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European Journal of Echocardiography 2005 6(4):251-259; doi:10.1016/j.euje.2004.10.007
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Copyright © 2004, The European Society of Cardiology

Noninvasive assessment of coronary flow velocity reserve in left anterior descending artery adds diagnostic value to both clinical variables and dobutamine echocardiography: a study based on clinical practice

Rafael Florenciano-Sánchez*, Gonzalo de la Morena-Valenzuela, Manuel Villegas-García, Federico Soria-Arcos, Ramón Rubio-Patón, Francisca Teruel-Carrillo, José Hurtado and Mariano Valdés-Chávarri

Hospital Universitario Virgen de la Arrixaca, Ctra. Madrid-Cartagena, 30120 El Palmar, Murcia, Spain

Received 4 May 2004; received in revised form 4 October 2004; accepted after revision 5 October 2004.

* Corresponding author. C/Historiador Torres Fontes,18;4°E, 30011 Murcia, Spain. Tel.: +34 968264510; fax: +34 968369662. E-mail: r_florenciano@hotmail.com


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
 References
 
Aims Our objective was to evaluate, in clinical practice, whether noninvasive assessment of coronary flow velocity reserve in left anterior coronary artery adds diagnostic information to both clinical variables and wall motion abnormalities derived from dobutamine stress echocardiography.

Methods and results We studied 130 patients who were scheduled for coronary angiography after undergoing dobutamine stress echocardiography. The same day, flow in left anterior descending artery was detected by transthoracic Doppler echocardiography. A Doppler signal of left anterior descending artery was detected in 110 patients (85%). We identified significant left anterior descending artery stenosis (>50% diameter stenosis) in 42 patients. Sensitivity and specificity of abnormal coronary flow velocity reserve (<2) to detect left anterior descending artery stenosis were 86% and 57%, respectively. Wall motion abnormalities had a sensitivity and specificity of 52% and 82%. After forcing the clinical and dobutamine stress echo variables into a regression model with three modeling steps, an abnormal coronary flow velocity reserve provided incremental information in predicting significant left anterior descending artery stenosis.

Conclusion An abnormal coronary flow velocity reserve by transthoracic Doppler echocardiography adds diagnostic value to both clinical data and variables derived from dobutamine stress echo to detect significant left anterior descending artery stenosis.

Keywords: Coronary flow velocity reserve; Dobutamine stress echocardiography; Left anterior descending artery; Transthoracic Doppler echocardiography


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
 References
 
Dobutamine stress echocardiography has become an established method for the diagnosis of coronary artery disease, with both sensitivities and specificities that varied from 72% to 89%, and from 66% to 93%, respectively.1–4 However, the ability to diagnose coronary artery disease was not only lower in patients taking a beta-blocker,2 but also in patients with single-vessel disease.5 In the same way, when diagnostic capacity was assessed to detect disease in specific coronary arteries, the mean reported sensitivities and specificities in the left anterior descending artery were 72% and 88%, respectively.5 Therefore, new developments should be necessary for further improvement in diagnosis of left anterior descending artery stenosis.

Recently, new ultrasound systems have implemented high-frequency transducers that allow both to detect left anterior descending artery flow and to measure coronary flow velocity reserve noninvasively.6,7 The agreement between intracoronary and transthoracic measurements of coronary flow velocity reserve has been high.8,9 In addition, coronary flow velocity reserve by transthoracic Doppler echocardiography has been useful to identify significant stenosis in the left anterior descending artery, with sensitivities of 87%–92% and specificities of 74%–90%.6,7,10

From a theoretical point of view, the idea of adding the information derived from left anterior descending artery flow to wall motion abnormalities derived from dobutamine stress echocardiography would be attractive, so that we could improve our ability to diagnose left anterior descending artery stenosis noninvasively.

Considering that the clinical benefit of performing an investigation should be placed in the clinical context of the patient,11 the objective of the present study was to evaluate, in clinical practice, whether noninvasive assessment of coronary flow velocity reserve measured by dipyridamole stress could add diagnostic information to both clinical variables and wall motion abnormalities derived from dobutamine stress echocardiography.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conclusions
 Acknowledgments
 References
 
Study population
For the purposes of this prospective study, we studied 130 patients admitted to our hospital with suspected or known coronary artery disease, in sinus rhythm, who were scheduled for coronary angiography after undergoing dobutamine stress echocardiography. All studied patients were consecutive and unselected. Exclusion criteria were as follows: previous or acute anterior myocardial infarction or contraindication to administer dipyridamole (second- or third-degree atrioventricular block, sinus node abnormality, severe chronic obstructive pulmonary disease, or bronchospasm). Patients were refrained from consuming both long-term theophylline and xanthin-containing food and beverages during the 24h prior to transthoracic Doppler echocardiography. The anti-ischemic and antiplatelet therapies installed were that considered appropriate by the physician responsible for each individual patient. All patients gave informed and written consent. The research protocol was approved by the locally appointed ethics committee. The study was complied with the Declaration of Helsinki.

Dobutamine stress echocardiography
Dobutamine infusion started at 10µg/kg per minute and increased in 3-min stages up to 40µg/kg per minute. Additional atropine, up to 2mg, was added to achieve the target heart rate (220 minus age in years). End points for test termination were: (1) attainment of target heart rate; (2) completion of stress protocol; (3) development of obvious echocardiographic abnormalities; (4) complex arrhythmias; (5) systolic blood pressure >220mmHg, diastolic blood pressure >120mmHg, systolic blood pressure <80mmHg; or (6) intolerable symptoms. Two-dimensional echocardiographic monitoring was performed throughout drug infusion and up to 5min thereafter. The left ventricular wall was divided into 16 segments whose motion was scored as follows: 1=normal, 2=hypokinetic, 3=akinetic, and 4=dyskinetic. For assessing regional wall motion in the left anterior descending artery territory, nine segments (basal anteroseptal, basal anterior, midinterventricular septum, midanteroseptal, midanterior and four apical segments) were assigned to the left anterior descending artery territory.12 A test result was considered positive for ischemia if stress induced an increase in the wall motion score in one or more segments, with the exception of a change from akinesis to dyskinesis. We defined positive result in left anterior descending artery territory if the dobutamine stress echocardiography was positive for ischemia in one or more segments assigned to the left anterior descending artery.

Transthoracic Doppler echocardiography
Transthoracic Doppler echocardiography was performed with a SONOS 5500 ultrasound system (Philips, Andover, Massachusetts) using an S12 high-frequency transducer (5–12MHz).

Echocardiographic images were obtained from the acoustic window around mid-clavicular line in the fourth and fifth intercostal spaces in the left lateral decubitus position. After the lower portion of the interventricular sulcus had been located in the long-axis cross section, the ultrasound beam was rotated laterally, visualizing the distal portion of the left anterior descending coronary artery under high-frequency (5MHz) color Doppler technique.6 For color Doppler echocardiography, the velocity range was set in the range from ±15cm/s to ±19cm/s, and depth was adjusted at 7cm. Blood flow velocity was measured by pulsed wave Doppler echocardiography (frequency 5MHz), using a 1.9mm sample volume. We tried to align the ultrasound beam direction with the distal left anterior descending artery flow as parallel as possible. All studies were continuously recorded on super-VHS videotape, and clips were also stored digitally on magneto-optical disks for off-line analysis.

An echocardiographic contrast agent (SonoVue, Bracco, The Netherlands) was used to enhance visualization of the Doppler signals. We administered an intravenous bolus of 1ml of the dilution proposed by the manufacturer.

Measurement of coronary flow velocity reserve
Measurement of coronary flow velocity reserve was performed the same day of dobutamine stress echocardiography. We recorded spectral Doppler signals of distal left anterior descending artery at baseline and at 10min after starting an infusion of dipyridamole (0.84mg/kg IV over 6min). The position of the transducer was not changed during dipyridamole administration. The echocardiographic contrast agent was administered before and after dipyridamole infusion. The electrocardiogram and heart rates were monitored continuously during the patient's examination. Blood pressure was recorded at baseline and every 1min after intravenous dipyridamole infusion was started. After measurement of coronary flow velocity reserve, we used aminophylline to antagonize the effects of dipyridamole.

An experienced operator, who had no knowledge of the results of coronary angiography, measured variables derived from spectral Doppler signal. Both peak systolic and peak diastolic flow velocities at baseline and peak hyperemia were the measured variables. Each variable was averaged over five consecutive cycles. Coronary flow velocity reserve was calculated as the ratio of hyperemic to basal peak diastolic flow velocities. Normal coronary flow velocity reserve was defined as ≥2.0 (Fig. 1).13


Figure 1
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  		Figure 1 Patient with abnormal CFVR (45/29cm/s=1.55), DSE with negative result and significant proximal LAD stenosis in coronary arteriography. CFVR: coronary flow velocity reserve; DSE: dobutamine stress echocardiography; LAD: left anterior descending coronary artery.

 
Coronary angiography
Coronary angiography was performed in all patients, during admission, by using standard techniques. Angiographic data were analyzed by an experienced operator who had no knowledge of the echocardiographic results. The severity of coronary stenosis was determined by quantitative coronary angiography (Inturis Cardioview 1.2, Philips, The Netherlands) and expressed as the percent lumen diameter. Stenosis was considered significant if there was >50% diameter stenosis.

Statistical analysis
Quantitative variables were expressed as mean (standard deviation). Univariate comparisons between groups of continuous variables were performed using the Student's t-test for unrelated samples and the Mann–Whitney U test if data had not a normal distribution. Qualitative variables were expressed as percentages, and univariate comparisons were performed by using the chi-square test and applying the Fisher correction when necessary. Sensitivity and specificity were reported with the corresponding 95% confidence intervals. Univariate and multivariate associations of variables with significant left anterior descending artery stenosis were assessed by binary logistic regression. Variables studied in the univariate analysis were: ≥65 years, male gender, smoking, hypercholesterolemia, hypertension, diabetes, previous myocardial infarction, motive for undergoing dobutamine stress echocardiography (known or suspected coronary artery disease), positive result in left anterior descending artery territory and abnormal CFRV. We included in the multivariate analysis those variables associated with significant left anterior descending artery stenosis in the univariate analysis at a significance level of 0.05. Variables were selected in a stepwise forward selection manner with entry and retention set at a significance level of 0.05. The incremental value of information related to left anterior descending artery flow over clinical variables and dobutamine stress echocardiography was assessed in three modeling steps. The first step consisted of fitting a multivariable model of only clinical data. Variables selected from the first step were then used as baseline factors, and variables derived from dobutamine stress echocardiography were added in a stepwise forward selection manner. Variables selected from the first two steps were then used as a baseline model, and the abnormal coronary flow velocity reserve was added to this model in a stepwise forward selection manner. A significant improvement in model prediction was based on the likelihood ratio statistic, which follows a chi-square distribution. The predictive accuracy of each modeling step was assessed by using the concordance index (C-index),14 that in case of binary logistic regression, is identical to the area under ROC curve.15 A model having C-index greater than 0.8 has some utility in predicting the responses of individual subjects.16 All calculations were performed using the SPSS statistical software package.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conclusions
 Acknowledgments
 References
 
Study population
We detected the Doppler signal of left anterior descending artery in 85% (110/130) of patients, who constituted our study population. Characteristics of study population according to the presence of significant left anterior descending artery stenosis are shown in Table 1. It is necessary to highlight that 66 out of 110 patients (60%) were taking a beta-blocker. However, the percentage of patients who were taking either nitrates (47/110, 43%) or calcium antagonists (12/110, 11%) was lower.


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  		Table 1 Clinical characteristics of patients according to the presence of significant LAD stenosis

 
Dobutamine stress echocardiography
The main indication to undergo dobutamine stress echocardiography was a known coronary artery disease (86/110, 78%). Atropine was administered to 62% (68/110) of patients, nevertheless, only 35% (38/110) of patients reached the target heart rate. In 82 out of 110 patients (75%) had a positive result in one or more territories. Dobutamine stress echocardiography showed a positive result in right, left anterior descending artery and circumflex coronary territories in 71%, 40% and 25%, respectively. A single-vessel disease was suggested in 53 out of 82 patients (65%). During dobutamine stress echocardiography, 41% (45/110) of patients had angina.

Transthoracic Doppler echocardiography
There were not statistically significant differences in diastolic and systolic basal velocities according to the presence of significant left anterior descending artery stenosis [31.9 (13.7)cm/s vs. 29.0 (12.2)cm/s, p=NS; 15.9 (9.4)cm/s vs. 16.1 (8.7)cm/s, p=NS]. However, diastolic velocities were lower after dipyridamole in patients with significant left anterior descending artery stenosis [63.0 (26.8)cm/s vs. 42.0 (20.6)cm/s, p=0.0001], leading to a significantly lower coronary flow velocity reserve in this group [2.0 (0.5) vs. 1.5 (0.4), p=0.0001].

Coronary angiography
Coronary angiography showed significant coronary artery disease in 84 out of 110 patients (76%), single-vessel disease in 39 (46%) and multivessel disease in 45 (54%). We identified significant stenosis in left anterior descending artery, right and circumflex coronary arteries in 42, 54 and 49 patients, respectively. The prevalence of significant left anterior descending artery stenosis was higher when left anterior descending artery flow was not detected (60% vs. 29%, p=0.01).

Predictors of significant left anterior descending artery stenosis
Sensitivity and specificity to detect left anterior descending artery stenosis for wall motion abnormalities were 52% (37%–67%) and 82% (73%–91%), respectively. Sensitivity was higher for abnormal coronary flow velocity reserve [86% (76%–96%)], however, specificity was lower [57% (46%–68%)]. When we applied coronary flow velocity reserve in patients with a negative dobutamine stress echocardiography in left anterior descending artery territory (76 patients), most of them (57%) were not able to reach the target heart rate, sensitivity and specificity for abnormal coronary flow velocity reserve to detect left anterior descending artery stenosis were 75% (56%–94%) and 64% (52%–76%), respectively. So, in this group, a normal value of coronary flow velocity reserve (38 out of 76 patients) ruled out significant LAD stenosis in 33 out of 38 patients. Moreover, an abnormal coronary flow velocity reserve (38 out of 76 patients) identified 15 out of 38 patients with significant stenosis not detected by a negative result in the dobutamine stress echocardiography.

Table 2 shows the univariate predictors of significant left anterior descending artery stenosis. Table 3 lists the independent predictors of significant left anterior descending artery stenosis derived from the three steps modeling. When we considered only the clinical model, smoking provided a C-index of 0.61. A positive result in left anterior descending artery territory added diagnostic information. The C-index of this model was 0.72. The final model that included abnormal coronary flow velocity reserve provided a C-index of 0.80.


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  		Table 2 Univariate predictors of significant LAD stenosis

 


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  		Table 3 Independent predictors of significant LAD stenosis

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conclusions
 Acknowledgments
 References
 
This prospective study proves that assessment of coronary flow velocity reserve obtained noninvasively adds diagnostic information to dobutamine stress echocardiography to detect significant left anterior descending artery stenosis in clinical practice. An abnormal coronary flow velocity reserve had higher sensitivity than wall motion abnormalities, however, its specificity was lower. Sensitivity remained high in patients with a negative dobutamine stress echocardiography in left anterior descending artery territory.

Value of dobutamine stress echocardiography to diagnose significant left anterior descending artery stenosis
Dobutamine stress echocardiography has become an established method for the diagnosis of coronary artery disease, with both mean sensitivities and specificities of 81% and 85%, respectively.15 Even, from the point of view of the clinical practice, dobutamine stress echocardiography has shown its usefulness to reclassify patients previously assigned to subgroups of pre-test probability of coronary artery disease according to clinical parameters. Importantly, the accuracy of predicting coronary artery disease in the high pre-test probability group and the absence of coronary artery disease in the low pre-test probability group after dobutamine stress echocardiography was excellent (87%).11 However, when specific coronary arteries were studied, the diagnostic ability of dobutamine stress echocardiography varied. For instance, mean sensitivities for the detection of significant left anterior descending artery stenosis were low (72%), but mean specificities were high (88%).3,17 In our study, with a new approach, and after incorporating clinical variables into the model, a positive result in left anterior descending artery territory was predictive of significant left anterior descending artery stenosis.

Detection of significant left anterior descending artery stenosis is important because of its prognostic significance. Recently, Elhendy et al.18 showed that exercise wall motion abnormalities in the distribution of the left anterior descending artery were associated with an increased risk of cardiac death and nonfatal myocardial infarction. This risk was independent of the resting ejection fraction and the extent of wall motion abnormalities during exercise.

Considering that our population consisted of admitted patients, certain characteristics in this group of patients can limit the diagnostic ability of dobutamine stress echocardiography. In our studied population, sensitivity for wall motion abnormalities during dobutamine stress echocardiography was low (52%), probably because 60% of our patients were taking a beta-blocker, which could diminish the diagnostic capacity of the test,2 mainly by not reaching the target heart rate. For this reason, it would be interesting to find a noninvasive technique to avoid this and/or possible factors that could impair the detection of significant left anterior descending artery stenosis by dobutamine stress echocardiography.

Value of coronary flow velocity reserve by means of transthoracic Doppler echocardiography to diagnose significant left anterior descending artery stenosis
Recently, new ultrasound systems have implemented high-frequency transducers that allow noninvasive detection of left anterior descending artery6 and left internal mammary artery,19 and therefore, making feasible the determination of coronary flow velocity reserve when a vasodilator is administered.7 Abnormal coronary flow velocity reserve measured by transthoracic Doppler echocardiography has an adequate ability to diagnose significant left anterior descending artery stenosis, with sensitivities of 86%–92% and specificities of 76%–90%.6,7,10 However, discrepancies between angiographic and physiological estimates of coronary lesion severity exist, specially in lesions that cause moderate obstruction.20 Coronary flow velocity reserve, as measured by transthoracic Doppler echocardiography, permits the physiological assessment of coronary stenosis. Daimon et al.21 found that an abnormal coronary flow velocity reserve by transthoracic Doppler echocardiography predicted reversible perfusion defects obtained by exercising thallium-201 single-photon emission computed tomography with a sensitivity of 92% and a specificity of 90%.

This report shows that an abnormal coronary flow velocity reserve is a predictor of significant left anterior descending artery stenosis in both uni and multivariate analyses (Tables 2 and 3Go). Sensitivity of abnormal coronary flow velocity reserve (86%) to detect significant left anterior descending artery was excellent, however specificity (57%) was suboptimal, probably due to the accompanying disease that could produce microvascular dysfunction, such as diabetes22 and hypertension.23

Incremental diagnostic value of assessment of left anterior descending artery flow over dobutamine stress echocardiography
Although dobutamine stress echocardiography has proved to be a useful test to diagnose coronary artery disease, to the date, its main limitation is the lack of an accurate quantification of either wall motion or systolic thickening during the test. At this point, coronary flow velocity reserve could be useful since it provides a definite "figure", with low intra- and interobserver variability,6,7,10 that could be complementary to the information derived from dobutamine stress echocardiography.

Measuring left anterior descending artery flow during dobutamine stress echocardiography is feasible, as demonstrated by Takeuchi et al.24 This author proposed a ratio of peak to basal coronary flow velocities measured during dobutamine stress echocardiography that could accurately detect the presence of stress-induced wall motion abnormalities in the left anterior descending artery territory. However, the value of that study is limited because of the lack of coronary angiography. Moreover, the mechanisms by which dobutamine and specific vasodilators (dipyridamole and adenosine) augment coronary flow are distinctly different. Some studies suggest that dobutamine at doses used for stress testing induces maximal vasodilation in patients with coronary artery disease,25 nevertheless, other studies show that the increase of coronary flow induced by adenosine or dipyridamole is higher, at least in healthy patients.26 Therefore, we found more reasonable to use a specific vasodilator (dipyridamole) to measure coronary flow velocity reserve since no study have confirmed the equality of dobutamine to vasodilators.

Recently, several papers have showed that the addition of coronary flow velocity reserve to wall motion abnormalities derived from dipyridamole stress echocardiography improved sensitivity but impaired specificity, maintaining the same accuracy.27–29 As far as we know, there is no report that have studied the complementary value of coronary flow velocity reserve to dobutamine stress echocardiography to detect significant left anterior descending artery stenosis. We used a double stress approach because dobutamine stress echocardiography is more sensitive than dipyridamole stress echocardiography for the detection of coronary artery disease, mainly due to a higher sensitivity in patients with single-vessel disease, although accuracy is similar.5 Moreover, despite the simultaneous assessment of coronary flow velocity reserve and dipyridamole stress echocardiography are feasible, probably, a single imaging approach is more technically challenging than a double stress, single imaging approach. In relation to sensitivities and specificities, our data are concordant with previous studies27–29: abnormal coronary flow velocity reserve was more sensitive but less specific than stress-induced wall motion abnormalities for the detection of significant left anterior descending artery stenosis. When we included patients with a negative dobutamine stress echocardiography in left anterior descending artery territory, most of them (57%) were not able to reach the target heart rate, sensitivity remained high (76%) and specificity improved (64%). If so, both tests should be complementary, probably because of a normal value of coronary flow velocity reserve could rule out significant left anterior descending artery stenosis, especially if the target heart rate is not reached.

We should keep in mind that diagnostic tests need to be placed in the clinical context of the patient, so the information added to both clinical data and established diagnostic tests can be evaluated. In this study we found, by means of a regression modeling strategy, that dobutamine stress echocardiography and the assessment of left anterior descending artery flow added diagnostic information to clinical data (Table 3), with a good predictive accuracy of the model (C-index of 0.80). It is possible that the complementary information added by left anterior descending artery flow is related to patients with significant stenosis who do not show echocardiographic ischemia in left anterior descending artery territory due to several reasons: moderate degrees of stenosis that provoke sufficient hemodynamic severity to impair coronary flow velocity reserve but not to the extent to induce ischemia,30 not achievement of the target heart rate (for instance: administration of a beta-blocker), or discontinuation of dobutamine stress echocardiography because of angina or ischemia in other territories. All of these issues are common in clinical practice, as our study population showed.


   Conclusions
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
Acknowledgments
 References
 
An abnormal coronary flow velocity reserve in the left anterior descending artery by means of transthoracic Doppler echocardiography adds diagnostic value to both clinical data and variables derived from dobutamine stress echocardiography for the detection of significant left anterior descending artery stenosis in clinical practice.


   Acknowledgments
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
References
 
We thank Juan A. Castillo-Moreno, MD (Hospital Sta. Ma del Rosell, Cartagena, Spain) and José Galcerá-Tomás, MD (Hospital Universitario Virgen de la Arrixaca, Murcia, Spain) for their helpful suggestions concerning the contents of this article.

Supported in part by the "Fundación de Investigación Cardiológica Murciana", Murcia, Spain.

This study received the national award granted by "Fundación Uriach", Spain.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conclusions
 Acknowledgments
 References
 

  1. Sawada S.G., Segar D.S., Ryan T., Brown S.E., Dohan A.M., Williams R., et al. Echocardiographic detection of coronary artery disease during dobutamine infusion. Circulation (1991) 83:1605–1611.[Abstract/Free Full Text]
  2. Marwick T., D'Hondt A.M., Baudhuin T., Willemart B., Wijns W., Detry J.M., et al. Optimal use of dobutamine stress for the detection and evaluation of coronary artery disease: combination with echocardiography or scintigraphy, or both? J Am Coll Cardiol (1993) 22:159–167.[Abstract]
  3. Takeuchi M., Araki M., Nakashima Y., Kuroiwa A. Comparison of dobutamine stress echocardiography and stress thallium-201 single-photon emission computed tomography for detecting coronary artery disease. J Am Soc Echocardiogr (1993) 6:593–602.[Medline]
  4. Marcovitz P.A., Armstrong W.F. Accuracy of dobutamine stress echocardiography in detecting coronary artery disease. Am J Cardiol (1992) 69:1269–1273.[CrossRef][Web of Science][Medline]
  5. Geleijnse M.L., Fioretti P.M., Roelandt J.R.T.C. Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography. J Am Coll Cardiol (1997) 30:595–606. 10.1016/S0735-1097(97)00206-4.[Abstract]
  6. Hozumi T., Yoshida K., Ogata Y., Akasaka T., Asami Y., Takagi T., et al. Noninvasive assessment of significant left anterior descending coronary artery stenosis by coronary flow velocity reserve with transthoracic color Doppler echocardiography. Circulation (1998) 97:1557–1562.[Abstract/Free Full Text]
  7. Caiati C., Montaldo C., Zedda N., Montisci R., Ruscazio M., Lai G., et al. New noninvasive method for coronary flow reserve assessment. Contrast-enhanced transthoracic second harmonic echo Doppler. Circulation (1999) 99:771–778.[Abstract/Free Full Text]
  8. Hozumi T., Yoshida K., Akasaka T., et al. Noninvasive assessment of coronary flow velocity and coronary flow velocity reserve in the left anterior descending coronary artery by Doppler echocardiography. Comparison with invasive technique. J Am Coll Cardiol (1998) 32:1251–1259. 10.1016/S0735-1097(98)00389-1.[Abstract/Free Full Text]
  9. Caiati C., Montaldo C., Zedda N., et al. Validation of a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) for the evaluation of coronary flow reserve. Comparison with intracoronary Doppler flow wire. J Am Coll Cardiol (1999) 34:1193–1200. 10.1016/S0735-1097(99)00342-3.[Abstract/Free Full Text]
  10. Florenciano Sánchez R., de la Morena Valenzuela G., Soria Arcos F., Rubio Paton R., Lopez Palop R., Villegas Garcia M., et al. Detección de estenosis angiográfica de la arteria coronaria descendente anterior mediante ecocardiografía-Doppler transtorácica: utilidad de la medida no invasiva de la reserva del flujo coronario. Rev Esp Cardiol (2003) 56:561–568.[CrossRef][Web of Science][Medline]
  11. Geleijnse M.L., Marwick T.H., Boersma E., Deckers J.W., Melin J.A., Fioretti P.M., et al. Optimal pharmacological stress testing for the diagnosis of coronary artery disease: a probabilistic approach. Eur Heart J (1995) 16(Suppl. M):3–10.[Abstract/Free Full Text]
  12. Segar D.S., Brown S.E., Sawada S.G., Ryan T., Feigenbaum H. Dobutamine stress echocardiography: correlation with coronary lesion severity as determined by quantitative angiography. J Am Coll Cardiol (1992) 19:1197–1202.[Abstract]
  13. Matsumara Y., Hozumi T., Watanabe H., Fujimoto K., Sugioka K., Takemoto Y., et al. Cut-off value of coronary flow velocity reserve by transthoracic Doppler echocardiography for diagnosis of significant left anterior descending artery stenosis in patients with coronary risk factors. Am J Cardiol (2003) 92:1389–1393. 10.1016/j.amjcard.2003.08.042.[CrossRef][Web of Science][Medline]
  14. Harrell F.E. Jr., Lee K.L., Mark D.B. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med (1996) 15:361–387.[CrossRef][Web of Science][Medline]
  15. Hanley J.A., McNeil B.J. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology (1982) 143:29–36.[Abstract/Free Full Text]
  16. Harrell F.E. Jr. Binary logistic regression. In: Regression modeling strategies. With applications to linear models, logistic regression and survival analysis—Harrell F.E. Jr., ed. (2001) New York: Springer-Verlag. 215–265.
  17. Mazeika P.K., Nadazdin A., Oakley C.M. Dobutamine stress echocardiography for detection and assessment of coronary artery disease. J Am Coll Cardiol (1992) 19:1203–1211.[Abstract]
  18. Elhendy A., Mahoney D.W., Khanderia B.K., Paterick T.E., Burger K.N., Pellikka P.A. Prognostic significance of the location of wall motion abnormalities during exercise echocardiography. J Am Coll Cardiol (2002) 40:1623–1629. 10.1016/S0735-1097(02)02338-0.[Abstract/Free Full Text]
  19. Sualís A., Carreras F., Borrás X., Garcia-Picart J., Montiel J., Pons-Llado G. Evaluación de la permeabilidad de los injertos de arteria mamaria interna izquierda mediante análisis de la velocidad del flujo por técnica Doppler transcutánea. Rev Esp Cardiol (1999) 52:681–687.[Web of Science][Medline]
  20. Vogel R.A. Assessing stenosis significance by coronary arteriography: are the best variables good enough? J Am Coll Cardiol (1998) 12:692–693.
  21. Daimon M., Watanabe H., Yamagishi H., Muro T., Akioka K., Hirata K., et al. Physiologic assessment of coronary artery stenosis by coronary flow reserve measurements with transthoracic Doppler echocardiography: comparison with exercise thallium-201 single-photon emission computed tomography. J Am Coll Cardiol (2001) 37:1310–1315. 10.1016/S0735-1097(01)01167-6.[Abstract/Free Full Text]
  22. Nasher P.J. Jr., Brown R.E., Oskarsson H., Winniford M.D., Rossen J.D. Maximal coronary flow reserve and metabolic coronary vasodilation in patients with diabetes mellitus. Circulation (1995) 91:635–640.[Abstract/Free Full Text]
  23. Schwartzkopff B., Motz W., Frenzel H. Structural and functional alterations of the intramyocardial coronary arterioles in patients with arterial hypertension. Circulation (1993) 88:993–1003.[Abstract/Free Full Text]
  24. Takeuchi M., Miyazaki C., Yoshitani H., Otani S., Sakamoto K., Yoshikawa J. Assessment of coronary flow velocity with transthoracic Doppler echocardiography during dobutamine stress echocardiography. J Am Coll Cardiol (2001) 38:117–123. 10.1016/S0735-1097(01)01322-5.[Abstract/Free Full Text]
  25. Bartunek J., Wijns W., Heyndrickx G.R., de Bruyne B. Effects of dobutamine on coronary stenosis physiology and morphology: comparison with intracoronary adenosine. Circulation (1999) 100:243–249.[Abstract/Free Full Text]
  26. Skandrian A.S., Verani M.S., Heo J. Pharmacologic stress testing: mechanism of action, hemodynamic responses, and results in detection of coronary artery disease. J Nucl Cardiol (1994) 1:94–111.[Web of Science][Medline]
  27. Rigo F., Richieri M., Pasanisi E., Cutaia V., Zanella C., Della Valentina P., et al. Usefulness of coronary flow reserve over regional wall motion when added to dual-imaging dipyridamole echocardiography. Am J Cardiol (2003) 91:269–273. 10.1016/S0002-9149(02)03153-3.[CrossRef][Web of Science][Medline]
  28. Nohtomi Y., Takeuchi M., Nagasawa K., Arimura K., Miyata K., Kuwata K., et al. Simultaneous assessment of wall motion and coronary flow velocity in the left anterior descending coronary artery during dipyridamole stress echocardiography. J Am Soc Echocardiogr (2003) 16:457–463.[CrossRef][Web of Science][Medline]
  29. Lowenstein J., Tiano C., Marquez G., Presti C., Quiroz C. Simultaneous analysis of wall motion and coronary flow reserve of the left anterior descending coronary artery by transthoracic Doppler echocardiography during dipyridamole stress echocardiography. J Am Soc Echocardiogr (2003) 16:607–613.[CrossRef][Web of Science][Medline]
  30. Picano E. Stress echocardiography. From pathophysiological toy to diagnostic tool. Circulation (1992) 85:1604–1612.[Free Full Text]

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P. Meimoun and C. Tribouilloy
Non-invasive assessment of coronary flow and coronary flow reserve by transthoracic Doppler echocardiography: a magic tool for the real world
Eur J Echocardiogr, July 1, 2008; 9(4): 449 - 457.
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