Cardiovascular Imaging

Stress Echo

Theodora A Zaglavara, MD, PhD

Cardiac Imaging Department

INTERBALKAN MEDICAL CENTER

Thessaloniki GREECE

Evolution of Stress Echo:From Innovation to a Widely Established Technique

Increasing Workload

Contrast Echo/ Flow reserve

Goals of Cardiac Imaging in Coronary Artery Disease

➢ Direct imaging of coronary arteries

➢ Coronary Flow Reserve ?

➢ Myocardial Perfusion ?

➢ Assessment of Ischaemic Burden

➢ Prognosis / risk startification in patients with known or suspected CAD

➢ Ventricular dimensions and overall function

➢ Coexisting significant valve disease

➢ Detection of myocardial viability/myocardial scar

New 2017!!!!!

• Diastolic function

• Hypertrophic Cardiomyopathy

• Heart Failure, Cardiomyopathy

• Cardiac Resynchronization Therapy

• Response to Therapy

• Native Valve Disease (MR, AR, MS, AS)

• Low flow, Low gradient Aortic Stenosis

• Prosthetic Heart Valves

• Pulmonary Hypertension and Pulmonary Arterial

Pressure Assessment

• Athletes heart

• Congenital Heart Disease

Myocardial Response to Dobutamine Infusion

Normal Response to Stress:

Increase in EF and Decrease in End-Systolic Volume

REST- HR 78/min STRESS- HR 142/min

Abnormal Response

Inducible Ischaemia at a Low Ischaemic Threshold

REST

HR 70/min

PEAK STRESS

HR 100/min

LOW DOSE

A High Risk Coronary Lesion Detected in a 46 year old Man with Multiple Risk Factors including Diabetes

Ischaemic threshold :

HR 100

220-age 220-46

Heart rate (dobutamine dose) at which ischaemia develops

Correlates both with number of stenosed vessels and EF response to exercise (Panza, Circ 1995)

57%

3-D EchocardiographyVolumetric Calculation of LV Ejection

Fraction and Volumes

3D Stress Echo: Dynamic Slices

Normal Response to Stress: Enhanced Radial Strain

✓ ASE strongly supports the

use of contrast agents in

clinical practice.

✓ These agents assist

physicians in maximizing the

accuracy of information

obtained from

echocardiograms and thus

optimizing patient care.

✓ ASE also believes that

these agents are generally

safe and well tolerated

✓

The Impact of Contrast Use on

Stress Echo Quality

Myocardial Contrast Stress Echocardiography

Prognostic Stratification of a Negative Stress Echo Test

Maximal Stress Achieved

Resting EF> 50%

Anti- ischeamic Therapy Off

Very Low Risk of Hard

Cardiac Events

(<0.5%/year)

Abnormal Response- Inducible Ischaemia

A High Risk Coronary Lesion Detected

Stress Echo High Risk Characteristics (High Annual Risk >10%)

Low Dose/Workload (Ischaemic

Threshold)

Resting EF<40%

Anti – ischaemic Therapy On

LAD Coronary Territory

High Peak WMSI

Slow Recovery

Heterozonal Positivity or Baseline

Dyssynergy

The assessment and quantification of

ischaemic burden rather than the pure

detection of myocardial ischaemia, is the next

important step towards optimizing therapy

strategies in patients with CAD

Cumulative effect of ischemic extent and maximal severity (jeopardized myocardium) of wall motion

abnormalities on event rate/year

Yao SS et al. Am J Cardiol 2004

Marwick T, et al. J Am Coll Cardiol 2001

Cardiac Mortality Based on Dobutamine Stress Echocardiography (3156 patients)

Independent and incremental value of stress echocardiography over clinical and stress ECG parameters for the prediction of hard cardiac events in new-onset suspected

angina with no history of CAD

Chelliah R et al . Eur J Echocardiography 2010

Exercise cohort:347

All Patients:547

Risk Stratification after Myocardial Infarction

EPIC/EDIC Groups. J Am Soc Echocardiogr 2004;17:114-20.

Stress Echocardiography: Effective Risk Stratification in Women

Bangalore s et al. ASE 2007

Stress Echocardiography: A Powerful Prognostic Tool in High Risk Populations

Cortigianni L et al. JACC 2006

DIABETES MELITUS

Stress echocardiography for detection of CAD/Risk assessment:

Symptomatic or ischaemic equivalent

Journal of the American Society of Echocardiography, March 2011

Stress echocardiography following prior treadmill ECG, coronary calcium scoring, or carotid intimal medial thickness test results

Journal of the American Society of Echocardiography, March 2011

Stress echocardiography following prior stress imaging or coronary angiogram

test results.

Journal of the American Society of Echocardiography, March 2011

Stress Echocardiography for risk assessment

Perioperative evaluation for noncardiac surgery without

active cardiac conditions

Journal of the American Society of Echocardiography, March 2011

Stress echocardiography for risk assessment

Postrevascularization (PCI or CABG)

Journal of the American Society of Echocardiography, March 2011

Circulation 2012

2014

Chaudhry FA, Tauke JT, Alessandrini RS, et al: J Am Coll

Cardiol 34:730-738,1999

Assessment of Myocardial Viability with Dobutamine Stress Echocardiography

Cusick et al. J Heart Lung Transpant 1997

Melutzin et al. J Am Coll Cardiol 1997

Prediction of Viable Myocardium in AkineticSegments: Incremental Value of Diastolic Wall

Thickness Measurement

Zaglavara et al. Heart 2005

80%

60%

90%

51%

92%

75%

52%

82%

71%

80% 78%

92%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

DWT>0.6 DSE DSE or DWT> 0.8

Sensitivity Specificity PPV NPV

Algorithm of Management of Patients with Ischaemic LV dysfunction

Rahimtoola SH, et al. JACC Cardiovascular Imaging 2008

Ionizing Radiation in Cardiac Imaging.

American Heart Association Recommendations:

Cardiac imaging studies that expose patients to ionizing radiation should be ordered only after thoughtful consideration of the potential benefit to the patient and in keeping with established appropriatness criteria (Class I)

Considerations should include options for answering the clinical question at hand by means that do not use ionizing radiation or choosing the type of study that exposes the patient to the lowest amount of radiation (Class I)

Routine surveillance radionuclide stress tests or cardiac CTs in asymptomatic patients at low risk for ischaemic heart disease are not recommended (Class I)

Healthcare providers should discuss the risks and benefits of planned imaging procedures with patients whenever practical or appropriate (Class I)

Circulation 2009

Multimodality Cardiovascular Imaging in CAD

Trends in the Use of Cardiac Imaging up to the Year 2020

(British Cardiovascular Society Working Group)

The right test for the right patient at the right time!

First Do Not Harm!“Ωφελέειν, ή Μη Βλάπτειν”

The art (medicine) consists in three things: the disease, the patient and the physician.

Hippocrates, Epidemics, 5th century B.C