Stress echocardiography and the human factor: the importance of being expert

C.N.R. Clinical Physiology Institute, University of Pisa, Italy.

The aim of this study was to evaluate how the diagnostic accuracy of a stress echocardiographic procedure, such as a dipyridamole echocardiography test, depends on the specific experience of the physician interpreting the test. Recordings of 50 consecutive dipyridamole echocardiographic tests were selected for the first part of the study. They were analyzed by 20 experienced echocardiographers with different backgrounds in stress echocardiography: 10 beginners (less than 20 stress studies interpreted with trained staff) and 10 experienced observers (greater than or equal to 100 stress studies performed). Diagnostic accuracy (true positive + true negative/total number of tests) versus the angiographic reference standard (greater than 70% coronary stenosis of at least one major coronary artery) was 62 +/- 6% for beginners and 85 +/- 3% for experienced observers (p less than 0.0001). In the second part of the study, 10 observers (5 beginners and 5 experienced observers) evaluated 2 different sets of 50 dipyridamole echocardiographic test studies before and after the training of the beginners. Before training, the accuracy of beginners was lower than that of experienced observers (61 +/- 7% versus 85 +/- 3%; p less than 0.001). After training, the accuracy gap was closed (83 +/- 3% versus 86 +/- 2%; p = NS). Therefore, interpretation of stress echocardiographic tests by an echocardiographer without specific training severely underestimates the diagnostic potential of this technique. One hundred stress echocardiographic studies are more than adequate to build the individual learning curve and reach the plateau of diagnostic accuracy that the test can yield.

This article has been cited by other articles:

				C. Li, J. Zhang, X. Li, C. Zhou, H. Li, H. Tang, and L. Rao Quantification of chronic aortic regurgitation by vector flow mapping: a novel echocardiographic method Eur J Echocardiogr, November 21, 2009; (2009) jep175v1. [Abstract] [Full Text] [PDF]

				T. H. Marwick The future of echocardiography Eur J Echocardiogr, July 1, 2009; 10(5): 594 - 601. [Abstract] [Full Text] [PDF]

				Q. Ciampi, L. Pratali, R. Citro, M. Piacenti, B. Villari, and E. Picano Identification of responders to cardiac resynchronization therapy by contractile reserve during stress echocardiography Eur J Heart Fail, May 1, 2009; 11(5): 489 - 496. [Abstract] [Full Text] [PDF]

				K. J. Nichols, A. Van Tosh, Y. Wang, C. J. Palestro, and N. Reichek Validation of Gated Blood-Pool SPECT Regional Left Ventricular Function Measurements J. Nucl. Med., January 1, 2009; 50(1): 53 - 60. [Abstract] [Full Text] [PDF]

				C. W. McIntyre, S. G. John, and H. J. Jefferies Advances in the cardiovascular assessment of patients with chronic kidney disease NDT Plus, December 1, 2008; 1(6): 383 - 391. [Abstract] [Full Text] [PDF]

				J. Thambyrajah, K. Vijayalakshmi, R.J. Graham, A.J. Turley, M.A. de Belder, and M.J. Stewart Strain rate imaging pre- and post-percutaneous coronary intervention: a potential role in the objective detection of ischaemia in exercise stress echocardiography Eur J Echocardiogr, September 1, 2008; 9(5): 646 - 654. [Abstract] [Full Text] [PDF]

				R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC) Eur J Echocardiogr, July 1, 2008; 9(4): 415 - 437. [Abstract] [Full Text] [PDF]

				C. Jenkins, M. Monaghan, G. Shirali, R. Guraraja, and T. H. Marwick An intensive interactive course for 3D echocardiography: is 'crop till you drop' an effective learning strategy? Eur J Echocardiogr, May 1, 2008; 9(3): 373 - 380. [Abstract] [Full Text] [PDF]

				S. Y. Hayashi, A. Seeberger, B. Lind, S. Gunnes, A. Alvestrand, M. M. d. Nascimento, B. Lindholm, and L.-A. Brodin Acute effects of low and high intravenous doses of furosemide on myocardial function in anuric haemodialysis patients: a tissue Doppler study Nephrol. Dial. Transplant., April 1, 2008; 23(4): 1355 - 1361. [Abstract] [Full Text] [PDF]

				T. Ryan, W. F. Armstrong, and B. K. Khandheria Task Force 4: Training in Echocardiography: Endorsed by the American Society of Echocardiography J. Am. Coll. Cardiol., January 22, 2008; 51(3): 361 - 367. [Full Text] [PDF]

				P. Reant, L. Labrousse, S. Lafitte, P. Bordachar, X. Pillois, L. Tariosse, S. Bonoron-Adele, P. Padois, C. Deville, R. Roudaut, et al. Experimental Validation of Circumferential, Longitudinal, and Radial 2-Dimensional Strain During Dobutamine Stress Echocardiography in Ischemic Conditions J. Am. Coll. Cardiol., January 15, 2008; 51(2): 149 - 157. [Abstract] [Full Text] [PDF]

				F. Rigo, R. Sicari, S. Gherardi, A. Djordjevic-Dikic, L. Cortigiani, and E. Picano The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stress echo Eur. Heart J., January 1, 2008; 29(1): 79 - 88. [Abstract] [Full Text] [PDF]

				A. Zagatina, N. Zhuravskaya, and A. Kotelnikova Application of tissue Doppler to interpretation of exercise echocardiography: Diagnostics of ischemia localization in patients with ischemic heart disease Eur J Echocardiogr, December 1, 2007; 8(6): 463 - 469. [Abstract] [Full Text] [PDF]

				B. Bijnens, P. Claus, F. Weidemann, J. Strotmann, and G. R. Sutherland Investigating Cardiac Function Using Motion and Deformation Analysis in the Setting of Coronary Artery Disease Circulation, November 20, 2007; 116(21): 2453 - 2464. [Full Text] [PDF]

				C. Bjork Ingul, A. Stoylen, S. A. Slordahl, R. Wiseth, M. Burgess, and T. H. Marwick Automated analysis of myocardial deformation at dobutamine stress echocardiography: an angiographic validation. J. Am. Coll. Cardiol., April 17, 2007; 49(15): 1651 - 1659. [Abstract] [Full Text] [PDF]

				C. B. Ingul, E. Rozis, S. A. Slordahl, and T. H. Marwick Incremental Value of Strain Rate Imaging to Wall Motion Analysis for Prediction of Outcome in Patients Undergoing Dobutamine Stress Echocardiography Circulation, March 13, 2007; 115(10): 1252 - 1259. [Abstract] [Full Text] [PDF]

				V. Mor-Avi, L. Sugeng, R. J. Weiss, E. Toledo, L. Weinert, T. Bouchard, K. T. Spencer, and R. M. Lang Computerized evaluation of echocardiographic stress tests in patients with poorly visualized endocardium using analysis of color-encoded contrast-enhanced images Eur J Echocardiogr, March 1, 2006; 7(2): 122 - 133. [Abstract] [Full Text] [PDF]

				L. Hanekom, C. Jenkins, L. Jeffries, C. Case, J. Mundy, C. Hawley, and T. H. Marwick Incremental Value of Strain Rate Analysis as an Adjunct to Wall-Motion Scoring for Assessment of Myocardial Viability by Dobutamine Echocardiography: A Follow-Up Study After Revascularization Circulation, December 20, 2005; 112(25): 3892 - 3900. [Abstract] [Full Text] [PDF]

				S. Langeland, J. D'hooge, P. F. Wouters, H. A. Leather, P. Claus, B. Bijnens, and G. R. Sutherland Experimental Validation of a New Ultrasound Method for the Simultaneous Assessment of Radial and Longitudinal Myocardial Deformation Independent of Insonation Angle Circulation, October 4, 2005; 112(14): 2157 - 2162. [Abstract] [Full Text] [PDF]

				R. Sicari, A. Palinkas, E. G. Pasanisi, L. Venneri, and E. Picano Long-term survival of patients with chest pain syndrome and angiographically normal or near-normal coronary arteries: the additional prognostic value of dipyridamole echocardiography test (DET) Eur. Heart J., October 2, 2005; 26(20): 2136 - 2141. [Abstract] [Full Text] [PDF]

				T. Bombardini, M. Agrusta, N. Natsvlishvili, F. Solimene, R. Pap, F. Coltorti, A. Varga, G. Mottola, and E. Picano Noninvasive assessment of left ventricular contractility by pacemaker stress echocardiography Eur J Heart Fail, March 2, 2005; 7(2): 173 - 181. [Abstract] [Full Text] [PDF]

				R. Sharma and S. J Brecker Dobutamine stress echocardiography in diabetes The British Journal of Diabetes & Vascular Disease, January 1, 2005; 5(1): 42 - 46. [Abstract] [PDF]

				C. Storaa, P. Cain, B. Olstad, B. Lind, and L.-A. Brodin Tissue motion imaging of the left ventricle--quantification of myocardial strain, velocity, acceleration and displacement in a single image Eur J Echocardiogr, October 1, 2004; 5(5): 375 - 385. [Abstract] [Full Text] [PDF]

				J.-U. Voigt, U. Nixdorff, R. Bogdan, B. Exner, K. Schmiedehausen, G. Platsch, T. Kuwert, W. G. Daniel, and F. A. Flachskampf Comparison of deformation imaging and velocity imaging for detecting regional inducible ischaemia during dobutamine stress echocardiography Eur. Heart J., September 1, 2004; 25(17): 1517 - 1525. [Abstract] [Full Text] [PDF]

				H. S. Maniar, B. P. Cupps, D. D. Potter, P. Moustakidis, C. J. Camillo, C. M. Chu, M. K. Pasque, and T. M. Sundt III Ventricular function after coronary artery bypass grafting: Evaluation by magnetic resonance imaging and myocardial strain analysis J. Thorac. Cardiovasc. Surg., July 1, 2004; 128(1): 76 - 82. [Abstract] [Full Text] [PDF]

				S. Y. Hayashi, L.-A. Brodin, A. Alvestrand, B. Lind, P. Stenvinkel, M. Mazza do Nascimento, A. R. Qureshi, S. Saha, B. Lindholm, and A. Seeberger Improvement of cardiac function after haemodialysis. Quantitative evaluation by colour tissue velocity imaging Nephrol. Dial. Transplant., June 1, 2004; 19(6): 1497 - 1506. [Abstract] [Full Text] [PDF]

				D.V Anand, I.D Theodosiadis, and R Senior Improved interpretation of dobutamine stress echocardiography following 4 months of systematic training in patients following acute myocardial infarction Eur J Echocardiogr, January 1, 2004; 5(1): 12 - 17. [Abstract] [Full Text] [PDF]

				E. Castillo, J. A. C. Lima, and D. A. Bluemke Regional Myocardial Function: Advances in MR Imaging and Analysis RadioGraphics, October 1, 2003; 23(90001): S127 - 140. [Abstract] [Full Text] [PDF]

				C.F Madler, N Payne, U Wilkenshoff, A Cohen, G.A Derumeaux, L.A Pierard, J Engvall, L-A Brodin, G.R Sutherland, A.G Fraser, et al. Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study Eur. Heart J., September 1, 2003; 24(17): 1584 - 1594. [Abstract] [Full Text] [PDF]

				M. V. Podgoreanu, G. N. Djaiani, E. Davis, B. Phillips-Bute, and J. P. Mathew Quantitative Echocardiographic Assessment of Regional Wall Motion and Left Ventricular Asynchrony with Color Kinesis in Cardiac Surgery Patients Anesth. Analg., May 1, 2003; 96(5): 1294 - 1300. [Abstract] [Full Text] [PDF]

				J.-U. Voigt, B. Exner, K. Schmiedehausen, C. Huchzermeyer, U. Reulbach, U. Nixdorff, G. Platsch, T. Kuwert, W. G. Daniel, and F. A. Flachskampf Strain-Rate Imaging During Dobutamine Stress Echocardiography Provides Objective Evidence of Inducible Ischemia Circulation, April 29, 2003; 107(16): 2120 - 2126. [Abstract] [Full Text] [PDF]

				E. Poggianti, L. Venneri, V. Chubuchny, Z. Jambrik, L. A. Baroncini, and E. Picano Aortic valve sclerosis is associatedwith systemic endothelial dysfunction J. Am. Coll. Cardiol., January 1, 2003; 41(1): 136 - 141. [Abstract] [Full Text] [PDF]

				T. H Marwick Stress echocardiography Heart, January 1, 2003; 89(1): 113 - 118. [Full Text] [PDF]

				A. Palinkas, E. Toth, R. Amyot, F. Rigo, L. Venneri, and E. Picano The value of ECG and echocardiography during stress testing for identifying systemic endothelial dysfunction and epicardial artery stenosis Eur. Heart J., October 2, 2002; 23(20): 1587 - 1595. [Abstract] [Full Text] [PDF]

				T. Edvardsen, B. L. Gerber, J. Garot, D. A. Bluemke, J. A.C. Lima, and O. A. Smiseth Quantitative Assessment of Intrinsic Regional Myocardial Deformation by Doppler Strain Rate Echocardiography in Humans: Validation Against Three-Dimensional Tagged Magnetic Resonance Imaging Circulation, July 2, 2002; 106(1): 50 - 56. [Abstract] [Full Text] [PDF]

				T. H. Marwick, C. Case, S. Sawada, C. Vasey, L. Short, and M. Lauer Use of Stress Echocardiography to Predict Mortality in Patients With Diabetes and Known or Suspected Coronary Artery Disease Diabetes Care, June 1, 2002; 25(6): 1042 - 1048. [Abstract] [Full Text] [PDF]

				T. H. Marwick, C. Case, S. Sawada, C. Vasey, and J. D. Thomas Prediction of Outcomes in Hypertensive Patients With Suspected Coronary Disease Hypertension, June 1, 2002; 39(6): 1113 - 1118. [Abstract] [Full Text] [PDF]

				R. Hoffmann, T.H. Marwick, D. Poldermans, H. Lethen, R. Ciani, P. van der Meer, H.-P. Tries, P. Gianfagna, P. Fioretti, J.J. Bax, et al. Refinements in stress echocardiographic techniques improve inter-institutional agreement in interpretation of dobutamine stress echocardiograms Eur. Heart J., May 2, 2002; 23(10): 821 - 829. [Abstract] [Full Text] [PDF]

				M.B Mishra, D.A Lythall, and J.B Chambers A comparison of wall motion analysis and systolic left ventricular long axis function during dobutamine stress echocardiography Eur. Heart J., April 1, 2002; 23(7): 579 - 585. [Abstract] [Full Text] [PDF]

				M. del Mar de la Torre, J. A. San Roman, J. Bermejo, G. Pastor, J. Alonso, and F. Fernandez-Aviles Prognostic Power of Dobutamine Echocardiography After Uncomplicated Acute Myocardial Infarction in the Elderly Chest, October 1, 2001; 120(4): 1200 - 1205. [Abstract] [Full Text] [PDF]

				V. Mor-Avi, E. G. Caiani, K. A. Collins, C. E. Korcarz, J. E. Bednarz, and R. M. Lang Combined Assessment of Myocardial Perfusion and Regional Left Ventricular Function by Analysis of Contrast-Enhanced Power Modulation Images Circulation, July 17, 2001; 104(3): 352 - 357. [Abstract] [Full Text] [PDF]

				V. Mor-Avi, K. A. Collins, C. E. Korcarz, M. Shah, K. T. Spencer, and R. M. Lang Detection of regional temporal abnormalities in left ventricular function during acute myocardial ischemia Am J Physiol Heart Circ Physiol, April 1, 2001; 280(4): H1770 - H1781. [Abstract] [Full Text] [PDF]

				C Dodi, L Cortigiani, M Masini, I Olivotto, A Azzarelli, and E Nannini The incremental prognostic value of pharmacological stress echo over exercise electrocardiography in women with chest pain of unknown origin Eur. Heart J., January 2, 2001; 22(2): 145 - 152. [Abstract] [PDF]

				J.e. Garot, D. A. Bluemke, N. F. Osman, C. E. Rochitte, E. A. Zerhouni, J. L. Prince, and J. A. C. Lima Transmural contractile reserve after reperfused myocardial infarction in dogs J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2339 - 2346. [Abstract] [Full Text] [PDF]

				H. von Bibra, A. Tuchnitz, A. Klein, J. Schneider-Eicke, A. Schomig, and M. Schwaiger Regional diastolic function by pulsed doppler myocardial mapping for the detection of left ventricular ischemia during pharmacologic stress testing: A comparison with stress echocardiography and perfusion scintigraphy J. Am. Coll. Cardiol., August 1, 2000; 36(2): 444 - 452. [Abstract] [Full Text] [PDF]

				L. Hatle and G. R. Sutherland Regional myocardial function--a new approach. Eur. Heart J., August 1, 2000; 21(16): 1337 - 1357. [PDF]

				J. Garot, D. A. Bluemke, N. F. Osman, C. E. Rochitte, E. R. McVeigh, E. A. Zerhouni, J. L. Prince, and J. A. C. Lima Fast Determination of Regional Myocardial Strain Fields From Tagged Cardiac Images Using Harmonic Phase MRI Circulation, March 7, 2000; 101(9): 981 - 988. [Abstract] [Full Text] [PDF]

				A Franke, R Hoffmann, H P Kühl, W Lepper, O A Breithardt, M Schormann, and P Hanrath Non-contrast second harmonic imaging improves interobserver agreement and accuracy of dobutamine stress echocardiography in patients with impaired image quality Heart, February 1, 2000; 83(2): 133 - 140. [Abstract] [Full Text]

				S. Tommasi, E. Carluccio, M. Bentivoglio, L. Corea, and E. Picano Low-dose dipyridamole infusion acutely increases exercise capacity in angina pectoris: A double-blind, placebo controlled crossover stress echocardiographic study J. Am. Coll. Cardiol., January 1, 2000; 35(1): 83 - 88. [Abstract] [Full Text] [PDF]

				R. Koch, R. M. Lang, M.-J. Garcia, L. Weinert, J. Bednarz, C. Korcarz, B. Coughlan, A. Spiegel, E. Kaji, K. T. Spencer, et al. Objective evaluation of regional left ventricular wall motion during dobutamine stress echocardiographic studies using segmental analysis of color kinesis images J. Am. Coll. Cardiol., August 1, 1999; 34(2): 409 - 419. [Abstract] [Full Text] [PDF]

				J. Garot, G.A. Derumeaux, J.L. Monin, A.M. Duval-Moulin, M. Simon, D. Pascal, A. Castaigne, J.L. Dubois-Rande, B. Diebold, and P. Gueret Quantitative systolic and diastolic transmyocardial velocity gradients assessed by M-mode colour Doppler tissue imaging as reliable indicators of regional left ventricular function after acute myocardial infarction Eur. Heart J., April 2, 1999; 20(8): 593 - 603. [Abstract] [PDF]

				J A S. Román, I Vilacosta, J A Castillo, M J Rollán, M Hernández, V Peral, I Garcimartín, M d. M. de la Torre, and F Fernández-Avilés Selection of the optimal stress test for the diagnosis of coronary artery disease Heart, October 1, 1998; 80(4): 370 - 376. [Abstract] [Full Text]

				R. L. Larsen, P. M. Applegate, D. A. Dyar, P. A. Ribeiro, S. D. Fritzsche, N. F. Mulla, G. S. Shirali, M. A. Kuhn, R. E. Chinnock, and P. M. Shah Dobutamine stress echocardiography for assessing coronary artery disease after transplantation in children J. Am. Coll. Cardiol., August 1, 1998; 32(2): 515 - 520. [Abstract] [Full Text] [PDF]

				G. Geskin, C. M. Kramer, W. J. Rogers, T. M. Theobald, D. Pakstis, Y.-L. Hu, and N. Reichek Quantitative Assessment of Myocardial Viability After Infarction by Dobutamine Magnetic Resonance Tagging Circulation, July 21, 1998; 98(3): 217 - 223. [Abstract] [Full Text] [PDF]

				G. Derumeaux, M. Ovize, J. Loufoua, X. Andre-Fouet, Y. Minaire, A. Cribier, and B. Letac Doppler Tissue Imaging Quantitates Regional Wall Motion During Myocardial Ischemia and Reperfusion Circulation, May 19, 1998; 97(19): 1970 - 1977. [Abstract] [Full Text] [PDF]

				S. Maffei, M. Baroni, M. Terrazzi, F. Paoli, P. Ferrazzi, and A. Biagini Preoperative Assessment of Coronary Artery Disease in Aortic Stenosis: A Dipyridamole Echocardiographic Study Ann. Thorac. Surg., February 1, 1998; 65(2): 397 - 402. [Abstract] [Full Text] [PDF]

				L. Bolognese, G. Cerisano, P. Buonamici, A. Santini, G. M. Santoro, D. Antoniucci, and P. F. Fazzini Influence of Infarct-Zone Viability on Left Ventricular Remodeling After Acute Myocardial Infarction Circulation, November 18, 1997; 96(10): 3353 - 3359. [Abstract] [Full Text]

				S. C. Smart, T. Knickelbine, T. R. Stoiber, M. Carlos, J. C. Wynsen, and K. B. Sagar Safety and Accuracy of Dobutamine-Atropine Stress Echocardiography for the Detection of Residual Stenosis of the Infarct-Related Artery and Multivessel Disease During the First Week After Acute Myocardial Infarction Circulation, March 18, 1997; 95(6): 1394 - 1401. [Abstract] [Full Text]

				R. M. Lang, P. Vignon, L. Weinert, J. Bednarz, C. Korcarz, J. Sandelski RDMS, R. Koch, D. Prater, and V. Mor-Avi Echocardiographic Quantification of Regional Left Ventricular Wall Motion With Color Kinesis Circulation, May 15, 1996; 93(10): 1877 - 1885. [Abstract] [Full Text]

				S. Carstensen, S. M. Ali, F. V. Stensgaard-Hansen, J. Toft, S. Haunso, H. Kelbęk, and K. Saunamaki Dobutamine-Atropine Stress Echocardiography in Asymptomatic Healthy Individuals : The Relativity of Stress-Induced Hyperkinesia Circulation, December 15, 1995; 92(12): 3453 - 3463. [Abstract] [Full Text]

				C. Lu, E. Picano, A. Pingitore, R. Sicari, R. Tongiani, M. Baratto, C. Palmieri, M. Marzilli, and A. L'Abbate Complex Coronary Artery Lesion Morphology Influences Results of Stress Echocardiography Circulation, March 15, 1995; 91(6): 1669 - 1675. [Abstract] [Full Text]

				R. L. Popp `High Time' for Noninvasive Assessment of Regional Ventricular Diastolic Ischemic Dysfunction Circulation, January 15, 1995; 91(2): 552 - 554. [Full Text]

				T. W. Martin, J. F. Seaworth, J. P. Johns, L. E. Pupa, and W. R. Condos Comparison of Adenosine, Dipyridamole, and Dobutamine in Stress Echocardiography Ann Intern Med, February 1, 1992; 116(3): 190 - 196. [Abstract] [PDF]