title: Selection of the optimal stress test for the diagnosis of coronary artery disease.
abstract: OBJECTIVE
  To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease.
  
  
  METHODS
  The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography.
  
  
  METHODS
  Two tertiary care and university centres.
  
  
  METHODS
  102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results.
  
  
  RESULTS
  MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa = 0.72; regional analysis 93%, kappa = 0.72; diagnosis of the "culprit" vessel 95%, kappa = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa = 0.84 with dobutamine and 92%, kappa = 0.85 with dipyridamole).
  
  
  CONCLUSIONS
  Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.
authors.affiliation: Department of Cardiology, Hospital Universitario, Valladolid, Spain.
authors.forename: J A
authors.initials: JA
authors.lastname: San Román
authors.forename: I
authors.initials: I
authors.lastname: Vilacosta
authors.forename: J A
authors.initials: JA
authors.lastname: Castillo
authors.forename: M J
authors.initials: MJ
authors.lastname: Rollán
authors.forename: M
authors.initials: M
authors.lastname: Hernández
authors.forename: V
authors.initials: V
authors.lastname: Peral
authors.forename: I
authors.initials: I
authors.lastname: Garcimartín
authors.forename: M M
authors.initials: MM
authors.lastname: de la Torre
authors.forename: F
authors.initials: F
authors.lastname: Fernández-Avilés
mesh_terms: D000318:Adrenergic beta-Agonists; D000368:Aged; D000889:Anti-Arrhythmia Agents; D017023:Coronary Angiography; D003327:Coronary Disease / Q000175:diagnosis*; D004176:Dipyridamole; D004280:Dobutamine; D004452:Echocardiography; D005069:Evaluation Studies as Topic; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D014665:Vasodilator Agents
chemical_list: D000318:Adrenergic beta-Agonists; D000889:Anti-Arrhythmia Agents; D014665:Vasodilator Agents; D004280:Dobutamine; D004176:Dipyridamole; D017256:Technetium Tc 99m Sestamibi