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.
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.
Geleijnse
M L
ML
Thoraxcentre, University Hospital Rotterdam-Dijkzigt and Erasmus University, Rotterdam, The Netherlands.
Vigna
C
C
Kasprzak
J D
JD
Rambaldi
R
R
Salvatori
M P
MP
Elhendy
A
A
Cornel
J H
JH
Fioretti
P M
PM
Roelandt
J R
JR
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
D002316:Cardiotonic Agents; D004280:Dobutamine; D001285:Atropine