Diagnostic and prognostic value of dipyridamole echocardiography in patients with suspected coronary artery disease. Comparison with exercise electrocardiography.

Abstract

BACKGROUND Before any new diagnostic test is accepted in clinical practice, such a test should be compared with established diagnostic tools in an appropriately large series of patients encompassing the complete spectrum of challenges to which the test is exposed. The aim of the present study was to assess the relative diagnostic and prognostic accuracies of high-dose dipyridamole echocardiography (two-dimensional echocardiographic monitoring during dipyridamole infusion up to 0.84 mg/kg over 10 hours) versus maximal symptom-limited bicycle exercise ECG test in patients with angina. METHODS AND RESULTS We studied 429 consecutive in-hospital patients who met the following inclusion criteria: history of chest pain, off antianginal therapy for at least 2 days (1 week for beta-blockers), no previous myocardial infarction and/or obvious regional left ventricular dyssynergy of contraction (akinesis or dyskinesis) at baseline, and acceptable acoustic window under resting conditions. All patients underwent dipyridamole echocardiography and exercise ECG--on different days and in random order--within 1 week of coronary angiography (which was performed independent of test results) and were followed up for 37.8 +/- 14 months (range, 1 to 73 months). Criteria of positivity were for dipyridamole echocardiography, a transient regional dyssynergy absent in the baseline examination; for exercise ECG, an ST-segment shift of > or = 0.1 mV from baseline; and for coronary angiography, a luminal reduction of > or = 75% in at least one major coronary vessel (50% for left main). There were 183 patients without and 246 with coronary artery disease; 132 had one-, 70 had two-, and 44 had three- and/or left main vessel disease. The specificity was higher for dipyridamole echocardiography than for exercise ECG (90% versus 51%, P < .001). The overall sensitivity of dipyridamole echocardiography was similar to that of exercise ECG (75% versus 74%, P = NS), with no significant differences in the subset with one- (67% versus 69%, P = NS), two- (79% versus 77%, P = NS), or three- (93% versus 86%, P = NS) vessel disease. During the follow-up, there were 20 deaths, 13 nonfatal myocardial infarctions, and 126 revascularization procedures. In the univariate analysis, dipyridamole resulted in higher chi 2 values than did exercise stress testing. A Cox forward stepwise survival analysis identified the dipyridamole time as the most powerful prognostic predictor of death (chi 2 = 19.4, P < .0001) of all invasive and noninvasive parameters. The dipyridamole time also provided independent and additional prognostic information when it was adjusted for age, diabetes, resting ECG, and exercise stress test according to a modified, interactive stepwise procedure. This is true when death only, death and myocardial infarction, and death, myocardial infarction, and revascularization procedures were considered end points. CONCLUSIONS In patients with no previous myocardial infarction and good resting left ventricular function, compared with exercise ECG, dipyridamole echocardiography has a similar sensitivity and a higher specificity for the noninvasive detection of angiographically assessed coronary artery disease. Dipyridamole echocardiography also provides information in addition to that provided by exercise ECG for predicting death, infarction, and all events when the presence as well as the timing, severity, and extension of dipyridamole-induced wall motion abnormalities are considered.

Stress Echocardiography Positivity Predicts Cancer Death

“…As expected and in keeping with previous extensive evidences,6, 7, 8, 9, 10, 11, 12, 13 a negative SE was associated with a significantly lower death rate compared with patients with positive SE. However, the 25‐year mortality difference between patients with SE positive versus those with SE negative results, albeit significant because of the large sample size, was modest: 70% versus 60% for all‐cause death and 40% versus 31% for cardiovascular death.…”

“…The prognostic value of SE was shown initially for cumulative end points, mainly consisting of soft end points such as recurrence of angina or coronary revascularization,5, 6, 7, 8 later for hard end points such as myocardial infarction (MI)9, 10 and—as data matured—for all‐cause death and cardiac death 11, 12, 13. The clinical meaning of the prognostic stratification is based not only on statistical but also on biological plausibility 14.…”

Valor prognóstico da ecocardiografia com estresse pela dobutamina associada à atropina

“…Estes resultados são corroborados por autores com o uso da ECO com esforço 5,6 , pela ECO pelo dipiridamol 7,8,15 e pela ECO pela dobutamina 9,10 . Em nosso trabalho, o menor poder discriminativo para eventos futuros foi em relação à ocorrência de IAM com probabilidade de 1,4% para o grupo com teste negativo; enquanto que no grupo de pacientes com testes positivos, a probabilidade de infarto foi de 5,6%.…”

Special article Magnetocardiography in clinical cardiology. Status quo and future applications

“…But there is also a dilemma for cardiologists and their patients with known CAD, after multiple coronary interventions and finally coronary bypass grafting, who after a symptom-free period of three years develop angina again. Neither established diagnostic methods such as 12-lead ECG, [15][16][17][18][19][20]. Transient myocardial ischaemia, however, causes well-recognizable changes in a variety of MCG parameters, first described by Cohen and Kaufman in 1975 [21].…”