Circulation, Vol 89, 1160-1173, Copyright © 1994 by American Heart Association
S Severi, E Picano, C Michelassi, F Lattanzi, P Landi, A Distante and A L'Abbate
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.
ARTICLES
Diagnostic and prognostic value of dipyridamole echocardiography in patients with suspected coronary artery disease. Comparison with exercise electrocardiography
CNR-Institute of Clinical Physiology, Pisa, Italy.
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