2. TRANSTHORACIC ECHOCARDIOGRAPHY & STRESS ECHO IHD MORTEZA ABDAR ESFAHANI MD. ADVANCED ECHOCARDIOLOGIST ( 3 D ) ASSOCIATE PROFESSOR OF ISFAHAN UNIVERSITY MEMBERSHIP OF EHA, & EES

4. Different type Echo mehode : RESTING CONVENTIONALTRANSTHORACIC ECHOCARDIOGRAPHY EXERCISE SERESS ECHOCARDIOGRAPHY DOBUTAMIN STRESS ECHOCARDIOGRAPHY

10. RESTING CONVENTIONALTRANSTHORACIC ECHOCARDIOGRAPHY EXERCISE SERESS ECHOCARDIOGRAPHY DOBUTAMIN STRESS ECHOCARDIOGRAPHY

11. Chronic stable angina CLASSINDICATIONLEVEL OF EVIDENCE** I (indicated) 1. Patients with systolic murmur suggestive of aortic stenosis or hypertrophic cardiomyopathy C 2. Evaluation of extent (severity) of ischemia (e.g., LV segmental wall motion abnormality) when the echocardiogram can be obtained during pain or within 30 min after its abatement C IIa (good supportive evidence) IIb (weak supportive evidence) Patients with a click or murmur to diagnose mitral valve prolapse C III (not indicated) Patients with a normal ECG, no history of myocardial infarction, and no signs or symptoms suggestive of heart failure, valvular heart disease, or hypertrophic cardiomyopathy C T -- ACC/AHA Guidelines for Echocardiography for Diagnosis of Cause of Chest Pain in Patients with Suspected Chronic Stable Angina Pectoris Echocardiography in

13.  Echocardiography can also be used, with and without stress, to detect wall motion abnormalities consistent with myocardial ischemia.  The presence of induced or baseline regional wall motion abnormalities correlates with a worse prognosis.  The sensitivity of stress echocardiography appears to be comparable to myocardial perfusion imaging ( ∼ 85%), and the specificity is somewhat better (95% versus 90%). [49] [49]

14. Echocardiography stable Angina – lV FUNCTION  Echocardiographic assessment of LV function is one of the most valuable aspects of noninvasive imaging.  Such testing is not necessary for all patients with angina pectoris and, in patients with a normal ECG and no previous history of MI, the likelihood of preserved LV systolic function is high.  In contrast, in patients with a history of MI, ST-T wave changes, or conduction defects or Q waves on the ECG, LV function should be measured with echocardiography or an equivalent technique.  The presence or absence of inducible regional wall motion abnormalities and the response of the ejection fraction to exercise or pharmacologic stress appear to provide incremental prognostic information to the data provided by the resting echocardiogram.

15. MODALITYTOTAL NO. OF PATIENTSs sensivity especi [fi†] [fi†] Exercise ECG24,0470.680.77 Exercise SPECT5,2720.880.72 Adenosine SPECT2,1370.900.82 Exercise echocardiography 2,7880.850.81 Dobutamine echocardiography 2,5820.810.79 * Without correction for referral bias. † Weighted average pooled across individual trials. TABLE 57-2 -- Sensitivity and Specificity of Stress Testing** Data from Gibbons RJ, Abrams J, Chatterjee K, et al: ACC/AHA 2002 guideline update for the management of patients with chronic stable angina : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to update the 1999 guidelines for the management of patients with chronic stable angina) (http://www.acc.org/clinical/guidelines/stable/stable.pdf ).http://www.acc.org/clinical/guidelines/stable/stable.pdf

16. Exercise STRESS ECHO IN Stable angina  Numerous studies have shown that exercise echocardiography can detect the presence of CAD with an accuracy similar to that of stress myocardial perfusion imaging  and superior to exercise electrocardiography alone.  Stress echocardiography is also valuable in localizing and quantifying ischemic myocardium.

17. STRESS ECHO  Stress echocardiography and radionuclide scans are the preferred noninvasive testing modalities for patients who cannot undergo treadmill electrocardiographic testing because of physical disability or who have resting ECGs that confound interpretation.  Imaging studies are less readily available and more expensive than exercise electrocardiography, but have increased sensitivity for the detection of coronary disease and the ability to quantify the extent of, and localize, jeopardized myocardium.

18.  Stress Echocardiography  Stress echocardiography is an excellent method for :  comparing wall motion (regional contractility), myocardial perfusion,  pressure gradient,  pulmonary pressure,  valvular regurgitation,  or filling pressures before and after a stress to identify pathologic conditions that are not apparent at rest.

19. EXERCISE STRESS ECHO  Because exercise-induced regional wall motion abnormalities due to ischemia usually last for a few minutes after the termination of exercise, images taken immediately after exercise can be compared with the baseline pre-exercise images to detect exercise- induced regional wall motion abnormalities.

20. EXERCISE ECHO  The typical exercise echocardiography protocol, ( SEE IN NEXT SLIDE ) .  Some centers favor a supine bicycle exercise protocol, as images can be obtained at peak exercise.

24. Diagnostic Criteria for Stress Echocardiography  Normally with exercise, dobutamine, or pacing, LV wall motion becomes Hyperdynamihc. The lack of hyperdynamic motion may indicate ischemia, but it is less specific.  When the stress level is inadequate or the patient is taking a beta blocker, however, the entire LV segment may contract normally without hyperdynamic motion  Worsening of wall motion abnormalities or the development of new abnormalities is the hallmark of stress-induced myocardial ischemia. .  Not infrequently, an akinetic myocardial segment becomes dyskinetic during stress echocardiography, but this change was not found to have any diagnostic or prognostic implication.

25. LV SIZE & SYSTOLIC FUNCTION  Other adjunctive diagnostic criteria for an abnormal stress echocardiogram include LV cavity dilation and a decrease in global systolic function. These adjunctive diagnostic criteria are more specific for detection of severe coronary artery disease.  Also, the response to dobutamine is different from that due to exercise. Even in patients with severe coronary artery disease, including left main coronary artery disease, the LV cavity may not dilate and global systolic function may improve with dobutamine infusion despite new wall motion abnormalities due to severe ischemia.

26. Exercise Echocardiography = Thallium scan  The sensitivity of exercise echocardiography and exercise thallium imaging for coronary artery disease in patients with single-, double-, or triple-vessel involvement was also similar : (58%, 86%,and 94% versus 61%, 86%, and 94%, respectively).  When a diagnostic test is used routinely, the diagnostic accuracy depends on the population of patients, the expertise of the interpreter, and the quality of the image.

27. Stress Echocardiography as a Prognostic Indicator  The likelihood of a cardiac event (cardiac death, nonfatal infarct, or coronary revascularization) after normal stress echocardiography is extremely low.  Moreover, a negative stress test portends a low risk for future events (less than 1%/person-year).

28. DSE in myocardial viability  Several human studies have demonstrated that a low dose of dobutamine (5 to 20 µg/kg per minute) induces contractility in viable myocardium, whether stunned or hibernating.  Dobutamine-responsive wall motion improvement predicts subsequent improvement in regional LV wall thickening after coronary revascularization

29. DSE (dose of dobutamin )  Most of the initial improvement in wall motion takes place with a low dose of dobutamine, between 10 and 20 µg/kg per minute, and worsening occurs at a higher dose, 30 to 40 µg/kg per minute, or with atropine.

30. Preoperative non cardiovascular evaluation by stress echo  Stress echocardiography has also been widely used as a preoperative test . One advantage of this test is that it assesses myocardial ischemia dynamically in response to increased inotropy and HR, such as may occur during the perioperative period.  The presence of new wall motion abnormalities that occur at low HR is the best predictor of increased perioperative risk, with large areas of defect being of secondary importance

31. Multi slices CT

32. CT Angio Using multidetector computed tomography (MDCT), coronary CTA has a sensitivity of approximately 90% and a specificity of 65% to 90% for coronary stenosis greater than 50%. * renal function and very high X ray EXPOSE

34. Definite indication  CABG  Congenital coronary abnormality  Don’t recommended for screening test