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Indian Heart Journal 2014Resting echocardiography is the most important tool for diagnosing valvular heart disease. However, treatment planning in valvular heart diseases may require additional... (Review)
Review
Resting echocardiography is the most important tool for diagnosing valvular heart disease. However, treatment planning in valvular heart diseases may require additional information in some patients, particularly asymptomatic patients with severe valve disease or symptomatic patients with moderate disease. Stress echocardiography provides invaluable information in these situations and aids decision making. Stress echocardiography is performed using either physical stress or dobutamine stress and various valve parameters are monitored during the stress. Further, the ventricular performance, which is an important determinant of outcome in valve disease is also closely monitored during stress which helps immensely in planning the intervention. Lastly, possibility of associated coronary artery disease can also be evaluated, especially in the elderly. This article discusses the role of stress evaluation in assessment of valve disease in the commonly encountered clinical situations.
Topics: Aortic Valve Insufficiency; Aortic Valve Stenosis; Echocardiography, Stress; Evaluation Studies as Topic; Female; Heart Valve Diseases; Humans; Male; Mitral Valve Stenosis; Sensitivity and Specificity; Severity of Illness Index; Ventricular Dysfunction, Left
PubMed: 24581111
DOI: 10.1016/j.ihj.2013.12.051 -
Kardiologia Polska 2019Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologi-cally critical epicardial artery stenosis... (Review)
Review
Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologi-cally critical epicardial artery stenosis which determines subendocardial underperfusion. Recently, the core protocol of SE has been enriched by the addition of left ventricular contractile reserve (LVCR) based on force. Changes in force can be caused by microvascular and/or epicardial coronary artery disease, but also by myocardial scar, necrosis, and/or sub-epicardial layer disease. Left ventricular contractile reserve is calculated as the stress-to-rest ratio of force (systolic arterial pressure measured by cuff sphygmomanometer to end-systolic volume determined by two-dimensional echocardiography). In contrast to the ejection fraction, force is not dependent on changes in preload and afterload. Cut-off values for a preserved LVCR are > 2.0 for dobu-tamine or exercise stress and > 1.1 for vasodilators, which are weaker inotropic stimuli. Patients with a "strong" heart (normal LVCR values) have a better outcome than patients with a "weak" heart (reduced LVCR values), and this is the prognostic "bright side of the force," meaning that the prognostic value of force-based contractile reserve is higher than that of ejection fraction-based contractile reserve or RWMA. The addition of force to standard SE based on RWMA detection increases the spectrum of risk stratification without any signifi-cant increase in imaging time and only a slight increase in analysis time. In both ischaemic (with RWMA) and non-ischaemic (without RWMA) hearts, the preserved force is associated with a more benign prognosis. The prospective multicentre interna-tional Stress Echo 2020 trial which started in September 2016 has already recruited > 5000 patients with dual RWMA-force imaging and will systematically test the impact of force on the prognosis within and beyond coronary artery disease, including heart failure and hypertrophic cardiomyopathy.
Topics: Echocardiography; Echocardiography, Stress; Heart Ventricles; Humans; Myocardial Contraction
PubMed: 30644080
DOI: 10.5603/KP.a2019.0002 -
Open Heart Apr 2021
Topics: Echocardiography, Stress; Humans; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Prognosis
PubMed: 33888594
DOI: 10.1136/openhrt-2021-001641 -
JACC. Cardiovascular Imaging Jun 2015Valve stress echocardiography (VSE) is increasingly used both within specialist valve clinics and within dedicated VSE services, mandating practical guidance for... (Review)
Review
Valve stress echocardiography (VSE) is increasingly used both within specialist valve clinics and within dedicated VSE services, mandating practical guidance for referral, procedure, reporting, and clinical implementation of results. Therefore, a didactic VSE guide was compiled based on current European Society of Cardiology and American College of Cardiology/American Heart Association valve disease management guidelines, review of existing evidence, and the authors' extensive experience with VSE. The VSE indications were grouped into 3 categories: symptoms despite nonsevere valve disease, asymptomatic severe valve disease, and valve disease with reduced left ventricular systolic function. The aim of the test, the type of stress to be used, the sequence of image acquisition, the information to be included in the report, and the implication of the VSE results for clinical management were described for every indication and summarized in user-friendly tables.
Topics: Aortic Valve Stenosis; Echocardiography, Stress; Humans; Practice Guidelines as Topic; Referral and Consultation
PubMed: 26068289
DOI: 10.1016/j.jcmg.2015.02.010 -
Nature Reviews. Cardiology Apr 2015Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to... (Review)
Review
Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).
Topics: Cardiac Resynchronization Therapy; Clinical Decision-Making; Echocardiography, Doppler; Echocardiography, Stress; Exercise; Humans; Mitral Valve; Mitral Valve Annuloplasty; Mitral Valve Insufficiency
PubMed: 25666403
DOI: 10.1038/nrcardio.2015.16 -
Clinical Cardiology Dec 2018Stress echocardiography (SE) is a very useful method in clinical practice, because it offers important information of both the patient's functional status and... (Review)
Review
Stress echocardiography (SE) is a very useful method in clinical practice, because it offers important information of both the patient's functional status and hemodynamic changes during stress. Therefore, SE provides strong diagnostic and prognostic data in a wide spectrum of cardiovascular diseases. This review summarizes the clinical applications of SE in conditions beyond coronary artery disease (CAD) and highlights practical recommendations and key issues for each condition that need further investigation. SE is an established method for the evaluation of symptomatic and asymptomatic patients with valvular heart disease (VHD) and cardiomyopathies, and provides important information regarding prognosis and management of patients with congenital heart disease, pulmonary hypertension or diastolic dysfunction. Moreover, when one or multiple VHD and cardiomyopathy or CAD coexist in one patient, SE is a very useful clinical tool for the evaluation of etiology and symptomatology.
Topics: Coronary Artery Disease; Echocardiography, Stress; Hemodynamics; Humans; Reproducibility of Results
PubMed: 30315566
DOI: 10.1002/clc.23094 -
Singapore Medical Journal Mar 2020During stress echocardiography, the echocardiologist routinely collects both echocardiographic images and stress electrocardiogram (ECG) concurrently. The managing... (Observational Study)
Observational Study
INTRODUCTION
During stress echocardiography, the echocardiologist routinely collects both echocardiographic images and stress electrocardiogram (ECG) concurrently. The managing physician faces a dilemma when the stress ECG and stress echocardiography results are discordant; for example, when a patient has negative stress echocardiography but positive stress ECG. We therefore sought to evaluate the prognostic value of stress echocardiography in relation to concordant or discordant stress ECG findings in our local Singapore setting, which has a well-defined Southeast Asian population.
METHODS
This was a retrospective observational study of all patients who underwent stress echocardiography in 2012 at Changi General Hospital, Singapore. All study patients were followed up for 18 months via electronic medical records.
RESULTS
There was no difference in the major adverse cardiovascular events (MACE) outcome of patients with normal stress echocardiography and normal stress ECG (reference group) as compared with patients with normal stress echocardiography but positive (discordant) stress ECG (odds ratio 2.02, 95% confidence interval 0.82‒4.98; p = 0.125).
CONCLUSION
This study will help to reassure cardiologists that discordant results (negative stress echocardiography but positive stress ECG) do not portend a higher risk of MACE when compared to concordant results (i.e. both stress echocardiography and stress ECG are negative).
Topics: Adult; Aged; Cause of Death; Comorbidity; Coronary Artery Disease; Echocardiography, Stress; Exercise Test; Female; Humans; Male; Middle Aged; Prognosis; Retrospective Studies; Risk Factors; Singapore
PubMed: 32488267
DOI: 10.11622/smedj.2019105 -
Acta Medica Academica Dec 2021To evaluate the role of functional and imaging parameters during exercise stress echocardiography (SE) in the presence of ST-segment elevation (ST-E) in aVR leads to...
The Value of Stress Echocardiography Imaging and Functional Parameters in Patients with aVR Lead ST-Segment Elevation during an Exercise Stress Test to Detect Significant Left Main Stenosis.
OBJECTIVE
To evaluate the role of functional and imaging parameters during exercise stress echocardiography (SE) in the presence of ST-segment elevation (ST-E) in aVR leads to predict significant left main/left main equivalent/or ostial left anterior descending (LAD) stenosis (LM+).
METHODS
The study population included 548 patients with ECG and echo markers of myocardial ischemia, in whom diagnostic coronary angiography was performed. We analyzed the patients' clinical characteristics, ECG changes, wall motion score index (WMSI) by stress echocardiography (SE), as well as functional capacity during exercise (METs) and Duke treadmill score.
RESULTS
aVR ST-segment elevation was found in 60/548 (11%) patients, whereas aVR ST-E was found in 23/57 patients with left main LM stenosis (Sn 40%, Sp 92%, PPV 38%, NPV 93%). When aVR ST-E was combined with other functional/imaging parameters, patients with aVR ST-E and LM+ had significantly worse functional capacity in METs (5.0±2.2 vs. 6.7±2.3, P=0.005), lower Duke score (-6.8±6.8 vs. -3.6±4.1, P=0.049), and higher deterioration of WMSI (0.51±0.24 vs. 0.39±0.24, P=0.046). Significant multivariable predictors of the left main (LM) stenosis were aVR ST-E and positive SE in LAD territory in the whole group of patients, and Delta WMSI, Duke score and METs achieved in patients presented with aVR ST-E during exercise.
CONCLUSION
The aVR ST-segment alone has intermediate sensitivity in detecting significant LM stenosis in patients referred to SE testing for chest pain. When combined with other functional and imaging parameters, including poor exercise functional capacity in METs, lower Duke score or greater WMA in the territory of LAD, its diagnostic power to detect LM significantly increases.
Topics: Constriction, Pathologic; Coronary Angiography; Coronary Stenosis; Echocardiography, Stress; Electrocardiography; Exercise Test; Humans
PubMed: 35164511
DOI: 10.5644/ama2006-124.354 -
The British Journal of Radiology Dec 2011This article reviews the recent developments in echocardiography that have maintained this technology at the forefront of day-to-day imaging in clinical cardiology. The... (Review)
Review
This article reviews the recent developments in echocardiography that have maintained this technology at the forefront of day-to-day imaging in clinical cardiology. The primary reason for most requests for imaging in cardiovascular medicine is to assess left ventricular structure and function. As our understanding of left ventricular mechanics has become more intricate, tissue Doppler and speckle tracking modalities have been developed that deliver greater insights into diagnosis of cardiomyopathy and earlier warning of ventricular dysfunction. Increased accuracy has been achieved with the dissemination of real-time three-dimensional echocardiography, which has also acquired a central role in the pre-operative assessment of patients prior to reparative valvular surgery. The use of contrast has broadened the indications for transthoracic echocardiography and has increased the accuracy of stress echocardiography, while reducing the number of patients who cannot be scanned because of a limited acoustic window. Finally, echocardiography will be seen in the future not only as a diagnostic tool in those affected by cardiovascular disease but also as a method for prediction of risk and perhaps activation of targeted treatment.
Topics: Cardiomyopathies; Contrast Media; Echocardiography; Echocardiography, Doppler, Color; Echocardiography, Stress; Echocardiography, Three-Dimensional; Heart Ventricles; Humans; Myocardial Contraction; Ultrasonography, Interventional; Ventricular Dysfunction, Left
PubMed: 22723531
DOI: 10.1259/bjr/77730594 -
ESC Heart Failure Aug 2021Haemodynamic assessment during stress testing is not commonly performed in patients with heart failure with reduced ejection fraction (HFrEF) because of its...
AIMS
Haemodynamic assessment during stress testing is not commonly performed in patients with heart failure with reduced ejection fraction (HFrEF) because of its invasiveness, lower feasibility, and safety concerns. This study aimed to assess the haemodynamic characteristics of patients with HFrEF in response to non-invasive preload stress during dynamic postural alterations achieved by combining both semi-sitting position and passive leg-lifting and to evaluate whether combined postural stress could be used for risk stratification in these patients.
METHODS AND RESULTS
For this study, 101 patients with HFrEF and 35 age-matched and sex-matched healthy controls were prospectively recruited. After all standard echocardiographic measurements were obtained in the left decubitus position, all subjects underwent postural stress testing, which consisted of changing from semi-sitting position to passive leg-lifting. During a median follow-up period of 12.2 months, 21 (21%) patients developed adverse cardiovascular events. In patients without adverse cardiovascular events, the stroke volume index (SVi) significantly changed from 28 ± 8 to 35 ± 10 mL/m (P < 0.001) during combined postural stress. By contrast, ΔSVi during combined dynamic postural stress was significantly smaller in patients with cardiovascular events than in those without events (ΔSVi 3.4 ± 4.0 vs. 6.4 ± 3.8 mL/m , P = 0.002), which indicated severely diseased heart operated on a relatively flat portion of the Frank-Starling curve. In a multivariate Cox proportional hazard analysis, ΔSVi (hazard ratio 0.81, P = 0.02) was an independent predictor of future adverse cardiovascular events.
CONCLUSIONS
The combined assessment of dynamic postural stress is a non-invasive, simple, quick, and easy-to-use clinical tool for assessing preload reserve and risk stratification in HFrEF patients.
Topics: Echocardiography, Stress; Heart Failure; Humans; Prognosis; Stroke Volume; Ventricular Function, Left
PubMed: 33934528
DOI: 10.1002/ehf2.13346