Objectives: This study aimed to systematically assess and to compare the diagnostic performance of stress myocardial perfusion imaging (sMRI) and dobutamine stress-echocardiography (DSE) for the non-invasive diagnosis of relevant CAD through a meta-analysis of the existing evidence using conventional invasive methods as the reference standard.
Search methods: The data bases of MEDLINE, EMBASE and the Cochrane Library have been searched for literature evaluating either sMRI, DSE or both for the diagnosis of relevant CAD. The meta-analysis has been performed based on Cochrane guidelines.
Selection criteria: A study was included if (1) CCA or FFR was used as a reference standard for diagnosing of relevant CAD, defined as >70% stenosis respectively <0.80 pressure gradient in hyperaemia; (2) sufficient data to permit analysis and to reconstruct contingency tables (explicitly true-positive, false-positive, false-negative and true-negative findings) was provided; (3) there was a minimal sample size of 20 patients; (4) stress-perfusion was facilitated using either adenosine or regadenoson, respectively dobutamine; and (5) the studies was of prospective design.
Data collection and analysis: From the 5.634 studies identified, 1.306 relevant articles were selected after title screening. Just 47 fulfilled all inclusion criteria on full-text review, resulting in a total sample size of 4.742 patients. Data extraction was performed for each study by two reviewers independently.Pooled analysis was performed based on a random effects models.
Results: The sensitivity, specificity and diagnostic odds ratio (DOR) for sMRI were 0.88 (95% CI: 0.85-0.90), 0.84 (95% CI: 0.81-0.87), and 38 (95% CI: 29-49), respectively 0.72 (95% CI: 0.61-0.81), 0.89 (95% CI: 0.83-0.93), and 20 (95% CI: 9-46) for DSE. Post-test probability was augmented by positive (likelihood ratio) LR of 5.5 (95% CI: 4.7-6.5) and negative LR of 0.14 (95% CI: 0.12-0.18) based on Bayes’ theorem, as compared to LR of 6.3 (95% CI: 3.8, 10.4) and negative LR of 0.31 (95% CI: 0.21, 0.46) for DSE. The size of the prediction region on the hierarchical summary receiver operating characteristic (HSROC) plot for sMRI (0.2894; 95 % CI 0.1087–0.7703) was significantly smaller compared to the one of DSE (1.0665; 95 % CI 0.2721–4.1938; p<0.01).
Conclusion: The results of this systematic review and meta-analysis attest sMRI a superior diagnostic performance of relevant CAD compared to DSE and can refine the post-test probability of CAD.