Abstract
In the presence of left bundle brunch block (LBBB) exercise electrocardiography cannot be used for diagnosis of underlying coronary artery disease (CAD) and TI 201 SPECT exercise myocardial scintigraphy has a limited specificity for exclusion of CAD in the area of left anterior descending artery distribution. We prospectively compared pharmacological stress TI 201 SPECT with dobutamine stress echocardiography (dob-ECHO). Thirty six consecutive patients with LBBB were studied using dob-ECHO, TI 201 SPECT dipyridamole or adenosine myocardial scintigraphy and coronary angiography. A decrease of regional wall thickness or production of akinesis were considered as positive indications for CAD. A positive dob-ECHO response for the LAD area was present in 8/36 patients. In 7/8 a significant (more than 70% diameter stenosis) LAD lesion was found whereas in one there was no evidence of LAD lesion despite the absence of increase in regional wall thickening. In the remaining 28 patients, 12 had normal coronary arteries (8 with dilated cardiomyopathy) whereas in the other 16 significant lesions were present in right and/or circumflex coronary arteries (RCA/Cx). Positive TI 201 SPECT for septal ischemia was found in 8/36 patients in whom only 2 had LAD disease. The indices of diagnostic performance of dob-ECHO /TI 201 SPECT for CAD detection were as follows: % total LAD RCA or Cx sensitivity 67/52 63/37 69/61 specificity 97/76 95/58 * 94/94 positive pred. value 93/58 * 84/38 * 94/92 negative pred. value 82/72 86/69 79/75 * p < 0.001 Concordance between dob-ECHO and TI 201 SPECT was evident in 72% of RCA/Cx segments, whereas it was limited to 15% for LAD area. In conclusion, in LBBB, dob-ECHO has a higher diagnostic performance for the detection of LAD and overall coronary artery disease than pharmacological stress TI 201 SPECT, thus providing a useful alternative clinical means for the detection of CAD in this pathology.
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