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A Randomized Cross-Over Study for Evaluation of the Effect of Image Optimization With Contrast on the Diagnostic Accuracy of Dobutamine Echocardiography in Coronary Artery Disease

The OPTIMIZE Trial

Methodist DeBakey Heart Center, Department of Cardiology and Baylor College of Medicine, Houston, Texas.

^_* Reprint requests and correspondence: Dr. William A. Zoghbi, Director, Cardiovascular Imaging Center, 6550 Fannin Street, SM677, Houston, Texas 77030. (Email: wzoghbi{at}tmhs.org).

Objectives: The purpose of this study was to evaluate whether the addition of a contrast agent to dobutamine stress echocardiography (DSE) improves its diagnostic accuracy for coronary artery disease (CAD) and to determine the effect of image quality on the diagnostic impact of contrast agent use in this setting.

Background: Contrast agents can improve endocardial border definition. To date, however, there are no randomized trials that have evaluated the impact of contrast agent use on the accuracy of DSE.

Methods: Patients referred for stress testing with dobutamine echocardiography underwent 2 DSE studies: 1 with and 1 without a contrast agent, at least 4 h apart in a randomized order and within a 24-h period.

Results: A total of 101 patients underwent both DSE studies. Similar hemodynamics were achieved during the 2 stress testing sessions. The use of a contrast agent improved the percentage of segments adequately visualized at baseline (from 72 ± 24% to 95 ± 8%) and more so at peak stress (67 ± 28% to 96 ± 7%); both p < 0.001. Interpretation of wall motion with high confidence also increased with contrast agent use from 36% to 74% (p < 0.001). Segment visualization with the use of a contrast agent improved in all views, but was more pronounced in the apical views. In unenhanced DSE, 36% of studies were normal, 51% had ischemia, and 8% were uninterpretable—all of which became interpretable with the use of a contrast agent. When compared with angiography (n = 92; 55 patients with CAD), accurate detection of ischemia was higher with contrast-enhanced studies versus nonenhanced studies (p = 0.02). As endocardial visualization and confidence of interpretation decreased in unenhanced studies, a greater impact of the use of a contrast agent on DSE accuracy was observed (p < 0.01).

Conclusions: During dobutamine stress echocardiography, contrast agent administration improves endocardial visualization at rest and more so during stress, leading to a higher confidence of interpretation and greater accuracy in evaluating CAD. The lesser the endocardial border visualization, the higher the impact of contrast echocardiography on accuracy.

Abbreviations and Acronyms   CAD = coronary artery disease   CX = circumflex artery   DSE = dobutamine stress echocardiography   GEE = general estimating equation   LAD = left anterior descending artery   LV = left ventricle/ventricular   RCA = right coronary artery

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Echocardiography Contrast for Image Optimization: Beyond Confidence, It Is a Matter of Accuracy

Patricia A. Pellikka and Sharon L. Mulvagh
JACC Imaging 2008 1: 153-155. [Full Text]  

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