Stress Echocardiography: Recommendations for Performance and Interpretation of Stress Echocardiography

doi:10.1016/S0894-7317(98)70132-4

Journal of the American Society of Echocardiography

Volume 11, Issue 1, January 1998, Pages 97-104

https://doi.org/10.1016/S0894-7317(98)70132-4 Get rights and content

Abstract

Cardiovascular stress testing remains the mainstay of provocative evaluation for patients with known or suspected coronary artery disease. Stress echocardiography has become a valuable means of cardiovascular stress testing. It plays a crucial role in the initial detection of coronary disease, in determining prognosis, and in therapeutic decision making. The purpose of this document is to outline the recommended methodology for stress echocardiography with respect to personnel and equipment as well as the clinical use of this recently developed technique. Specific limitations will also be discussed. (J Am Soc Echocardiogr 1998;11:97-104)

Section snippets

Imaging Techniques and Equipment

For the diagnosis of coronary artery disease, stress echocardiograms are performed in conjunction with two dimensional echocardiographic imaging. Doppler flow profiles, which reflect global parameters of either systolic or diastolic function, can be employed but are less useful clinically. Doppler stress echocardiography may be of clinical use in evaluating patients with valvular heart disease to determine valve gradients and areas or the degree of regurgitation with stress. Tricuspid

Accuracy (Tables 3 and 4)

The accuracy of stress echocardiographic techniques has been established in numerous laboratories; it is superior to that of exercise electrocardiography alone and equivalent to that obtained with radionuclide perfusion techniques.

. Accuracy of exercise echocardiography for detection of coronary artery disease

Author	Year	Stress Type	Total Pts.	All	SV	MV	Specificity	No. MI	All	SV	MV
Empty Cell				Sensitivity			Empty Cell		Sensitivity
Limacher¹	1983	TME	77	51/56	7/11	44/45	15/17	10	19/24	3/7	16/17
				91%	64%	98%	88%		79%	43%	94%
Armstrong⁴	1987	TME	123	89/101	34/42

Prognostic Implications

In addition to the diagnosis of coronary artery disease, stress echocardiography has shown substantial value as a prognostic tool. Available data suggest a benign prognosis in patients following normal exercise echocardiography and an adverse prognosis of new inducible wall motion abnormalities in the convalescent period following myocardial infarction. Several studies have addressed the role of pharmacologic stress echocardiography for preoperative risk assessment prior to noncardiac surgery.

Conclusions

Stress echocardiography is an accurate, versatile, and clinically valuable technique for evaluating patients with known or suspected ischemic heart disease. It is accurate for detection of both patients with coronary disease and individual stenoses. In experienced hands, accuracy is equivalent to that of more established radionuclide techniques. Recent developments in the field suggest a promising role for assessment of prognosis and myocardial viability.

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Cited by (317)

Incremental value of <sup>18</sup>F-FDG cardiac PET imaging over dobutamine stress echocardiography in predicting myocardial ischemia in patients with suspected coronary artery disease
2022, Journal of Nuclear Cardiology
To assess the incremental value of ¹⁸F-fluorodeoxyglucose (FDG) cardiac positron emission tomography (PET) over dobutamine stress echocardiography (DSE) in predicting myocardial ischemia in patients with suspected coronary artery disease (CAD).
Forty-one patients with suspected CAD underwent within 7 days apart rest-stress cardiac PET with ⁸²Rb and DSE followed by cardiac ¹⁸F-FDG PET imaging. ¹⁸F-FDG images were scored on a 0 (no discernible uptake) to 2 (intense uptake) scale. Logistic regression analysis was performed to identify predictors of stress-induced ischemia. The incremental value of ¹⁸F-FDG PET over DSE in detecting ischemia at ⁸²Rb PET cardiac imaging was assessed by the likelihood ratio chi-square and net reclassification index.
On ⁸²Rb-PET imaging, myocardial ischemia (ischemic total perfusion defect ≥ 5%) was detected in 20 (49%) patients. Inducible ischemia was found in 22 (54%) patients on DSE (biphasic or worsening response pattern in ≥ 1 segment) and in 21 (51%) patients on ¹⁸F-FDG PET (uptake score of 2 in ≥ 1 segment). ¹⁸F-FDG PET resulted as statistically significant predictor of ischemia on ⁸²Rb-PET. The addition of ¹⁸F-FDG PET to DSE increased the likelihood of ischemia on ⁸²Rb-PET (P < .05). ¹⁸F-FDG PET was able to reclassify the probability of stress-induced myocardial ischemia on both patient and vessel analyses.
¹⁸F-FDG PET performed after dobutamine stress test may provide incremental value to DSE in the evaluation of myocardial ischemia. These results suggest that stress-induced myocardial ischemia can be imaged directly using ¹⁸F-FDG PET after dobutamine stress test.
Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: An expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology
2022, Hellenic Journal of Cardiology
Stress echocardiography (SE) is a well established and valid technique, widely used for the diagnostic evaluation of patients with ischemic and nonischemic cardiac diseases. This statement of the Echocardiography Working Group of the Hellenic Society of Cardiology summarizes the consensus of the writing group regarding the applications of SE, based on the expertise of their members and on a critical review of present medical literature. The main objectives of the consensus document include a comprehensive review of SE methodology and training—which focus on the preparation, the protocols used, the analysis of the SE images, and updated, evidence-based knowledge about SE applications on ischemic and nonischemic heart diseases, such as in cardiomyopathies, heart failure, and valvular heart disease.
Consistency of Positron Emission Tomography and Myocardial Contrast Echocardiography in Diagnosing Mental Stress-Induced Myocardial Ischemia: Study Protocol of a Prospective Study—Background, Design and Method
2020, Ultrasound in Medicine and Biology
Mental stress-induced myocardial ischemia (MSIMI) has attracted increasing attention in the last 30 y. Positron emission tomography/computed tomography (PET/CT) is among the most accurate methods for evaluating myocardial perfusion. Even so, echocardiography seems to be a more harmless option when the radiation exposure and high expense of PET/CT are considered. To date, no previous studies have compared the consistency between echocardiography and PET/CT in the diagnosis of MSIMI. The primary aim of this research was to compare the consistency of myocardial contrast echocardiography and PET/CT in diagnosing MSIMI in women with angina symptom/ischemia but no obstructive coronary artery disease (INOCA). Fifty adult female patients with INOCA were recruited for a 12-min-long mental stress test. Each patient underwent both echocardiography and PET/CT at baseline and during mental stress testing; the interval between the two examinations was 1–3 d and the sequence was assigned naturally. MSIMI is defined by a summed difference score (SDS) ≥3 on PET-CT during mental stress testing. It is also defined by new abnormal wall motion, ejection fraction reduction ≥5%, and/or development of ischemic ST change on the electrocardiogram during mental stress testing. This study examined the consistency of PET/CT and myocardial contrast echocardiography in diagnosing MSIMI.
Impact of Anemia on Exercise and Pharmacologic Stress Echocardiography
2020, Journal of the American Society of Echocardiography
The safety and diagnostic accuracy of stress testing in anemic patients have not been well studied. Despite a lack of data, significant anemia may be considered a relative contraindication to stress testing because of safety concerns related to insufficient myocardial oxygen supply.
The authors reviewed 28,829 consecutive patients with blood hemoglobin drawn within 48 hours of stress echocardiography (15,624 exercise and 13,205 dobutamine). The associations of blood hemoglobin concentration with arrhythmia and other stress echocardiographic findings were examined. Additionally, the effect of anemia on the positive predictive value of stress echocardiography for the detection of significant coronary artery stenosis (≥50%) was assessed in patients who subsequently underwent coronary angiography.
Anemia was present in 6,401 patients (22.2%) and was severe (hemoglobin < 8.0 g/dL) in 52. Stress testing with either exercise or dobutamine was safe, with no significant increase in serious arrhythmia events or need for hospitalization. In the exercise cohort, worsening anemia was associated with reduced treadmill exercise time, lower peak heart rate, peak rate-pressure product, and achieved workload. In the dobutamine stress cohort, worsening anemia was associated with higher resting heart rate, more use of atropine, and fewer patients attaining target heart rate. The positive predictive value of stress echocardiography was higher in patients with moderate anemia compared with those without anemia (71.8% vs 60.2%, P = .01).
This study demonstrates that stress testing is safe in patients with mild and moderately anemia, albeit with a small increase in mild supraventricular arrhythmias with exercise. However, worsening anemia was associated with a significant reduction in exercise capacity. Additionally, worsening anemia was associated with an improvement in the positive predictive value of stress echocardiography. Extrapolation of these data to patients with severe anemia should be performed with caution given the limited number of patients with severe anemia in this study.
Stress Cardiovascular Magnetic Resonance: Wall Motion
2018, Cardiovascular Magnetic Resonance: A Companion to Braunwald’s Heart Disease
Cardiac magnetic resonance (CMR) wall motion–related stress testing presents clinicians and investigators with a sensitive and specific means of evaluating for obstructive coronary artery disease (CAD). Dobutamine remains the primary stress agent used to provoke wall motion abnormalities to evaluate for inducible ischemia. Compared with dobutamine stress echocardiography, dobutamine CMR stress testing has improved sensitivity (86% vs. 74%), improved specificity (86% vs. 70%), and enhanced accuracy (86% vs. 73%). By stressing at different levels of dobutamine infusion, CMR can also evaluate for biphasic stress-related changes, which can indicate whether the myocardium is viable and would respond to coronary revascularization. Multiple techniques, such as tissue tagging and feature tracking, can be used to further enhance the sensitivity and specificity of wall motion analyses. However, certain clinical situations, including individuals with resting wall motion abnormalities, left ventricular concentric hypertrophy, and inadequate stress load, may limit the sensitivity of dobutamine CMR stress testing. CMR can also be used to evaluate for wall motion abnormalities during exercise stress testing. While adenosine and dipyridamole are traditionally used for CMR perfusion stress testing, if adenosine or dipyridamole provoke a wall motion abnormality during stress testing, it indicates a high risk for obstructive CAD.
LDL apheresis improves coronary flow reserve on the left anterior descending artery in patients with familial hypercholesterolemia and chronic ischemic heart disease
2017, Atherosclerosis Supplements
LDL apheresis (LA) influences the microcirculation, endothelial function and cardiovascular homeostasis. The aim of our study was to analyze temporal variations of coronary flow reserve (CFR) on the left anterior descending artery, obtained during dipyridamole stress echocardiography (DSE), in patients with severe familial hypercholesterolemia on LA (LA group) or not (not LA group) and ischemic heart disease (IHD).
The LA group consisted in 10 patients (mean age 65 ± 7 years, male 70%) with Familial Hypercholesterolemia and chronic IHD on maximally tolerated lipid lowering therapy and chronic LA treatment (median 7 years, interquartile range 6–14 years). Hyperlipoproteinemia (a) was also present in 6/10 subjects. LA was performed biweekly by dextran-sulfate or heparin-induced LDL precipitation technique. IHD was diagnosed at a mean age of 44 ± 8 years.
The control group was matched for age, sex and follow-up period.
CFR was calculated as the ratio between blood diastolic velocity sampled at peak stress with dipyridamole and baseline diastolic velocity (normal value > 2.0). No relevant comorbidities were present.
During a median follow-up of 27 months (interquartile range 23–50 months), a significant increase in CFR (from 1.86 ± 0.47 to 2.25 ± 0.35; p < 0.001) was observed in LA group. During this period, no patients modified their anti-ischemic therapy and no cardiovascular events were reported. In the control group, during the study time (24 months – interquartile range 14–57 months) no significant variation in CFR was observed (from 2.08 ± 0.39 to 1.92 ± 0.26; p 0.283).
Myocardial blood perfusion, measured as CFR by dipyridamole stress echocardiography-is increased in patients with severe familial hypercholesterolemia chronically treated with LA.
DSE might be a reliable tool to monitor the therapeutic effect of lipid lowering therapy.

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Stress Echocardiography: Recommendations for Performance and Interpretation of Stress Echocardiography☆,☆☆,★,★★

Abstract

Section snippets

Imaging Techniques and Equipment

Accuracy (Tables 3 and 4)

Prognostic Implications

Conclusions

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