Comprehensive Dobutamine Stress CMR Versus Echocardiography in LBBB and Suspected Coronary Artery Disease

OBJECTIVES: Noninvasive diagnosis of CAD in patients with pre-existent LBBB is difficult because single-photon emission computed tomography and stress echocardiography both have limitations. We hypothesized that a comprehensive DSCMR examination including cine, perfusion, and late gadolinium enhancement imaging would be more accurate than DSE, thus potentially reducing the number of unnecessary invasive coronary angiograms. We aimed to compare dobutamine stress cardiac magnetic resonance (DSCMR) with dobutamine stress echocardiography (DSE) in patients with left bundle branch block (LBBB) and suspected coronary artery disease (CAD).

METHODS: We prospectively evaluated 82 consecutive patients with LBBB referred to our cardiology clinic for investigation of suspected CAD. All 82 patients underwent DSE, DSCMR, and invasive quantitative coronary angiography within 14 days. We compared the diagnostic accuracy of DSE, CMR cine imaging, the additive value of first-pass perfusion, and late gadolinium enhancement. In the comprehensive examination, a positive result was adjudged as the presence of either subendocardial or transmural late gadolinium enhancement with or without inducible peri-infarct ischemia or an inducible perfusion defect corresponding to an inducible regional wall motion abnormality.

RESULTS: CMR cine imaging (regional wall motion abnormalities) had higher specificity, negative predictive value, and overall diagnostic accuracy than did DSE (87.5% vs. 72.9%; 80.8% vs. 67.3%; and 80.4% vs. 72.0%, respectively), although sensitivity was the same (72.0%). The addition of first-pass stress perfusion and late gadolinium enhancement (scar) further improved diagnostic confidence (sensitivity 82.4%, specificity 95.8%, positive predictive value 93.3%, negative predictive value 88.5%, and diagnostic accuracy 90.2%).

CONCLUSIONS: DSCMR is a safe procedure and has greater diagnostic accuracy than does DSE in assessing patients with suspected CAD and LBBB. A comprehensive examination with the addition of perfusion and late gadolinium enhancement to CMR cine imaging significantly boosted specificity and sensitivity, making DSCMR a reliable alternative to invasive quantitative coronary angiography in this group of patients. 


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  1. See also:

    Improved diagnosis and prognosis using Decisions Informed by Combining Entities (DICE): results from the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE).
    Doyle M, Pohost GM, Merz CN, Shaw LJ, Sopko G, Rogers WJ, Sharaf BL, Pepine CJ, Vido-Thompson DA, Rayarao G, Tauxe L, Kelsey SF, Mc Nair D, Biederman RW.
    Cardiovasc Diagn Ther. 2013 Dec;3(4):216-27.
    PMCID: PMC3878119.

  2. Interesting study! Stress echo is challenging in LBBB due to the abnormal septal motion. I would have thought that would apply to DS-CMR as well. It does seem as though the CMR stress perfusion component improved accuracy further, as would be expected.

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