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European Journal of Heart Failure 2003 5(1):63-72; doi:10.1016/S1388-9842(02)00030-2
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© 2002 European Society of Cardiology

Transmitral pulsed-Doppler echocardiography is a more accurate technique compared with two-dimensional echocardiography using dobutamine, in patients with one vessel coronary artery disease

Gani Bajraktaria,*, Spiro Qirkoa, Rossana Fuscob, Angela Milazzob, Brunilda Xhaxhoa and Antonio Pezzanob,*

a II Clinic of Cardiology, University Hospital Center ‘Mother Teresa’ Tirana, Albania
b II Division of Cardiology, Niguarda Ca'Granda Hospital Milan, Italy

* Corresponding author. Present address: Service of Cardiology, University Clinical Centre, Prishtinë, Kosovo; Tel.: +381-38-542-286; fax: +381-38-542-286 E-mail address: ganibaj{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 References
 
To examine the effects of dobutamine on pulsed-Doppler left ventricular filling indices and its utility for evaluation of CAD we studied 14 patients with normal coronary arteries (Group 1) and 39 patients with significant CAD (>70% diameter stenosis). Patients with coronary artery disease (CAD) were divided into two groups: patients with one-vessel coronary disease (Group 2); and those with multivessel CAD (Group 3). After stopping cardioactive treatment, patients underwent incremental dobutamine stress (5, 10, 20, 30 and 40 µg/kg/min) during pulsed-Doppler interrogation of diastolic filling with simultaneous heart rate and blood pressure measurements. The following transmitral Doppler variables were measured at baseline and at peak-dose of dobutamine: peak early (E) and peak atrial (A) velocity; E/A ratio; acceleration time (AT) and deceleration time (DT) of E wave; isovolumic relaxation time (IVRT); and time–velocity integral (TVI). Two-dimensional echocardiography was performed to detect regional asinergy and analyzed using a 16 segment model. Results: Normals and CAD patients showed comparable changes in heart rate and blood pressure (P=NS between groups). Intergroup analysis of the changes of transmitral flow showed the significant changes for these indices (P<0.001): E velocity (–2.78±10.04, 12.4±9.4 and 16.47±10.65 cm/s); AT of E wave (1.66±2.47, –5.2±1.38 and –4.66±2.39 m/s2); DT of E wave (–0.23±0.18, 0.2±0.2 and 0.2±0.28 m/s2); and TVI of transmitral flow (–1.26±0.7, 3.5±1.75 and 4.1±1.66 cm), respectively for Groups 1, 2 and 3. All other transmitral Doppler variables showed insignificant changes (P=NS) to dobutamine between groups. It is important that the significance of these changes were the same for patients with one-vessel and those with multivessel coronary disease. In conclusion, during dobutamine stress testing, patients with CAD, had an abnormal response of these transmitral Doppler indices: E wave; AT of E wave; DT of E wave; and the TVI of transmitral flow. The abnormal responses of these Doppler indices of left ventricular filling are more accurate markers of significant single vessel CAD than new wall motion abnormalities during conventional DSE.

Key Words: Myocardial ischaemia • Stress-echocardiography • Doppler echocardiography • Dobutamine

Received March 30, 2001; Revised July 24, 2001; Accepted September 20, 2001


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 References
 
Myocardial ischaemia may be manifest as: anginal discomfort [1]; deviation of ST segment on the ECG [2]; reduced uptake of Thalium-201 in myocardial perfusion images [3]; or regional or global impairment of ventricular function [4].

It is well known that after a brief episode of severe ischaemia, prolonged myocardial dysfunction with gradual return of contractile activity occurs, a condition termed myocardial stunning [5]. Myocardial stunning may occur following exercise-induced ischaemia [6] and coronary spasm [7]. It affects both systolic and diastolic function and can occur in the globally as well as in the regionally ischaemic heart [8]. The sequence of biochemical events whereby transient myocardial ischaemia leads to protracted depression of myocardial contractility has not been elucidated definitively [9].

Impaired relaxation is an early event during the ischaemia [10]. A proposed metabolic explanation is that there is impaired generation of energy, which diminishes the supply of ATP required for the early diastolic uptake of calcium by SR, and cytosolic calcium level delays its return to normal in the early diastolic period. This effect may in part be the cellular basis for the abnormal myocardial relaxation detected in patients with ischaemic heart disease [11].

The mitral flow velocity curve, during pulsed-wave Doppler echocardiographic recordings, provides a considerable amount of information about the diastolic filling characteristics of the left ventricle. It is most likely that CAD has direct influence in Doppler parameters of mitral flow [12].

Patients may have normal studies at rest, but will show wall motion abnormalities with stress-induced ischaemia [13]. Transient wall motion abnormalities represent an earlier and more sensitive marker of myocardial ischaemia than the chest pain or ST-segment changes [14]. Dobutamine stress-cross-sectional echocardiography with transient regional asynergy as the diagnostic end point is emerging as an accurate method of detecting CAD [15]. Many investigators have compared dobutamine stress-echocardiography (DSE) with dipyridamole stress-echocardiography and exercise stress testing for diagnosis of CAD and results have shown that DSE was superior to other forms of stress echocardiography [16].

Recently, some investigators have described the non-linear course of the E/A ratio or deceleration time changes during stress [17], so that the clinical interpretation of the Doppler filling pattern changes may be difficult [18].

The results of previous studies of the effects of the myocardial ischaemia induced by DSE on the transmitral Doppler-derived variables are contradictory [17,19,35–38,44].

This prospective study was therefore undertaken to characterize the effects of DSE on pulsed Doppler transmitral indices in controls and CAD patients with and without inducible asynergy to determine the diagnostic usefulness of this approach. The aim of this study was also to assess the added value of transmitral Doppler flow indices during DSE and to compare sensitivity, specificity and diagnostic accuracy of these indices with conventional DSE.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 5. Study limitations
 References
 
2.1. Study patients
We studied 56 patients awaiting coronary angiography for suspected CAD. Patients with: valvular heart disease; left ventricular hypertrophy; uncontrolled systemic hypertension; myocardial infarction within the preceding 2 months; extensive regional asinergy or globally impaired left ventricular function on 2-dimensional echocardiography; bundle branch block; or rhythm disturbances were excluded. Data from three patients were subsequently excluded because of technically inadequate Doppler recordings or cross-sectional echocardiography. The remaining 53 patients (41 men and 12 women, mean age 60 years, range 45–76), all in sinus rhythm, were divided into three groups on the basis of the coronary anatomy. Their CAD was verified by coronary angiography (luminal diameter narrowing ≥70% of at least one major vessel was considered significant). Patients in Group 1 had normal coronary arteries. Those in Group 2 and 3 had significant CAD; subjects in Group 2 had single vessel CAD, whereas patients in Group 3 had multivessel (double and triple) CAD. The number of patients with none, single and multi-vessel disease were 14, 20 and 19, respectively. In Group 3, 13 patients had two vessel disease, six had three vessel disease and one of them also had left main coronary artery stenosis. Nine patients had a history and ECG evidence of a prior myocardial infarction, five patients had arterial hypertension and six patients had mild resting inconstant mitral regurgitation (depending on the cycle of breathing) based on systolic dysfunction of the left ventricle. Groups were matched for age, heart rate, systolic and diastolic blood pressure, left ventricular ejection fraction and Doppler filling indices at baseline (Table 1). All antianginal medications were withdrawn for four half-lives.


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  		Table 1 Baseline characteristics of study groups

 
2.2. Study protocol
The hospital ethics committee approved the protocol. All patients gave written consent to participate.

Patients were studied in the left lateral decubitus position using parasternal long axis and short axis and apical four and two chambers views. Baseline heart rate, blood pressure, 12 lead ECG, 2-dimensional echocardiography and Doppler study was performed. Dobutamine was infused into a peripheral vein using a graded stress regimen of 5, 10, 20, 30 and 40 µg/kg/min, each dose for 5 min. Atropine (0.25–1 mg) was added while continuing dobutamine in eight patients without signs of ischaemia (wall motion abnormalities, ST segment changes, angina) who had not achieved 85% of predicted maximal exercise heart rate during administration of dobutamine alone. A 12 lead ECG and arterial pressure were recorded at the end of each dose.

2.2.1. Echocardiography
We used Esoate Biomedica 7000 echocardiographic equipment with 2.5 and 3.5 MHz probes. Two-dimensional echocardiography in parasternal long axis and short axis, and apical four and two chamber views was performed continuously, except during Doppler and color interrogation. Echocardiograms were recorded on VHS videotape during the last minute of the first four stages, and continuously in the last stage and up to 10 min after discontinuation of the infusion. Digital acquisition of images and side-by-side display of cine-loops were used. All echocardiographic images were independently evaluated from video playback by two experienced observers (R.F. and G.B.), who had no knowledge of the history and angiographic findings of the patients. In case of a disagreement, a consensus was reached after joint review of the images. Wall motion and thickening of the baseline and peak recordings was semi-quantitatively assessed and scored using 16 segment left ventricular model from the American Society of Echocardiography (six segments at basal and mid levels and four segments for the apex) and each segment was graded on a 4 point scoring system: normal=1, hypokinetic=2, akinetic=3 and dyskinetic=4. A score from 1 (normal) to 4 (dyskinetic) was assigned to each segment under basal conditions and during the tests; a wall motion score index was derived by summation of the individual segment scores divided by the number of the adequately visualized segments. A test result was considered positive if either a new wall motion developed, or if there was a deterioration of resting abnormality, i.e. hypokinesia becoming akinesia or dyskinesia. A study was judged adequate for analysis when all segments could be visualized in at least one view. The presence of a wall motion abnormality at baseline was not considered a sufficient condition for the diagnosis of CAD. The absence of hyperkinesia in normal myocardial segments in response to dobutamine was not considered a criterion for a positive test result. The location of wall motion abnormalities was correlated with the site of coronary lesions according to a three region scheme of coronary perfusion. Seven segments (basal, mid and apical anterior, basal and midanteroseptal, basal and midseptal) were assigned to the left anterior descending coronary artery perfusion bed; three (basal and midposterior, and basal septal) to the right coronary artery perfusion bed; and four (basal and midlateral, and basal and midposterior) to the left circumflex territory; one segment (apical lateral) was considered an overlap area of the left anterior descending and left circumflex coronary artery distribution, and one segment (apical inferior) was considered an overlap area of the left anterior descending and right coronary artery distribution.

2.2.2. Doppler examination
Pulsed Doppler recordings were obtained from the apical four chamber view using a 2.5 MHz transducer with cursor oriented parallel to mitral inflow and the sample volume with its size of 5 mm positioned at the mitral leaflet tips during mid-expiratory apnea. The following Doppler-derived indices of left ventricular filling were measured: peak early filling velocity (E); peak atrial velocity (A); peak early to atrial (E/A) ratio; E wave deceleration time; A wave deceleration time and isovolumic relaxation period. Mitral regurgitation was evaluated by color flow Doppler imaging (by 2.5 MHz transducer) in the parasternal long axis and apical four chamber views at baseline and peak dose dobutamine infusion. All of these parameters were measured at basal conditions and at peak dose of dobutamine. No patient needed intravenous β-blocker or nitrates to reverse dobutamine stress or to treat angina.

2.2.3. Cardiac catheterization
Left ventriculography, aortography and coronary angiography were performed within 7 days of the dobutamine stress test using of standard techniques and with visualization of the coronary arteries in multiple projections. A computer-assisted quantitative angiographic system based on automatic border recognition was performed for coronary measurements. A quantitatively determined diameter of <70% in a major epicardial coronary artery was considered significant. Percent ejection fraction was calculated by the area–length ellipsoid method [53].

2.3. Statistical analysis
The discrete variables were expressed as counts and compared with Fisher's exact test. Continuous variables were expressed as mean±S.D. The differences between two groups were compared by unpaired 2-tailed t-test or paired t-test for paired variables. ANOVA test was applied to assess the differences between baseline and stress results of the individual variables in subjects divided into three groups according to the presence and extent of CAD. Sensitivity, specificity, predictive value and accuracy of the tests were calculated with standard formulas. A P value <0.05 was considered statistically significant.

For all Doppler transmitral indices that were significantly different between control and single vessel CAD group, the best cut-off values were identified by ROC-curve in terms of sensitivity and specificity.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 5. Study limitations
 References
 
All patients had technically adequate echocardiograms and Doppler recordings of the mitral flow.

3.1. Two-dimensional echocardiogaphic analysis
Two observers (R.F and G.B.) independently reviewed all 53 echocardiographic stress tests, with an interobserver agreement of 94% (50 of 53 studies). One observer reviewed all studies twice, with an intraobserver agreement of 98%.

In basal conditions (at rest) 40 (75%) patients had a normal wall motion in all segments, whereas 13 (25%) had regional wall motion abnormalities. Of the 40 patients with normal wall motion, 26 (65%) had significant CAD and 14 (35%) no critical lesion, whereas all (100%) of the 13 patients with abnormal wall motion had significant CAD.

The sensitivity of 2-dimensional dobutamine echocardiography in detection of CAD was 85% (95% for multivessel vs. 75% for one-vessel CAD), the specificity was 78%, and the diagnostic accuracy was 83% (88% for multivessel vs. 76% for patients with one-vessel CAD).

3.2. Haemodynamic response to dobutamine
Baseline haemodynamics for the study groups are shown in Table 2, and there was no significant difference between groups. For groups 1, 2 and 3 the respective peak heart rates (151.3±18.16, 143.6±16.3 and 149±17.5 bpm), systolic blood pressures (170.3±13.8, 169±18.4 and 165±15.5 mmHg) and rate–pressure products attained (25.9±4.6, 24.2±3.3 and 24.56±3.6 mmHg/minx103) during dobutamine stress were not significantly different.


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  		Table 2 Haemodynamic variables at baseline and peak dobutamine stress in control subjects and patients with CAD (CAD)

 
The changes in heart rate, systolic blood pressure and diastolic blood pressure, from baseline to peak dose of dobutamine were not significant between the three groups (P=NS).

3.3. Transmitral Doppler analysis
In Table 3 the values of Doppler variables at baseline and at peak dose of dobutamine for all three groups are shown.


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  		Table 3 Transmitral Doppler indices at baseline and peak dobutamine stress in control subjects and patients with CAD (CAD)

 
Multiple comparisons between the groups identified significant differences in some Doppler transmitral indices between control subjects and patients with CAD (Table 3). The differences from baseline to peak dose of dobutamine for E wave velocity (–2.78±10.04, 12.4±9.4 and 16.47±10.65 cm/s for groups 1, 2 and 3), acceleration time of E wave (1.66±2.47, –5.2±1.38 and –4.66±2.39 m/s2, respectively), deceleration time of E-wave (–0.23±0.18, 0.2±0.2 and 0.2±0.28 m/s2, respectively) and time–velocity integral of transmitral flow (–1.26±0.7, 3.5±1.75 and 4.1±1.66 cm, respectively) results were significantly different between the groups (P<0.001). The A velocity, E/A ratio and isovolumic relaxation period didn't show significant differences between groups.

The changes in all these variables from baseline to peak dobutamine, for all three groups are shown in Figs. 1 and 2.


Figure 1
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  		Fig. 1 Individual, mean and standard deviation values of peak early (E) and atrial (A) filling velocities, and their ratio (E/A), obtained at baseline and peak dose of dobutamine from the three study groups.

 


Figure 2
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  		Fig. 2 The changes ({triangleup}) of AT (A) and DT (B) of E velocity wave, IVRT (C) and TVI (D) from baseline to peak dose of dobutamine in the study groups and their inter-group probability values. AT=acceleration time; DT=deceleration time; IVRT=isovolumic relaxation time; TVI=time–velocity integral of mitral flow.

 
In Group 1 two subjects showed E/A <1 at baseline and 10 subjects had E/A<1 at peak dose of dobutamine, whereas three and four patients in Group 2 and 3, respectively, had E/A<1 at baseline, while 20 and 19 patients, respectively, had E/A<1 at peak dose of dobutamine.

ROC curves identified the best cut off values in terms of sensitivity and specificity. For the E wave, the difference of 10 cm/s was the best cut off value, while for E-Acc, E-Dec and TVI, the values were –4.5 m/s [2], 0.1 m/s [2] and 2.1 cm, respectively. Fig. 3 shows that the Doppler transmitral indices had better sensitivity, specificity and diagnostic accuracy, in the detection of significant single vessel CAD, than new wall motion abnormalities during conventional DSE.


Figure 3
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  		Fig. 3 Figure showing sensitivity, specificity and diagnostic accuracy of 2-dimensional echocardiography and changes of transmitral Doppler indices during dobutamine infusion in patients with single vessel coronary artery disease.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
5. Study limitations
 References
 
Myocardial ischaemia is the condition in which an imbalance occurs between myocardial oxygen supply and demand and is commonly caused by atherosclerotic coronary obstruction and/or by platelet aggregates or thrombi [1,19,20]. The diagnosis of stable or unstable angina is based on clinical data (chest pain or anginal discomfort) [1], ECG changes (ST segment deviation) [2], reduced uptake of Thalium-201 in perfusion images [3] and regional or global impairment of ventricular function [4]. During myocardial ischaemia, myocardial stunning occurs, which affects both systolic and diastolic function and can occur in the globally as well as in the regionally ischaemic heart [5–7]. So, impaired relaxation, which is an active energy-dependent process, is an early event in angina pectoris [11].

Doppler echocardiography has become a unique technique for evaluation of diastolic function, because of its ability to measure blood flow velocity directly [21,22]. Left ventricular filling is influenced by many factors such as: extrinsic constraint; atrial function; intrinsic structural properties of the ventricle; and the biochemical and ionic events regulating myocardial relaxation [23]. Other factors that affect the diastolic function of the left ventricle are: patient age [24]; heart rate [25]; preload; afterload [26]; cardioactive treatment [27]; and left ventricular hypertrophy [28].

In recent years stress has been widely used for the non-invasive diagnosis of CAD [29]. Nowadays, the most frequently used non-invasive method for detection of CAD is dobutamine stress combined with a variety of imaging modalities, including cross-sectional echocardiography, thallium scintigraphy and nuclear magnetic resonance [30,41]. In previous studies, the sensitivity of dobutamine echocardiography ranged from 54 to 89% [14,16,31]. The results in our study are in keeping with previous reports showing a higher sensitivity and specificity of 2-dimensional dobutamine echocardiography in patients with multivessel disease compared to those with single vessel CAD [14,16,32]. In our study, the sensitivity for the detection of myocardial ischaemia by conventional DSE for all patients was higher than that reported by Salustri et al. (79%) [31] and Previtali et al. (79%) [16], and lower than in the study of Segar et al. (95%) [33], whereas the specificity was similar compared with the first study (78%), and lower than in the second (83%) and third study (82%).

So far, the changes in transmitral Doppler indices during dobutamine echocardiography remain incompletely distinguished [3,8,34,36]. Previous studies have tried to identify myocardial ischaemia through diastolic dysfunction, using pulsed Doppler and exercise [37], pacing [38], or dobutamine [35]. These studies suggest that Doppler changes can provide additional diagnostic information besides wall motion abnormalities for identifying myocardial ischaemia. We studied the Doppler transmitral flow response to dobutamine in controls and CAD patients, and compared these responses in one vessel with those in multivessel CAD patients. Our patients with CAD had similar filling characteristics at baseline to controls. Despite the results that may indicate normal or near normal diastolic function, the pseudonormalized pattern caused by the coexistence of approximately equally important abnormalities of chamber stiffness and relaxation may have effected the initial results [17,39,42].

The changes in haemodynamic parameters (heart rate, systolic and diastolic blood pressure, and rate–pressure product) were not significant in our study. These findings are consistent with those in previous studies [12,40,43].

In patients with CAD (group 2 and 3), there was a significant change in all Doppler transmitral variables from baseline to peak dose of dobutamine, as in previous studies [12,38,44], whereas in controls the peak early filling wave (E) and acceleration time of E was not significantly different from baseline to peak dose of dobutamine. The last data are not in keeping with those reported by two previous studies [38,44,45], in which a significant change of E wave from baseline to peak dose of dobutamine was observed.

The corresponding mean and standard deviation of response of the E wave velocity to dobutamine for groups 1, 2 and 3 (–2.78±10.04, 12.4±9.4 and 16.47±10.65 cm/s) showed a significant difference between control subjects (Group 1) and patients (Group 2 and 3) with a P<0.001, like in the study of El Said et al. [44] and contrary to the study of Mazeika et al. [12].

The changes of A wave were non-significant between controls and CAD patients and these results are in line with previous studies [12,44].

In previous studies, some authors have reported that myocardial ischaemia results in a significant decrease in the E/A ratio [46] and others have found an increase in the E/A ratio during ischaemia [37]. In our study, we registered a decrease of E/A caused by myocardial ischaemia. In a previous study [44], the changes in E/A were significant (P=0.09) between patients with CAD without wall motion abnormalities during dobutamine infusion and controls [12], whereas in the same study, these changes were not significant for determination of CAD. In our study, no significant changes of this Doppler variable were observed between groups, and it cannot be used as a marker in detection of myocardial ischaemia during dobutamine echocardiography.

In our study the change of isovolumic relaxation period from baseline to peak dose of dobutamine was significant in patients with CAD and in controls. But, similar to other studies [12,46], we found no significant changes of isovolumic relaxation period between groups.

In our study, like in previous studies [14,16,31–33] the diagnostic accuracy of single vessel CAD by conventional DSE was low. We compared the sensitivity, specificity and diagnostic accuracy between conventional (2-dimensional) DSE and the changes of the Doppler indices that were significant for the detection of CAD (E, E-Acc, E-Dec and TVI) for the patients with single vessel CAD. This comparison shows that the transmitral Doppler indices had better diagnostic accuracy, in the detection of significant single vessel CAD, than new wall motion abnormalities during conventional DSE (Fig. 3). Our study suggests that the use of transmitral Doppler indices during DSE could have an added value in identifying patients with CAD. The differences in values of transmitral Doppler indices between our study and previous studies could be explained by different baseline characteristics [35–37,8,39,40,43].


   5. Study limitations
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
References
 
Doppler echocardiography, like other imaging techniques, has specific limitations that should be not to overlooked: (1) Doppler ultrasound displays velocity–time information. To obtain true filling variables (volume/s), mitral annulus must be known and is a major source of error. When considering the effects of short-term interventions, however, this variable can be ignored (thus eliminating a considerable source of error) provided that the annulus size is not affected by the intervention itself. (2) Sampling position may affect early and atrial peak flow velocity; however, the ratio between them is not affected by changes in sampling sites. (3) The quality of Doppler ultrasound tracing is not always good enough to perform quantitative evaluations. We excluded patients with bad transmitral Doppler tracing from our study. (4) Doppler-derived filling variables reflect the overall filling of the left ventricle. As happens with the overall ejection fraction, overall filling can be totally preserved even in the presence of regional alterations in diastolic left ventricular abnormalities because of the compensatory mechanism that the non-ischaemic exerts. However, in our study, this factor can be a limitation because of number of patients with prior myocardial infarction (nine patients) in group 3.

There are a lot of other factors which influence left ventricular diastolic filling including preload [47], afterload [48], systolic [49] and diastolic [50] functions of the left ventricle and atrium, age [24], heart rate [25], atrioventricular conduction [51], different phases of respiration [52], etc. The very important factors including heart rate and systemic blood pressure were carefully monitored in our study. However, the major limitation of our study was that we didn't assess invasively left ventricular diastolic function during dobutamine infusion (by left ventricular catheterization).

A limitation of our study could also be the presence of previous myocardial infarction in patients with CAD, and the changes in transmitral Doppler indices could correspond to myocardial viability. However, most of our patients didn't have previous myocardial infarction and we believe that changes in transmitral Doppler indices could represent changes caused by myocardial ischaemia.

Another limitation of our study, was that we did not analyze the pulmonary venous flow velocity pattern and its change during dobutamine infusion which, as suggested in a recent report [50], correlates with left ventricular diastolic pressure and may be more accurate than mitral Doppler in detecting abnormal haemodynamic variables. However, all of these measurements cannot be obtained simultaneously and pulmonary venous flow can be confounded in high cardiac frequencies.

In conclusion, despite many limitations and the oversimplification of a complex phenomenon, mitral flow velocity recordings have clinical potential for non-invasive evaluation of left ventricular diastolic properties in patients with CAD.

Our findings demonstrate that during dobutamine stress testing, patients with CAD had an abnormal response of these transmitral Doppler indices: peak early diastolic velocity flow (E wave), acceleration time of E wave, deceleration time of E wave and the time–velocity integral of transmitral flow. The abnormal responses of these Doppler indices of left ventricular filling are more accurate markers of significant single vessel CAD than the detection by new wall motion abnormalities during conventional DSE.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 5. Study limitations
 References
 

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