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CLINICAL STUDIES

Comparison of stress/rest myocardial perfusion tomography, dipyridamole and dobutamine stress echocardiography for the detection of coronary disease in hypertensive patients with chest pain and positive exercise test

^a Divisione di Cardiologia, Istituto Scientifico H San Raffaele, Milan, Italy

Manuscript received October 26, 1998; revised manuscript received March 6, 1999, accepted April 30, 1999.

Reprint requests and correspondence: Dr. Gabriele Fragasso, Istituto Scientifico H San Raffaele, Divisione di Cardiologia, Via Olgettina, 60, 20132 Milan, Italy
fragasso.gabriele{at}hsr.it

OBJECTIVES

Although different noninvasive tests have been proposed for detecting coronary artery disease (CAD) in patients with hypertension and chest pain symptoms, the relative performance of the available techniques has not been systematically assessed.

BACKGROUND

Patients with hypertension frequently complain of chest pain and exhibit ischemic-like ST segment changes on the exercise electrocardiogram (ECG). However, the specificity of such changes for predicting significant CAD is very low, because these patients often exhibit a normal coronary angiogram.

METHODS

In 101 patients with hypertension, chest pain and positive exercise ECG, we performed stress/rest myocardial single photon emission computed tomography with 99mTc-MIBI, dipyridamole and dobutamine stress echocardiography and coronary angiography. All patients had normal global ventricular function and 57 had left ventricular hypertrophy. All were kept on ACE inhibitors during the study period.

RESULTS

No patients had significant side effects during perfusion scintigraphy. Dose-limiting side effects were observed in five patients with dipyridamole and in seven patients with dobutamine. Only 56% of study patients exhibited significant CAD. Sensitivity, specificity, accuracy, positive and negative predictive values were, respectively, 98%, 36%, 71%, 67% and 94% for perfusion scintigraphy, 61%, 91%, 74%, 90% and 64% for dipyridamole and 88%, 80%, 84%, 85% and 83% for dobutamine stress echocardiography.

CONCLUSIONS

This study shows that stress echo in patients with hypertension yields a satisfactory diagnostic accuracy for identifying significant epicardial CAD. Our results indicate that dobutamine might be superior to dipyridamole. The low specificity of myocardial scintigraphy probably relates to the fact that this method traces perfusion abnormalities, not necessarily caused by epicardial CAD, possibly due to microvascular disease and not causing obvious wall motion abnormalities.

Abbreviations and Acronyms   ATP = adenosine triphosphate   CAD = coronary artery disease   ECG = electrocardiogram   LVMI = left ventricular mass index   MIBI = methoxy-isobutyl-isonitrile   RPP = rate-pressure product   SPECT = single photon emission computed tomography

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