Should the diagnosis of coronary artery disease be based on the evaluation of myocardial function or perfusion?

The aim of this review was to define the place of stress (exercise, dobutamine, and vasodilator) echocardiography in the context of perfusion scintigraphic techniques for the detection of coronary artery disease. Echocardiography and nuclear imaging have their strong and weak points. Echocardiography has the benefit of widespread availability, relatively low cost, portability, absence of radiation, safety, and determination of ischaemic threshold. However, echocardiographic imaging cannot be performed during treadmill exercise, the echocardiographic windows are variable with sometimes poor echogenicity, and interpretation is subjective and requires an important learning curve. Diagnostic comparisons were focused on studies involving echocardiographic and nuclear imaging in the same patients. These direct comparisons show that exercise or dobutamine echocardiography and perfusion imaging have similar accuracies for the detection and localization of coronary artery disease. Perfusion imaging may be more sensitive in the detection of mild coronary artery disease; echocardiography, however, has a better specificity. Vasodilator perfusion imaging is superior to vasodilator echocardiography, although the new dipyridamole-atropine echocardiography test will make future reassessment necessary. Once the condition of adequate echocardiographic training is fulfilled, we believe that the selection of one or other test should be tailored to clinical circumstances rather than be a uniform decision.