Dobutamine-atropine stress echocardiography for the detection of coronary artery disease in patients with left ventricular hypertrophy - Importance of chamber size and systolic wall stress

Background-Left ventricular hypertrophy is st heterogeneous disorder with d istinct morphologies. Changes in wall thickness, left ventricular chamber d iameter, and mass alter systolic wall stress of the left ventricle and may influence ischemic threshold. Thus, the goal of this study was to investiga te the effect of the different patterns of left ventricular hypertrophy on the accuracy of dobutamine-atropine stress echocarcliography. Methods and Results-Three-hundred eighty-six patients underwent multistage dobutomine-atropine stress echocardiography and diagnostic angiography. Ech ocardiograms were measured for mean and relative wall thicknesses, chamber size, left ventricular mass, and end-systolic wall stress. The patterns of ventricular hypertrophy were concentric hypertrophy (increased wall thickne ss and mass), eccentric hypertrophy (normal walt thickness and increased ma ss), and concentric remodeling (increased wall thickness and normal mass). The overall sensitivity, specificity, and accuracy of dobutamine-atropine s tress echocardiography for the detection of coronary artery disease were 85 %, 87%, and 86%, respectively. Increased left ventricular mass index alone did not affect accuracy. Sensitivity was markedly reduced (36%) only in tho se with concentric remodeling. The univariate predictors of false-negative studies were single-vessel left circumflex disease, increased wall thicknes s, small chamber size, hyperdynamic ejection fraction, and left ventricular concentric remodeling. Multivariate predictors were concentric remodeling (P<0.0001; odds ratio, 13.5), left ventricular ejection fraction >2 SD abov e normal (P<0.001), and single-vessel left circumflex disease (P<0.0007; od ds ratio, 7.6). Sensitivity was excellent in patients with small ventricles and normal wall thickness and in those with normal: or large chambers rega rdless of wall thickness. Conclusions-Dobutamine-atropine stress echocardiography is an accurate test in most patients with left ventricular hypertrophy, but it is insensitive in the small subset with concentric remodeling.