Circulation, Vol 87, 345-354, Copyright © 1993 by American Heart Association
T Marwick, B Willemart, AM D'Hondt, T Baudhuin, W Wijns, JM Detry and J Melin
BACKGROUND. The mechanisms of action of exercise-simulating and vasodilator
stressors support their combination with imaging techniques that evaluate
left ventricular function and perfusion, respectively. However, reported
accuracies of either pharmacological stress together with two-dimensional
echocardiography (2DE) or single photon emission computed tomography
(SPECT) of myocardial perfusion are similar. The purpose of this study was
to establish the optimal stress for each imaging technique by comparing the
results of digitized 2DE and 99mTc- methoxyisobutyl isonitrile (MIBI) SPECT
using both dobutamine and adenosine stresses in the same patients and
conditions. METHODS AND RESULTS. Ninety-seven consecutive patients without
evidence of previous infarction undergoing coronary angiography for
clinical indications were studied prospectively. Dobutamine was infused
during clinical, ECG, and echocardiographic monitoring in dose increments
from 5 to 40 micrograms.kg-1.min-1. Adenosine was infused under the same
conditions in doses of 0.10, 0.14, and 0.18 mg.kg-1.min-1. For each
protocol, the end points were achievement of peak dose, development of
severe ischemia, or intolerable side effects. At peak stress, 20 mCi of
MIBI was injected, and SPECT imaging was performed 2 hours later; abnormal
poststress images were compared with resting SPECT. Digitized 2DE images
were compared qualitatively before, during, and after stress in a cine-loop
display. Significant coronary disease (n = 59 patients) was defined by the
quantification of > 50% stenosis in a major epicardial vessel. The
sensitivity of adenosine 2DE was 58%, less than those of adenosine MIBI
(86%, p = 0.001), dobutamine 2DE (85%, p = 0.001), and dobutamine MIBI
(80%, p = 0.01). Their respective specificities were 87%, 71%, 82%, and 74%
(p = NS). The accuracy of adenosine 2DE was 69%, compared with 80% for
adenosine MIBI (p < 0.001), 84% for dobutamine 2DE (p = 0.001), and 77%
for dobutamine MIBI (p = 0.005); the latter three did not differ
significantly in either sensitivity or accuracy. CONCLUSIONS. This
prospective, direct comparison of alternative pharmacological stresses in
patients without myocardial infarction shows vasodilator stress
scintigraphy and dobutamine stress echocardiography and scintigraphy to
share equivalent levels of sensitivity. All three are significantly more
sensitive than adenosine stress echocardiography. Dobutamine stress may be
used for wall motion or perfusion imaging, but adenosine stress is best
combined with perfusion scintigraphy.
ARTICLES
Selection of the optimal nonexercise stress for the evaluation of ischemic regional myocardial dysfunction and malperfusion. Comparison of dobutamine and adenosine using echocardiography and 99mTc-MIBI single photon emission computed tomography
Division of Cardiology, Cliniques Universitaires St. Luc, University of Louvain, Brussels, Belgium.
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