The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis.
BACKGROUND
Recent American Heart Association/American College of Cardiology guidelines state that "dobutamine stress echo has substantially higher sensitivity than vasodilator stress echo for detection of coronary artery stenosis" while the European Society of Cardiology guidelines and the European Association of Echocardiography recommendations conclude that "the two tests have very similar applications". Who is right?


OBJECTIVE
To evaluate the diagnostic accuracy of dobutamine versus dipyridamole stress echocardiography through an evidence-based approach.


METHODS
From PubMed search, we identified all papers with coronary angiographic verification and head-to-head comparison of dobutamine stress echo (40 mcg/kg/min +/- atropine) versus dipyridamole stress echo performed with state-of-the art protocols (either 0.84 mg/kg in 10' plus atropine, or 0.84 mg/kg in 6' without atropine). A total of 5 papers have been found. Pooled weight meta-analysis was performed.


RESULTS
the 5 analyzed papers recruited 435 patients, 299 with and 136 without angiographically assessed coronary artery disease (quantitatively assessed stenosis > 50%). Dipyridamole and dobutamine showed similar accuracy (87%, 95% confidence intervals, CI, 83-90, vs. 84%, CI, 80-88, p = 0.48), sensitivity (85%, CI 80-89, vs. 86%, CI 78-91, p = 0.81) and specificity (89%, CI 82-94 vs. 86%, CI 75-89, p = 0.15).


CONCLUSIONS
When state-of-the art protocols are considered, dipyridamole and dobutamine stress echo have similar accuracy, specificity and - most importantly - sensitivity for detection of CAD. European recommendations concluding that "dobutamine and vasodilators (at appropriately high doses) are equally potent ischemic stressors for inducing wall motion abnormalities in presence of a critical coronary artery stenosis" are evidence-based.
CNR, Institute of Clinical Physiology, Pisa, Italy. picano@ifc.cnr.it
Eugenio
E
Picano
Sabrina
S
Molinaro
Emilio
E
Pasanisi
D000368:Aged; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D025401:Echocardiography, Stress / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index