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 DiseaseThe OPTIMIZE Trial
Juan Carlos Plana, MD, FACC,
Issam A. Mikati, MD, FACC,
Hisham Dokainish, MD, FACC,
Nasser Lakkis, MD, FACC,
John Abukhalil, RT(R),
Robert Davis, RDCS,
Brian C. Hetzell, MS,
William A. Zoghbi, MD, FACC*
Methodist DeBakey Heart Center, Department of Cardiology and Baylor College of Medicine, Houston, Texas.
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Figure 1 Impact of Contrast Agent Use on Visualization of Segments and Confidence of Interpretation
With the use of a contrast agent, an increase in percentage of segments with excellent or adequate endocardial visualization (score 1) is seen. Furthermore, the distribution of the degree of confidence of interpretation was different, with a much larger percentage of studies interpreted with high confidence when the contrast agent was added.
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Figure 2 Visualization of Segments by View at Peak Stress: Contrast Agent Versus Noncontrast Enhancement
With the use of a contrast agent, an increase in percentage of segments with excellent or adequate endocardial visualization (score 1) was seen in all echocardiographic views, with a larger impact in the apical views. PLA = parasternal long axis; SAX = short axis; 4C and 2C = 4 and 2 chambers.
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Figure 3 Example of the Effect of Contrast Agent Use on DSE in a Patient With Suboptimal Endocardial Visualization
Quad-screens of end-systolic frames from the 4-chamber view of noncontrast dobutamine stress echocardiographic images (left) (Online Video 1) and contrast-enhanced images (right) (Online Video 2) are shown. Noncontrast images had significant endocardial dropout and identified an apical fixed wall motion abnormality. Contrast agent enhancement clearly delineated the endocardial segments and allowed the identification of ischemia in the lateral wall and apex (arrows) as well as dilation of the ventricle at end-systole at maximal stress. DSE = dobutamine stress echocardiography.
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Figure 4 Example of the Effect of Contrast Agent Use on DSE in a Patient With Excellent Endocardial Visualization
Quad-screens of end-systolic frames of noncontrast (Online Video 3) and contrast-enhanced (Online Video 4) dobutamine stress echocardiographic (DSE) images from the short axis. Noncontrast images are of excellent quality. Contrast agent administration decreased the image quality and endocardial border definition in certain regions. Still, ischemia was observed in the inferoposterior wall (arrows) in both DSE studies.
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Figure 5 Impact of Contrast Agent Use on Accuracy of DSE in Relation to Confidence of Interpretation in Unenhanced DSE Studies
There was no impact of contrast agent use on the agreement of dobutamine stress echocardiography (DSE) with angiography (accuracy) if the confidence of interpretation was high in unenhanced studies. However, a significant impact was seen when the confidence of interpretation was low, with an intermediate effect in studies with medium confidence.
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Figure 6 Effect of Contrast Agent Use on the Sensitivity and Specificity of DSE
The effect of contrast agent use on the sensitivity and specificity of dobutamine stress echocardiography (DSE) for coronary artery disease is shown, grouped by confidence of interpretation in unenhanced studies. Only interpretable studies are included in the analysis. A trend was seen mostly for improvement in specificity in low- to medium-confidence studies and a lesser improvement in sensitivity, and a trend for worsening in specificity was observed in unenhanced studies interpreted with high confidence.
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Figure 7 Effect of Contrast Agent Use on Accuracy of DSE in Relation to the Number of Segments Visualized
A significant impact of the use of a contrast agent on accuracy of dobutamine stress echocardiography (DSE) was seen when >2 myocardial segments were not visualized in unenhanced studies. Lesser impact was seen when 1 to 2 segments were not seen, and no impact was observed if all segments were already visualized.
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