REVIEW ARTICLES Dobutamine Stress Myocardial Perfusion Imaging

In patients with limited exercise capacity and (relative) contraindications to direct vasodilators such as dipyridamole or adenosine, dobutamine stress nuclear myocardial perfusion imaging (DSMPI) represents an alternative, exercise-independent stress modality for the detection of coronary artery disease (CAD). Nondiagnostic test results (absence of reversible perfusion defects with submaximal stress) do occur in approximately 10% of patients. Serious side effects during DSMPI are rare, with no death, myocardial infarction or ventricular fibrillation reported in three DSMPI safety reports for a total of 2,574 patients. On the basis of a total number of 1,014 patients reported in 20 studies, the sensitivity, specificity and accuracy of the test for the detection of CAD were 88%, 74% and 84%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 84%, 95% and 100%, respectively. The sensitivity for detection of left circumflex CAD (50%) was lower, compared with that for left anterior descending CAD (68%) and right CAD (88%). The sensitivity of predicting multivessel disease by multiregion perfusion abnormalities varied widely, from 44% to 89%, although specificity was excellent in all studies (89% to 94%). In direct diagnostic comparisons, DSMPI was more sensitive, but less specific, than dobutamine stress echocardiography and comparable with direct vasodilator myocardial perfusion imaging. In the largest prognostic study, patients with a normal DSMPI study had an annual hard event rate less than 1%. An ischemic scan pattern provided independent prognostic value, with a direct relationship between the extent and severity of the perfusion defects and prognosis. In conclusion, DSMPI seems a safe and useful nonexercise-dependent stress modality to detect CAD and assess prognosis. (J Am Coll Cardiol 2000;36:2017‐27) © 2000 by the American College of Cardiology Confirming or excluding coronary artery disease (CAD) in patients with chest pain remains a challenge because this disease is still the leading cause of death in the western world (1). Traditionally, exercise stress testing is performed as a first-line noninvasive diagnostic stress test (2). However, large numbers of patients referred for evaluation of chest pain are unable to perform adequate exercise testing, mainly because of deconditioning or neurologic, respiratory, peripheral vascular or orthopedic limitations (3). In these patients, pharmacological stress nuclear myocardial perfusion imaging (MPI) represents an alternative, exerciseindependent stress modality. Usually, dipyridamole or adenosine is used as a stressor because of their superiority in creating blood flow heterogeneity (4) and the extensive experience with these stress modalities. For patients with (relative) contraindications to these direct vasodilators, such as severe obstructive airway disease (particularly patients with active wheezing or recent hospitalization for an exacerbation), high-grade atrioventricular block, arterial hypotension, ingestion of caffeine-containing beverages ,12 h before testing or the use of dipyridamole or theophyllinecontaining compounds or medications ,24 h before testing, dobutamine stress myocardial perfusion imaging (DSMPI) represents an alternative stress modality. Since its clinical