Clinical Investigation
CAD-Stress Echocardiography
Factors Affecting Sensitivity and Specificity of Diagnostic Testing: Dobutamine Stress Echocardiography

https://doi.org/10.1016/j.echo.2009.07.006Get rights and content

Background

Clinical characteristics of patients, angiographic referral bias, and several technical factors may all affect the reported diagnostic accuracy of tests. The aim of this study was to assess their influence on the diagnostic accuracy of dobutamine stress echocardiography (DSE).

Methods

The medical literature from 1991 to 2006 was searched for diagnostic studies using DSE and meta-analysis was applied to the 62 studies thus retrieved, including 6881 patients. These studies were analyzed for patient characteristics, angiographic referral bias, and several technical factors.

Results

The sensitivity of DSE was significantly related to the inclusion of patients with prior myocardial infarctions (0.834 vs 0.740, P < .01) and defining the results of DSE as already positive in case of resting wall motion abnormalities rather than obligatory myocardial ischemia (0.786 vs 0.864, P < .01). Specificity tended to be lower when patients with resting wall motion abnormalities were included in a study (0.812 vs 0.877, P < .10). The presence of referral bias adversely affected the specificity of DSE (0.771 vs 0.842, P < .01).

Conclusion

This analysis suggests that the reported sensitivity of DSE is likely higher and the specificity lower than expected in routine clinical practice because of the inappropriate inclusion of patients with prior myocardial infarctions, the definition of positive results on DSE, and the negative influence of referral bias. However, in the patient subset that will be sent to coronary angiography, the opposite results can be expected.

Section snippets

Literature Review

A Medline search for diagnostic dobutamine stress echocardiographic studies published up to 2006 using the terms “dobutamine stress” and “coronary artery disease” was performed. In addition, we reviewed the reference lists of review articles and eligible studies to complete the data search. Excluded from this search were reports solely on patients with poor echocardiographic windows, left bundle branch block, hypertension, and/or left ventricular hypertrophy or prior myocardial infarction. To

Sensitivities and Specificities

For the 62 unique study groups in the 60 reports, 6881 patients were studied with DSE and coronary angiography with sufficient data to record sensitivity and specificity. Of these, 4718 had angiographic CAD, whereas 2163 did not. A total of 3882 patients had true-positive findings on DSE, resulting in a sensitivity of 0.812. There were 1790 true-negative findings, resulting in a specificity of 0.822. Sensitivities and specificities for each of the 62 study groups are reported in Table 2.

Effects of Patient Characteristics

The

Discussion

This meta-analysis indicates that patient characteristics, referral bias, and technical factors (such as the definition of positive results on DSE) all significantly affect the reported sensitivity and specificity of DSE.

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