Detection of Coronary Artery Disease by Combined Assessment of Wall Motion, Myocardial Perfusion and Coronary Flow Reserve: A Multiparametric Contrast Stress-Echocardiography Study

Background: Wall motion (WM), Doppler-derived measurement of the coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD), and myocardial perfusion imaging (MPI) can be sequentially assessed during dipyridamole stress echocardiography. Data regarding the relative diagnostic value of each of these parameters when assessed during the same examination in patients with suspected coronary artery disease (CAD) are lacking. Methods: Dipyridamole stress echocardiography was performed in 400 patients at two centers, before the performance of clinically indicated coronary angiography. The diagnostic accuracy of WM, CFR-LAD, combined WM and CFR-LAD, and MPI was measured in comparison with quantitative angiographic results. Results: For CAD defined as >= 1 stenosis >50%, MPI had the highest sensitivity (96%), lowest specificity (66%), and highest accuracy (86%); WM and CFR-LAD had the highest specificities (85% and 80%), lowest sensitivities (63% and 66%), and lowest overall accuracies (70% and 71%). Combined WM and CFR-LAD obtained intermediate values for both sensitivity (84%) and specificity (71%) and the second best accuracy (80%). For CAD defined as >70% stenosis, MPI, combined WM and CFR-LAD, and WM obtained similar accuracies (P = NS), but WM showed the best balance of sensitivity (73%) and specificity (73%), with the highest Youden index. Conclusions: MPI had the highest sensitivity and accuracy for the detection of CAD >50% during dipyridamole stress echocardiography, despite showing the lowest specificity among tested parameters. Standalone WM and combined WM and CFR-LAD were not significantly inferior in terms of overall accuracy when CAD >70% was the diagnostic end point. The addition of MPI or CFR-LAD to standard WM assessment allows the detection of milder CAD. (J Am Soc Echocardiogr 2010;23:1242-50.)