Abstract
The accuracy of exercise electrocardiography (ECG) for detecting coronary artery disease (CAD) in women is limited. Dobutamine stress echocardiography (DSE) is an alternative. Limited and conflicting data exist on the utility of DSE. This prospective study determines value and limitations of DSE compared with exercise ECG in women with suspected CAD.
A total of 114 consecutive women without previous myocardial infarction underwent standard exercise ECG and DSE prior to coronary angiography performed within 5±2 days. Pretest probability of CAD was calculated from clinical parameters and significant CAD was defined as ≥50% coronary artery luminal narrowing.
Prevalence of CAD was 39.5% with multivessel disease in 49%. Most patients had a low or intermediate pretest probability of CAD (75%). Exercise ECG recordings were diagnostic in 71% and DSE in 90% of women. Overall sensitivity, specificity and accuracy for DSE were superior to exercise ECG (80%, 81%, and 80%, respectively, versus 65%, 55%, and 59%, respectively; p<0.05). Accuracy of DSE was increased in multivessel disease (85%), good echocardiographic image quality (86%) compared to single vessel disease (73%) and moderate image quality (69%). Accuracy of DSE demonstrated little differences in subgroups of pretest probability (78–85%), whereas accuracy of exercise ECG ranged from 44% to 71%.
DSE is superior to exercise ECG in the evaluation of suspected CAD in women. Accuracy of ST-segment analysis in exercise ECG remains questionable for the investigation of myocardial ischemia in women and may be supplemented or substituted by DSE.
Zusammenfassung
Die diagnostische Genauigkeit des Belastungs-EKGs bei Frauen mit der Verdachtsdiagnose der koronaren Herzerkrankung ist eingeschränkt und seine Zuverlässigkeit daher fragwürdig. Als Alternative kann die Stressechokardiographie mittels dynamischer oder pharmakologischer Belastung durchgeführt werden. Der Stellenwert der pharmakologischen Stressechokardiographie mittels Dobutamin (DSE) bei Frauen ist derzeit nicht hinreichend geklärt. Die vorliegenden Ergebnisse belegen dagegen, dass die DSE bei Frauen 90% verwertbare Untersuchungen liefert im Vergleich zum Belastungs-EKG (71%). Die Genauigkeit der DSE ist mit 80% signifikant höher als das Belastungs-EKG (59%). Bei Mehrgefäßerkrankung und guter Bildqualität erreicht die DSE eine höhere Testgenauigkeit. Damit ist die Frage nach einer Myokardischämie bei Frauen mittels Dobutaminstressechokardiographie zuverlässiger zu beantworten als mit dem Belastungs-EKG.
Similar content being viewed by others
References
Travin MI, Johnson LL (1997) Assessment of coronary artery disease in women. Current Opinion in Cardiology 12:587–594
Guiteras VP, Chaitman BR, Waters DD, Bourassa MG, Scholl JM, Ferguson RJ, Wegniart P (1982) Diagnostic accuracy of exercise ECG lead systems in clinical subsets of women. Circulation 65:1465–1474
Barolsky SM, Gilbert CA, Faruqui A, Nutter DO, Schlant RC (1979) Differences in electrocardiographic responses to exercise of women and men: a non-Bayesian factor. Circulation 60:1021–1027
Sketch MH, Mohiuddin SM, Lynch JD, Zencka AE, Runco V (1975) Significant sex differences in the correlation of electrocardiographic exercise testing and coronary arteriograms. Am J Cardiol 36:169–173
Hlatky MA, Pryor DB, Harrell FE, Califf RM, Rosati RA (1984) Factor affecting sensitivity and specificity of exercise electrocardiography: multivariate analysis. Am J Med 77:64–71
Weiner DA, Ryan TJ, McCabe CH et al (1979) Exercise stress testing. Correlations among history of angina, ST-segment response and prevalence of coronary artery disease in the Coronary Artery Surgery Study (CASS). N Engl J Med 301:230–235
Shaw L, Miller D, Romeis J et al (1994) Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease. Ann Intern Med 120:559–566
Detry JR, Kapita BM, Cosyns J et al (1977) Diagnostic value of history and maximal exercise electrocardiography in men and women suspected of coronary heart disease. Circulation 56:756–761
Manca C, Dei Cas L, Bernakini B et al (1984) Comparative evaluation of exercise ST response in healthy males and females. Cardiology 71:341–347
Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister BD, Mooss AN, O'Reilly MG, Winters WL, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs JA, Russell RO, Smith SC (2002) ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 40:1531–1540
Sawada SG, Ryan T, Fineberg NS, Armstrong WF, Judson WE, McHenry PL, Feigenbaum H (1989) Exercise echocardiographic detection of coronary artery disease in women. J Am Coll Cardiol 14:1440–1447
Williams MJ, Marwick TH, O'Gorman D, Foale RA (1994) Comparison of exercise echocardiography with an exercise score to diagnose coronary artery disease in women. Am J Cardiol 74:435–438
Marwick TH, Anderson T, Williams MJ, Haluska B, Melin JA, Pashkow F, Thomas JD (1995) Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women. J Am Coll Cardiol 26:335–341
Roger VL, Pellika PA, Bell MR, Chow CWH, Bailey KR, Seward JB (1997) Sex and test verification bias: impact on the diagnostic value of stress echocardiography. Circulation 95:405–410
Blomstrand P, Engvall J, Swahn E, Safstrom K, Thulesius O, Wranne B (1996) Cardiovascular effects of dobutamine stress testing in women with suspected coronary artery disease. Heart 75:463–468
Takeuchi M, Sonoda S, Miura Y, Kuroiwa A (1996) Comparative diagnostic value of dobutamine stress echocardiography and stress thallium-201 single-photon-emission computed tomography for detecting coronary artery disease in women. Coronary Artery Disease 7:831–835
Hiro J, Hiro T, Reid CL, Ebrahimi R, Matsuzaki M, Gardin JM (1997) Safety and results of dobutamine stress echocardiography in women versus men and in patients older and younger than 75 years of age. Am J Cardiol 80:1014–1020
Elhendy A, Geleijnse ML, van Domburg RT, Nierop PR, Poldermans D, Bax JJ, TenCate FJ, Nosir YFM, Ibrahim MM, Roelandt JRTC (1997) Gender differences in the accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease. Am J Cardiol 80:1414–1418
Elhendy A, van Domburg RT, Bax JJ, Nierop PR, Geleijnse ML, Ibrahim MM, Roelandt JRTC (1998) Noninvasive diagnosis of coronary artery stenosis in women with limited exercise capacity: Comparison of dobutamine stress echocardiography and Tc-99m sestamibi single-photon emission CT. Chest 114:1097–1104
Secknus MA, Marwick TH (1997) Influence of gender on physiologic response and accuracy of dobutamine stress echocardiography. Am J Cardiol 80:721–724
Ho YL, Wu CC, Huang PJ, Lin LC, Chieng PU, Chen PJ, Chen MF, Lee YT (1998) Assessment of coronary artery disease in women by dobutamine stress echocardiography: Comparison with stress thallium-201 single-photon emission computed tomography and exercise electrocardiography Am Heart J 135:655–662
Dionisopoulos PN, Collins JD, Smart SC, Knickelbine TA, Sagar KB (1997) The value of dobutamine stress echocardiography for the detection of coronary artery disease in women. J Am Soc Echocardiogr 10:811–817
Lewis JF, Lin L, McGorray S, Pepine CJ, Doyle M, Edmundowicz R, Holubkov R, Pohost G, Reichek N, Rogers W, Sharaf BL, Sopko B, Merz CN (1999) Dobutamine stress echocardiography in women with chest pain. Pilot phase data from the National Heart, Lung and Blood Institute women's ischemia syndrome evaluation (WISE). J Am Coll Cardiol 33:1462–1468
Salustri A, Fioretti PM, Pozzoli MM, McNeill AJ, Roelandt JR (1992) Dobutamine stress echocardiography: its role in the diagnosis of coronary artery disease. Eur Heart J 13:70–77
Mazeika PK, Nadazdin A, Oakley CM (1992) Dobutamine stress echocardiography for detection and assessment of coronary artery disease. J Am Coll Cardiol 19:1203–1211
Marwick T, D'Hondt AM, Baudhuin T, Willemart B, Wijns W, Detry LM, Melin J (1993) Optimal use of dobutamine stress for the detection and evaluation of coronary artery disease: combination with echocardiography or scintigraphy, or both? J Am Coll Cardiol 22:159–167
Slavich GA, Guerra UP, Morocutti G, Fioretti PM, Fresco C, Orlandi C, Orsolon PG, Forster T, Feruglio GA (1996) Feasibility of simultaneous Tc99m sestamibi and 2D-echo cardiac imaging during dobutamine pharmacologic stress. Preliminary results in a female population. Int J Card Imaging 12:113–118
Laurienzo JM, Cannon RO III, Quyyumi AA, Dilsizian V, Panza JA (1997) Improved specificity of transoesophageal dobutamine stress echocardiography compared to standard tests for evaluation of coronary artery disease. Am J Cardiol 80:1402–1407
Sizemore C, Lewis JF (1999) Clinical relevance of chest pain during dobutamine stress echocardiography in women. Clin Cardiol 22:715–718
Rollan MJ, San Roman JA, Vilacosta I, Ortega JR, Serrador A, Pastor G, Medina A, Bratos JL, Fernandez- Aviles F (1999) The influence of sex on the performance of dobutamine echocardiography for the diagnosis of ischemic cardiopathy. Rev Esp Cardiol 52:1060–1065
Rollan MJ, San Roman JA, Vilacosta I, Ortega JR, Bratos JL (2002) Dobutamine stress echocardiography in the diagnosis of coronary artery disease in women with chest pain: comparison with different noninvasive tests. Clin Cardiol 25:559–564
Shaw LJ, Bairey Merz CN, Pepine CJ, Reis SE, Bittner V, Kelsey SF, Olson M, Johnson BD, Mankad S, Sharaf BL, Rogers WJ, Wessel TR, Arant CB, Pohost GM, Lerman A, Quyyumi AA, Sopko G; WISE Investigators (2006) Insights from the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol 47:S4–S20
Shaw LJ, Vasey C, Sawada S, Rimmermann C, Marwick TH (2005) Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men. European Heart J 26:447–456
Geleijnse ML, Boudewijn JK, Soliman O, Nemes A, Galema TW, ten Cate FJ (2007) Dobutamine stress echocardiography for the detection of coronary artery disease in women. Am J Cardiol 99:714–717
Diamond GA, Forrester JS (1979) Analysis of probability as an aid in the clinical diagnosis of coronary artery disease. N Eng J Med 24:1350–1358
Kasprzak JD, Paelinck B, Ten Cate FJ, Vletter WB, de Jong N, Poldermans D, Elhendy A, Bouakaz A, Roelandt JRTC (1999) Comparison of native and contrast-enhanced harmonic echocardiography for visualization of left ventricular endocardial border. Am J Cardiol 83:211–217
Schiller N, Shah P, Crawford M, De-Maria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I, for the American Society of Echocardiography Committee on Standards on Quantitation of Two-Dimensional Echocardiograms (1989) Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr 2:358–367
Geleijnse ML, Fioretti PM, Roelandt JRTC (1997) Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography. J Am Coll Cardiol 30:595–606
Bach DS, Muller DW, Gros BJ, Armstrong WF (1994) False positive dobutamine stress echocardiograms: characterization of clinical, echocardiographic and angiographic findings. J Am Coll Cardiol 24:928–933
Picano E, Mathias W, Pingitore A, Bigi R, Previtali M, for the Echo Dobutamine International Study Group (1994) Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicenter study. Lancet 344:1190–1192
Schartl M, Beckmann S, Bocksch W, Fateh-Moghadam S, Fleck E (1997) Stress echocardiography in special groups: in women, in left bundle branch block, in hypertension and after heart transplantation. Eur Heart J 18(Suppl D):63–67
Douglas PS, Ginsburg GS (1996) The evaluation of chest pain in women. N Engl J Med 334:1311–1315
Nagel E, Lehmkuhl HB, Bocksch W, Klein C, Vogel U, Frantz E, Ellmer A, Dreysse S, Fleck E (1999) Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation 99:763–770
Nagel E, Lehmkuhl HB, Klein C, Schneider U, Frantz E, Ellmer A, Bocksch W, Dreysse S, Fleck E (1999) Influence of image quality on the diagnostic accuracy of dobutamine stress magnetic resonance imaging in comparison with dobutamine stress echocardiography for the noninvasive detection of myocardial ischemia. Z Kardiol 88:622–630
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lehmkuhl, H.B., Siniawski, H., Lehmkuhl, E. et al. Value and limitations of dobutamine stress echocardiography in women with suspected coronary artery disease. Z Herz- Thorax- Gefäßchir 21, 250–258 (2007). https://doi.org/10.1007/s00398-007-0598-9
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/s00398-007-0598-9
Key words
- stress echocardiography
- dobutamine
- women
- coronary artery disease
- image quality
- pretest probability
- exercise electrocardiography