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Feasibility and diagnostic power of transthoracic coronary Doppler for coronary flow velocity reserve in patients referred for myocardial perfusion imaging
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
1Department of Clinical Physiology, Ryhov County Hospital, SE-551 85 Jönköping, Sweden.
2008 (English)In: Cardiovascular Ultrasound, ISSN 1476-7120, E-ISSN 1476-7120, Vol. 6, no 12Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Myocardial perfusion imaging (MPI), using single photon emission computed tomography (SPECT) is a validated method for detecting coronary artery disease. Transthoracic Doppler echocardiography (TTDE) of flow at rest and during adenosine provocation has previously been evaluated in selected patient groups. We therefore wanted to compare the diagnostic ability of TTDE in the left anterior descending coronary artery (LAD) to that of MPI in an unselected population of patients with chest pain referred for MPI. Our hypothesis was that TTDE with high accuracy would identify healthy individuals and exclude them from the need for further studies, enabling invasive investigations to be reserved for patients with a high probability of disease.

METHODS: Sixty-nine patients, 44 men and 25 women, age 61 +/- 10 years (range 35-82), with a clinical suspicion of stress induced myocardial ischemia, were investigated. TTDE was performed at rest and during adenosine stress for myocardial scintigraphy.

RESULTS: We found that coronary flow velocity reserve (CFVR) determined from diastolic measurements separated normal from abnormal MPI findings with statistical significance. TTDE identified coronary artery disease, defined from MPI, as reversible ischemia and/or permanent defect, with a sensitivity of 60% and a specificity of 79%. The positive predictive value was 43% and the negative predictive value was 88%. There was an overlap between groups which could be due to abnormal endothelial function in patients with normal myocardial perfusion having either hypertension or diabetes.

CONCLUSION: TTDE is an attractive non-invasive method to evaluate chest pain without the use of isotopes, but the diagnostic power is strongly dependent on the population investigated. Even in our heterogeneous clinical cardiac population, we found that CFVR>2 in the LAD excluded significant coronary artery disease detected by MPI.

Place, publisher, year, edition, pages
2008. Vol. 6, no 12
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-18311DOI: 10.1186/1476-7120-6-12PubMedID: 18373873OAI: oai:DiVA.org:liu-18311DiVA: diva2:217944
Available from: 2009-05-18 Created: 2009-05-18 Last updated: 2017-12-13Bibliographically approved
In thesis
1. Noninvasive Evaluation of Myocardial Ischemia and Left Ventricular Function
Open this publication in new window or tab >>Noninvasive Evaluation of Myocardial Ischemia and Left Ventricular Function
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general aim of this thesis was, following the path of the ischemic cascade, to evaluate the feasibility of some new non-invasive techniques for the detection of myocardial ischemia, the extent of infarcted myocardium, and for the quantification of systolic left ventricular function.

Reduced longitudinal myocardial velocity and displacement may be early signs of ischemia. We evaluated the diagnostic sensitivity and specificity of pulsed tissue Doppler for the detection of ischemia and scar during dobutamine stress testing and compared it with myocardial perfusion scintigraphy (SPECT) in patients with a history of unstable angina. Pulsed tissue Doppler was useful for objective quantification of left ventricular longitudinal shortening and for differentiation between patients with a normal, ischemic or necrotic myocardium.

The coronary flow velocity reserve (CFVR) of the left anterior descending artery (LAD) was studied with transthoracic Doppler echocardiography (TTDE) during adenosine stress. Patients with a clinical suspicion of stress induced myocardial ischemia were investigated, and the results were compared with the findings from SPECT. A CFVR >2 in the LAD could exclude significant coronary artery disease in a clinical setting, however, in cases with low CFVR, multiple cardiovascular and metabolic risk factors as well as epicardial coronary artery disease or microvascular dysfunction might be responsible. TTDE is a promising tool, e.g. for follow-up after coronary interventions or for evaluating endothelial function over time.

A third study focused on the importance of accurate and reproducible measurements of left ventricular volumes and ejection fraction (LVEF). Patients with known or suspected coronary artery disease with different levels of LVEF were enrolled. We compared the LVEF determined with an automatic echocardiographic method with manual planimetry, visual assessment of LVEF and with quantitative myocardial gated SPECT. The software using learned pattern recognition and artificial intelligence (AutoEF) applied on biplane apical echocardiographic views reduced the variation in measurements without increasing the time required. The method seems to be able to reduce variation in the assessment of LVEF in clinical patients, especially for less experienced readers.

We evaluated a new feature tracking software for its ability to detect infarcted myocardium on cine-MR images. Patients were selected based on the presence or absence of myocardial scar in the perfusion area of the LAD. The software tracked myocardial wall motion and allowed the calculation of velocity, displacement and strain in radial and longitudinal directions. Feature tracking of cine-MR images detected scar segments with transmurality >50% within the distribution of the LAD with 80% sensitivity and 86% specificity (radial strain), without the need for the administration of gadolinium-based contrast.

In summary, we have evaluated some of the noninvasive techniques in the wide array of diagnostic tools available for the diagnosis of ischemic heart disease. Their availability, low costs, freedom from radiation and repeatability are essential as well as their diagnostic ability.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2009. 74 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1109
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-18315 (URN)978-91-7393-675-0 (ISBN)
Public defence
2009-05-27, Aulan, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-05-18 Created: 2009-05-18 Last updated: 2009-08-21Bibliographically approved

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Maret, EvaEngvall, JanNylander, Eva

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