Clinical Investigation
Coronary Artery Disease
Quantitative Dobutamine Stress Echocardiography Using Speckle-Tracking Analysis versus Conventional Visual Analysis for Detection of Significant Coronary Artery Disease after ST-Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.echo.2015.07.023Get rights and content

Background

Residual ischemia detection after ST-segment elevation myocardial infarction (STEMI) during dobutamine stress echocardiography (DSE) using visual analysis is challenging. The aim of the present study was to investigate the feasibility and accuracy of two-dimensional speckle-tracking strain DSE to detect significant coronary artery disease (CAD) after STEMI.

Methods

First STEMI patients (n = 105; mean age, 60 ± 11 years; 86% men) treated with primary percutaneous coronary intervention undergoing full-protocol DSE at 3 months and repeat coronary angiography within 1 year were retrospectively included. Using two-dimensional speckle-tracking echocardiography, segmental and global left ventricular peak longitudinal systolic strain (PLSS) at rest and peak stress and change (Δ) in PLSS were measured. Significant CAD was defined as detection of >70% diameter stenosis at coronary angiography.

Results

In total, 1,653 (93%) and 1,645 (92%) segments were analyzable at rest and peak stress, respectively. At follow-up, 38 patients (36%) showed significant angiographic CAD. These patients demonstrated greater worsening in global PLSS from rest to peak (−16.8 ± 0.5% to −12.6 ± 0.5%) compared with patients without significant CAD (−16.6 ± 0.4% to −14.3 ± 0.3%; group-stage interaction P < .001). The optimal cutoff of ΔPLSS for the detection of significant CAD on receiver operating characteristic curve analysis was ≥1.9% (area under the curve, 0.70; sensitivity, 87%; specificity, 46%; accuracy, 60%). Using a sentinel segment approach (apex, midposterior, and midinferior for the left anterior descending, left circumflex, and right coronary artery territories, respectively), larger segmental ΔPLSS was also independently associated with significant CAD (odds ratio, 1.1; 95% CI, 1.1–1.2).

Conclusions

Two-dimensional speckle-tracking echocardiographic strain analysis is feasible on DSE after STEMI and represents a promising new technique to detect significant angiographic CAD at follow-up.

Section snippets

Patient Population

All first STEMI patients presenting to our institution between November 2010 and February 2012 and treated according to the MISSION! protocol were evaluated for inclusion in this retrospective study. This protocol is designed to improve care around all aspects of STEMI and is based on the most recent American College of Cardiology Foundation and American Heart Association and European Society of Cardiology guidelines.2, 16, 17 Diagnosis of acute myocardial infarction was made on the basis of

Patient Population

Of 135 first STEMI patients meeting the initial inclusion criteria, 7% (n = 10) were excluded because of the occurrence of a dobutamine stress echocardiographic end point other than completion of the protocol (Figure 1). A further 15% (n = 20) were excluded because of either inadequate image quality at rest or peak dose or inaccurate tracking involving a full regional wall or more than two segments within the same coronary territory. Clinical characteristics of the remaining 105 patients (mean

Discussion

Analysis of 2D speckle-tracking echocardiographic longitudinal strain parameters during full-protocol DSE alongside conventional visual analysis was feasible in the majority of patients after STEMI at peak dose as well as at rest. At the global level, ΔPLSS was independently associated with the presence of significant CAD at follow-up, unlike ΔWMS, and provided incremental value to conventional visual analysis for the detection of significant CAD at follow-up. Segmental ΔPLSS similarly

Conclusions

Two-dimensional speckle-tracking echocardiographic strain analysis is feasible on full-protocol DSE after STEMI and represents a promising new quantitative technique to detect significant angiographic CAD at follow-up.

PLSS investigated at rest and the peak stage of DSE was the optimal parameter to detect the ischemic substrate in stable patients after myocardial infarction and provided incremental value to conventional visual wall analysis. However, low specificity, segment-to-segment

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      Whether the cutoff value for each major coronary artery should be different is another issue. Joyce et al.8 reported variable diagnostic accuracy using the same cutoff value for the strain parameter in different coronary arteries. Thus, various diagnostic criteria have been used when applying strain imaging on DSE.

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    Dr Joyce and Ms Hoogslag contributed equally to this work and share first authorship.

    Dr Joyce was supported during the period of this research by a European Society of Cardiology Training Grant and an Irish national educational bursary sponsored by Merck, Sharp & Dohme. Ms Hoogslag received a PhD grant provided by the Leiden University Medical Center. Dr Debonnaire was supported by a Sadra Medical Research Grant (Boston Scientific).

    The Department of Cardiology at Leiden University Medical Center receives unrestricted grants from Biotronik (Berlin, Germany), Boston Scientific (Natick, MA), GE Healthcare (Buckinghamshire, United Kingdom), and Medtronic (Minneapolis, MN). Dr Delgado received consulting fees from Medtronic and St. Jude Medical (St. Paul, MN).

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