title: Usefulness and limitations of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in patients with left bundle branch block. A multicentre study.
abstract: BACKGROUND
  Patients with left bundle branch block exhibit abnormal septal motion which may limit the interpretation of stress echocardiograms. This study sought to assess the diagnostic value of dobutamine-atropine stress echocardiography in left bundle branch block patients.
  
  
  RESULTS
  Sixty-four left bundle branch block patients (mean age 59 years, 24 men) with suspected coronary artery disease underwent dobutamine-atropine stress echocardiography and coronary arteriography. Myocardial ischaemia was defined as new or worsening wall thickening abnormalities. Coronary artery disease was quantitatively defined as a diameter stenosis >/=50% in a major epicardial artery. Rest septal motion was normal (apart from the early systolic septal notch) in 34 patients (53%) and abnormal in 30 patients (47%). Rest septal thickening was normal in 32 patients (50%) and abnormal in 32 patients (50%). All seven patients with a QRS duration >/=160 ms and an abnormal QRS axis had abnormal rest septal motion and thickening. Inter-observer agreement for ischaemia was 88%. In all but one patient disagreement was in the septum. For the anterior and posterior circulation, respectively, sensitivity was 60% (9/15) and 67% (8/12), specificity was 94% (46/49) and 98% (51/52), and accuracy was 86% (55/64) and 92% (59/64). Sensitivity for the anterior circulation tended to be better in patients with normal rest septal thickening (83% vs 44%).
  
  
  CONCLUSIONS
  Dobutamine-atropine stress echocardiography has excellent diagnostic specificity in left bundle branch block patients with suspected coronary artery disease. In patients with abnormal rest septal thickening, however, dobutamine-atropine stress echocardiography may lack good sensitivity for detection of coronary artery disease in the anterior circulation. Left bundle branch block patients who potentially most benefit from dobutamine-atropine stress echocardiography may initially be selected by their resting electrocardiogram.
authors.affiliation: Thoraxcentre, University Hospital Rotterdam-Dijkzigt and Erasmus University, Rotterdam, The Netherlands.
authors.forename: M L
authors.initials: ML
authors.lastname: Geleijnse
authors.forename: C
authors.initials: C
authors.lastname: Vigna
authors.forename: J D
authors.initials: JD
authors.lastname: Kasprzak
authors.forename: R
authors.initials: R
authors.lastname: Rambaldi
authors.forename: M P
authors.initials: MP
authors.lastname: Salvatori
authors.forename: A
authors.initials: A
authors.lastname: Elhendy
authors.forename: J H
authors.initials: JH
authors.lastname: Cornel
authors.forename: P M
authors.initials: PM
authors.lastname: Fioretti
authors.forename: J R
authors.initials: JR
authors.lastname: Roelandt
mesh_terms: D000328:Adult; D000368:Aged; D001285:Atropine / Q000009:adverse effects; D002037:Bundle-Branch Block / Q000150:complications*; D002316:Cardiotonic Agents / Q000009:adverse effects; D003327:Coronary Disease / Q000150:complications* / Q000000981:diagnostic imaging*; D004280:Dobutamine / Q000009:adverse effects; D004452:Echocardiography / Q000592:standards*; D004562:Electrocardiography; D005080:Exercise Test / Q000592:standards*; D005188:False Negative Reactions; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging; D015588:Observer Variation
chemical_list: D002316:Cardiotonic Agents; D004280:Dobutamine; D001285:Atropine