🫀 Mirza's Cardiology Notes

Stress Echocardiography

5 min read

  • With any stress modality, want a double product (adequate stress to draw prognostic information) >20,000 and ideally >25,000.
  • See 2019 ASE Guidelines
  • Make sure you get a good baseline Echo, e.g. “regional wma, severe AS, aortic enlargement, you sure you want to put him on a treadmill?”
  • Bicycle 🚴‍♀️ is useful for measurement of MR
    • Need to interpret with a grain of salt b/c venous return is very high relative to exercise and LV cavity will be large d/t this preload w/ bike.
  • Prognostic information is comparable to SPECT
  • Dobutamine: start at 5-10, increase every 3 minutes (20 → 30 → 40)
    • If still not achieved, can give atropine
  • Hypertensive response
    • SBP >182 or DBP > 96 for DSE
    • SBP > 220 for ESE
  • Incidence of AFib with DSE is 1%
    • <1 hr (61%) and <24h (96%)
    • Rivas: will give some metoprolol and monitor in the lab. If still rapid AFib, will monitor and they typically go back into sinus overnight.
  • False negatives
    • suboptimal workload
    • single vessel disease
      • especially LCx disease
    • concentric LVH, HCM
    • severe AI or MR because you have a hyperdynamic LV
  • False positives
    • Hyperrtensive response to stress
    • LVH/HCM, DM → low MPR
    • exercise-induced coronary spasm
    • cardiomyopathy
    • LBBB (pharmacologic MPI is test of choice)
  • High risk features - see Table 3 from the ASE guideline paper
  • Contraindications
    • Poor windows
    • Unable to reach target HR
    • Uncontrolled HF
    • High-risk unstable angina, active ACS or AMI (<2 d)
    • Serious ventricular arrhythmia or high risk for arrhythmias attributable to QT prolongation
    • Respiratory failure
    • Severe COPD, acute PE, severe pulmonary hypertension
    • Contraindications to dobutamine (if pharmacologic stress test needed)
    • Severe systemic arterial hypertension (e.g., ≥200/110 mm Hg)
  • Useful if patient can exercise and ECG uninterpretable
  • Widely available & easy to perform
  • Inexpensive
  • No ionizing radiation
  • Body habitus and echo window
  • Qualitative interpretation
  • Limited sensitivity (~70%) but better specificity (~80%)
  • For detection of CAD, stress echocardiography has similar sensitivity to tomographic nuclear perfusion imaging.
  • However, stress echocardiography has higher specificity (89% vs. 77%).
  • For detection of left main or multivessel CAD, stress echocardiography has greater sensitivity.
  • 📄 Pellikka, P. A., Arruda-Olson, A., Chaudhry, F. A., Chen, M. H., Marshall, J. E., Porter, T. R., & Sawada, S. G. (2020). Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Journal of the American Society of Echocardiography, 33(1), 1-41.e8. https://doi.org/10.1016/j.echo.2019.07.001
  • Indications
    • Known or suspected coronary artery disease
    • Myocardial viability
    • Dyspnea of possible cardiac origin
    • Pulmonary hypertension
    • Mitral valve disease
    • Aortic stenosis (low-flow)
    • Hypertrophic cardiomyopathy
      • e.g. don’t have 30 mmHg threshold at rest echo
  • Interpretation
    • At least two adjacent segments are required for test positivity.
    • The wall motion score index (WMSI) is derived by dividing the sum of the scores of individual segments by the number of segments visualized (severely abnormal > 1.7).
      • 1.2 - 1.7 is moderate
    • 📄 Sicari, R., Nihoyannopoulos, P., Evangelista, A., Kasprzak, J., Lancellotti, P., Poldermans, D., Voigt, J.-U., & Zamorano, J. L. (2008). Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). European Journal of Echocardiography, 9(4), 415–437. https://doi.org/10.1093/ejechocard/jen175

Image source: 📄 Pellikka, P. A., Arruda-Olson, A., Chaudhry, F. A., Chen, M. H., Marshall, J. E., Porter, T. R., & Sawada, S. G. (2020). Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Journal of the American Society of Echocardiography, 33(1), 1-41.e8. https://doi.org/10.1016/j.echo.2019.07.001

Stress methodNormal response

Regional		Ischemic response

Regional		Normal response

Global		Ischemic response

Global
TreadmillHyperkinesis post-exercise

compared to rest		Hypokinesis

compared to rest		Increase in EDV

Decrease in ESV

Increase in EF		Increase in EDV

Increase in ESV Decrease in EF in left main, multivessel disease
Supine

Bicycle		Hyperkinesis with exercise but less than with treadmill, dobutamineHypokinesis

compared to rest		Small increase in EDV

Decrease in ESV

Modest increase in EF		Increase in EDV

Increase in ESV Decrease in EF in left main, multivessel disease
DobutamineMarked hyperkinesis

Increased velocity of contraction compared to rest and low dose		Hypokinesis and decreased velocity of contraction compared to low dose, and usually compared to restDecrease in EDV

Marked decrease in ESV Marked increase in EF		Decrease in EF,

cavity dilatation are

infrequent with left main, multivessel disease
VasodilatorHyperkinesis with stress compared to restHypokinesis

compared to rest		Decrease in EDV

Decrease in ESV

Increase in EF		Decrease in EF,

cavity dilatation are

infrequent with left main, multivessel disease
Atrial PacingMild hyperkinesis or no change in function compared to restHypokinesis

compared to rest		Decrease in EDV

Decrease in ESV

No change in EF		Decrease in EDV

No change or increase in ESV

Decrease in EF with left main, multivessel disease

Table Source: Table 3 from 📄 Pellikka, P. A., Arruda-Olson, A., Chaudhry, F. A., Chen, M. H., Marshall, J. E., Porter, T. R., & Sawada, S. G. (2020). Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. Journal of the American Society of Echocardiography, 33(1), 1-41.e8. https://doi.org/10.1016/j.echo.2019.07.001

Prognostic value of Stress Echo

Table source: 📄 Sicari, R., Nihoyannopoulos, P., Evangelista, A., Kasprzak, J., Lancellotti, P., Poldermans, D., Voigt, J.-U., & Zamorano, J. L. (2008). Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). European Journal of Echocardiography, 9(4), 415–437. https://doi.org/10.1093/ejechocard/jen175

Abnormal Stress Echo, but Normal Cors

Focus on the apex

Talal recommends focus on the apex when assessing stress echo. LAD ischemia?

  • Wall motion abnormalities in the absence of significant angiographic coronary stenosis should have you thinking of the following:
    • Microvascular abnormalities
    • Endothelial dysfunction
    • Vasospasm
    • Small vessel CAD
    • Apical ballooning syndrome
    • Amyloidosis

Graph View

Backlinks