Selection of the Optimal Nonexercise Stress for the Evaluation of Ischemic Regional Myocardial Dysfunction and Malperfusion - Comparison of Dobutamine and Adenosine Using Echocardiography and Tc-99m-mibi Single Photon-emission Computed-tomography

Abstract

Background. The mechanisms of action of exercise-simulating and vasodilator stressors support their combination with imaging techniques that evaluate left ventricular function and perfusion, respectively. However, reported accuracies of either pharmacological stress together with two-dimensional echocardiography 2DE) or single photon emission computed tomography (SPECT) of myocardial perfusion are similar. The purpose of this study was to establish the optimal stress for each imaging technique by comparing the results of digitized 2DE and Tc-99m-methoxyisobutyl isonitrile (MIBI) SPECT using both dobutamine and adenosine stresses in the same patients and conditions. Methods and Results. Ninety-seven consecutive patients without evidence of previous infarction undergoing coronary angiography for clinical indications were studied prospectively. Dobutamine was infused during clinical, ECG, and echocardiographic monitoring in dose increments from 5 to 40 mug . kg-1 . min-1. Adenosine was infused under the same conditions in doses of 0.10, 0.14, and 0.18 mg . kg-1 . min-1. For each protocol, the end points were achievement of peak dose, development of severe ischemia, or intolerable side effects. At peak stress, 20 mCi of MIBI was injected, and SPECT imaging was performed 2 hours later, abnormal poststress images were compared with resting SPECT. Digitized 2DE images were compared qualitatively before, during, and after stress in a cine-loop display. Significant coronary disease (n=59 patients) was defined by the quantification of >50% stenosis in a major epicardial vessel. The sensitivity of adenosine 2DE was 58%, less than those of adenosine MIBI (86%, p=0.001), dobutamine 2DE (85%, p=0.001), and dobutamine MIBI (80%, p=0.01). Their respective specificities were 87%, 71%, 82%, and 74% (p=NS). The accuracy of adenosine 2DE was 69%, compared with 80% for adenosine MIBI (p<0.001), 84% for dobutamine 2DE (p=0.001), and 77% for dobutamine MIBI (p=0.005); the latter three did not differ significantly in either sensitivity or accuracy. Conclusions. This prospective, direct comparison of alternative pharmacological stresses in patients without myocardial infarction shows vasodilator stress scintigraphy and dobutamine stress echocardiography and scintigraphy to share equivalent levels of sensitivity. All three are significantly more sensitive than adenosine stress echocardiography. Dobutamine stress may be used for wall motion or perfusion imaging, but adenosine stress is best combined with perfusion scintigraphy