title: Analysis of interinstitutional observer agreement in interpretation of dobutamine stress echocardiograms.
abstract: OBJECTIVE
  This study sought to determine the degree of interinstitutional agreement in the interpretation of dobutamine stress echocardiograms.
  
  
  BACKGROUND
  Dobutamine stress echocardiography involves subjective interpretation. Consistent methods for acquisition and interpretation are of critical importance for obtaining high interobserver agreement and for facilitating communication of test results.
  
  
  METHODS
  Five experienced centers were each asked to submit 30 dobutamine stress echocardiograms (dobutamine up to 40 micrograms/kg body weight per min and atropine up to 1 mg) obtained in patients undergoing coronary angiography. Thus, a total of 150 dobutamine stress echocardiograms were interpreted by each center without knowledge of any other patient data. Left ventricular wall motion was assessed using a 16-segment model but was otherwise not standardized. No patient was excluded because of poor image quality or inadequate stress level. Echocardiographic image quality was assessed using a five-point scale.
  
  
  RESULTS
  Angiographically significant coronary artery disease (> or = 50% diameter stenosis) was present in 95 patients (63%). By a majority decision (three or more centers), the sensitivity, specificity and accuracy of dobutamine echocardiography were 76%, 87% and 80%, respectively. Abnormal or normal results of stress echocardiography were agreed on by four or all five of the centers in 73% of patients (mean kappa value 0.37, fair agreement only). Agreement on the left anterior descending artery territory (78%) was similar to that for the combined right coronary artery/left circumflex artery territory (74%), and for specific segments the agreement ranged from 84% to 97% and was highest for the basal anterior segment and lowest for the basal inferior segment. Agreement was higher in patients with no (82%) or three-vessel coronary artery disease (100%) and lower in patients with one- or two-vessel disease (61% and 68%, respectively). Agreement on positivity or negativity of stress test results was 100% for patients with the highest image quality but only 43% for those with the lowest image quality (p = 0.003).
  
  
  CONCLUSIONS
  The current heterogeneity in data acquisition and assessment criteria among different centers results in low interinstitutional agreement in interpretation of stress echocardiograms. Agreement is higher in patients with no or advanced coronary artery disease and substantially lower in those with limited echocardiographic image quality. To increase interinstitutional agreement, better standardization of image acquisition and reading criteria of stress echocardiography is recommended.
authors.affiliation: Medical Clinic I, Rheinisch Wesfalische Techische Hochschule Aachen, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Hoffmann
authors.forename: H
authors.initials: H
authors.lastname: Lethen
authors.forename: T
authors.initials: T
authors.lastname: Marwick
authors.forename: M
authors.initials: M
authors.lastname: Arnese
authors.forename: P
authors.initials: P
authors.lastname: Fioretti
authors.forename: A
authors.initials: A
authors.lastname: Pingitore
authors.forename: E
authors.initials: E
authors.lastname: Picano
authors.forename: T
authors.initials: T
authors.lastname: Buck
authors.forename: R
authors.initials: R
authors.lastname: Erbel
authors.forename: F A
authors.initials: FA
authors.lastname: Flachskampf
authors.forename: P
authors.initials: P
authors.lastname: Hanrath
mesh_terms: D002316:Cardiotonic Agents; D017023:Coronary Angiography; D003327:Coronary Disease / Q000000981:diagnostic imaging* / Q000453:epidemiology; D004280:Dobutamine; D004452:Echocardiography / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D016277:Ventricular Function, Left
chemical_list: D002316:Cardiotonic Agents; D004280:Dobutamine