blood pressure recordings were obtained at each step. End points o test were the achievement of rn~irn~ heart rate-b pressure product or the development of ischemia (typical chest pain or ischemia-related symptoms or ST segment ~~~~~~~~~~~ or elevation ~1.5 mV). Immediately after the ~~~~~~~~~~~ exercise ended, the echocardiograpluc was repeated in the left lateral decubitus position using the same views as the baseline examination. Images were also stored in quad-screendigitalformat specificallydeveloped to compare rest and stress images and visualize the time interval occurring between stress interruption and the acqui-

al atrial stimulation was pe

min until chest pain or severe wall motion abnormalities appeared or until the maximalstep of 150beats/mittfor 5 mm was completed. ACthe end of each stimulation period, the 1%leadECG and cuff blood pressure were recorded. Apical tomog~phic planes (two- and four-chamber and long-axis) and whichever was best of the precordial :ong- and shortaxi, images were recorded before and throughout the entire transesophageal atria1pacing procedure. S~rnu~ta~e~~s 12lead ECG was monitored continuously during each stress procedure using a corn~~e~c ECG system (Cardiovit Digitalechocad three stress procedures the echocardiographic images were simultaneouslyrecorded on a 0.75~in.videotape and a 5.25 in. floy;pydisk; images were acquired on-line in quad screen

score was as51

I atrial pacing was not erance to the transeso

ages were successfully with inadequate posttread evaluated by tra~sesop~agea~atrial paciragand dipy~damo~e by. A group of 60 patients successfully mansesophzgeal atria1 amole ecbocardio sitivity = true positive studies&truepositive studies t false negative studies]: specificity = true negative studies/[true negative studies t false positive studies]; accuracy = true positive and negative studies/total studies). For each variable the value gbtainzd and i 5% confidenceinterval calculated. The results of d rem procedures were and by using the Fisher exact test.

h~cardiQgrQp~y.

ln 24 of iography was inconclusive because of the inadequate quality of exercse echocardiographic images or EC@ trigger-i hysical exercise in t

e), and 33 showed no signifrca patients who e~tere the study, 40 showed no significantcoronary artery disease, and 64 had significant coronary artery disease (25 singlevessel, 28 two-vessel and 11 three-vessel disease).

in 42 patients (13 with single-vessel, 18 with two-vessel, 11 with three-vessel disease), in the latter in 3. Thus, test sensitivity was 89% (confidence interval [Ct] 81%to 98%),

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JACC Vol. 24. No. I July I :117-M

AL. ATRIALPACINGANDDIFYRIDAMOLE

MARAMGELEE ET EXERCISE.

Results ofExercise and Alternative Stress Procedures in tudy Patients NegativeTest (no.of pls)

PositiveTest (no.of pts)

Ex-2DE(66 pts) TAP-2DE(60 pts) DIP-2DE(60pts)

CAD

No CAD .-

CAD

No CAD

31 29 I5

3 6 2

4 6 20

22 19 23

CAD = comary arterydisease(slcoosisZZ% in at teas1one major Ex = exerciseon treadmill;pts = patienls; vessel);DIP = d paciug:2DE = twodimensional echocardiog = trausesop

ercise echocar d three-vessel coron disease was, respectively, Xi%, 95% and Head-to-head comparison of exercise e tra~~e~o~~a~ea~ at~i~~ pacing echocardiography and dipyresults obtained in idamole echocurdiogra

subjected to all three Tables I, 2 and 3. Pe -predicted maximal heart rate and rate-pressu re, respectively, 86 2 % and 25.4 i: 5.2 x I exercise echocardi phy, 84 f 5% and 21.9 f

no significant coronary artery disease, and 16, 14 and 5 ha single-, two- and three-vessel disease, res~ct~veiy. In the 2 patients without signJkant coronary artery disease, exercise ive in 22, t~~scso~hagea~ atoms 19 and dipy~d~mole ecbocardicity of the three tests was therefore 92%, respectively (Tables I and 2). In the 35 ificant cormwy artery disease, exercise was positive in 31, transesoph hy in 29 and dipyridamole echocarditivity of the three tests was therefore pectively. The accuracy of exercise

Ex-2DE 8

95% Cl

-%

Sensitivity

$9

78-99

Specilkity

Accuracy

intravenous oitrates wall motion abnorm

the sensitivity of exerle to that of transesoph= NS) and higher than

TAP-2DE

DIP-2DE

95% Cl

%

95%Cl

p Value

83

70-95

43

26-59

88

7S-100 76

59-93

92

81-100

811

82-95

72-88

63

51-74

Ex-2DEvs.TAP-2DE= NS Ex-2DEvs.DIP-2DE= 0. TAP-2DEvs. DIP-2DE = Ex-2DEvs. TAP-2DE= NS Ex-2DEvs. DIP-2DE = NS TAP-2DEvs. DIP-2DE = 0.12 Ex-2DEvs. TAP-2DE= NS Ex-2DEvs. DIP-2DE = 0.0012 TAP-2DEvs. DIP-2DE = 0.034

80

Cl = confidence interval:otherabbreviations as in TableI.

of videotape or

use

tively the comparative used echocarciiographic suPtsof Exercise and Alternative Stress Procedures .s With Nohdiagnostic ~~st-Treadmil~ Exercise ~w~-~~~ne~~~nai EcRocardiograyhy PW hilive

CAD

TAP-ZDE(22pts) DB2DE(22 ptn) Abbreviations

II

5 as in Table 1.

Values of Exercise and ~~~diag~~st nsional ~~~o~ardi~~~a~~v tients With

Negative Test (no. of ptsa

Tesi

(no. of pts)

DIP&

TAP-2DE %

No CAD

diagnostic vahe of three routine!y stress procedures in the same series

95%CI

%

Sensitivity

13

51-96

33

2

4

5

Specificity

38-100

2

10

5

Accuracy

71 73

71 45

Abbreviations

58-89

as in Tabies

I and 2.

95%CI

p Value

9-54-

0.03

38-l

NS

27-64

O.O6

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JACC Voi. 24. No. 1 July 1994:117-24

MARANGELLI ET AL. EXERCISE, ATRIAL i’ACING AND DII’YRIDAMGLE

ofpatients and in a clinicalcontext. The diagnosticpotential of exercise, transesophageal atrial pacing and dipyridamote echocardiography has been individually evaluated in previous studies (l-8). oreover, the latter two have also been compared independently with exercise echocardiography (5,7); however, in these comparative studies, transesophageal atrial pacing (5) and dipyridamole (7)echocardiography werecomparedwith supinebicycle exercise echocardiography with no digitaltine loop recordingor review support. Thistechnicalsupport,as well as the use of a more stressing exercise protocol(such as treadmill), is nowadays consid,snd irreplaceable for optimal exercise

infusionrequires a particularanatomic coronary condition to have an ischemia-ind~ci~ studies (16). Additi

with two-dimensional

abnormalities(40%in

that this stnss in

to perform adequate exercise. On the whole, the feasibility of dipytidamoleechocardiographywas higher than for transal atrial pacing echocardiography because of the number of patients who showed intolerance either to the catheter or to electrical stimulationor because it was impossible to obtain high ventricular rate as a result of a LucianiWenckebachatrioventricularblock. The feasibilityof transesophagealatrial pacing echocardiography, although slightly higher (22 [92%]of 24 patients) in patients with inadequate exercise echocardiography, was not significanilydi from the overall group (77%,p = 0.09). In our study the sensitivity of dipyridamole and trans-

others. For d~~y~~arno~eechocardiog

ous myocardial infarction or rest w are generally higher than values o tients (1I). mechanismsof the two stresses (14.15).Even though it acts exclusively on heart rate and not on blood pressure, atria1

pacing consistently ind ces an increase in myocardiaioxyn demand, as shown by the increase in heart rate-blood SSUR product (14). However, dipyridamole infusion only minimal@ changes the myocardial oxygen consumption but acts by inducing blood steal in the coronary areas with fixed stenoses and particular anatomic conditions that favor such mechanisms in different ways (15!; this is a somewhat less effectiveischemia-inducingmechanism (14).In ourseriesof tients we observed how the proportionof patientswith multivesseldisease in the group of patients correctlyidentifiedas having significantcoronary artery disease was higher by dieyridamole than by transesophagealatria!pacing echocardiography (73% and 59%);in patients with single-vessel disease the sensitivity of dipyridamole echocardiography was decidedly lower than that of transesophageai atria] pacing (25% VS. 75%). This suggests that dipyridamoie

sulted from the use of both tests. In particular, the ischemicalterations induced by atrial pacing regressed spontaneously within a few seconds after the end of the stimulation, and on no occasion was it necessary to administer drugs to terminate the ischemia more rapidly. On the basis of previous experience we can state that atrial pacing is a very safe stress and may be used in more severe patients or as a prognostic stre soon after acute myocardial infarction(19-21). our series of patients dipyridamole infusion almost invariably produced unpleasant side effects requiring the administration of amino~hylline, even when there were no ECG or echocardiographic ischemic changes. oreover, in seven patients with ischemia induced by dipyridarnole,aminophylline alone did not bring about a quick return to baseline conditions; this only occurredafterseveral minutesof ad-

JACC Vol. 24, No. 1 July t!%Xt 17-24

wbi~bcomrasts with a relas it particularly useful for of limited value and n our Series of B

agealatria1pacing appeared to be more reliableand therefore ttseful than d~~yr~damo~e a greater percent (73%vs. studies suggest that dobruta

comparison between tra~~sesop~agea b~t~mine echocardiography in a routine clinical setting. In addition, although all our studies have been performed after cardi~a~tive drug wit drawal, inadequate or omitted withdrawal of such drugs, especially beta-adrenergic bio~~i~~ agents, can potentially reduce the sensitivity of exercise echocardiography more than alternative stress procedures, an interesting issue that should be specificallyaddressed in future studies. ok of digita! ~e~~~~~gy. The evaluaiion of echocardiographic stress images has been helped enormously by the use of digital technology, particularly for exsrcise echocardiogrsphy. This problem is ~eg~igib~~for stresses, such as transesophageal atria! pacing or dipyridamole, that do not affect echocardiographic image quality. Howeveri even for these stress methods, digital systems can be of great benefit. The storage and adequate combination of simultaneously displayed images related not only to the peak stress phase but also to the intermediate phases allow easy evaluation of onset and extent of wall motion abnormalities during any stage of transesophageal atrial pacing or dipyridamole protocols (an operation that is practically impossible when

atory should routinely use an exert

We thank Kate Butt and t7osalind Lee for their assistance in the preparation of the manuscript and Angelo Radio, RN for technical assistance.

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MARANGELLI ET AL. EXERCISE.ATRlAL PACINGANDDIPYRIDAMOLE

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