cardioКардиологияKardiologiia0022-90402412-5660Kardiomag10.18087/cardio.2021.3.n1462cardio-1462Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИRESEARCH ARTICLESСпекл-трекинг стресс-эхокардиография с использованием тредмил-теста в оценке функциональной значимости степени стеноза коронарных артерийSpeckle Tracking Stress Echocardiography on Treadmill in Assessment of the Functional Significance of the Degree of Coronary Artery DiseaseСтепановаА. И.StepanovaA. I.

аспирантка 3-го года кафедры терапии, кардиологии и функциональной диагностики с курсом нефрологии

Postgraduate student of the Department of Therapy, Cardiology and Functional Diagnostics with the Course of Nephrology 

fr.anya.dz@gmail.comРадоваН. Ф.RadovaN. F.

к.м.н., врач отделения функциональной диагностики 

Physician of the Department of Functional Diagnostics of the Central Clinical Hospital of Department оf Presidential Affairs, Ph.D. 

radova.natalia@yandex.ruАлехинМ. Н.AlekhinM. N.

Заведующий отделением функциональной диагностики ФГБУ "Центральная клиническая больница с поликлиникой" Управления делами Президента РФ

д.м.н., заслуженный врач России, профессор кафедры терапии, кардиологии и функциональной диагностики с курсом нефрологии 

Head of the Department of Functional Diagnostics of the Central Clinical Hospital of Department оf Presidential Affairs

Professor of the Department of Therapy, Cardiology and Functional Diagnostics with the Course of Nephrology of the Central State Medical Academy of Department оf Presidential Affairs; Doctor of Medical Sciences, Honored Doctor of the Russian Federation

amn@mail.ruФГБУ ДПО "Центральная государственная медицинская академия" Управления делами Президента РФ, МоскваРоссияCentral State Medical Academy of Department оf Presidential Affairs, MoscowRussian FederationФГБУ ДПО "Центральная государственная медицинская академия" Управления делами Президента РФ, Москва; ФГБУ "Центральная клиническая больница с поликлиникой" Управления делами Президента РФ, МоскваРоссияCentral State Medical Academy of Department оf Presidential Affairs, Moscow; Central Clinical Hospital with Out-patient Clinic of Department of Presidential Affairs, MoscowRussian FederationФГБУ ДПО "Центральная государственная медицинская академия" Управления делами Президента РФ, Москва; ФГБУ "Центральная клиническая больница с поликлиникой" Управления делами Президента РФ, МоскваРоссияCentral State Medical Academy of Department оf Presidential Affairs, Moscow Central Clinical Hospital with Out-patient Clinic of Department of Presidential Affairs, MoscowRussian Federation202130032021613411Copyright © Kardiomag, 20212021KardiomagKardiomaghttps://cardio.elpub.ru/jour/about/submissions#copyrightNoticehttps://cardio.elpub.ru/jour/article/view/1462

Цель      Определение диагностических возможностей глобальной продольной систолической деформации (ГПСД) левого желудочка (ЛЖ) при стресс-эхокардиографии (стресс-ЭхоКГ) с использованием тредмил-теста в диагностике функциональной значимости степени стеноза коронарных артерий (КА).

Материал и методы        В исследование был включен 121 пациент (73 мужчины, средний возраст 68,3±7,7 года), с подозрением или с ранее установленным диагнозом ишемической болезни сердца (ИБС). Всем пациентам проводили спекл-трекинг стресс-ЭхоКГ (технология отслеживания пятен в двухмерном серошкальном ультразвуковом изображении) с использованием тредмил-теста и коронарографию. Пациенты были разделены на 3 группы в зависимости от выраженности стеноза КА по шкале Gensini.

Результаты       ГПСД ЛЖ в покое статистически значимо не различалась между исследуемыми группами пациентов. После прекращения нагрузки ГПСД ЛЖ у пациентов с выраженным стенозом КА была статистически значимо ниже, чем у пациентов без стеноза КА и с умеренным стенозом КА – 15,9±4,6 % в сравнении с 20,6±3,7 % (p<0,001) и 19,6±3,0 % (p=0,003) соответственно. ГПСД ЛЖ после прекращения нагрузки менее 16,9 % позволяла предполагать выраженный стеноз КА с чувствительностью 80 % и специфичностью 70 % (площадь под кривой AUC 0,76±0,06 при 95 % доверительном интервале – ДИ 0,63–0,89; р<0,001). В группе пациентов без стеноза КА наблюдался статистически значимый прирост ГПСД ЛЖ после прекращения нагрузки (с 19,1±3,1 до 20,6±3,7; p=0,04).

Заключение         Оценка ГПСД ЛЖ и ее динамики при стресс-ЭхоКГ с использованием тредмил-теста может быть перспективной у пациентов с ИБС, поскольку у большинства пациентов с выраженным стенозом КА ГПСД ЛЖ снижена в исходном состоянии и уменьшается в ответ на нагрузку. ГПСД ЛЖ у пациентов без поражения КА после прекращения нагрузки увеличивается.

Aim        To determine diagnostic capabilities of left ventricular (LV) global longitudinal systolic strain (GLSS) in stress echocardiography (stress-EchoCG) with a treadmill test for diagnosing the functional significance of the degree of coronary stenosis.

Material and methods        The study included 121 patients (73 men aged 68.3±7.7 years) with suspected or previously diagnosed ischemic heart disease (IHD). Speckle-tracking stress-EchCG (method of tracking speckles on two-dimensional gray-scale ultrasonic images) with a treadmill test and coronarography was performed for all patients. The patients were divided into 3 groups based on the severity of coronary artery (CA) stenosis according to the Gensini scale.

Results   LV GLSS at rest did not significantly differ between the study groups. After the exercise, LV GLSS was significantly lower in patients with pronounced CA stenosis than in patients without or with moderate CA stenosis (15.9±4.6 % vs. 20.6±3.7 % (p<0.001) and 19.6±3.0 % (p=0.003), respectively). Postexercise LV GLSS <16.9% suggested a pronounced CA stenosis with a sensitivity of 80% and a specificity of 70% (area under the curve, AUC, 0.76±0.06 at 95 % confidence interval, CI, 0.63–0.89; р<0.001). In the patient group without CA stenosis, LV GLSS showed a significant increase after completion of the exercise (from 19.1±3.1 to 20.6±3.7; p=0.04).

Conclusion            Evaluation of LV GLSS and its dynamics in stress-EchoCG with a treadmill test may be promising in patients with IHD, since in most patients with pronounced CA stenosis, LV GLSS is reduced at baseline and further reduces in response to exercise. In patients without CA stenosis, LV GLSS increases after completing the exercise.

 

Ишемическая болезнь сердцаспекл-трекингстресс-эхокардиографиятредмил-тестглобальная продольная систолическая деформацияIschemic heart diseasespeckle-trackingstress-echocardiographytreadmill testglobal longitudinal systolic strainКонфликт интересов не заявлен.No conflict of interest is reported.ReferencesNowbar AN, Gitto M, Howard JP, Francis DP, Al-Lamee R. Mortality From Ischemic Heart Disease: Analysis of Data From the World Health Organization and Coronary Artery Disease Risk Factors From NCD Risk Factor Collaboration. Circulation: Cardiovascular Quality and Outcomes. 2019;12(6):e005375. DOI: 10.1161/CIRCOUTCOMES.118.005375Nowbar AN, Gitto M, Howard JP, Francis DP, Al-Lamee R. Mortality From Ischemic Heart Disease: Analysis of Data From the World Health Organization and Coronary Artery Disease Risk Factors From NCD Risk Factor Collaboration. Circulation: Cardiovascular Quality and Outcomes. 2019;12(6):e005375. DOI: 10.1161/CIRCOUTCOMES.118.005375Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography. Journal of the American Society of Echocardiography. 2007;20(9):1021–41. DOI: 10.1016/j.echo.2007.07.003Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography. Journal of the American Society of Echocardiography. 2007;20(9):1021–41. DOI: 10.1016/j.echo.2007.07.003Smiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? European Heart Journal. 2016;37(15):1196–207. DOI: 10.1093/eurheartj/ehv529Smiseth OA, Torp H, Opdahl A, Haugaa KH, Urheim S. Myocardial strain imaging: how useful is it in clinical decision making? European Heart Journal. 2016;37(15):1196–207. DOI: 10.1093/eurheartj/ehv529Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015;28(1):1-39.e14. DOI: 10.1016/j.echo.2014.10.003Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015;28(1):1-39.e14. DOI: 10.1016/j.echo.2014.10.003Cha M-J, Kim H-S, Kim SH, Park J-H, Cho G-Y. Prognostic power of global 2D strain according to left ventricular ejection fraction in patients with ST elevation myocardial infarction. PLOS ONE. 2017;12(3):e0174160. DOI: 10.1371/journal.pone.0174160Cha M-J, Kim H-S, Kim SH, Park J-H, Cho G-Y. Prognostic power of global 2D strain according to left ventricular ejection fraction in patients with ST elevation myocardial infarction. PLOS ONE. 2017;12(3):e0174160. DOI: 10.1371/journal.pone.0174160Hubbard RT, Arciniegas Calle MC, Barros-Gomes S, Kukuzke JA, Pellikka PA, Gulati R et al. 2-Dimensional Speckle Tracking Echocardiography predicts severe coronary artery disease in women with normal left ventricular function: a case-control study. BMC Cardiovascular Disorders. 2017;17(1):231. DOI: 10.1186/s12872-017-0656-5Hubbard RT, Arciniegas Calle MC, Barros-Gomes S, Kukuzke JA, Pellikka PA, Gulati R et al. 2-Dimensional Speckle Tracking Echocardiography predicts severe coronary artery disease in women with normal left ventricular function: a case-control study. BMC Cardiovascular Disorders. 2017;17(1):231. DOI: 10.1186/s12872-017-0656-5Billehaug Norum I, Ruddox V, Edvardsen T, Otterstad JE. Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review. BMC Medical Imaging. 2015;15(1):25. DOI: 10.1186/s12880-015-0067-yBillehaug Norum I, Ruddox V, Edvardsen T, Otterstad JE. Diagnostic accuracy of left ventricular longitudinal function by speckle tracking echocardiography to predict significant coronary artery stenosis. A systematic review. BMC Medical Imaging. 2015;15(1):25. DOI: 10.1186/s12880-015-0067-yRumbinaitė E, Žaliaduonytė-Pekšienė D, Vieželis M, Čeponienė I, Lapinskas T, Žvirblytė R et al. Dobutamine-stress echocardiography speckle-tracking imaging in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of coronary artery disease. Medicina. 2016;52(6):331–9. DOI: 10.1016/j.medici.2016.11.005Rumbinaitė E, Žaliaduonytė-Pekšienė D, Vieželis M, Čeponienė I, Lapinskas T, Žvirblytė R et al. Dobutamine-stress echocardiography speckle-tracking imaging in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of coronary artery disease. Medicina. 2016;52(6):331–9. DOI: 10.1016/j.medici.2016.11.005Nishi T, Funabashi N, Ozawa K, Nishi T, Kamata T, Fujimoto Y et al. Regional layer-specific longitudinal peak systolic strain using exercise stress two-dimensional speckle-tracking echocardiography for the detection of functionally significant coronary artery disease. Heart and Vessels. 2019;34(8):1394–403. DOI: 10.1007/s00380-019-01361-wNishi T, Funabashi N, Ozawa K, Nishi T, Kamata T, Fujimoto Y et al. Regional layer-specific longitudinal peak systolic strain using exercise stress two-dimensional speckle-tracking echocardiography for the detection of functionally significant coronary artery disease. Heart and Vessels. 2019;34(8):1394–403. DOI: 10.1007/s00380-019-01361-wPark JH, Woo JS, Ju S, Jung SW, Lee I, Kim JB et al. Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease. Medicine. 2016;95(32):e4549. DOI: 10.1097/MD.0000000000004549Park JH, Woo JS, Ju S, Jung SW, Lee I, Kim JB et al. Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease. Medicine. 2016;95(32):e4549. DOI: 10.1097/MD.0000000000004549Mansour MJ, AlJaroudi W, Hamoui O, Chaaban S, Chammas E. Multimodality imaging for evaluation of chest pain using strain analysis at rest and peak exercise. Echocardiography. 2018;35(8):1157–63. DOI: 10.1111/echo.13885Mansour MJ, AlJaroudi W, Hamoui O, Chaaban S, Chammas E. Multimodality imaging for evaluation of chest pain using strain analysis at rest and peak exercise. Echocardiography. 2018;35(8):1157–63. DOI: 10.1111/echo.13885Ejlersen JA, Poulsen SH, Mortensen J, May O. Diagnostic value of layerspecific global longitudinal strain during adenosine stress in patients suspected of coronary artery disease. The International Journal of Cardiovascular Imaging. 2017;33(4):473–80. DOI: 10.1007/s10554-016-1022-xEjlersen JA, Poulsen SH, Mortensen J, May O. Diagnostic value of layerspecific global longitudinal strain during adenosine stress in patients suspected of coronary artery disease. The International Journal of Cardiovascular Imaging. 2017;33(4):473–80. DOI: 10.1007/s10554-016-1022-xKnuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, FunckBrentano C et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal. 2020;41(3):407–77. DOI: 10.1093/eurheartj/ehz425Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, FunckBrentano C et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. European Heart Journal. 2020;41(3):407–77. DOI: 10.1093/eurheartj/ehz425Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR et al. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Journal of the American Society of Echocardiography. 2020;33(1):1-41.e8. DOI: 10.1016/j.echo.2019.07.001Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR et al. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Journal of the American Society of Echocardiography. 2020;33(1):1-41.e8. DOI: 10.1016/j.echo.2019.07.001Picano E, Bombardini T, Kovačević Preradović T, Cortigiani L, Wierzbowska-Drabik K, Ciampi Q. Left ventricular contractile reserve in stress echocardiography: the bright side of the force. Kardiologia Polska. 2019;77(2):164–72. DOI: 10.5603/KP.a2019.0002Picano E, Bombardini T, Kovačević Preradović T, Cortigiani L, Wierzbowska-Drabik K, Ciampi Q. Left ventricular contractile reserve in stress echocardiography: the bright side of the force. Kardiologia Polska. 2019;77(2):164–72. DOI: 10.5603/KP.a2019.0002Гаврилова Н.Е., Метельская В.А., Перова Н.В., Яровая Е.Б., Бойцов С.А., Мазаев В.П. Выбор метода количественной оценки поражения коронарных артерий на основе сравнительного анализа ангиографических шкал. Российский кардиологический журнал. 2014;19(6):24-9. DOI: 10.15829/1560-4071-2014-6-24-29Gavrilova N.E., Metelskaya V.A., Perova N.V., Yarovaya E.B., Boytsov S.A., Mazaev V.P. Factor analysis and individual prognosis for the patients with first revealed arterial hypertension. Russian Journal of Cardiology. 2014;19(6):24–9. DOI: 10.15829/1560-4071-2014-6-24-29Moustafa S, Elrabat K, Swailem F, Galal A. The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris. Indian Heart Journal. 2018;70(3):379–86. DOI: 10.1016/j.ihj.2017.09.220Moustafa S, Elrabat K, Swailem F, Galal A. The correlation between speckle tracking echocardiography and coronary artery disease in patients with suspected stable angina pectoris. Indian Heart Journal. 2018;70(3):379–86. DOI: 10.1016/j.ihj.2017.09.220Gaibazzi N, Pigazzani F, Reverberi C, Porter TR. Rest global longitudinal 2D strain to detect coronary artery disease in patients undergoing stress echocardiography: a comparison with wall-motion and coronary flow reserve responses. Echo Research and Practice. 2014;1(2):61–70. DOI: 10.1530/ERP-14-0020Gaibazzi N, Pigazzani F, Reverberi C, Porter TR. Rest global longitudinal 2D strain to detect coronary artery disease in patients undergoing stress echocardiography: a comparison with wall-motion and coronary flow reserve responses. Echo Research and Practice. 2014;1(2):61–70. DOI: 10.1530/ERP-14-0020Aggeli C, Lagoudakou S, Felekos I, Panagopoulou V, Kastellanos S, Toutouzas K et al. Two-dimensional speckle tracking for the assessment of coronary artery disease during dobutamine stress echo: clinical tool or merely research method. Cardiovascular Ultrasound. 2015;13(1):43. DOI: 10.1186/s12947-015-0038-zAggeli C, Lagoudakou S, Felekos I, Panagopoulou V, Kastellanos S, Toutouzas K et al. Two-dimensional speckle tracking for the assessment of coronary artery disease during dobutamine stress echo: clinical tool or merely research method. Cardiovascular Ultrasound. 2015;13(1):43. DOI: 10.1186/s12947-015-0038-zUusitalo V, Luotolahti M, Pietilä M, Wendelin-Saarenhovi M, Hartiala J, Saraste M et al. Two-Dimensional Speckle-Tracking during Dobutamine Stress Echocardiography in the Detection of Myocardial Ischemia in Patients with Suspected Coronary Artery Disease. Journal of the American Society of Echocardiography. 2016;29(5):470-479.e3. DOI: 10.1016/j.echo.2015.12.013Uusitalo V, Luotolahti M, Pietilä M, Wendelin-Saarenhovi M, Hartiala J, Saraste M et al. Two-Dimensional Speckle-Tracking during Dobutamine Stress Echocardiography in the Detection of Myocardial Ischemia in Patients with Suspected Coronary Artery Disease. Journal of the American Society of Echocardiography. 2016;29(5):470-479.e3. DOI:Hwang H-J, Lee H-M, Yang I-H, Lee JL, Pak HY, Park C-B et al. The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography. Journal of Cardiovascular Ultrasound. 2014;22(3):127–33. DOI: 10.4250/jcu.2014.22.3.1271016/j.echo.2015.12.013Пирцхалава С.Д., Асымбекова Э.У., Ахмедярова Н.К., Рахимов А.З., Бузиашвили В.Ю., Тугеева Э.Ф. и др. Изменения деформации миокарда левого желудочка у больных ишемической болезнью сердца при стресс-эхокардиографии. Клиническая физиология кровообращения. 2018;15(4):249-60. DOI: 10.24022/1814-6910-2018-15-4-249-260Hwang H-J, Lee H-M, Yang I-H, Lee JL, Pak HY, Park C-B et al. The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography. Journal of Cardiovascular Ultrasound. 2014;22(3):127–33. DOI: 10.4250/jcu.2014.22.3.127Cortigiani L, Ramirez P, Coltelli M, Bovenzi F, Picano E. Drop-off in positivity rate of stress echocardiography based on regional wall motion abnormalities over the last three decades. The International Journal of Cardiovascular Imaging. 2019;35(4):627–32. DOI: 10.1007/s10554-018- 1501-3Pirtskhalava S.D., Asymbekova E.U., Akhmedyarova N.K., Rakhimov A.Z., Buziashvili V.Yu., Tugeeva E.F. et al. Changes in myocardial deformation of the left ventricle in patients with ischemic heart disease under stress echocardiography. Clinical Physiology of Circulation. 2018;15(4):249–60. DOI: 10.24022/1814-6910-2018-15-4-249-260Barbieri A, Mantovani F, Bursi F, Bartolacelli Y, Manicardi M, Lauria M et al. 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility. Journal of Cardiovascular Echography. 2018;28(1):32–8. DOI: 10.4103/jcecho.jcecho_48_17Cortigiani L, Ramirez P, Coltelli M, Bovenzi F, Picano E. Drop-off in positivity rate of stress echocardiography based on regional wall motion abnormalities over the last three decades. The International Journal of Cardiovascular Imaging. 2019;35(4):627–32. DOI: 10.1007/s10554-018- 1501-3Gupta K, Kakar TS, Gupta A, Singh A, Gharpure N, Aryal S et al. Role of left ventricle deformation analysis in stress echocardiography for significant coronary artery disease detection: A diagnostic study meta‐analysis. Echocardiography. 2019;36(6):1084–94. DOI: 10.1111/echo.14365Barbieri A, Mantovani F, Bursi F, Bartolacelli Y, Manicardi M, Lauria M et al. 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility. Journal of Cardiovascular Echography. 2018;28(1):32–8. DOI: 10.4103/jcecho.jcecho_48_17Yu Y, Villarraga HR, Saleh HK, Cha SS, Pellikka PA. Can ischemia and dyssynchrony be detected during early stages of dobutamine stress echocardiography by 2-dimensional speckle tracking echocardiography? The International Journal of Cardiovascular Imaging. 2013;29(1):95–102. DOI: 10.1007/s10554-012-0074-9Gupta K, Kakar TS, Gupta A, Singh A, Gharpure N, Aryal S et al. Role of left ventricle deformation analysis in stress echocardiography for significant coronary artery disease detection: A diagnostic study meta‐analysis. Echocardiography. 2019;36(6):1084–94. DOI: 10.1111/echo.14365Ng ACT, Sitges M, Pham PN, Tran DT, Delgado V, Bertini M et al. Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography. American Heart Journal. 2009;158(5):836–44. DOI: 10.1016/j.ahj.2009.09.010Yu Y, Villarraga HR, Saleh HK, Cha SS, Pellikka PA. Can ischemia and dyssynchrony be detected during early stages of dobutamine stress echocardiography by 2-dimensional speckle tracking echocardiography? The International Journal of Cardiovascular Imaging. 2013;29(1):95–102. DOI: 10.1007/s10554-012-0074-9Ng ACT, Sitges M, Pham PN, Tran DT, Delgado V, Bertini M et al. Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography. American Heart Journal. 2009;158(5):836–44. DOI: 10.1016/j.ahj.2009.09.010Ng ACT, Sitges M, Pham PN, Tran DT, Delgado V, Bertini M et al. Incremental value of 2-dimensional speckle tracking strain imaging to wall motion analysis for detection of coronary artery disease in patients undergoing dobutamine stress echocardiography. American Heart Journal. 2009;158(5):836–44. DOI: 10.1016/j.ahj.2009.09.010

The authors declare that there are no conflicts of interest present.