HEAD-TO-HEAD COMPARISON OF EXERCISE STRESS-TESTING, PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY, AND PERFUSION TOMOGRAPHY AS FIRST-LINE EXAMINATION FOR CHEST PAIN IN PATIENTS WITHOUT HISTORY OF CORONARY-ARTERY DISEASE

Background. To overcome the relatively low accuracy of exercise stress testing (EST) in detecting coronary artery disease (CAD), both echoca rdiography and perfusion scintigraphy have been evaluated in conjuncti on with pharmacologic stress, but there is still uncertainty of the re lative value of these tests as possible first-line examinations for su spected CAD. This study evaluated the accuracy of EST, dipyridamole an d dobutamine stress echocardiography (DIP-ECHO, DOE-ECHO), and dipyrid amole and dobutamine technetium 99m sestamibi tomography (DIP-MIBI, DO B-MIBI) for the detection of CAD in patients evaluated for the first t ime because of chest pain. Methods and results. Sixty patients underwe nt EST, DIP-ECHO, DOE-ECHO, DIP-MIBI, and DOB-MIBI. Echocardiographic images mere acquired simultaneously with sestamibi injections, and the scintigraphic images were collected 1 hour later. Coronary angiograph y was performed within 15 days. Out of 33 patients with significant (> 70%) coronary stenoses, 19 (58%) were correctly identified by EST, 18 (55%) by DIP-ECHO, 20 (61%) by DOE-ECHO, 32 (97%) by DIP-MIBI, and 30 (91%) by DOB-MIBI (p < 0.005 for MIBI vs EST and ECHO). The specificit y of EST was 67% (p < 0.05 vs ECHO and MIBI), 96%, 96%, 89%, and 81%, respectively. Of the 62 stenotic coronary arteries, 20 (32%) were corr ectly identified by DIP-ECHO, 24 (39%) by DOE-ECHO, 48 (77%) by DIP-MI BI, and 45 (73%) by DOB-MIBI. The sensitivity of the imaging technique s in predicting the presence of multivessel disease was 14% and 29% fo r DIP and DOE-ECHO compared with 48% and 57% for DIP and DOB-MIBI. Con clusions. Our results confirm the limited reliability of EST in detect ing CAD and the good diagnostic value of DIP and DOE-MIBI. Conversely, the lower sensitivity and the poorer capability to recognize multives sel CAD do not support the role of either DIP or DOE-ECHO as first-lin e examination for suspected CAD.