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Accuracy of stress echocardiography

EACVI 3D Echocardiography Box


Accuracy of a diagnostic test (stress echocardiography) is the proportion of people correctly classified by the test. For stress echocardiography accuracy, along with other measures of diagnostic techniques, is mainly estimated for detection of coronary artery disease and myocardial viability.

Standard terminology used in diagnostic testing

The following standard terminology is used in diagnostic testing [1]:

  • True positive = Abnormal test result in individual with disease
  • False positive = Abnormal test result in individual without disease
  • True negative = Normal test result in individual without disease
  • False negative = Normal test result in individual with disease
  • Sensitivity = True positives/(True positives + False negatives)
  • Specificity = True negatives/(True negatives + False positives)
  • Accuracy = (True positives + True negatives)/Total number of tests performed
  • Positive predictive value = True positives/(True positives + False positives)
  • Negative predictive value = True negatives/(True negatives + False negatives)
  • Likelihood ratio positive = sensitivity /(1 − specificity)
  • Likelihood ratio negative = (1 − sensitivity)/ specificity

Diagnostic accuracy of the different stress echocardiograpy techniques for detection of Coronary Artery Disease

According to EAE expert consensus statement exercise, high-dose dobutamine, and high-dose (accelerated or with atropine) dipyridamole have not only similar accuracies, but also similar sensitivities (Tables 1 and 2) [2]. It should be noted that diagnostic accuracy of any test varies according to the pre-test likelihood of CAD in the population tested.

Table 1. Dipyridamole-stress vs dobutamine-stress echocardiography for detection of coronary artery disease



Table 2. Dipyridamole vs exercise stress echocardiography for detection of coronary artery disease -
Open the table >

Exercise Echocardiography

In a recently performed meta-analysis [3] assessing diagnostic accuracy of exercise stress testing for coronary artery disease it was shown that discriminatory abilities of stress echocardiography and SPECT are significantly better than exercise testing with ECG alone. Overall, treadmill echo testing (LR+ = 7.94) performed better than treadmill ECG testing (LR+ = 3.57) for ruling in CAD and was similarly better at ruling out CAD (echo LR) = 0.19 vs. ECG LR) = 0.38). Bicycle echo testing (LR+ = 11.34) performed better than treadmill echo testing (LR+ = 7.94), which both outperformed treadmill ECG (LR+ = 3.57) or bicycle ECG (LR+ = 2.94).

Pharmacological Stress Echocardiography

In meta-analysis by E. Picano et al. [4] it was shown that dipyridamole and dobutamine have similar accuracy (87%, 95% confidence intervals, CI, 83–90, vs. 84%, CI, 80–88, p = 0.48), sensitivity (85%, CI 80–89, vs. 86%, CI 78–91, p = 0.81) and specificity (89%, CI 82–94 vs. 86%, CI 75–89, p = 0.15). It should be noted that in this meta-analysis only studies with state-of-the art protocols were considered.

Diagnostic accuracy of stress echocardiography for detection of myocardial viability

The concept of myocardial hibernation was introduced by Rahimtoola to describe a condition of chronically, dysfunctional myocardium due to chronic underperfusion in patients who have coronary artery disease and in whom revascularization causes the recovery of LV function. Despite clinical relevance of viability was questioned after STICH trial[5], several noninvasive techniques are readily available to detect signs of viability, such as an intact cell membrane, residual glucose metabolism, or contractile reserve. Dobutamine stress echocardiography is by far the most widely used echo method for assessing viable myocardium based on presence of contractile reserve. Because hibernating myocardium represents a balance among flow and function it is possible that contractility reserve is lost while more basal characteristics, such as glucose metabolism and cell membrane integrity are preserved. This situation may explain, in part, differences in sensitivity and specificity of imaging techniques focusing on contractile reserve in comparison with perfusion imaging. Analysis of viability studies by Bax et al. (Table 3) showed reduced sensitivity and higher specificity of dobutamine stress echocardiography in comparison with PET and SPECT [6].

Technique No. of studies % Sensitivity % Specificity % NPV % PPV
18F-FDG PET 20 93 58 85 77
201Tl imaging 33 87 55 81 64
99mTc-labeled tracers 20 81 66 77 71
DSE 32 81 80 85 77

Diagnostic accuracy of new stress echocardiograpy techniques

Contrast stress echocardiography

As with most imaging techniques patient dependant factors can limit image quality in stress echocardiography, which can adversely affect accuracy. Ultrasound contrast agents for LV opacification are recommended by EAE consensus statement to enhance endocardial border detection when suboptimal imaging is present. Myocardial contrast echocardiography also allows qualitative and quantitative assessment of myocardial perfusion. In meta-analysis by S. Abdelmoneim et al. [7] pooled LRs for positive test were 1.33 (1.13–1.57), 3.76 (2.43–5.80), and 3.64 (2.87–4.78) and LRs for negative test were 0.68 (0.55–0.83), 0.30 (0.24–0.38), and 0.27 (0.22–0.34) for A, b, and Ab reserves, respectively. Existing data support a moderate diagnostic accuracy of quantitative myocardial contrast echocardiography in the detection of coronary artery disease.

3D stress echocardiography

Real time 3D stress echocardiography is a promising technique allowing simultaneous assessment of overall motion of the entire ventricle in different planes. Several studies showed feasibility of real time 3D stress echocardiography both in pharmacological and exercise-induced stress (Table 4) [8].

Study No. Stress Validation Sen. Sp. Sen. Sp.
Ahmad, 2001 58 DSE Coronary angiography 79 88
Matsumura, 2005 56 DSE Thalium201-SPECT 86 83 86 80
Takeuchi, 2006 78 DSE None 58 75    
Aggeli, 2007 56 DSE Coronary angiography 73 78 93 89
Yoshitani, 2009 71 DSE-3D Multiplane Coronary angiography 72 72
    DSE-3D Multislice Coronary angiography 77 95
Jenkins, 2009 90 Treadmill exercise-2D Coronary angiography 83 65    
    Treadmill exercise-3D Coronary angiography 40 84
    Treadmill exercise-3D +CFM Coronary angiography 55 78
Badano, 2010 107 Dipyridamole None 78 91 80 87
Abdelmoneim, 2010 30 Adenosine 2D Tc 99m Sestamibi SPECT 92 75
    Adenosine Live 3D Tc 99m Sestamibi SPECT 91 69
    Adenosine Full volume 3D Tc 99m Sestamibi SPECT 90 79


But several limitations of real time 3D stress echocardiography including low spatial and resolution, image artifacts due to respiration, patient motion have to be overcome to meet the clinical requirements.



  • E. Picano Stress Echocardiography, 5-th edition, Springer, 2009
  • Sicari R, Nihoyannopoulos P, Evangelista A et al. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC)Eur J Echocardiogr. 2008 Jul;9(4):415-37.
  • Banerjee A, Newman DR, Van den Bruel A et al. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. Int J Clin Pract, May 2012, 66, 5, 477–492
  • Picano E., Molinaro S., Pasanisi E. The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis. Cardiovascular Ultrasound 2008, 6:30
  • Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med. 2011 Apr 28;364(17):1617-25. Epub 2011 Apr 4.
  • Bax JJ, Poldermans D, Elhendy A, et al. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol. 2001;26:142–186
  • Abdelmoneim S, Dhoble A, Bernier M. Quantitative myocardial contrast echocardiography during pharmacological stress for diagnosis of coronary artery disease: a systematic review and meta-analysis of diagnostic accuracy studies. European Journal of Echocardiography (2009) 10, 813–825
  • Abusaid GH, Ahmad M. Real Time Three-Dimensional Stress Echocardiography Advantages and Limitations. Echocardiography. 2012 Feb;29(2):200-6

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