A meta-analytic comparison of echocardiographic stressors.
BACKGROUND
The relative performance of alternative stressors for stress echocardiography for the diagnosis of coronary artery disease (CAD) is not well established.


METHODS
All studies published between 1981 to December 2001 who met inclusion criteria were included in this analysis. We performed a summary receiver operator characteristic (SROC) analysis and calculated weighted mean of the likelihood ratio and sensitivity/specificity. A covariate analysis using meta-regression methods was also performed.


RESULTS
Forty-four studies presented data on Exercise, 11 on Adenosine, 80 on Dobutamine, 40 on Dipyridamole, 16 on transatrial pacing transesophageal echocardiography (Tap-TEE), and 7 on transatrial pacing transthorasic echocardiography (Tap-TTE). SROC analysis showed that the following order of most discriminatory to least: Tap-TEE, Exercise, Dipyridamole, Dobutamine and Adenosine. Weighted means sensitivity/specificity were Exercise: 82.6/84.4%, Adenosine: 68.4/80.9%, Dobutamine: 79.6/85.1%, Dipyridamole: 71.0/92.2%, Tap-TTE: 90.7/86.1%, and Tap-TEE: 86.2/91.3%. Covariate analysis showed that the discriminatory power of Exercise decreased with increasing mean age.


CONCLUSIONS
Tap-TEE is a very accurate test for both ruling in and ruling out CAD although its invasiveness may limit its clinical acceptability. Exercise is a well-balanced satisfactory test for both ruling in and ruling out but performance might be lower for the elderly. Dobutamine offers a reasonable compromise for Exercise. Dipyridamole might be good for ruling in but not for ruling out CAD. The incapability in ruling-out CAD was a major problem in clinical application of the stress. Adenosine was the least useful stressor in diagnosing CAD.
Noguchi
Yoshinori
Y
Division of General Internal Medicine, Department of Medicine, Fujita Health University School of Medicine, Toyoake, Japan. yoshi-noguchi@umin.ac.jp
Nagata-Kobayashi
Shizuko
S
Stahl
James E
JE
Wong
John B
JB
D000241:Adenosine; D000367:Age Factors; D002304:Cardiac Pacing, Artificial; D003324:Coronary Artery Disease / Q000175:diagnosis*; D004176:Dipyridamole; D004452:Echocardiography / Q000379:methods*; D005080:Exercise Test; D006801:Humans; D015999:Multivariate Analysis; D012372:ROC Curve; D012680:Sensitivity and Specificity; D012737:Sex Factors; D014665:Vasodilator Agents
D014665:Vasodilator Agents; D004176:Dipyridamole; D000241:Adenosine