Effect of Image Optimization With Contrast on the Diagnostic Accuracy of Dobutamine Echocardiography in Coronary Artery Disease - OPTIMIZE

Description:

The goal of this trial was to evaluate echocardiographic image quality with and without echo contrast in patients undergoing dobutamine echocardiography.

Hypothesis:

Echo contrast will be more effective in showing endocardial borders and enhancing interpretation of dobutamine echocardiography.

Study Design

  • Randomized
  • Blinded
  • Crossover

Patients Screened: 108
Patients Enrolled: 101
Mean Patient Age: 60
Female: 26
Mean Ejection Fraction: 56

Patient Populations:

Patients with intermediate to high risk of coronary artery disease undergoing dobutamine echocardiography

Exclusions:

• History of a recent myocardial infarction (within 1 week)
• Left ventricular systolic dysfunction (ejection fraction <40%)
• Severe valvular regurgitation or stenosis
• Unstable angina
• Heart failure (New York Heart Association functional class III or IV)
• Ventricular tachycardia
• Systolic blood pressure <90 or >180 mm Hg

Primary Endpoints:

Percentage of myocardial segments with adequate visualization of endocardium

Secondary Endpoints:

Confidence in interpretation of myocardial wall motion and accurate detection of ischemia

Drug/Procedures Used:

A total of 101 patients undergoing stress testing were randomized to dobutamine echocardiography with Definity contrast and at least 4 hours later without contrast.

Concomitant Medications:

At baseline: 55% of patients were on an angiotensin-converting enzyme inhibitor, 65% were on a beta-blocker, and 81% were on a lipid-lowering agent.

Principal Findings:

Resting heart rate was 68 bpm without contrast and 71 bpm with contrast (p = 0.03). There was no difference in any other vital sign between the groups. The percentage of myocardial segments adequately visualized at baseline was 72% without contrast and 95% with contrast (p < 0.001), and 67%-96% at peak exercise (p < 0.001), respectively. The improvement in wall motion was most apparent in the apex.

Without contrast, 36% of studies were interpreted as normal, 50% were ischemic, 6% were scar, and 8% were uninterpretable. With contrast, 40% were normal, 55% were ischemic, and 5% were scar (p = 0.01). There were 91 patients who underwent coronary angiography. The sensitivity and specificity for noncontrast studies were 75% and 51%, and for contrast studies were 80% and 55%, respectively. Overall concordance of agreement between coronary angiography and stress test results was 57% without contrast and 68% with contrast (p = 0.06).

Interpretation:

Among patients with intermediate to high risk of coronary artery disease, the use of contrast during dobutamine echocardiography improved the visualization of myocardial segments both at rest and peak stress. This effect was most pronounced for apical segments and especially with suboptimal baseline images. The overall distribution of test results (e.g., normal, ischemic, or scar) was approximately the same, except there were no longer uninterpretable results with the use of contrast. Although contrast improved the detection of coronary disease, there were still 32% of patients with discordance results between dobutamine echocardiography and coronary angiography.

The Food and Drug Administration has issued a warning concerning a small risk of possible adverse reactions to the use of contrast agents. The exclusion criteria of this study are especially important in helping to guide which patients with suboptimal images should receive contrast agents.

References:

Plana JC, Mikati IA, Dokainishet H, al. A Randomized Cross-Over Study for Evaluation of the Effect of Image Optimization With Contrast on the Diagnostic Accuracy of Dobutamine Echocardiography in Coronary Artery Disease: The OPTIMIZE Trial. J Am Coll Cardiol Img 2008;1:145-152.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Contrast Media, Coronary Artery Disease, Dobutamine, Cicatrix, Coronary Angiography, Heart Rate, Echocardiography, Exercise Test


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