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Dynamic Left Ventricular Outflow Tract Obstruction: Comparison between Dobutamine and Exercise Stress-Echo


F. Innocenti, C. Burgisser, C. Agresti, R. Pini


Department of Clinical and Experimental Medicine, High Dependency Observation Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy

Corresponding author: Francesca Innocenti, MD, High Dependency Observation Unit, Largo Brambilla 4, 50142 Firenze, Italy; +39 055 7947748; e-mail: innocentif@aou-careggi.toscana.it
Abstract
A 62 years old man with high cardiovascular risk profile underwent dobutamine stress echocardiography for suspected silent myocardial ischemia; the test showed severe dynamic intraventricular obstruction (maximum gradient 210 mmHg) and was prematurely stopper for high intraventricular gradient.
A maximal exercise stress-echo, performed according to Bruce protocol, showed the same response, in absence of any new asynergic area.
Case report
A 62-year old man was referred to our Hypertension Out-patient Clinic for a recent (three month ago) occasional finding of high blood pressure values (180/90 mmHg), treated with irbesartan and manidipine. He reported a long history of dyslipidemia, treated with simvastatin; he was overweight (body mass index 28.4 kg/m2) and, five years before our visit, a diagnosis of type 2 diabetes was established and a treatment with glimepiride was started. 
In total absence of any symptom, the routine EKG showed a 1 mm horizontal  ST-downsloping in inferior and precordial leads: this pattern could suggest left ventricular hypertrophy, that was not confirmed by following investigations. An echocardiogram showed left ventricular (LV) normal dimensions (end-diastolic diameter 46 mm, 24 mm/m2; septal and posterior wall thickness 7 mm), with global  hyperkinesia.
This patients had an intermediate pre-test probability of CAD according to last guidelines; as his EKG was uninterpretable for CAD assessment, an imaging stress modality could be appropriate  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [1].
A dobutamine stress echo (DSE) was then performed to rule-out coronary artery disease; during the test the patient developed severe dynamic left ventricular outflow tract obstruction, reaching 210 mmHg as maximum intraventricular gradient (Fig. 1), so that the test was stopped at the end of fourth stage (30 �/kg/min, peak heart rate 116/b/min, arterial pressure 150/40 mmHg; basal heart rate 81 b/min, arterial pressure 135/90 mmHg) without new asynergic areas or chest pain; EKG showed an ascending ST downsloping 0.5 mm in D2, aVF, V4-V6, evolving in horizontal downsloping fashion during recovery. Coronary flow velocity on left anterior descending artery (LAD) was measured non-invasively, with pulsed-Doppler and color-Doppler guidance, in a modified 2-chamber view, baseline (Fig. 2) and at the end of high dose dobutamine infusion (Fig. 3); coronary flow reserve was calculated as ratio between peak and rest maximal diastolic coronary flow velocity and was normal (2.4, normal value >2).   
The patient underwent thereafter an exercise stress-echo (ESE): we followed a resting and post-exercise protocol and the exercise was performed according to modified Bruce protocol. The test was stopped for hypertensive response (maximal heart rate, HR, 159 b/min, 100% maximal predicted heart rate; systolic arterial pressure, SBP, 240 mmHg; rate pressure product RPP, 39500 b/min*mmHg; work load 6.8 METS) and the post-exercise echocardiographic examination showed a normal global and regional systolic function, with dynamic intraventricular obstruction (peak gradient 165 mmHg) (Fig. 4); the patient remained asymptomatic and there were no significant EKG modifications.
The patient reached a high workload and performed a negative exercise stress-echo; moreover coronary flow reserve was normal. The negative predictive value of a normal exercise stress-echo is really very high and, despite the high risk profile, we decided not to perform a coronary angiography and to begin a treatment with a �-blocking agent  ADDIN REFMGR.CITE <Refman><Cite><Author>Innocenti</Author><Year>2013</Year><RecNum>198</RecNum><IDText>Stress echocardiography in the ED: diagnostic performance in high-risk subgroups</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>198</Ref_ID><Title_Primary>Stress echocardiography in the ED: diagnostic performance in high-risk subgroups</Title_Primary><Authors_Primary>Innocenti,F.</Authors_Primary><Authors_Primary>Lazzeretti,D.</Authors_Primary><Authors_Primary>Conti,A.</Authors_Primary><Authors_Primary>Zanobetti,M.</Authors_Primary><Authors_Primary>Vicidomini,S.</Authors_Primary><Authors_Primary>Pini,R.</Authors_Primary><Date_Primary>2013/9</Date_Primary><Keywords>Acute Coronary Syndrome</Keywords><Keywords>Aged</Keywords><Keywords>Angiography</Keywords><Keywords>Arteries</Keywords><Keywords>ARTERY DISEASE</Keywords><Keywords>Chest Pain</Keywords><Keywords>CHEST-PAIN</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>CORONARY-ARTERY-DISEASE</Keywords><Keywords>diagnosis</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>ECHO</Keywords><Keywords>Echocardiography</Keywords><Keywords>Emergencies</Keywords><Keywords>Exercise</Keywords><Keywords>Ischemia</Keywords><Keywords>Italy</Keywords><Keywords>MANAGEMENT</Keywords><Keywords>methods</Keywords><Keywords>Pain</Keywords><Keywords>PATIENT</Keywords><Keywords>PROGNOSTIC VALUE</Keywords><Keywords>Stress</Keywords><Keywords>Troponin</Keywords><Reprint>Not in File</Reprint><Start_Page>1309</Start_Page><End_Page>1314</End_Page><Periodical>American Journal of Emergency Medicine</Periodical><Volume>31</Volume><Issue>9</Issue><ISSN_ISBN>0735-6757</ISSN_ISBN><Address>Univ Florence, Dept Crit Care Med &amp; Surg, Intens Observat Unit, Florence, Italy&#xA;Azienda Osped Univ Careggi, Florence, Italy</Address><Web_URL>ISI:000324332900003</Web_URL><ZZ_JournalFull><f name="System">American Journal of Emergency Medicine</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[2]. An ergometric test was repeated after one month; the patient reached a higher work load, with lower rate pressure product (work load 8 METS; peak HR 128 b/min, BP 210/110 mmHg, RPP 26800 b/min*mmHg), without symptoms; the EKG showed a horizontal  ST-downsloping  0.5-1 mm in V4-V6, with fast recovery.    
Discussion
Dynamic LV outflow tract obstruction (DLVOTO) is a relatively common response to DSE, occurring in about 22% of patients  ADDIN REFMGR.CITE <Refman><Cite><Author>Pellikka</Author><Year>1992</Year><RecNum>57</RecNum><IDText>Dynamic intraventricular obstruction during dobutamine stress echocardiography. A new observation</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>57</Ref_ID><Title_Primary>Dynamic intraventricular obstruction during dobutamine stress echocardiography. A new observation</Title_Primary><Authors_Primary>Pellikka,P.A.</Authors_Primary><Authors_Primary>Oh,J.K.</Authors_Primary><Authors_Primary>Bailey,K.R.</Authors_Primary><Authors_Primary>Nichols,B.A.</Authors_Primary><Authors_Primary>Monahan,K.H.</Authors_Primary><Authors_Primary>Tajik,A.J.</Authors_Primary><Date_Primary>1992/11</Date_Primary><Keywords>Aged</Keywords><Keywords>Coronary Disease</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>drug effects</Keywords><Keywords>DYNAMIC INTRAVENTRICULAR OBSTRUCTION</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Doppler</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>HYPOTENSION</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>physiopathology</Keywords><Keywords>Prospective Studies</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Function,Left</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>1429</Start_Page><End_Page>1432</End_Page><Periodical>Circulation</Periodical><Volume>86</Volume><Issue>5</Issue><Address>Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905</Address><Web_URL>PM:1423956</Web_URL><ZZ_JournalStdAbbrev><f name="System">Circulation</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[3]; the underlying mechanism seems to be an hyperdynamic response of global LV function, that determines a cavity obliteration, perhaps in combination with peripheral vasodilation. It develops more frequently in women and in subjects with little LV and  normal systolic function; also a narrowed left ventricular outflow tract seems to play a significant role  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [4-6]. This response has been advocated, in repeated series, to explain symptoms of chest pain and dyspnea in patients without flow-limiting coronary stenosis  ADDIN REFMGR.CITE <Refman><Cite><Author>Henein</Author><Year>1997</Year><RecNum>4</RecNum><IDText>Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>4</Ref_ID><Title_Primary>Stress-induced left ventricular outflow tract obstruction: a potential cause of dyspnea in the elderly</Title_Primary><Authors_Primary>Henein,M.Y.</Authors_Primary><Authors_Primary>O&apos;Sullivan,C.</Authors_Primary><Authors_Primary>Sutton,G.C.</Authors_Primary><Authors_Primary>Gibson,D.G.</Authors_Primary><Authors_Primary>Coats,A.J.</Authors_Primary><Date_Primary>1997/11/1</Date_Primary><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Dyspnea</Keywords><Keywords>Echocardiography</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Exercise Tolerance</Keywords><Keywords>Female</Keywords><Keywords>Hemodynamic Processes</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>Ventricular Dysfunction,Left</Keywords><Reprint>Not in File</Reprint><Start_Page>1301</Start_Page><End_Page>1307</End_Page><Periodical>J.Am.Coll.Cardiol.</Periodical><Volume>30</Volume><Issue>5</Issue><Address>Cardiac Department, Royal Brompton Hospital, London, England, United Kingdom. m.henein@rbh.nthames.nhs.uk</Address><Web_URL>PM:9350931</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[7], but  it can frequently occur in asymptomatic subjects and its clinical value is a topic of debate  ADDIN REFMGR.CITE <Refman><Cite><Author>Luria</Author><Year>1999</Year><RecNum>5</RecNum><IDText>Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>5</Ref_ID><Title_Primary>Prevalence and significance of left ventricular outflow gradient during dobutamine echocardiography</Title_Primary><Authors_Primary>Luria,D.</Authors_Primary><Authors_Primary>Klutstein,M.W.</Authors_Primary><Authors_Primary>Rosenmann,D.</Authors_Primary><Authors_Primary>Shaheen,J.</Authors_Primary><Authors_Primary>Sergey,S.</Authors_Primary><Authors_Primary>Tzivoni,D.</Authors_Primary><Date_Primary>1999/3</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Coronary Disease</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Doppler</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Follow-Up Studies</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Prevalence</Keywords><Keywords>Prognosis</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Stroke Volume</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Function,Left</Keywords><Reprint>Not in File</Reprint><Start_Page>386</Start_Page><End_Page>392</End_Page><Periodical>Eur.Heart J.</Periodical><Volume>20</Volume><Issue>5</Issue><Address>Department of Cardiology, Jesselson Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel</Address><Web_URL>PM:10206385</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.Heart J.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[8]. It can reduce DSE sensitivity, especially for single vessels� disease, but we know that it carries a favourable prognostic value, because it may represent a form of increased contractile reserve  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [9,10]. Moreover, in this situation, the RPP underestimates the actual increase in myocardial oxygen demand imposed on the mid-to-apical cavity by the obliteration, so that the real �work load� achieved would be re-evaluated. 
Few reports described this response also during ESE, identifying the same echocardiographic predisposing factors evidenced for DSE  ADDIN REFMGR.CITE <Refman><Cite><Author>Cabrera-Bueno</Author><Year>2009</Year><RecNum>68</RecNum><IDText>Dynamic left ventricular obstruction evoked by exercise: importance of outflow tract size</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>68</Ref_ID><Title_Primary>Dynamic left ventricular obstruction evoked by exercise: importance of outflow tract size</Title_Primary><Authors_Primary>Cabrera-Bueno,F.</Authors_Primary><Authors_Primary>Molina-Mora,M.J.</Authors_Primary><Authors_Primary>Jimenez-Navarro,M.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>de Teresa,Galvan E.</Authors_Primary><Date_Primary>2009/1</Date_Primary><Keywords>adverse effects</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Probability</Keywords><Keywords>Risk Assessment</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>163</Start_Page><End_Page>164</End_Page><Periodical>Eur.J.Echocardiogr.</Periodical><Volume>10</Volume><Issue>1</Issue><Misc_3>jen293 [pii];10.1093/ejechocard/jen293 [doi]</Misc_3><Web_URL>PM:18945725</Web_URL><ZZ_JournalStdAbbrev><f name="System">Eur.J.Echocardiogr.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[11], especially increased LV mass, reduced LV diastolic dimension and outflow tract diameter; abnormal mitral valve anatomy has also been advocated  ADDIN REFMGR.CITE <Refman><Cite><Author>Alhaj</Author><Year>2013</Year><RecNum>128</RecNum><IDText>Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>128</Ref_ID><Title_Primary>Symptomatic exercise-induced left ventricular outflow tract obstruction without left ventricular hypertrophy</Title_Primary><Authors_Primary>Alhaj,E.K.</Authors_Primary><Authors_Primary>Kim,B.</Authors_Primary><Authors_Primary>Cantales,D.</Authors_Primary><Authors_Primary>Uretsky,S.</Authors_Primary><Authors_Primary>Chaudhry,F.A.</Authors_Primary><Authors_Primary>Sherrid,M.V.</Authors_Primary><Date_Primary>2013/5</Date_Primary><Keywords>Adult</Keywords><Keywords>Cardiomyopathy,Hypertrophic</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>etiology</Keywords><Keywords>Exercise</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy,Left Ventricular</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Mitral Valve</Keywords><Keywords>PATIENT</Keywords><Keywords>physiology</Keywords><Keywords>physiopathology</Keywords><Keywords>Prognosis</Keywords><Keywords>Stress</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>556</Start_Page><End_Page>565</End_Page><Periodical>J Am Soc Echocardiogr</Periodical><Volume>26</Volume><Issue>5</Issue><Misc_3>S0894-7317(13)00112-0 [pii];10.1016/j.echo.2013.02.007 [doi]</Misc_3><Address>Division of Cardiology, Department of Medicine, St. Luke&apos;s-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY, USA</Address><Web_URL>PM:23534983</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Am Soc Echocardiogr</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[12]. When both DSE and ESE were performed in the same patients to compare  DLVOTO prevalence and entity, during DSE this response was more frequent and peak intraventricular gradient was significantly higher  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [13,14]. No study reported detailed data about differences in EKG response to stress test between subjects with and without DLVOTO.
In our patient we observed, during both tests, the same response, comparable also for gradient�s entity (210 mmHg during DSE and 165 mmHg during ESE), that was somewhat lower during ESE, but however severe, always without symptoms or new asynergic areas and with similar EKG modifications. In a population of patients with suspected CAD, we evidenced a higher prevalence of LV dynamic obstruction in  diabetic patients compared with non-diabetics, altogether with a higher heart rate at all DSE stages. We hypothesized that this response could be an early sign of parasympathetic dysfunction, leaving an unbalanced prevalence of sympathetic drive of cardiac rate and contractility. In this perspective we could also explain the rest LV hypercontractility in this patient  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [15]. 
Baseline EKG changes could resemble LV hypertrophy, that was not confirmed: nevertheless we know that repolarisation abnormalities possibly associated with LV hypertrophy have a low accuracy and reproducibility  ADDIN REFMGR.CITE <Refman><Cite><Author>Brady</Author><Year>2005</Year><RecNum>205</RecNum><IDText>ECG patterns confounding the ECG diagnosis of acute coronary syndrome: left bundle branch block, right ventricular paced rhythms, and left ventricular hypertrophy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>205</Ref_ID><Title_Primary>ECG patterns confounding the ECG diagnosis of acute coronary syndrome: left bundle branch block, right ventricular paced rhythms, and left ventricular hypertrophy</Title_Primary><Authors_Primary>Brady,W.J.</Authors_Primary><Authors_Primary>Lentz,B.</Authors_Primary><Authors_Primary>Barlotta,K.</Authors_Primary><Authors_Primary>Harrigan,R.A.</Authors_Primary><Authors_Primary>Chan,T.</Authors_Primary><Date_Primary>2005/11</Date_Primary><Keywords>Acute Coronary Syndrome</Keywords><Keywords>Bundle-Branch Block</Keywords><Keywords>Chest Pain</Keywords><Keywords>CHEST-PAIN</Keywords><Keywords>complications</Keywords><Keywords>diagnosis</Keywords><Keywords>Electrocardiography</Keywords><Keywords>Emergencies</Keywords><Keywords>Emergency Medicine</Keywords><Keywords>etiology</Keywords><Keywords>Humans</Keywords><Keywords>Hypertrophy,Left Ventricular</Keywords><Keywords>Myocardial Infarction</Keywords><Keywords>PATIENT</Keywords><Keywords>physiopathology</Keywords><Keywords>Syndrome</Keywords><Keywords>Tachycardia,Ventricular</Keywords><Keywords>Ventricular Dysfunction,Right</Keywords><Reprint>Not in File</Reprint><Start_Page>999</Start_Page><End_Page>1025</End_Page><Periodical>Emerg Med Clin.North Am</Periodical><Volume>23</Volume><Issue>4</Issue><Misc_3>S0733-8627(05)00056-8 [pii];10.1016/j.emc.2005.07.004 [doi]</Misc_3><Address>Department of Emergency Medicine and Internal Medicine, University of Virginia, Charlottesville, 22908, USA. wb4z@virginia.edu</Address><Web_URL>PM:16199335</Web_URL><ZZ_JournalStdAbbrev><f name="System">Emerg Med Clin.North Am</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[16]. However, in a large, multicenter study Pope et al found that the 9% of ED patients with symptoms suggestive of ACS and either had ECG�LVH or BBB were older, carried a heavier burden of prior cardiac and related diseases, and were at least twice as likely to have confirmed diagnosis of ACS than similar patients without ST segment or T wave abnormalities  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [17]. The situation of our patient, who never reported chest pain, is different from this, but we think that this high-risk subjects deserved further investigations. EKG repolarisation changes during stress test have already been described in patients with angiographically normal coronary arteries  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [18] and the meaning of such a response did not find a univocal interpretation. Presence of a normal coronary flow reserve excludes both a critical coronary stenosis and significant microvascular dysfunction. We did not consider to perform a myocardial SPECT because of the similar diagnostic accuracy, compared with stress-echo  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [19]. We did not consider to perform a coronary CT scan: a negative exercise stress echo yields a very high negative prognostic value  ADDIN REFMGR.CITE <Refman><Cite><Author>Innocenti</Author><Year>2013</Year><RecNum>198</RecNum><IDText>Stress echocardiography in the ED: diagnostic performance in high-risk subgroups</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>198</Ref_ID><Title_Primary>Stress echocardiography in the ED: diagnostic performance in high-risk subgroups</Title_Primary><Authors_Primary>Innocenti,F.</Authors_Primary><Authors_Primary>Lazzeretti,D.</Authors_Primary><Authors_Primary>Conti,A.</Authors_Primary><Authors_Primary>Zanobetti,M.</Authors_Primary><Authors_Primary>Vicidomini,S.</Authors_Primary><Authors_Primary>Pini,R.</Authors_Primary><Date_Primary>2013/9</Date_Primary><Keywords>Acute Coronary Syndrome</Keywords><Keywords>Aged</Keywords><Keywords>Angiography</Keywords><Keywords>Arteries</Keywords><Keywords>ARTERY DISEASE</Keywords><Keywords>Chest Pain</Keywords><Keywords>CHEST-PAIN</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>CORONARY-ARTERY-DISEASE</Keywords><Keywords>diagnosis</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>ECHO</Keywords><Keywords>Echocardiography</Keywords><Keywords>Emergencies</Keywords><Keywords>Exercise</Keywords><Keywords>Ischemia</Keywords><Keywords>Italy</Keywords><Keywords>MANAGEMENT</Keywords><Keywords>methods</Keywords><Keywords>Pain</Keywords><Keywords>PATIENT</Keywords><Keywords>PROGNOSTIC VALUE</Keywords><Keywords>Stress</Keywords><Keywords>Troponin</Keywords><Reprint>Not in File</Reprint><Start_Page>1309</Start_Page><End_Page>1314</End_Page><Periodical>American Journal of Emergency Medicine</Periodical><Volume>31</Volume><Issue>9</Issue><ISSN_ISBN>0735-6757</ISSN_ISBN><Address>Univ Florence, Dept Crit Care Med &amp; Surg, Intens Observat Unit, Florence, Italy&#xA;Azienda Osped Univ Careggi, Florence, Italy</Address><Web_URL>ISI:000324332900003</Web_URL><ZZ_JournalFull><f name="System">American Journal of Emergency Medicine</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>[2], comparable with the cardiac CT scan  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [20]. We did not think that the demonstration of a coronary stenosis that was not functionally significant could anyway modify the management strategy in this patient.   
Previous studies  ADDIN REFMGR.CITE  ADDIN EN.CITE.DATA [14] investigated reproducibility of DSE induced DLVOTO during ESE to explain angina-like symptoms in patients with angiographically normal coronary arteries. In this patient, we could demonstrate that severe dynamic intraventricular obstruction can be evoked also by physical exercise and could be the pathogenetic mechanism of some cases of unexplained EKG modifications.


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Images Legend
Figure 1: CW Doppler imaging of left ventricular outflow tract velocity at peak DSE.
Figure 2: PW Doppler imaging of baseline distal left anterior descending coronary artery flow velocity.
Figure 3: PW Doppler imaging of high dose DSE distal left anterior descending coronary artery flow velocity.
Figure 4: CW Doppler imaging of left ventricular outflow tract velocity at peak exercise.


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�UmH	sH	Uh{}jmHnHsH	u20p�1�X��. ��A!�n"�n#��$�n%�������JD<Refman><Cite><Author>Wolk</Author><Year>2014</Year><RecNum>206</RecNum><IDText>ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>206</Ref_ID><Title_Primary>ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons</Title_Primary><Authors_Primary>Wolk,M.J.</Authors_Primary><Authors_Primary>Bailey,S.R.</Authors_Primary><Authors_Primary>Doherty,J.U.</Authors_Primary><Authors_Primary>Douglas,P.S.</Authors_Primary><Authors_Primary>Hendel,R.C.</Authors_Primary><Authors_Primary>Kramer,C.M.</Authors_Primary><Authors_Primary>Min,J.K.</Authors_Primary><Authors_Primary>Patel,M.R.</Authors_Primary><Authors_Primary>Rosenbaum,L.</Authors_Primary><Authors_Primary>Shaw,L.J.</Authors_Primary><Authors_Primary>Stainback,R.F.</Authors_Primary><Authors_Primary>Allen,J.M.</Authors_Primary><Date_Primary>2014/2/4</Date_Primary><Keywords>Algorithms</Keywords><Keywords>Angiography</Keywords><Keywords>Arteries</Keywords><Keywords>ASSOCIATION</Keywords><Keywords>Calcium</Keywords><Keywords>Cardiology</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>Coronary Occlusion</Keywords><Keywords>Cost-Benefit Analysis</Keywords><Keywords>Decision Making</Keywords><Keywords>diagnosis</Keywords><Keywords>Diagnostic Imaging</Keywords><Keywords>DISEASE</Keywords><Keywords>ECHO</Keywords><Keywords>Echocardiography</Keywords><Keywords>Electrocardiography</Keywords><Keywords>Exercise</Keywords><Keywords>Heart</Keywords><Keywords>heart failure</Keywords><Keywords>HEART-DISEASE</Keywords><Keywords>Humans</Keywords><Keywords>Myocardial Ischemia</Keywords><Keywords>PATIENT</Keywords><Keywords>Patient Safety</Keywords><Keywords>Probability</Keywords><Keywords>Radiation Dosage</Keywords><Keywords>radionuclide imaging</Keywords><Keywords>Risk</Keywords><Keywords>Risk Assessment</Keywords><Keywords>Risk Factors</Keywords><Keywords>standards</Keywords><Keywords>Stress</Keywords><Keywords>surgery</Keywords><Keywords>United States</Keywords><Keywords>Vascular Calcification</Keywords><Reprint>Not in File</Reprint><Start_Page>380</Start_Page><End_Page>406</End_Page><Periodical>J Am Coll.Cardiol.</Periodical><Volume>63</Volume><Issue>4</Issue><Misc_3>S0735-1097(13)06147-0 [pii];10.1016/j.jacc.2013.11.009 [doi]</Misc_3><Web_URL>PM:24355759</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Am Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�D<Refman><Cite><Author>Semba</Author><Year>2012</Year><RecNum>129</RecNum><IDText>Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular hypertrophy</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>129</Ref_ID><Title_Primary>Basic echocardiographic features of patients with latent left ventricular outflow tract obstruction without left ventricular 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ventricular size and function</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>3</Ref_ID><Title_Primary>Left ventricular cavity obliteration during dobutamine stress echocardiography is associated with female sex and left ventricular size and function</Title_Primary><Authors_Primary>Khanal,S.</Authors_Primary><Authors_Primary>Daggubati,R.</Authors_Primary><Authors_Primary>Gaalla,A.</Authors_Primary><Authors_Primary>Shah,P.M.</Authors_Primary><Authors_Primary>Pai,R.G.</Authors_Primary><Date_Primary>1998/10</Date_Primary><Keywords>CORONARY-ARTERY DISEASE</Keywords><Keywords>diagnosis</Keywords><Keywords>DYNAMIC INTRAVENTRICULAR OBSTRUCTION</Keywords><Keywords>Female</Keywords><Keywords>HYPOTENSION</Keywords><Reprint>Not in File</Reprint><Start_Page>957</Start_Page><End_Page>960</End_Page><Periodical>Journal of the American Society of Echocardiography</Periodical><Volume>11</Volume><Issue>10</Issue><Address>Jerry L Pettis Mem VA Hosp, Cardiol Sect, Loma Linda, CA 92357 USA&#xA;Loma Linda Univ, Med Ctr, Cardiol Sect, Loma Linda, CA 92350 USA</Address><Web_URL>ISI:000076490500007</Web_URL><ZZ_JournalFull><f name="System">Journal of the American Society of Echocardiography</f></ZZ_JournalFull><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Camara</Author><Year>2009</Year><RecNum>41</RecNum><IDText>Baseline echocardiographic predictors of dynamic intraventricular obstruction of the left ventricle during dobutamine stress echocardiogram</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>41</Ref_ID><Title_Primary>Baseline echocardiographic predictors of dynamic intraventricular obstruction of the left ventricle during dobutamine stress echocardiogram</Title_Primary><Authors_Primary>Camara,E.J.</Authors_Primary><Authors_Primary>Oliveira,M.M.</Authors_Primary><Authors_Primary>Ribeiro,F.M.</Authors_Primary><Date_Primary>2009/11</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>DYNAMIC INTRAVENTRICULAR OBSTRUCTION</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Image Enhancement</Keywords><Keywords>Image Interpretation,Computer-Assisted</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>PATIENT</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>Stress</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>1195</Start_Page><End_Page>1203</End_Page><Periodical>Echocardiography.</Periodical><Volume>26</Volume><Issue>10</Issue><Misc_3>ECHO953 [pii];10.1111/j.1540-8175.2009.00953.x [doi]</Misc_3><Address>Universidade Federal da Bahia, Salvador-Bahia, Brazil. ecamara@ufba.br</Address><Web_URL>PM:19725857</Web_URL><ZZ_JournalStdAbbrev><f name="System">Echocardiography.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>0D<Refman><Cite><Author>Secknus</Author><Year>1998</Year><RecNum>8</RecNum><IDText>Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>8</Ref_ID><Title_Primary>Diagnostic and prognostic implications of left ventricular cavity obliteration response to dobutamine echocardiography</Title_Primary><Authors_Primary>Secknus,M.A.</Authors_Primary><Authors_Primary>Niedermaier,O.N.</Authors_Primary><Authors_Primary>Lauer,M.S.</Authors_Primary><Authors_Primary>Marwick,T.H.</Authors_Primary><Date_Primary>1998/6/1</Date_Primary><Keywords>Aged</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Cause of Death</Keywords><Keywords>Coronary 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Cleveland Clinic Foundation, Ohio 44195, USA</Address><Web_URL>PM:9631970</Web_URL><ZZ_JournalStdAbbrev><f name="System">Am.J.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Christiaens</Author><Year>2001</Year><RecNum>59</RecNum><IDText>Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>59</Ref_ID><Title_Primary>Normal coronary angiogram and dobutamine-induced left ventricular obstruction during stress echocardiography: a higher hemodynamic responsiveness to dobutamine</Title_Primary><Authors_Primary>Christiaens,L.</Authors_Primary><Authors_Primary>Duplantier,C.</Authors_Primary><Authors_Primary>Allal,J.</Authors_Primary><Authors_Primary>Donal,E.</Authors_Primary><Authors_Primary>Nanadoumgar,H.</Authors_Primary><Authors_Primary>Barraine,R.</Authors_Primary><Authors_Primary>Coisne,D.</Authors_Primary><Date_Primary>2001/5</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Adult</Keywords><Keywords>adverse effects</Keywords><Keywords>Aged</Keywords><Keywords>Aged,80 and over</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>blood</Keywords><Keywords>chemically induced</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>diagnosis</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise 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Ventricles</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>physiopathology</Keywords><Keywords>ultrasonography</Keywords><Reprint>Not in File</Reprint><Start_Page>1461</Start_Page><End_Page>1465</End_Page><Periodical>Rev.Port.Cardiol.</Periodical><Volume>21</Volume><Issue>12</Issue><Address>Servico de Cardiologia do Hospital Garcia de Orta, Almada</Address><Web_URL>PM:12621919</Web_URL><ZZ_JournalStdAbbrev><f name="System">Rev.Port.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite><Cite><Author>Cabrera-Bueno</Author><Year>2009</Year><RecNum>67</RecNum><IDText>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>67</Ref_ID><Title_Primary>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</Title_Primary><Authors_Primary>Cabrera-Bueno,F.J.</Authors_Primary><Authors_Primary>Gomez-Doblas,J.J.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>Montiel-Trujillo,A.</Authors_Primary><Authors_Primary>Jimenez-Navarro,M.</Authors_Primary><Authors_Primary>Martinez-Del-Valle,D.</Authors_Primary><Authors_Primary>Jimenez-Hoyuela,J.M.</Authors_Primary><Authors_Primary>de Teresa-Galvan,E.</Authors_Primary><Date_Primary>2009/3</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>complications</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>HEART-DISEASE</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Prognosis</Keywords><Keywords>Reproducibility of Results</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular Outflow Obstruction</Keywords><Reprint>Not in File</Reprint><Start_Page>272</Start_Page><End_Page>280</End_Page><Periodical>Echocardiography.</Periodical><Volume>26</Volume><Issue>3</Issue><Misc_3>ECHO808 [pii];10.1111/j.1540-8175.2008.00808.x [doi]</Misc_3><Address>Department of Cardiology, University Hospital Virgen de la Victoria, Malaga, Spain. fjcabrera@secardiologia.es</Address><Web_URL>PM:19175778</Web_URL><ZZ_JournalStdAbbrev><f name="System">Echocardiography.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�
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Mellitus</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>DOBUTAMINE STRESS ECHOCARDIOGRAPHY</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Doppler,Color</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>epidemiology</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Italy</Keywords><Keywords>Logistic Models</Keywords><Keywords>Male</Keywords><Keywords>Middle Aged</Keywords><Keywords>Multivariate Analysis</Keywords><Keywords>PATIENT</Keywords><Keywords>physiopathology</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Prevalence</Keywords><Keywords>Rest</Keywords><Keywords>Retrospective Studies</Keywords><Keywords>Risk Assessment</Keywords><Keywords>Risk Factors</Keywords><Keywords>Stress</Keywords><Keywords>Stroke Volume</Keywords><Keywords>surgery</Keywords><Keywords>Time Factors</Keywords><Keywords>ultrasonography</Keywords><Keywords>Ventricular 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Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>204</Ref_ID><Title_Primary>The impact of electrocardiographic left ventricular hypertrophy and bundle branch block on the triage and outcome of ED patients with a suspected acute coronary syndrome: a multicenter study</Title_Primary><Authors_Primary>Pope,J.H.</Authors_Primary><Authors_Primary>Ruthazer,R.</Authors_Primary><Authors_Primary>Kontos,M.C.</Authors_Primary><Authors_Primary>Beshansky,J.R.</Authors_Primary><Authors_Primary>Griffith,J.L.</Authors_Primary><Authors_Primary>Selker,H.P.</Authors_Primary><Date_Primary>2004/5</Date_Primary><Keywords>Acute Coronary Syndrome</Keywords><Keywords>Age Distribution</Keywords><Keywords>Aged</Keywords><Keywords>analysis</Keywords><Keywords>Analysis of Variance</Keywords><Keywords>Bundle-Branch Block</Keywords><Keywords>Chest Pain</Keywords><Keywords>CHEST-PAIN</Keywords><Keywords>complications</Keywords><Keywords>Coronary 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dobutamine stress echocardiography</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>17</Ref_ID><Title_Primary>Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography</Title_Primary><Authors_Primary>Panza,J.A.</Authors_Primary><Authors_Primary>Laurienzo,J.M.</Authors_Primary><Authors_Primary>Curiel,R.V.</Authors_Primary><Authors_Primary>Unger,E.F.</Authors_Primary><Authors_Primary>Quyyumi,A.A.</Authors_Primary><Authors_Primary>Dilsizian,V.</Authors_Primary><Authors_Primary>Cannon,R.O.,III</Authors_Primary><Date_Primary>1997/2</Date_Primary><Keywords>Adult</Keywords><Keywords>Aged</Keywords><Keywords>Arteries</Keywords><Keywords>blood</Keywords><Keywords>Cardiotonic Agents</Keywords><Keywords>Chest Pain</Keywords><Keywords>Coronary Angiography</Keywords><Keywords>diagnostic use</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Transesophageal</Keywords><Keywords>Electrocardiography</Keywords><Keywords>etiology</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>Humans</Keywords><Keywords>Image Processing,Computer-Assisted</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Myocardial Contraction</Keywords><Keywords>Myocardial Ischemia</Keywords><Keywords>PATIENT</Keywords><Keywords>physiopathology</Keywords><Keywords>Stress</Keywords><Reprint>Not in File</Reprint><Start_Page>293</Start_Page><End_Page>301</End_Page><Periodical>J.Am.Coll.Cardiol.</Periodical><Volume>29</Volume><Issue>2</Issue><Misc_3>S0735109796004810 [pii]</Misc_3><Address>Cardiology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland 20892, USA</Address><Web_URL>PM:9014980</Web_URL><ZZ_JournalStdAbbrev><f name="System">J.Am.Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�	D<Refman><Cite><Author>Metz</Author><Year>2007</Year><RecNum>207</RecNum><IDText>The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>207</Ref_ID><Title_Primary>The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis</Title_Primary><Authors_Primary>Metz,L.D.</Authors_Primary><Authors_Primary>Beattie,M.</Authors_Primary><Authors_Primary>Hom,R.</Authors_Primary><Authors_Primary>Redberg,R.F.</Authors_Primary><Authors_Primary>Grady,D.</Authors_Primary><Authors_Primary>Fleischmann,K.E.</Authors_Primary><Date_Primary>2007/1/16</Date_Primary><Keywords>Age Factors</Keywords><Keywords>Aged</Keywords><Keywords>Arteries</Keywords><Keywords>ARTERY DISEASE</Keywords><Keywords>Cohort Studies</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>Coronary Disease</Keywords><Keywords>CORONARY-ARTERY-DISEASE</Keywords><Keywords>DISEASE</Keywords><Keywords>Echocardiography</Keywords><Keywords>Echocardiography,Stress</Keywords><Keywords>Exercise</Keywords><Keywords>Female</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>mortality</Keywords><Keywords>Multivariate Analysis</Keywords><Keywords>Myocardial Infarction</Keywords><Keywords>PATIENT</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Prognosis</Keywords><Keywords>PROGNOSTIC VALUE</Keywords><Keywords>Prospective Studies</Keywords><Keywords>radionuclide imaging</Keywords><Keywords>Risk</Keywords><Keywords>Risk Assessment</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>Sex Factors</Keywords><Keywords>Survival Analysis</Keywords><Keywords>Tomography,Emission-Computed,Single-Photon</Keywords><Keywords>ultrasonography</Keywords><Reprint>Not in File</Reprint><Start_Page>227</Start_Page><End_Page>237</End_Page><Periodical>J Am Coll.Cardiol.</Periodical><Volume>49</Volume><Issue>2</Issue><Misc_3>S0735-1097(06)02506-X [pii];10.1016/j.jacc.2006.08.048 [doi]</Misc_3><Address>Department of Medicine, New York University School of Medicine, New York, New York, USA</Address><Web_URL>PM:17222734</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Am Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>
D<Refman><Cite><Author>Budoff</Author><Year>2008</Year><RecNum>14</RecNum><IDText>Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>14</Ref_ID><Title_Primary>Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) 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Angiography</Keywords><Keywords>Coronary Artery Disease</Keywords><Keywords>Coronary Stenosis</Keywords><Keywords>CORONARY-ARTERY-DISEASE</Keywords><Keywords>DISEASE</Keywords><Keywords>etiology</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>Humans</Keywords><Keywords>Image Interpretation,Computer-Assisted</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle Aged</Keywords><Keywords>Pain</Keywords><Keywords>PATIENT</Keywords><Keywords>physiopathology</Keywords><Keywords>Predictive Value of Tests</Keywords><Keywords>Prevalence</Keywords><Keywords>Prospective Studies</Keywords><Keywords>radiography</Keywords><Keywords>Risk Assessment</Keywords><Keywords>Sensitivity and Specificity</Keywords><Keywords>Severity of Illness Index</Keywords><Keywords>Single-Blind Method</Keywords><Keywords>Tomography,X-Ray Computed</Keywords><Reprint>Not in File</Reprint><Start_Page>1724</Start_Page><End_Page>1732</End_Page><Periodical>J Am Coll.Cardiol.</Periodical><Volume>52</Volume><Issue>21</Issue><Misc_3>S0735-1097(08)02609-0 [pii];10.1016/j.jacc.2008.07.031 [doi]</Misc_3><Address>Department of Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, California, USA. mbudoff@labiomed.org</Address><Web_URL>PM:19007693</Web_URL><ZZ_JournalStdAbbrev><f name="System">J Am Coll.Cardiol.</f></ZZ_JournalStdAbbrev><ZZ_WorkformID>1</ZZ_WorkformID></MDL></Cite></Refman>�D<Refman><Cite><Author>Cabrera-Bueno</Author><Year>2009</Year><RecNum>67</RecNum><IDText>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</IDText><MDL Ref_Type="Journal"><Ref_Type>Journal</Ref_Type><Ref_ID>67</Ref_ID><Title_Primary>Dobutamine stress echocardiography identifies patients with angina and dynamic left ventricular outflow obstruction in physiological exercise</Title_Primary><Authors_Primary>Cabrera-Bueno,F.J.</Authors_Primary><Authors_Primary>Gomez-Doblas,J.J.</Authors_Primary><Authors_Primary>Garcia-Pinilla,J.M.</Authors_Primary><Authors_Primary>Montiel-Trujillo,A.</Authors_Primary><Authors_Primary>Jimenez-Navarro,M.</Authors_Primary><Authors_Primary>Martinez-Del-Valle,D.</Authors_Primary><Authors_Primary>Jimenez-Hoyuela,J.M.</Authors_Primary><Authors_Primary>de Teresa-Galvan,E.</Authors_Primary><Date_Primary>2009/3</Date_Primary><Keywords>Adrenergic beta-Agonists</Keywords><Keywords>Angina Pectoris</Keywords><Keywords>complications</Keywords><Keywords>diagnostic use</Keywords><Keywords>DISEASE</Keywords><Keywords>Dobutamine</Keywords><Keywords>Echocardiography</Keywords><Keywords>Exercise Test</Keywords><Keywords>Female</Keywords><Keywords>Heart</Keywords><Keywords>HEART-DISEASE</Keywords><Keywords>Humans</Keywords><Keywords>Male</Keywords><Keywords>methods</Keywords><Keywords>Middle 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