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Stress Echo: Role in Pre-Operative Assessment
Dr. Rachael James MD, BSc, FRCPConsultant CardiologistgSussex Cardiac Centre
Brighton
T lk O liTalk Outline
Types stress echoyp
Dobutamine stress echo for ischaemia
Role stress echo in peri-operative work up
Does revascularisation affect peri operative outcome Does revascularisation affect peri-operative outcome
S E hStress Echo Introduced 1979 Introduced 1979
2D echo combined with a pharmacological, physical or electrical stress
Versatile technique primarily used for detecting ischaemia & determining prognosis
ESC Cl IC i di ti hi h i k ti t 3 li i l f t ESC Class IC indication high risk patients >3 clinical factors
Diagnostic endpoint for detection myocardial ischaemia: Transient regional wall motion abnormality distal to obstructiveTransient regional wall motion abnormality distal to obstructive
coronary artery stenosis
Other uses: Assessing presence myocardial viability Assessing presence myocardial viability Assessing severity valve disease Occult pulmonary hypertension
T S E hTypes Stress EchoI h i d
Pharmacological Dobutamine Ischaemia
Ischaemic cascade
Low flow low gradient AS Myocardial viability
Physical (bike or treadmill) Physical (bike or treadmill) Ischaemia Valve disease
Mitral regurgitation Mitral stenosis Aortic regurgitation
Electrical (PPM) Ischaemia
E i E h f I h iExercise Echo for Ischaemia Technically challenging
For treadmill test need patient quickly on the couchquickly on the couch
Upright bike images can be tricky
Increased chest wall movement
Hyperventilation
Limited to patients who can Limited to patients who can exercise
Higher inter-observer variability comparedvariability compared Dobutamine stress echo
Lower diagnostic accuracy
Stress Echo Patients with PPMPPM
C d t t t i PPM Can do stress test via PPM
Don’t get inotropic effect Dobutamine &required targetDobutamine &required target heart rate may exceed device
If possible use Dobutamine butIf possible use Dobutamine but may need adjust device upper rate
Generally more tricky studies: Wall motion abnormalities if
pacedp Particularly if switch from paced
to unpaced during the stress test ECG may be interpretable ECG may be interpretable
D b i S E hDobutamine Stress Echo Ischaemia
Investigation chest pain in patients intermediate risk
Positive DSE investigation exertional breathlessness
patients intermediate risk Assessment known coronary
stenoses borderline severity Risk stratification non cardiac
surgery
B fit f ll TTE Benefit full TTE
No ionising radiation
Less good investigation exertional breathlessness & no ischaemic historyischaemic history
Argulian E Eur J Echocardiogr 2013
H D W D I ?How Do We Do It? O it b t bl k Dilti Omit beta-blockers, Diltiazem,
Verapamil 48 hours
Avoid heavy meal / caffeine onAvoid heavy meal / caffeine on the day
If windows adequate (95% ti t ) & fpatients) & no cause for
symptoms found: Widespread resting regional
wall motion abnormalitieswall motion abnormalities Severe PHT
iv access & 0.5mL iv contrast agent Sonovue
H D W D I ?How Do We Do It?
Baseline Images
D b i S E hDobutamine Stress EchoC ti 12 l d ECG l d iti ill b b l Continuous 12 lead ECG – lead position will be abnormal
Images: low dose 5micg/Kg/min low dose 5micg/Kg/min mid dose 20micg/Kg/min peak 40micg/Kg/min +/- Atropine
Aiming target heart rate: 220-age – 85%
End points:End points: Completing protocol & attaining target heart rate at peak dose Development new regional wall motion abnormalities W i i ti RWMA Worsening pre-existing RWMA Failure develop hyperdynamic response Adverse events e.g. VT Chest pain / ECG change
R D b iResponse to DobutamineNormal Abnormal
> 2 adjacent myocardial
Improvement LV function
2 adjacent myocardial segments worsen function Normal to hypokinetic or
akinetic Reduction end systolic cavity
size Hypokinetic to akinetic /
dyskinetic
Early vs late All LV myocardial segments normal & become hyperdynamic
Early vs. late
Minimal myocardial segments vs. widespread
Failure develop hyperdynamic function Sudden deterioration LVSudden deterioration LV
function ?? LMS
Contraindications Dobutamine S E hStress Echo
Poor echo windows (5% patients BSUH)
Unable to lie in left lateral position
P l t ll d t i l Poorly controlled atrial arrhythmia
Uncontrolled hypertensionUncontrolled hypertension (systolic >220 or diastolic >120mmHg)
A t MI < 6 k Acute MI < 6 weeks
Recent ventricular arrhythmia
P di i V l DSEPredictive Value DSE Hi h lti l di D b t i h i Higher multivessel disease
(MVD) compared single vessel
Better for LAD territory than
Dobutamine has primary impact contractility
Usually target heart rate isBetter for LAD territory than posterior circulation
Exercise echo:
Usually target heart rate is reached
DSE detect 93% patients >50% t t i Sensitivity MVD
85-100% Sensitivity SVD
>50%coronary artery stenosis
Comparable to nuclear imaging
59-94%
Dobutamine increases heart rate & BP
ag g No soft tissue artifact Sensitivity MVD
91 98%rate & BP 91-98% Sensitivity SVD
66-95%
Armstrong WF J Am Coll Cardiol 2005, Sicari R J Am Coll Cardiol 2003, Huang PJ Cardiology 2004, Marwick T J Am Coll Cardiol 1993
F l P i i S E hFalse Positive Stress Echo I h i h d ti Ischaemia when reduction
coronary flow reserve (CFR)
In absence coronary artery
Mortality patients false positive & true positive DSE
In absence coronary artery disease, CFR reduced Microvascular disease
(syndrome X)(syndrome X) LVH (hypertension)
Increased incidence falseIncreased incidence false positive stress echo women
False positive DSE not without l t i klong term risk
From J Am Soc Echocardiogr 2010
N i DSENegative DSE
Normal stress echo event rate 3D probability cardiac event over 5
t ti i hrate 0.1% per year non fatal MI 1.1% cardiac death
years post negative exercise echo
Also have prognostic factors LV function Exercise capacity
Mazur W J Am Soc Echocardiogr 2003
P i O i MIPeri-Operative MI
Either ‘conventional’ MI
Coronary artery plaque rupture Thrombus formation Vessel occlusion Vessel occlusion
Peri-operative stress response: Abnormal cytokine response Catecholamine surge Platelet activation Reduced fibrinolytic activity Vasospasm
Or sustained myocardial supply / demand imbalance
Wh D S E hWhy Do a Stress Echo Pre op risk stratification: Markers increased risk: Pre-op risk stratification:
Assess risk planned surgery Direct pre-op investigation /
intervention
Markers increased risk: Angina / prior MI Prior heart failure Severe renal impairment
Inform patient about risk
Main evidence intermediate & high risk vascular surgery
p Poor functional capacity Severe valve disease Inducible ischaemia on functional
testing Up to 60% patients peripheral
vascular disease have underlying coronary disease
testing
Peri-op cardiac events low patients few clinical variables
Presence peripheral vascular disease associated with 6.6-fold increase relative risk death from coronary disease
few clinical variables
Inducible ischaemia DSE predictive peri-op cardiac events (death/MI)
N l t h 100% ti High risk morbidity & mortality
patients with peripheral artery disease undergoing surgical procedures
Normal stress echo 100% negative predictive power
procedures
Poldermans Am Coll Cardiol 1995, Lane J Vasc Surg 1991, Boersma JAMA 2001
N V lNon Vascular surgery Less evidence
Likelihood coronary disease l l ti
Dobutamine Stress Echo has incremental value over clinical (Eagle index), ECG &
more general population coming for non vascular surgery lower
standard echo variables in non vascular surgery
Normal stress echo 100% Problems relying on cardiac
symptoms in orthopedic population
Normal stress echo 100% negative predictive value
We can identify patients at population y pincreased risk of complication
E id th t i t i Evidence that intervening on coronary disease is elusive
Das MK J Am Coll Cardiol 2000
D I i H l ?Does Intervening Help? DECREASE V & CARP trials patients DECREASE-V & CARP trials patients
undergoing vascular surgery
Revascularisation not associated mortality benefit
Incidence All-Cause Mortality or MI Patients Inducible Ischaemia
DECREASE-V trial patients > 3 risk factors underwent DSE or stress nuclear imaging inducible ischaemia
only 86% completely revascularised
Short time interval between intervention & surgery
29/7 (13 65) CABG 29/7 (13-65) CABG 31/7 (19-39) PCI
Trial not powered to show difference between medical Rx & revascularisationbetween medical Rx & revascularisation in high risk patients
Deaths patients post revascularisation from ruptured AAA before planned surgery
DECREASE-V studyLight line medical treatmentDark line medical Rx + Revascularisationsurgery
Poldermans J Am Coll Cardiol 2007
D I i H l ?Does Intervening Help? CARP trial – nuclear stress testing
Patients stable coronary disease randomized to medical treatment or revascularisation
Coronary Artery Revascularization Prophylaxis trial
revascularisation
Post vascular surgery no difference in-house mortality or MI
Non significant trend toward benefit revascularisation in high risk patients
All male
But high risk patients were excluded: LMS >50% Severe AS LV EF <20% LV EF <20%
Doesn’t help us about role of screening high risk patients and revascularisation
McFalls NEJM 2004
D I i H l ?Does Intervening Help? F t l MI i i d ft Fatal MI peri-op period often
involves unstable plaque & plaque disruption
Intervening on stable coronary lesion may not add to optimal medical therapyto optimal medical therapy
PCI & CABG associated acute inflammatory response
Increased stent thrombosis rate ulcerated lesions & early post procedurepost procedure
Dangas Circulation 2011, Daemen Lancet 2007
Off label/real world DES thrombosis Rotterdam/Bern Registry
Wh T d ?What To do? No strong evidence
Methodological issues with
Coronary intervention symptomatic patients (ESC IA)Methodological issues with
studies
Some surgery very early post
IA)
Prophylactic revascularisation
intervention / CABG
Surgery (cardiac & non cardiac) associated systemic
asymptomatic patients prior to high risk surgery (ESC IIB)
Prophylacticcardiac) associated systemic inflammatory response & pro-thrombotic state
Prophylactic revascularisation patient found to have LMS / proximal severe coronary disease
Risk intervention itselfsevere coronary disease following stress echo
Poldermans Eur Heart J 2009
ACC/AHA G id liACC/AHA Guidelines
J Am Coll Cardiol 2007
A Q i ?Any Questions?