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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

Helene von Bibra, MD^a, Anja Tuchnitz, MD^*, Annegret Klein, MD^*, Jan Schneider-Eicke, MD, Albert Schömig, MD^* and Markus Schwaiger, MD

^a Department of Clinical Physiology, Karolinska Hospital, Stockholm, Sweden
^* Medizinische Klinik, Technische Universität, Munich, Germany
Nuklearmedizinische Klinik, Technische Universität, Munich, Germany

View larger version (105K): [in a new window]   Figure 1 Top: Representative pulsed Doppler myocardial recordings of the basal inferior wall in a control subject at rest (left) and during peak dobutamine stress (right) with stress induced increase of both systolic and diastolic peak velocities. Heart rate increased from 91 to 149 beats/min. Middle: Same setting of pulsed Doppler myocardial recordings of the basal anterior septum in a patient with 50% stenosis of the left anterior descending coronary artery with a stress induced decrease of early diastolic peak velocity from –9 to –5 cm/s. Bottom: Same setting of pulsed Doppler myocardial recordings of the basal inferior wall in a patient with 75% stenosis of the right coronary artery with a stress induced decrease of peak velocity during early diastolic filling from –9 to –6 cm/s.

View larger version (20K): [in a new window]   Figure 2 Myocardial velocities at rest and peak dobutamine stress in the control group. The box plots display the 50th (H), 25th and 75th (), 10th and 90th (—) percentiles and circles for the <10th and >90th percentiles of the variable. There is a highly significant (***p < 0.001) increase for each of the measured peak velocities whereas the ratio of early to late diastolic velocities remained unchanged. VPRE = peak velocity during preejection period; VC = peak contraction velocity during left ventricular ejection; VE = peak velocity during early diastolic filling; VA = peak velocity during atrial contraction; VE/VA = ratio of early to late diastolic velocities.

View larger version (22K): [in a new window]   Figure 3 Box plot of the percentiles (same setting and abbreviations as Fig. 3) of stress induced changes of myocardial velocities for the comparison of control segments with ischemic and scar segments. Individual data demonstrate least overlap for the ischemic versus the control data in VE. Ischemic VE is also significantly lower than VE in scar segments (p < 0.01). **p < 0.01 and ***p < 0.001 for the comparison with control segments; ##p < 0.01 for the comparison with ischemic segments.

View larger version (25K): [in a new window]   Figure 4 Top: Receiver operating curve (A) for the optimal level of VE reduction demonstrating clearly that a 2 cm/s decrease has the best level of discrimination. Receiver operating curve (B) for the diagnostic accuracy of stress induced VE reduction in relation to incremental angiographic luminal narrowing. Optimal discrimination is at 50% stenosis. Bottom (C): Receiver operating curve comparing the three noninvasive imaging modalities during stress tests each with reference to incremental angiographic luminal narrowing. Pulsed Doppler myocardial mapping has the highest discriminatory power with 0.90 area under the curve (12) as compared with 0.77 in two-dimensional echocardiography and 0.81 in SPECT. A 50% angiographic stenosis yields the optimal discriminatory power for PMD and stress echocardiography and a 75% luminal narrowing for SPECT. Doppler = PMD; PMD = pulsed Doppler myocardial mapping; SPECT = perfusion scintigraphy; 2D Echo = two-dimensional echocardiography.