The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis

<p>Abstract</p> <p>Background</p> <p>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?</p> <p>Aim</p> <p>To evaluate the diagnostic accuracy of dobutamine versus dipyridamole stress echocardiography through an evidence-based approach.</p> <p>Methods</p> <p>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.</p> <p>Results</p> <p>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).</p> <p>Conclusion</p> <p>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 "<it>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</it>" are evidence-based.</p

Comparison of exercise, dobutamine-atropine and dipyridamole-atropine stress echocardiography in detecting coronary artery disease

BACKGROUND: Dipyridamole and dobutamine stress echocardiography testing are most widely utilized, but their sensitivity remained suboptimal in comparison to routine exercise stress echocardiography. The aim of our study is to compare, head-to-head, exercise, dobutamine and dipyridamole stress echocardiography tests, performed with state-of-the-art protocols in a large scale prospective group of patients. METHODS: Dipyridamole-atropine (Dipatro: 0.84 mg/kg over 10 min i.v. dipyridamole with addition of up to 1 mg of atropine), dobutamine-atropine (Dobatro: up to 40 mcg/kg/min i.v. dobutamine with addition of up to 1 mg of atropine) and exercise (Ex, Bruce) were performed in 166 pts. Of them, 117 pts without resting wall motion abnormalities were enrolled in study (91 male; mean age 54 ± 10 years; previous non-transmural myocardial infarction in 32 pts, angina pectoris in 69 pts and atypical chest pain in 16 pts). Tests were performed in random sequence, in 3 different days, within 5 day period under identical therapy. All patients underwent coronary angiography. RESULTS: Significant coronary artery disease (CAD; ≥50% diameter stenosis) was present in 69 pts (57 pts 1-vessel CAD, 12 multivessel CAD) and absent in 48 pts. Sensitivity (Sn) was 96%, 93% and 90%, whereas specificity (Sp) was 92%, 92% and 87% for Dobatro, Dipatro and Ex, respectively (p = ns). Concomitant beta blocker therapy did not influence peak rate-pressure product and Sn of Dobatro and Dipatro (p = ns). CONCLUSION: When state-of-the-art protocols are used, dipyridamole and dobutamine stress echocardiography have comparable and high diagnostic accuracy, similar to maximal post-exercise treadmill stress echocardiography

Adherence issues related to sublingual immunotherapy as perceived by allergists

Objectives: Sublingual immunotherapy (SLIT) is a viable alternative to subcutaneous immunotherapy to treat allergic rhinitis and asthma, and is widely used in clinical practice in many European countries. The clinical efficacy of SLIT has been established in a number of clinical trials and meta-analyses. However, because SLIT is self-administered by patients without medical supervision, the degree of patient adherence with treatment is still a concern. The objective of this study was to evaluate the perception by allergists of issues related to SLIT adherence. Methods: We performed a questionnaire-based survey of 296 Italian allergists, based on the adherence issues known from previous studies. The perception of importance of each item was assessed by a VAS scale ranging from 0 to 10. Results: Patient perception of clinical efficacy was considered the most important factor (ranked 1 by 54% of allergists), followed by the possibility of reimbursement (ranked 1 by 34%), and by the absence of side effects (ranked 1 by 21%). Patient education, regular follow-up, and ease of use of SLIT were ranked first by less than 20% of allergists. Conclusion: These findings indicate that clinical efficacy, cost, and side effects are perceived as the major issues influencing patient adherence to SLIT, and that further improvement of adherence is likely to be achieved by improving the patient information provided by prescribers. © 2010 Scurati et al, publisher and licensee Dove Medical Press Ltd

Toxic metals in the air and soil of the Paso del Norte Region

In the first of the individual studies that comprise this chapter, air concentrations are presented for four toxic metals—copper (Cu), lead (Pb), arsenic (As), and chromium (Cr)—based on particulate matter (PM) trapped on filters from eight sampling stations in the Paso del Norte airshed in 1994, 1995, and 1996. One representative low-wind day in each season (spring, summer, fall, and winter) was chosen for analysis by inductively coupled plasma mass spectrometry (ICP-MS). The resultant data set thus can be interrogated to reveal both geographic and seasonal variation trends in airborne toxic metals. Concentrations of copper, lead, chromium, and arsenic were found to increase during fall and winter, relative to spring and summer. Ground-level atmospheric inversions during the colder seasons in this desert region are believed to trap anthropogenic particulates by preventing vertical mixing. Elevated metal levels characterized sampling stations in the urban core, with lower values at more distal samplers. This suggests the importance of local sources of the metals. The chapter also details a study in which levels of lead, copper, and arsenic in PM in the El Paso, Tex.-Ciudad Juárez, Chih., airshed were found to exhibit significant decreases over the past quartercentury. These overall trends are evident even in a limited data set of samples from 1977, 1980, 1987, 1994, and 2001. Decreases in lead are dramatic and a significant contribution to the public health of the El Paso-Ciudad Juárez binational community. The chapter further details the collection of soil samples from areas surrounding various facilities in El Paso that are potential point sources (historical as well as current) for metals contamination. Areas of interest include the American Smelting and Refining Company (Asarco) smelter on the west side of El Paso, Memorial Park in central El Paso (where the Federal smelter was formerly located), and the Phelps Dodge copper refinery on the east side of El Paso. Soil samples were also collected from outlying areas north and east of El Paso in an effort to observe the effects of distance from urban sources. The soil samples were prepared and analyzed for arsenic, barium, calcium, cadmium, copper, chromium, lead, nickel, selenium, and zinc. Values for arsenic, lead, copper, and chromium are presented on maps of the El Paso area and correlations between concentrations of the various metals were determined. Concentrations of arsenic, lead, copper, and chromium were highest in the area around the Asarco smelter. Higher concentrations were observed in the surface (2.5 centimeter &#091;cm&#093;) samples than in the samples taken at greater depths. The Memorial Park area exhibited slightly elevated levels of these metals relative to the El Paso urban background values. The samples from the Phelps Dodge refinery region were generally indistinguishable from the background samples. Finally, the geographic distribution of lead in El Paso soils is presented in maps based on more than 300 composite soil samples collected in the region. The use of such composites highlights the distribution of lead at the neighborhood level, and de-emphasizes any anomalous elevated level associated with an individual house or structure. Lead levels are highest in the downtown commercial district; in the adjacent area to the east, which comprises an old central business, transport, and light industry complex; and to the west in the area of the Asarco smelter. The continuity of this zone and the age of its structures make it difficult to differentiate lead sources. Lead values decrease systematically away from this urban core zone, with the lowest levels generally encountered in the peripheral, lightly populated developments and communities. This geographic distribution of lead in soil is consistent with lead measurements reported on PM taken from four air monitoring stations during the 1990s. Soil data thus can complement air studies by providing an essentially infinite geographic network of sampling sites that, with varying accuracy, record and integrate air conditions over years and decades