title: Head-to-head comparison of exercise stress testing, pharmacologic stress echocardiography, and perfusion tomography as first-line examination for chest pain in patients without history of coronary artery disease.
abstract: BACKGROUND
  To overcome the relatively low accuracy of exercise stress testing (EST) in detecting coronary artery disease (CAD), both echocardiography and perfusion scintigraphy have been evaluated in conjunction with pharmacologic stress, but there is still uncertainty of the relative value of these tests as possible first-line examinations for suspected CAD. This study evaluated the accuracy of EST, dipyridamole and dobutamine stress echocardiography (DIP-ECHO, DOB-ECHO), and dipyridamole and dobutamine technetium 99m sestamibi tomography (DIP-MIBI, DOB-MIBI) for the detection of CAD in patients evaluated for the first time because of chest pain.
  
  
  RESULTS
  Sixty patients underwent EST, DIP-ECHO, DOB-ECHO, DIP-MIBI, and DOB-MIBI. Echocardiographic images were acquired simultaneously with sestamibi injections, and the scintigraphic images were collected 1 hour later. Coronary angiography was performed within 15 days. Out of 33 patients with significant (>70%) coronary stenoses, 19 (58%) were correctly identified by EST, 18 (55%) by DIP-ECHO, 20 (61%) by DOB-ECHO, 32 (97%) by DIP-MIBI, and 30 (91%) by DOB-MIBI (p < 0.005 for MIBI vs EST and ECHO). The specificity of EST was 67% (p < 0.05 vs ECHO and MIBI), 96%, 96%, 89%, and 81%, respectively. Of the 62 stenotic coronary arteries, 20 (32%) were correctly identified by DIP-ECHO, 24 (39%) by DOB-ECHO, 48 (77%) by DIP-MIBI, and 45 (73%) by DOB-MIBI. The sensitivity of the imaging techniques in predicting the presence of multivessel disease was 14% and 29% for DIP and DOB-ECHO compared with 48% and 57% for DIP and DOB-MIBI.
  
  
  CONCLUSIONS
  Our results confirm the limited reliability of EST in detecting CAD and the good diagnostic value of DIP and DOB-MIBI. Conversely, the lower sensitivity and the poorer capability to recognize multivessel CAD do not support the role of either DIP or DOB-ECHO as first-line examination for suspected CAD.
authors.affiliation: Division of Cardiology, Careggi Hospital, Florence, Italy. carddept@tin.it
authors.forename: G M
authors.initials: GM
authors.lastname: Santoro
authors.forename: R
authors.initials: R
authors.lastname: Sciagrà
authors.forename: P
authors.initials: P
authors.lastname: Buonamici
authors.forename: N
authors.initials: N
authors.lastname: Consoli
authors.forename: V
authors.initials: V
authors.lastname: Mazzoni
authors.forename: F
authors.initials: F
authors.lastname: Zerauschek
authors.forename: G
authors.initials: G
authors.lastname: Bisi
authors.forename: P F
authors.initials: PF
authors.lastname: Fazzini
mesh_terms: D002637:Chest Pain / Q000209:etiology*; D017023:Coronary Angiography; D003327:Coronary Disease / Q000175:diagnosis*; D004176:Dipyridamole; D004280:Dobutamine; D004452:Echocardiography / Q000379:methods*; D004562:Electrocardiography; D005069:Evaluation Studies as Topic; D005080:Exercise Test; D006801:Humans; D015588:Observer Variation; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon
chemical_list: D004280:Dobutamine; D004176:Dipyridamole; D017256:Technetium Tc 99m Sestamibi