Management of spontaneous coronary artery dissection: review of the literature and discussion based on a series of 12 young women with acute coronary syndrome.

Spontaneous coronary artery dissection (SCAD) is a rare pathology, principally affecting young women free of atheroma risk factors. Its physiopathology remains little understood, and the prognosis for such acute coronary syndromes is poor, as they occur suddenly. Management is often difficult, and no guidelines exist. The present single-center retrospective study concerns 12 cases of SCAD occurring between 2001 and 2008 in female patients under the age of 60. Eleven patients survived, with a favorable long-term evolution. Only 2 had conservative medical therapy, the other 10 undergoing percutaneous coronary intervention (2 procedures involving a coronary artery bypass graft). On the basis of this series and data from the literature, we suggest a strategy to improve the often dire prognosis of SCAD. Emergency angiography to confirm diagnosis is essential. Treatment should be guided by the extent of the lesions, the myocardial ischemia and the hemodynamic status. Conservative medical therapy is a reasonable approach in the case of distal dissection or conserved coronary flow. Percutaneous coronary intervention is feasible in the acute phase to restore coronary perfusion and hemodynamic stability. Surgery - emergency bypass or assisted circulation - should be restricted to cases where percutaneous coronary intervention has failed or is impossible.

[Kawasaki disease is also a disease of adults: report of six cases]. / La maladie de Kawasaki est aussi une maladie de l'adulte: a propos de six observations.

Kawasaki disease is an inflammatory arterial disease of unknown cause usually affecting young children, the principal complication of which is coronary artery aneurysm. Early treatment with immunoglobulins and aspirin prevents this complication. The diagnosis requires expert clinical criteria and, in atypical forms, a more recent decisional diagnostic tree has to be used. The authors report 6 cases of adult Kawasaki disease. As in the other sixty or so cases in the literature, hepatic forms were the commonest (5/6). Only three of the six cases met the classical clinical criteria and the diagnosis was made by the decisional tree or after coronary complications in the oldest subject. The five treated patients progressed favourably after a course of immunoglobulins. Echocardiography detected 100% of children with coronary disease but it was more difficult in adults in whom new non-invasive methods of coronary imaging (fast CT and MRI) and stress testing should complete the investigations. The association of prolonged pyrexia, clinical criteria and a biological inflammatory syndrome should, after exclusion of the differential diagnoses, suggest a diagnosis of Kawasaki disease in the adult as in the child. The possibility of coronary disease, even though extremely rare, should be recognised by the cardiologist and lead to diagnostic and therapeutic managements as aggressive as in children.

[Implantation of mechanical pulmonary and tricuspid valve prostheses at a distance from complete repair of Tetralogy of Fallot]. / Implantation de deux prothèses mécaniques, pulmonaire et tricuspide, à distance d'une réparation complète de tétralogie de Fallot.

The authors report the case of a 39 years old woman operated for tetralogy of Fallot at the age of 6. Multiple complications due to postoperative atrioventricular block and a poor surgical result on the pulmonary outflow tract led to several reoperations. Right ventricular dysfunction with pulmonary regurgitation and mitral tricuspid valve disease in a context of endocarditis on the pacing catheter led to double pulmonary and tricuspid valve replacement with mechanical prostheses. The outcome at follow-up at 3 years is good. To the authors' knowledge, this is the first reported case of double mechanical valve replacement of the right heart after complete repair of tetralogy of Fallot.

Multicenter trial of intravenous anisoylated plasminogen streptokinase activator complex (APSAC) in acute myocardial infarction: effects on infarct size and left ventricular function.

Two hundred thirty-one patients with a first acute myocardial infarction were randomly allocated within 5 h after the onset of symptoms either to treatment with anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 min, or to conventional heparin therapy, 5,000 IU in a bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. One hundred twelve patients received APSAC and 119 received heparin within a mean period of 188 +/- 62 min after the onset of symptoms. Both groups were similar in age, location of the acute myocardial infarction, Killip functional class and time of randomization. Elective coronary arteriography was performed on an average of 4 +/- 1.2 days after initial therapy. Follow-up radionuclide angiography and thallium-201 single photon emission computed tomography were performed before hospital discharge. Infarct size was estimated from single photon emission computed tomography and expressed as a percent of total myocardial volume. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC group than in the heparin group. This was true for the entire study group (0.53 +/- 0.13 versus 0.47 +/- 0.12; p = 0.002) as well as for the subgroups of patients with anterior and inferior wall infarction (0.47 +/- 0.13 versus 0.40 +/- 0.11; p = 0.04 and 0.56 +/- 0.10 versus 0.51 +/- 0.11; p = 0.02, respectively). At 3 weeks, the difference remained significant for the anterior myocardial infarction subgroup. A significant 31% reduction in infarct size was found in the APSAC group (33% for the anterior infarction subgroup [p less than 0.05] and 16% for the inferior infarction subgroup [p = NS]). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -0.73, p less than 0.01). By the end of a 3 week follow-up period, seven APSAC-treated patients and six heparin-treated patients had died. In conclusion, the early infusion of APSAC in acute myocardial infarction produced a high early patency rate, significant limitation of infarct size and significant preservation of left ventricular systolic function, mainly in anterior wall infarction.

Effect of pravastatin on angiographic restenosis after coronary balloon angioplasty. The PREDICT Trial Investigators. Prevention of Restenosis by Elisor after Transluminal Coronary Angioplasty.

OBJECTIVES: This study sought to determine whether pravastatin affects clinical or angiographic restenosis after coronary balloon angioplasty. BACKGROUND: Experimental data and preliminary clinical studies suggest that lipid-lowering drugs might have a beneficial effect on restenosis after coronary angioplasty. METHODS: In a multicenter, randomized, double-blind trial, 695 patients were randomized to receive pravastatin (40 mg/day) or placebo for 6 months after successful balloon angioplasty. All patients received aspirin (100 mg/day). The primary angiographic end point was minimal lumen diameter (MLD) at follow-up, assessed by quantitative coronary angiography. A sample size of 313 patients per group was required to demonstrate a difference of 0.13 mm in MLD between groups (allowing for a two-tailed alpha error of 0.05 and a beta error of 0.20). To allow for incomplete angiographic follow-up (estimated lost to follow-up rate of 10%), 690 randomized patients were required. Secondary end points were angiographic restenosis rate (restenosis assessed as a categoric variable, > 50% stenosis) and clinical events (death, myocardial infarction, target vessel revascularization). RESULTS: At baseline, clinical, demographic, angiographic and lipid variables did not differ significantly between groups. In patients treated with pravastatin, there was a significant reduction in total and low density lipoprotein cholesterol and triglyceride levels and a significant increase in high density lipoprotein cholesterol levels. At follow-up the MLD (mean +/- SD) was 1.47 +/- 0.62 mm in the placebo group and 1.54 +/- 0.66 mm in the pravastatin group (p = 0.21). Similarly, late loss and net gain did not differ significantly between groups. The restenosis rate (recurrence > 50% stenosis) was 43.8% in the placebo group and 39.2% in the pravastatin group (p = 0.26). Clinical restenosis did not differ significantly between groups. CONCLUSIONS: Although pravastatin has documented efficacy in reducing clinical events and angiographic disease progression in patients with coronary atherosclerosis, this study shows that it has no effect on angiographic outcome at the target site 6 months after coronary angioplasty.

[Sudden transformation of pulmonary stenosis to trilogy of Fallot in a 65 year old patient]. / Transformation brutale d'un rétrécissement pulmonaire en trilogie de Fallot à 65 ans. Traitement par cathétérisme interventionnel.

The authors report the case of a 64 year old woman with typical valvular pulmonary stenosis in whom spontaneous and sudden reopening of the foramen ovale resulted in cyanosis. Transthoracic echocardiography with injection of contrast provides a complete diagnosis: valvular pulmonary stenosis with a mean pressure gradient of 83 mmHg and massive right-to-left interatrial shunt. The malformation was treated by interventional catheterisation in a two-stage procedure: pulmonary valvuloplasty followed by closure of the foramen ovale because of the persistence of a right-to-left interatrial shunt. The functional improvement was followed by the appearance of effort angina. Coronary angiography showed single vessel disease of the left anterior descending artery treated by stenting. The long-term outcome was satisfactory.

A comparison between conventional scintigraphy and emission tomography with thallium-201 in the detection of myocardial infarction: concise communication.

We have compared emission tomography and conventional scintigraphy with thallium-201 in a series including 15 normal subjects and 64 patients showing transmural myocardial necrosis in various locations, fully documented by clinical, electrocardiographic, and enzymatic evidence. The reconstruction was derived from 32 projection images collected around the left side of the patient's chest by a rotating scintillation camera. The conventional views and the transverse, frontal, and sagittal sections were interpreted independently by two observers. The final calculated sensitivity was 89% with conventional scintigraphy and 98% with emission tomography, and the specificity was 93% in the two cases. Thus, emission tomography provides a better sensitivity and also a better interobserver agreement than conventional scintigraphy in the detection of transmural myocardial necrosis with thallium-201.

Balloon angioplasty versus rotational angioplasty in chronic coronary occlusions (the BAROCCO study).

Chronic total coronary occlusion remains one of the limitations of percutaneous transluminal coronary angioplasty, and few therapeutic devices are specifically designed to address this problem. Among such devices, low-speed rotational angioplasty could improve the primary success rate of the procedure but has never been studied in a controlled trial. One hundred consecutive patients with total coronary occlusion (duration 10 days to 1 year) and an indication for myocardial revascularization were randomized to either rotational or conventional angioplasty if the occlusion morphology was judged suitable for either technique. All baseline variables were evenly distributed among the 2 groups. The primary success rate in the rotational angioplasty groupø was 66% (33 of 50) compared with 52% (26 of 50) in the conventional angioplasty group before crossover to the rotational technique (p=NS). According to lesion morphology, the respective primary success rates were 77% (10 of 13) versus 92% (11 of 12) for tapered occlusions (p=NS), and 61% (22 of 36) versus 38% (14 of 37) for "stump-like" occlusions (p < 0.05). After taking into account the crossovers after failed conventional angioplasty, there was no benefit in performing rotational angioplasty first versus conventional angioplasty first (primary success rates 66% vs 60%, p=NS). Thus, in chronic coronary occlusions of tapered morphology, rotational angioplasty is not superior to conventional angioplasty. In stump-like occlusions, the primary success rate is higher with the rotational angioplasty technique; however ther is a disadvantage in using rotational angioplasty as a second-line device if the conventional technique is unsuccessful.

Use of left ventricular function as an end point of thrombolytic therapy.

In recent acute myocardial infarction, early reperfusion of the infarct-related artery by intracoronary or intravenous thrombolytic therapy induces a significant limitation of infarct size, provided reperfusion occurs within a time frame that myocardial salvage can still be expected. Limitation of infarct size reduces scar tissue formation, aneurysm formation, infarct zone expansion, left ventricular volume enlargement, and eventually results in higher left ventricular ejection fraction. Infarct size limitation and left ventricular function preservation occur with all thrombolytic agents currently in clinical use: streptokinase, alteplase and, more recently, anistreplase. When anistreplase is compared with conventional heparin therapy, a 31% reduction in infarct size is found (estimated from single photon emission computed tomography, or SPECT). This translates into a significant preservation of left ventricular ejection fraction as observed in anistreplase-treated patients compared with heparin-treated patients (0.53 +/- 0.13 vs 0.47 +/- 0.12, p less than 0.002). In comparative trials of 2 thrombolytic agents, anistreplase was demonstrated to be as efficient as alteplase on left ventricular ejection fraction preservation and infarct size limitation.

Limitation of myocardial infarct size and preservation of left ventricular function by early administration of APSAC in myocardial infarction.

In cases of acute myocardial infarction (MI), it has been shown that preserving left ventricular function and limiting infarct size with early reperfusion of the occluded artery by means of a thrombolytic agent could eventually result in a reduced mortality rate. The aim of the APSIM study (anisoylated plasminogen streptokinase activator complex [APSAC] dans l'infarctus du Myocarde) was to demonstrate that early administration of APSAC in patients with recent acute MI could limit the infarct size and preserve left ventricular systolic function. In all, 231 patients with a first acute MI were randomly allocated to either APSAC (30 U over 5 minutes) or to conventional heparin therapy (5,000 IU in bolus injection) within 5 hours of the onset of symptoms. Of these patients, 112 received APSAC and 119 received heparin within a mean period of 188 +/- 62 minutes after the onset of symptoms. The patency rate of the infarct-related artery was 77% in the APSAC group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the APSAC than in the heparin group. This was true for the entire population (0.53 +/- 0.13 vs 0.47 +/- 0.13, p = 0.002) as well as for the subgroups of anterior and inferior wall infarctions (0.47 +/- 0.13 vs 0.4 +/- 0.16, p = 0.004 and 0.56 +/- 0.11 vs 0.51 +/- 0.09, p = 0.02). At 3 weeks, the difference remained significant for patients with anterior MI.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between thallium-201 and technetium-99m methoxyisobutyl isonitrile defect size in single-photon emission computed tomography at rest, exercise and redistribution in coronary artery disease.

Defect size on myocardial tomograms was measured in 30 patients who underwent 2 separate studies, 1 with thallium-201 (TI-201), the other with technetium-99m-methoxyisobutyl isonitrile (MIBI). A group of 15 patients with myocardial infarction was studied at rest and received both tracers on the same day. The other 15 patients had documented coronary artery disease. They were were given injections of TI-201 at peak exercise and underwent imaging immediately after exercise and again 4 hours later. They then received a dose of MIBI for imaging at rest. A week later they underwent a second exercise test with the same work load and received a second dose of MIBI. Defect size on single-photon emission computed tomographic images was measured and repeated twice. Results were expressed in percentage of the volume of the whole myocardium. Reproducibility of the defect size measurement was high for TI-201 (r = 0.978; SEE = 1.59) as well as for MIBI (r = 0.981; SEE = 0.80). In patients with coronary artery disease the mean size of the defects was significantly larger with TI-201 than with MIBI at exercise (6.7 +/- 5.2 vs 4.6 +/- 5.2%, respectively, p less than 0.05) and at redistribution (5.1 +/- 4.4 vs 2.8 +/- 3.2%, respectively, p less than 0.05), where no difference was seen in patients with myocardial infarction studied only at rest (11.2 +/- 10.4 vs 12.0 +/- 11.5%, respectively, p = not significant). Smaller MIBI defect sizes, when compared with TI-201, in the exercise and redistribution studies were not due to technical artefacts since there was no difference when they were compared at rest.

Traumatic aortic ruptures diagnosed by transesophageal echocardiography.

The aim of this study was to determine the diagnostic efficiency of transesophageal echocardiography (TEE) in isthmic aortic ruptures and to describe the echocardiographic Doppler anomalies. TEE was performed prospectively for 18 months in 33 patients with serious polytraumas requiring intensive care. The average age was 40.75 years (range, 17 to 78 years). Single or biplanar TEE was used. In three patients with aortic transection, echocardiography showed an intimal flap thicker than that of dissections. The flaps were torn and retracted on the free edge. It was difficult to distinguish the periaortic hematoma. Doppler imaging showed turbulent flows in several places around the aorta. These flows were especially visible at the beginning of the intimal flap. They were visible on M-mode color imaging during systole and diastole. During diastole, a large color flow was observed in the middle of the aortic lumen. It was turbulent in some places and mimicked the systolic filling of the aorta. These flows create the characteristic "to and fro sign" spectrum of Doppler imaging, usually seen in peripheral false arterial aneurysms. TEE findings were confirmed in two cases by surgery and in one case by aortography. TEE seems to be an effective means of detecting isthmic rupture, with the diagnosis resting on the data obtained from echocardiography and Doppler imaging. A suspected isthmic disruption should be assessed by an emergency TEE and aortography used only for uncertain or complex cases.

Assessment of stenosis severity using a novel method to estimate spatial and temporal variations of blood flow velocity in biplane coronarography.

The authors present a novel method to estimate absolute blood flow velocity in coronary arteries from biplane angiograms. Spatial and temporal velocity variations are derived giving simultaneously a direct geometric and an indirect functional index of stenosis severity, stenosis ratio and coronary flow reserve. No prior assumption concerning stenosis geometry is made. Deformable models are used to track a coronary artery segment dynamically in three dimensions. A densitometric map is obtained by summing densities across sections at every position along the previously calculated path and at every time of the cardiac cycle. An advection relationship between density and velocity is observed. The spatiotemporal velocity map is a solution of a nonlinear least-squares scheme. A simulation protocol based on simple geometric conformations and blood flow properties is used to assess numerical stability and immunity towards noise. Predicted results for temporal velocity variations are compared with the intracoronary Doppler recordings to test the model assumptions for basal state and hyperaemia examinations of the same patient. The stenosis ratio was accurate to within 3% for a simulated additive Gaussian noise with a standard deviation of 0.14. The limits of agreement between angiographic and Doppler velocities were -11.4 and 11.8 cm s-1 for a peak value of 23 cm s-1 (basal state) and -16.8 and 13.5 cm s-1 for a peak value of 52 cm s-1 (hyperaemia), corresponding to 18 and 3.5% errors on the average peak values and a 16% error on the coronary flow reserve. To summarize, the advection model derivation and its solution are presented. Simulated and experimental results corroborate the validity of the numerical schemes and support clinical applicability.

Comparison of the myocardial distributions of 201Tl and 99Tcm-MIBI on SPECT images.

The distributions of 201Tl and 99Tcm-MIBI on stress images were quantitatively measured in a series of 15 patients presenting with documented coronary artery disease. Following two sequential, one-week apart, peak-exercise injections of either 74 MBq of 201Tl or 370 MBq of 99Tcm-MIBI, tomographic views of the myocardium were reconstructed and two thick, central short-axis sections were divided into nine sectors. A sector was considered as showing a defect if its relative activity was lower than 30, 40, 50 or 60% of the highest level of activity in the 18 sectors. Results demonstrate that there were more defects with 201Tl than with 99Tcm-MIBI. However, the difference disappeared if the inferior wall was not included. These results suggest that depth attenuation could be, at least partly, responsible for the higher rate of positive results observed in single photon emission computed tomography with 201Tl than with 99Tcm-MIBI.

Effects on infarct size and left ventricular function of early intravenous injection of anistreplase in acute myocardial infarction. The APSIM Study Investigators.

A total of 231 patients suffering from a first acute myocardial infarction were randomly allocated within 4 hours following the onset of symptoms either to anistreplase or anisoylated plasminogen streptokinase activator complex (APSAC), 30 U over 5 minutes, or to conventional heparin therapy, 5000 IU in bolus injection. Heparin was reintroduced in both groups 4 h after initial therapy at a dosage of 500 IU/kg per day. A total of 112 patients received anistreplase and 119 received heparin within a mean period of 188 +/- 62 min following the onset of symptoms. Infarct size was estimated from single photon emission computerized tomography and expressed in percentage of the total myocardial volume. The patency rate of the infarct-related artery was 77% in the anistreplase group and 36% in the heparin group (p less than 0.001). Left ventricular ejection fraction determined from contrast angiography was significantly higher in the anistreplase group than in the heparin group (6 absolute percentage point difference). A significant 31% reduction in infarct size was found in the anistreplase group (33% for the anterior wall infarction subgroup [p less than 0.05] and 16% for the inferior wall infarction subgroup, NS). A close inverse relation was found between the values of left ventricular ejection fraction and infarct size (r = -.73, p less than 0.01). In conclusion, early infusion of anistreplase in acute myocardial infarction produced a high early patency rate, a significant limitation of infarct size, and a significant preservation of left ventricular systolic function, mainly in the anterior wall infarctions.

[Angioscintigraphy in the development of left ventricular dysfunction and prognosis of ischemic heart diseases]. / L'angioscintigraphie dans l'évolution de la dysfonction ventriculaire gauche et du pronostic des cardiopathies ischémiques.

Radionuclide angiography at rest or on effort is one of the most valuable diagnostic and prognostic non-invasive methods for investigating left ventricular function. This procedure provides perfectly reproducible quantitative information; However, its usefulness in detecting myocardial ischaemia is debatable: on the other hand, its prognostic value is uncontested and its role in therapeutic assessment, especially in myocardial infarction, is growing.

[Tomoscintigraphy of the myocardium labelled with thallium-201. Value in the quantification and prognosis of myocardial infarction]. / La tomoscintigraphie du myocarde marqué au thallium 201. Intérêt dans la quantification et le pronostic de l'infarctus du myocarde.

Myocardial thallium 201 tomography was performed in 112 patients admitted to hospital in the acute stage of a first myocardial infarction. Our quantification method for the myocardial lacuna, validated by animal studies, is described. The necrotic mass evaluated is compared with enzymatic (CPK) (r = 0.89) and angiographic (r = 0.78) quantitative assessments. Thallium 201 tomographic quantification has an unquestionable prognostic value. Thus, among patients whose infarcted mass represented more than 25% of the total myocardial mass, 71% died or developed severe heart failure. Conversely, 93% of patients with a small infarct (less than 20% of total myocardial mass) were asymptomatic on a 24-month follow-up. Myocardial thallium 201 tomography provides a reasonable quantification of the infarct. Its prognostic value seems to be satisfactory.

[Echocardiography in the diagnosis of mitral valve insufficiency due to valve mutilations or chordal ruptures. 41 cases with anatomical findings]. / Apport de l'échocardiographie dans les insuffisances mitrales par mutilations valvulaires ou ruptures de cordages. A propos de 41 cas avec corrélations anatomiques.

This study analyses the echocardiographic findings in 41 cases of severe mitral regurgitation due to chordal rupture (33 cases), elongation of chordae (4 cases) or valve trauma (4 cases). The operative findings are given. It was possible to make the diagnosis of chordal rupture in 60% of cases by recording one or more of the following signs:--For the anterior cusp: amplitude of motion equal to or greater than 38 mm; co-existence of chaotic diastolic fluttering and multiple systolic echoes; recording of several diastolic wave forms of the anterior cusp, out of phase and crossing each other;--For the posterior cusp: paradoxical movement of the cusp in systole and diastole; presence of an echo in the left atrium in systole. The group studied was compared with a group of 40 normal subjects and 48 cases of other types of mitral regurgitation which were severe and received surgery. The various signs had good specificity. The sensitivity of the different signs varied from 33 to 50% of cases. It was greater when the number of chordal ruptures was greater. Whichever cusp was affected, it was sometimes the site of high frequency and large amplitude systolic vibrations, which were found in a quarter of the patients. The specificity of this sign is discussed. The diagnosis of rupture of chordae is possible in a large proportion of cases and the causes of error are analysed.

[Congenital abnormalities of origin or distribution of the coronary arteries arising from the aorta]. / Anomalies congénitales d'origine ou de distribution des artères coronaires naissant de l'aorte

The authors report 16 cases of this type, without associated cardiac abnormality, seen in the course of 3000 coronary arteriographies in adults. The diagnosis has been made on the findings at selective coronary arteriography, completed eight times by one totalinjection above the sinus. A classification of distribution anomalies and of cases of hypoplasia of one coronary artery is put forward, based on the number of ostia. The role which these anomalies might play in the genesis of myocardial ischaemia is discussed, and was formally considered responsible in two cases. It has not been demonstrated that they play a part in the development of atheromatous stenosis of the coronary arteries. It is vital that these anomalies should be recognized preoperatively.

[Evaluation of a new stress echocardiography technique combining exercise and dobutamine in the detection of coronary disease]. / Evaluation d'une nouvelle technique d'échocardiographie de stress couplant effort et dobutamine dans la détection de la maladie coronaire.

Dobutamine stress echocardiography (DSE) and exercise stress echocardiography (ESE) are widely used for diagnosis of coronary artery disease. Each of these methods has limitations: secondary effects of Dobutamine, poor imaging quality, difficulty in attaining the maximal heart rate. The authors evaluated a test associating pedalling exercise at a constant low load (30-60 watts) with Dobutamine infusion (10-20-30-40 j/Kg/min +/- Atropine) (DES + E) in 42 patients referred for suspected coronary artery disease. All patients underwent coronary angiography on Day 1. There was significant coronary disease (> 50% stenosis) in 19 of the 42 patients. Sensitivity, specificity, negative predictive value, positive predictive value and overall diagnosis value were respectively 84, 87, 84, 87 and 86%. In the first 20 patients, the DES + E was compared directly with DES: There was only one undesirable side effect (hypertension) with DES + E compared with 5 with DES alone. The target heart rate was attained with lower doses of Dobutamine with DES + E (32.35 vs 39.42 j/Kg/min, p = 0.05). DES + E therefore seems to be a promising technique which is better tolerated than DES alone with very satisfactory diagnostic performances. However, these results require further confirmation in larger numbers of patients.