Dear Paulo,

I think Stress echocardiography with dobutamine infusion for detection of coronary artery disease is a potential alternative to exercise stress testing. Dobutamine stress echocardiography is well tolerated, is useful for detection and assessment of coronary artery disease and is applicable to patients unable to exercise.

Dear Anil,

I agree with you. And about contrast echo? Do you have experience with Dobumine Contrast Echocardiography or any other modality of contrast associated with stress test?

Dear Paulo,

Tredamill stress test is the best if the patient is able to do so. I don;t have experience with Dobutamine contrast Echo however few of my friend on some occasion used Saline (sterile salt water) and Definity as contrast solutions. Each can show the flow of blood through the heart and enhance the pictures of the heart.

When saline is used the saline is shaken to create very small harmless bubbles of air that are injected into the IV. When Definity is used this is also injected into the IV during the echocardiogram. The agitated saline or Definity can be seen flowing through the heart during the echocardiogram.

Definity contrast helps in enhancing the endocardial border in a poor acoustic window study. Its credibility is in distinguishing the LV thrombus and apical hypertrophy etc. LV non - compaction can also be well definied by definity contrast. I doubt whether definity contrast has any added advantage over stress echo/ dobutamine stress echo.

Contrast echo for LV opacification helps in better delieniation of endocardial borders but as far as myocardial perfusion  is concerned ; i believe there is still a learning curve which may get better over time.

In patients with difficult images there is no doubt that contrast can enhance endocardial definition and improve diagnosis. The down side is the additional time, cost and potential for adverse reaction. We now use a lot of Definite in our lab for both Dobutamine and exercise stress (technically easier with dobutamine though) as well as the other usual indications.

Tredamil excercis echocardiographic may be a good choice for detection of CAD. But this test is much operaters skill dependent. The sensitivity and specificity much higher Than DSE.

We keep DSE for patients with Myocardial infarction (post discharge or follow up), for those who can not exercise and for preoperative evaluation.

To us bicycle ergometer echo is preferred when the patients are haveing LVH or if we want to add 2 D strain.

Myocardial contrast echo for detection of CAD is not appealing to us.