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Presentation on theme: "PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY"— Presentation transcript:

Dr. Benny J Panakkal Senior Resident Dept. of Cardiology Medical College, Kozhikode

2 Understanding Basic Concepts

3 The answer to the Question “Why Echo”
Ischemia Cascade The answer to the Question “Why Echo” Chest pain – least specific. Regional malperfusion – most specific

4 May occur without producing Ischemia
Wall Motion More Specific Requires Ischemia Perfusion Changes More Sensitive May occur without producing Ischemia

5 Low cost Environment friendly No ionizing radiation Equally accurate
Why Echo in comparison to SPECT, PET etc. Low cost Environment friendly No ionizing radiation Equally accurate

6 Angina with ST-T changes WITHOUT Wall Motion Abnormalities
Coronary Flow Reserve Angina with ST-T changes WITHOUT Wall Motion Abnormalities Microvascular Ischemia Syndrome X LV Hypertrophy

7 Stressors in Stress Testing


9 Exercise Stress Testing
Treadmill Most potent Bicycle Imaging at Peak Stress and during each stage of stress Avoids problem of early resolution of ischemia Can accurately measure the time of onset of ischemia Prognostically important

10 Circumvented by Pharmacological Stressers
Exercise as a Stressor Prototype of Demand driven ischemic stress Drawbacks Hyperventilation Hypercontractility of Normal Walls Excessive Tachycardia Excessive chest wall movement Unable to exercise at all or maximally Circumvented by Pharmacological Stressers

11 Situations where Pharmacological Stress is preferred to Exercise Stress


13 Dipyridamol Dobutamine More More blood flow heterogeneity Less
myocardial dysfunction More blood flow heterogeneity Sometimes even without wall motion abnormalities Still supply is sufficient for the demand More blood flow heterogeneity Dobutamine

14 Adverse Effects and Complications




18 Protocols

19 Exercise Stress Test Protocol


21 Dipyridamol Stress Echo Protocol

22 Ergonovine Stress Protocol for Coronary Vasospasm
For coronary spasm Sensitivity 93%, Specificity 91% Cumulative dose of 0.35mg… 7 times

23 Imaging Equipment and Acquisition

24 Quad screen Format Normal response to Exercise, Dobutamine or Pacing Stress Echo

25 Follow a Road map Harmonic imaging Contrast Echo 2D imaging
Qualitiy issues Failure to image >1 seg (30%) Suboptimal visualization (10-15%) Harmonic imaging Contrast Echo Follow a Road map Avoid excessive gain settings Same window, Same view for optimal comparison Perfect Apical 2-chamber view

26 Contrast Echo in Stress Echo LV Opacification by micro bubbles
Contrast Echo and 3D Imaging Contrast Echo in Stress Echo LV Opacification by micro bubbles Improved Wall motion detection Simultaneous perfusion analysis Targetted approach to assess wall motion 3D Imaging Decreased Acquisition periods Technically easier

27 How Contrast Echo improves Endocardial border defintion

28 Excessive Gain setting spoiling the Endocardial border definition

29 Comparing Similar looking but totally different views

30 TDI or Strain Rate Imaging QRS to onset of Relaxation = 350 – 400ms
TDI in Stress Echo TDI or Strain Rate Imaging QRS to onset of Relaxation = 350 – 400ms Normally interval decreases by 34% ± 10% In Ischemia – 12% ± 18% Speckle Tracking Diastolic stunning Lasts longer than wall motion abnormalities

31 Applying Strain Rate Imaging in Stress Echo

32 Applying Strain Rate Imaging in Stress Echo
Low dose Dobutamine

33 Applying Strain Rate Imaging in Stress Echo
High dose Dobutamine

34 The Do(s) and Don’t(s)

35 Indications of Stress Echo CAD
Diagnosis Prognostication Pre Op risk assessment Exertional dyspnoea to rule out cardiac etiology Localizing ischemia Evaluation of valve stenosis severity

36 Special clinical conditions and target endpoints in Stress Echo
Discordant symptoms and severity of lesion Rise in contractile reserve Exercise induced peak sytolic pulmonary pressures > 60mm Hg Regurgitant lesions

37 Diagnostic and Prognostic value of CFR during Vasodilator testing
Standalone diagnostic criteria: Structural limitations Only LAD imaged LCx and RCA very difficult to image and impractical Cannot differentiate between microvascular and macrovascular CAD Addition of CFR – ↑ Sensitivity, with modest↓ in Specificity CFR – Flow (High Neg Pred Value) 2D – Function (High Pos Pred Value) Used in DCMP too!!

38 Interpretation

39 Wall motion scoring and attribution to coronary vascular territories



42 Interpretation of Pharmacological and Exercise Stress Echo

43 Stress induced myocardial ischemia – Hallmarks
Worsening of wall motion abnormalities Development of new wall motion abnormalities Specific Lack of hyperdynamic motion Beta Blockers THR not attained Non-Specific Akinetic segment becoming dyskinetic No meaning

44 Decreased Global LV systolic function TVD or Left Main disease
Adjunctive Diagnostic Criteria LV cavity dilatation Decreased Global LV systolic function TVD or Left Main disease Could be normal responses in exercise, but is abnormal in dobutamine stress echo Differential responses to Exercise and Dobutamine Stress Echo

45 Diagnostic End Points Max dose of pharmacological agent Achievement of THR Akinesis of ≥ 2 LV segements Severe Chest pain Obvious ECG positivity ≥ 2mm ST shift Submaximal Non-diagnostic End Points Non tolerable symptoms Limiting Asymptomatic side effects Hypertention (BP > 220/120) Hypotension (BP drop > 40mm Hg) Supraventricular Arrythmias Complex Ventricular Arrythmias VT Frequent polymorphic VPC

46 Dipyridamol Stress Preferred
Hypertension Atrial and Ventricular Arrhythmias Dobutamine Stress Preferred Conduction disturbances Bronchospastic diseases On Xanthine medications Caffeine containing drinks Tea Coffee Cola

47 Contents of Stress Echo Report

48 Statistics, Studies The Comparison

49 Single Centre Analysis ( >50,000 studies ) – Mayo Clinic
Exercise Stress Echo Dobutamine Stress Echo VT 1.4% 4% VF 1 2 SVT and AF are more common than VT/VF

50 Diagnostic Accuracy - Overall
Sensitivity Specificity Stress Echo 85% 88% Stress SPECT 81% Sensitivities in CAD subtypes SVD DVD TVD Stress Echo 58% 86% 94% Stress SPECT 61% All same Pellikka PA: Stress echocardiography for the diagnosis of coronary artery disease: Progress towards quantification. Curr Opin Cardiol 20:395, 2005. Armstrong WF, Zoghbi WA: Stress echocardiography: Current methodology and clinical applications. J Am Coll Cardiol 45:1739, 2005

51 Mayo Clinic Study comprising 1325 patients
Stress Echo as a Prognostic Indicator Cardiac Event : Cardiac Death, Non-fatal MI, Coronary Revascularization Normal Stress Echo – Event Rate < 3% (0.9% per person years of follow up) Predictors of Cardiac Event (TMT) Low effort tolerance LVH Advancing Age Mayo Clinic Study comprising 1325 patients

52 Event Rate was 2% per person year follow up
Predictors among patients with Good Effort Tolerance and Abnormal Stress Echo – Event Rate was 2% per person year follow up HR Diabetes 1.9 Previous MI 2.4 Increase or No change in LV systolic size 1.6 Kane GC, Hepinstall MJ, Kidd GM, et al: Safety of stress echocardiography supervised by registered nurses: Results of a 2-year audit of 15,404 patients. J Am Soc Echocardiogr 21:337, 2008

53 Among patients with a High Pretest Probability for CAD – cardiac event rate
At 1 yr At 3 yra Normal Stress Echo 2% 4% Abnormal Stress Echo 17% 25% Elhendy A, Mahoney DW, Burger KN, et al: Prognostic value of exercise echocardiography in patients with classic angina pectoris. Am J Cardiol 94:559, 2004

54 A Mayo clinic study of 530 patients
Dobutamine Stress Echo in Preop Evaluation and Prognostication Ischemic Threshold Event Rate < 60% THR 43% ≥ 60% THR 9% No Ischemia 0% A Mayo clinic study of 530 patients

55 Accuracy of different approaches for diagnosis of CAD with Stress Echo
Hoffmann R, Lethen H, Marwick T, et al. Standardized guidelines for the interpretation of dobutamine echocardiography reduce interinstitutional variance in interpretation. Am J Cardiol. 1998;82:1520–1524.

56 Dipyridamol vs Dobutamine Stress Echo

57 Dipyridamol vs Exercise Stress Echo testing

58 Dipyridamol vs Exercise Stress Echo testing

59 Sensitivity Specificity Accuracy
Meta analysis of major trials comparing Dipyridamol with Exercise Stess Testing Sensitivity Specificity Accuracy SVD MVD GLOBAL Dipyridamol 66 81 72 92 77 Exercise 90 79 82 80

60 3D Echo in Stess Testing

61 Prognostication

62 Prognostic Value of Inducible
Myocardial Ischemia Prognostic value of normal stress echo Normal test – Annual risk of Death = 0.4% – 0.9% Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta- analysis. J Am Coll Cardiol 2007; 49:227–37

63 Prognostic Value of Inducible
Myocardial Ischemia Stress Echo Titration of a Negative Test

64 Biphasic Response is the single most important response in predicting improvement in LV function in patients with LV dysfunction undergoing revascularization 72% vs <15%

65 Safety Data

66 Safety of Pharmacological Stress Echo

67 Safety of Pharmacological Stress Echo
Physical stress with exercise is probably safer than pharmacological testing Lattanzi F, Picano E, Adamo E, Varga A. Dobutamine stress echocardiography: safety in diagnosing coronary artery disease. Drug Saf 2000; 22:251–62. Varga A, Garcia MA, Picano E. International Stress Echo Complication Registry. Safety of stress echocardiography (from the International Stress Echo Complication Registry). Am J Cardiol 2006;98:541–3

68 Special Subsets Valvular Heart Disease

69 Contractile Reserve – 20% of stroke volume
Cut Offs for Diagnosis Contractile Reserve – 20% of stroke volume Valve area improvement to differentiate true from Pseudostenosis – 0.2% Asymptomatic Sev AS, mean gradient rise on exercise - > 20 mmHg

70 Special Subsets Non Cardiac Surgery

71 Reduced Fibrinolytic activity
Cytokine response Catecholamine Surge Hemodynamic stress Vasospasm Reduced Fibrinolytic activity Platelet activation Hyper-coagulability Perioperative Stress Response

72 Intermediate risk category with Poor functional capacity
When to perform Pharmacological Stress Echo in the context of Perioperative risk stratification High risk category Intermediate risk category with Poor functional capacity Age < 70 yrs β blocker therapy suffices Age > 70 yrs Revascularization Peripheral Vascular Disease Stress Echo positivity does not always mean Revascularization Left main or 2 vessel disease Only indication for revascularization Others β blockers and Statins

73 Special Subsets Emergency Department

74 Randomized muticenter trial - Italy 99%
Neg predictive value to r/o ACS Still has drawbacks Patients with negative stress test had early readmission with ACS

75 Special Subsets Myocardial Viability Assessment

76 Viable Thickness ≥ 6mm Scarred Thinned Echodense

77 Diagnostic Accuracy comparison for Myocardial Viability Assessment
Metanalysis Bax et al. 2001 Bax JJ, Poldermans D, Elhendy A, et al. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol. 2001;26:142–186

78 Examples

79 Detection of Myocardial Ischemia – Apical wall thickness, improves at low dose but
deteriorates and high dose dobutamine stress echo.

80 Thank you


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