PROTOCOL Diagnosing ischemia with stress echocardiography in comparison to and combination with perfusion imaging. ISCHEMIDIAGNOSTIKK MED STRESSEKKOKARDIOGRAFI I KOMBINASJON MED SCINTIGRAFISK MYOCARDPERFUSJONS-AVBILDING BACKGROUND:
Coronary angiography is the present”Gold standard” for the diagnosis of Coronary heart disease, although it is a measure of anatomical stenoses rather than ischemic function in terms of coronary reserve. As it is also invasive, non invasive methods are important. Myocardial perfusion by SPECT scintigraphy is evaluated during peak stress by injection of a radioactive tracer. It is an established method, and has a diagnostic sensitivity for Coronary heart disease of 80 - 90%, and a specificity of ca 80% (1). Stress echocardiography with exercise- or pharmacological stress, shows regional wall motion abnormalities in the presence of local ischemia during stress. The present method for interpretation is by visual evaluation of regional myocardial wall thickening and -function in gray scale images (Wall motion score, WMS). In clinical studies stress echocardiography has shown sensitivity for coronary heart disease of 80-90 %, and specificity of approximate 90% (2,3). The method is subjective, and demands expertise (4,5,6). Tissue Doppler measures wall motion velocities, and local deformation (strain) and strain rate can be derived from this (7). By this method, regional dysfunction can be quantitated (8, 9). This has been shown to give incremental information in stress echocardiography (10, 11). The increased sensitivity may also serve to reduce he stress level necessary for diagnosis of ischemia. Speckle tracking is a newer and less well studied method, where motion can be tracked by the speckle interference pattern in B-mode images (12). By this tracking, both regional strain and strain rate can be measured. Tissue Doppler has higher temporal resolution, and is less dependent on spatial smoothing, while speckle tracking has higher spatial resolution. It is unclear, however, whether the method tracks as well in high frame rate. The temporal smoothing I may also be of concern regarding sensitivity of this method in stress echo.
- Evaluate the performance of speckle tracking during high heart rate - Evaluate diagnostic sensitivity and specificity of strain rate imaging in stress echo
- Evaluate the diagnostic performance of speckle tracking during stress echo, compared
- Compare the diagnostic sensitivity and specificity of strain rate imaging stress
echocardiography to myocardial perfusion imaging by SPECT, and assess the eventual incremental information by combining both methods.
- Coronary angiography is the external reference. Even though this is no physiological
gold standard for ischemia, it will serve as an independent external reference for the comparison of the non invasive methods.
Diagnostic study, sensitivity and specificity versus external reference.
60 – 90 patients, with stable angina / chest pain and no previous infarction, who are referred for a diagnostic coronary angiography will be examined. The stress modality will be dobutamine stress, up to 40 μg with eventual additional atropine. Echo acquisitions will be done at baseline, at 10 μg, 20 μg and peak stress. At peak stress 99Technetium tetrofosmine will be given, and perfusion images acquired afterwards. Resting stress will be acquired separately. Data are post processed, blinded to angiography results. Both stress echo and SPECT will be analysed according to the ASE 16 segments model of the left ventricle (21). Segments will be analysed by Wall motion score, peak systolic strain rate and strain, and perfusion by SPECT. Inter- and inter observer variability will also be assessed.
Diagnostic sensitivity of WMS, SRI by both tissue Doppler at 20 μg and peak stress, as well as SPECT will be evaluated against coronary angiography as external reference. In addition, the incremental value of adding methods will be assessed.
60 – 90 patients who have been referred to coronary angiography. The number is based on previous studies in stress echocardiography, where this study size has been sufficient to demonstrate incremental value of strain rate imaging in stress echocardiography. ETHICS: The study is approved by the regional ethics committee and the data supervisory body for Norway. REFERENCES
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