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Paolo M Fioretti - One of the best experts on this subject based on the ideXlab platform.
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incremental prognostic value of Stress Echocardiography as an adjunct to exercise electrocardiography after uncomplicated myocardial infarction
Heart, 2001Co-Authors: Riccardo Bigi, Alessandro Desideri, Ciro Coletta, Cesare Fiorentini, Alfonso Galati, Paolo M FiorettiAbstract:Objective—To assess the prognostic value of Stress Echocardiography as an adjunct to exercise electrocardiography in patients with uncomplicated acute myocardial infarction. Design—496 patients underwent a maximum exercise ECG and pharmacological Stress Echocardiography (406 dobutamine and 90 dipyridamole) within 15 days of uncomplicated acute myocardial infarction and were followed for a mean of 25 months (range 1‐74 months) for reinfarction, unstable angina, and cardiac death. Patients undergoing revascularisation were omitted. Results—Exercise ECG was positive in 162 patients (32.6%) and low threshold positive ( 100 W) positive exercise ECG. Eventfree survival of patients with both tests positive was significantly less than in patients with only one positive test or with both tests negative. Conclusions—Stress Echocardiography provides additional prognostic information after uncomplicated acute myocardial infarction, but the greatest gain is found in patients with a high threshold positive exercise ECG. (Heart 2001;85:417‐423)
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usefulness and limitations of dobutamine atropine Stress Echocardiography for the diagnosis of coronary artery disease in patients with left bundle branch block a multicentre study
European Heart Journal, 2000Co-Authors: M L Geleijnse, Abdou Elhendy, Paolo M Fioretti, J D Kasprzak, Carlo Vigna, Ricardo Rambaldi, M P Salvatori, Ja H Cornel, Jos R T C RoelandAbstract:Background Patients with left bundle branch block exhibit abnormal septal motion which may limit the interpretation of Stress echocardiograms. This study sought to assess the diagnostic value of dobutamine–atropine Stress Echocardiography in left bundle branch block patients. Methods and Results Sixty-four left bundle branch block patients (mean age 59 years, 24 men) with suspected coronary artery disease underwent dobutamine–atropine Stress Echocardiography and coronary arteriography. Myocardial ischaemia was defined as new or worsening wall thickening abnormalities. Coronary artery disease was quantitatively defined as a diameter stenosis 50% in a major epicardial artery. Rest septal motion was normal (apart from the early systolic septal notch) in 34 patients (53%) and abnormal in 30 patients (47%). Rest septal thickening was normal in 32 patients (50%) and abnormal in 32 patients (50%). All seven patients with a QRS duration 160 ms and an abnormal QRS axis had abnormal rest septal motion and thickening. Inter-observer agreement for ischaemia was 88%. In all but one patient disagreement was in the septum. For the anterior and posterior circulation, respectively, sensitivity was 60% (9/ 15) and 67% (8/12), specificity was 94% (46/49) and 98% (51/52), and accuracy was 86% (55/64) and 92% (59/64). Sensitivity for the anterior circulation tended to be better in patients with normal rest septal thickening (83% vs 44%). Conclusions Dobutamine–atropine Stress Echocardiography has excellent diagnostic specificity in left bundle branch block patients with suspected coronary artery disease. In patients with abnormal rest septal thickening, however, dobutamine–atropine Stress Echocardiography may lack good sensitivity for detection of coronary artery disease in the anterior circulation. Left bundle branch block patients who potentially most benefit from dobutamine–atropine Stress Echocardiography may initially be selected by their resting electrocardiogram.
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safety and prognostic value of early dobutamine atropine Stress Echocardiography in patients with spontaneous chest pain and a non diagnostic electrocardiogram
European Heart Journal, 2000Co-Authors: M L Geleijnse, Abdou Elhendy, Paolo M Fioretti, Riccardo Rambaldi, J R T C Roelandt, Jaroslaw D Kasprzak, R T Van Domburg, Jan H Cornel, A P J Klootwijk, M L SimoonsAbstract:Aims To risk stratify and shorten hospital stay in patients with spontaneous (resting) chest pain and a non-diagnostic electrocardiogram (ECG). Methods and Results The study comprised 102 patients (mean age 58±12 years, 67 men) with spontaneous chest pain and a non-diagnostic ECG. Forty-three patients had suspected coronary artery disease and 59 had known (but of unknown actual significance) coronary artery disease. All patients underwent serial creatine kinase enzyme measurements, continuous ECG monitoring for at least 12h and early dobutamine–atropine Stress Echocardiography in patients with negative creatine kinase enzymes and normal findings at ECG monitoring. Dobutamine–atropine Stress Echocardiography was considered positive in patients with new or worsening wall thickening abnormalities. Patients with negative dobutamine–atropine Stress Echocardiography were discharged after the test. In-hospital and 6 month follow-up events noted were cardiac death, non-fatal myocardial infarction, unstable angina, and coronary artery bypass surgery or angioplasty. Thirteen patients had evidence of evolving myocardial infarction by elevated creatine kinase enzymes, or unstable angina by ECG monitoring. In the remaining 89 patients, dobutamine–atropine Stress Echocardiography was performed after a median observation period of 31h (range 12–68h). During dobutamine–atropine Stress Echocardiography no serious complications (death, non-fatal myocardial infarction, sustained ventricular tachycardia or ventricular fibrillation) occurred. Dobutamine–atropine Stress Echocardiography results were of poor quality in three, non-diagnostic in six, negative in 44 and positive in 36 patients. In the 80 patients with diagnostic dobutamine–atropine Stress Echocardiography, variables associated with in-hospital events (n=7) were history of exertional angina ( P <0·005), chest pain score ( P <0·005), Stress-induced angina ( P <0·001) and positive dobutamine–atropine Stress Echocardiography ( P <0·005). Variables associated with follow-up events (n=11) were history of exertional angina ( P <0·05), chest pain score ( P <0·001), Stress-induced angina ( P <0·01) and positive dobutamine–atropine Stress Echocardiography ( P <0·01). At multivariate analysis the only significant predictor of events was positive dobutamine–atropine Stress Echocardiography ( P <0·01). Conclusion Early dobutamine–atropine Stress Echocardiography may safely distinguish between low- and high-risk subsets for subsequent cardiac events in patients with spontaneous chest pain and a non-diagnostic ECG.
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Stress Echocardiography and exercise electrocardiography for risk stratification after non q wave uncomplicated myocardial infarction
American Journal of Cardiology, 1999Co-Authors: Alessandro Desideri, Gian Leone Suzzi, Ciro Coletta, Gino Valente, Dario Gregori, Riccardo Bigi, Paolo M FiorettiAbstract:: The aim of our study was to compare the prognostic value of Stress Echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 68 consecutive patients. Our data show that Stress Echocardiography and exercise electrocardiography offer similar prognostic information after uncomplicated non-Q-wave AMI.
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methodology feasibility safety and diagnostic accuracy of dobutamine Stress Echocardiography
Journal of the American College of Cardiology, 1997Co-Authors: M L Geleijnse, Paolo M Fioretti, Jos R T C RoelandtAbstract:Large numbers of patients referred for evaluation of chest pain are unable to perform adequate, diagnostic exercise testing. In these patients, dobutamine Stress Echocardiography (DSE) represents an alternative, exercise- independent Stress modality. Apart from the ~5% of patients with an inadequate acoustic window, 10% of patients referred for this test have nondiagnostic (sub-maximal negative) test results. Serious side effects during or shortly after DSE are uncommon, with ventricular fibrillation or myocardial infarction occurring in ~1 of 2,000 studies. No deaths have been reported. On the basis of a total number of 2,246 patients, reported in 28 studies, the sensitivity, specificity and accuracy of the test for the detection of coronary artery disease (CAD) were 80%, 84% and 81%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 74%, 86% and 92%, respectively. The sensitivity for detection of disease in the left circumflex coronary artery (55%) was lower, both compared with that for left anterior descending (72%) and right coronary artery disease (76%). The sensitivity of predicting multivessel disease by multiregion echocardiographic abnormalities varied widely, from 8% to 71%. In direct comparisons, DSE was superior to exercise electrocardiography and dipyridamole Echocardiography and comparable to exercise Echocardiography and radionuclide imaging. DSE is a useful, feasible and safe exercise-independent Stress modality for assessing the presence, localization and extent of CAD.
Eugenio Picano - One of the best experts on this subject based on the ideXlab platform.
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integration of wall motion coronary flow velocity and left ventricular contractile reserve in a single test prognostic value of vasodilator Stress Echocardiography in patients with diabetes
Journal of The American Society of Echocardiography, 2018Co-Authors: Lauro Cortigiani, Francesco Bovenzi, Quirino Ciampi, Tonino Bombardini, Alda Huqi, Eugenio PicanoAbstract:Background Coronary flow velocity reserve (CFVR) and left ventricular contractile reserve (LVCR) have demonstrated prognostic importance in patients with diabetes. The aim of this study was to investigate the prognostic contribution of combined evaluation of CFVR and LVCR in patients with diabetes with nonischemic Stress Echocardiography. Methods Three hundred seventy-five patients with diabetes (mean age, 68 ± 9 years) with nonischemic dipyridamole Stress Echocardiography underwent assessment of CFVR of the left anterior descending coronary artery (prospectively) and LVCR with left ventricular force (retrospectively) in a multicenter study. Results On receiver operating characteristic analysis, LVCR ≤ 1.1 was the best prognostic predictor and was considered an abnormal value. CFVR was abnormal (≤2) in 139 patients (37%), LVCR in 156 (42%), neither in 157 (42%), and both in 77 (21%). During a median follow-up period of 16 months, 86 major adverse cardiac events occurred: 16 deaths, 13 myocardial infarctions, and 57 revascularizations. Multivariate prognostic indicators were CFVR ≤ 2 ( P P = .03), and LVCR ≤ 1.1 ( P = .04). The 3-year rate of major adverse cardiac events was 63% in patients with both abnormal CFVR and LVCR, 42% in those with abnormal CFVR only, 19% in those with abnormal LVCR only, and 10% in patients with both normal CFVR and LVCR. The 3-year hard event rate was 3% in patients with both normal CFVR and LVCR, fivefold higher in patients with abnormal CFVR or LVCR only, and ninefold higher in patients with both abnormal CFVR and LVCR. Conclusions Patients with diabetes with nonischemic dipyridamole Stress Echocardiography may still have significant risk in presence of abnormal CFVR and/or LVCR, which assess the underlying, largely unrelated, microvascular and myocardial components of coronary circulation.
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prediction of mortality by Stress Echocardiography in 2835 diabetic and 11 305 nondiabetic patients
Circulation-cardiovascular Imaging, 2015Co-Authors: Lauro Cortigiani, Francesco Bovenzi, Eugenio Picano, Sabrina Molinaro, Lucia Borelli, Mauro Raciti, Rosa SicariAbstract:Background— To compare the capability by Stress Echocardiography results to predict overall mortality in a large unselected cohort of diabetic and nondiabetic patients. Methods and Results— The study group comprised 14 140 patients (2835 diabetics and 11 305 nondiabetics) who underwent Stress Echocardiography for evaluation of known (n=5671) or suspected (n=8469) coronary artery disease. Ischemia at Stress Echocardiography was observed in 768 (27%) diabetics and 2644 (23%) nondiabetics. During a median follow-up of 30 months (first quartile, 9; third quartile, 63), 1213 patients died. In diabetics, multivariable indicators of mortality were age (hazard ratio [HR], 1.07, 95% confidence interval [CI], 1.06–1.09), rest wall motion abnormality (HR, 2.43; 95% CI, 1.83–3.22), and ischemia at Stress Echocardiography (HR, 1.71; 95% CI, 1.34–2.18). In nondiabetics, multivariable indicators of mortality were age (HR, 1.07; 95% CI, 1.06–1.08), rest wall motion abnormality (HR, 2.19; 95% CI, 1.86–2.57), male sex (HR, 1.65; 95% CI, 1.41–1.93), ischemia at Stress Echocardiography (HR, 1.54; 95% CI, 1.32–1.80), and antischemic therapy at the time of test (HR, 1.15; 95% CI, 1.00–1.32). In Stress echo negative subjects for ischemia, antischemic therapy showed increased annual mortality in nondiabetic patients with (3.8% versus 3.1%; P =0.04) or without rest wall motion abnormality (1.6% versus 0.9%; P <0.0001); it failed to do so in diabetic patients with (5.7% versus 5.8%; P =0.89) or without rest wall motion abnormality (2.6% versus 1.9%; P =0.10). Conclusions— Ischemia at Stress Echocardiography is a strong and independent predictor of total mortality in diabetic as well as nondiabetic patients. Antischemic therapy markedly affects the negative predictive value of Stress Echocardiography in nondiabetic patients, whereas it is prognostically neutral in the diabetic population.
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End-Systolic Elastance and Ventricular-Arterial Coupling Reserve Predict Cardiac Events in Patients with Negative Stress Echocardiography
BioMed Research International, 2013Co-Authors: Tonino Bombardini, Marco Fabio Costantino, Quirino Ciampi, Lorenza Pratali, Rosa Sicari, Eugenio PicanoAbstract:Background. A maximal negative Stress echo identifies a low-risk subset for coronary events. However, the potentially prognostically relevant information on cardiovascular hemodynamics for heart-failure-related events is unsettled. Aim of this study was to assess the prognostic value of Stress-induced variation in cardiovascular hemodynamics in patients with negative Stress Echocardiography. Methods. We enrolled 891 patients (593 males mean age 63 ± 12, ejection fraction 48 ± 17%), with negative (exercise 172, dipyridamole 482, and dobutamine 237) Stress Echocardiography result. During Stress we assessed left ventricular end-systolic elastance index (ELVI), ventricular arterial coupling (VAC) indexed by the ratio of the ELVI to arterial elastance index (EaI), systemic vascular resistance (SVR), and pressure-volume area (PVA). Changes from rest to peak Stress (reserve) were tested as predictors of main outcome measures: combined death and heart failure hospitalization. Results. During a median followup of 19 months (interquartile range 8–36), 50 deaths and 84 hospitalization occurred. Receiver-operating-characteristic curves identified as best predictors ELVI reserve for exercise (AUC = 0.871) and dobutamine (AUC = 0.848) and VAC reserve (AUC = 0.696) for dipyridamole. Conclusions. Patients with negative Stress Echocardiography may experience an adverse outcome, which can be identified by assessment of ELVI reserve and VAC reserve during Stress echo.
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coronary flow reserve during dipyridamole Stress Echocardiography predicts mortality
Jacc-cardiovascular Imaging, 2012Co-Authors: Lauro Cortigiani, Sonia Gherardi, Francesco Bovenzi, Fausto Rigo, Eugenio Picano, Sabrina Molinaro, Rosa SicariAbstract:Objectives The goal of this study was to evaluate the ability of coronary flow reserve (CFR) over regional wall motion to predict mortality in patients with known or suspected coronary artery disease (CAD). Background CFR evaluated using pulsed Doppler Echocardiography testing on left anterior descending artery is the state-of-the-art method during vasodilatory Stress Echocardiography. Methods In a prospective, multicenter, observational study, we evaluated 4,313 patients (2,532 men; mean age 65 ± 11 years) with known (n = 1,547) or suspected (n = 2,766) CAD who underwent high-dose dipyridamole (0.84 mg/kg over 6 min) Stress Echocardiography with CFR evaluation of left coronary descending artery (LAD) by Doppler. Overall mortality was the only endpoint analyzed. Results Stress Echocardiography was positive for ischemia in 765 (18%) patients. Mean CFR was 2.35 ± 0.68. At individual patient analysis, 1,419 (33%) individuals had CFR ≤2. During a median follow-up of 19 months (1st quartile 8; 3rd quartile 36), 146 patients died. The 4-year mortality was markedly higher in subjects with CFR ≤2 than in those with CFR >2, both considering the group with ischemia (39% vs. 7%; p Conclusions CFR on LAD is a strong and independent indicator of mortality, conferring additional prognostic value over wall motion analysis in patients with known or suspected CAD. A negative result on Stress Echocardiography with a normal CFR confers an annual risk of death
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the emerging role of exercise testing and Stress Echocardiography in valvular heart disease
Journal of the American College of Cardiology, 2009Co-Authors: Eugenio Picano, Patrizio Lancellotti, Philippe Pibarot, Jean Luc Monin, Robert O BonowAbstract:Exercise testing has an established role in the evaluation of patients with valvular heart disease and can aid clinical decision making. Because symptoms may develop slowly and indolently in chronic valve diseases and are often not recognized by patients and their physicians, the symptomatic, blood pressure, and electrocardiographic responses to exercise can help identify patients who would benefit from early valve repair or replacement. In addition, Stress Echocardiography has emerged as an important component of Stress testing in patients with valvular heart disease, with relevant established and potential applications. Stress Echocardiography has the advantages of its wide availability, low cost, and versatility for the assessment of disease severity. The versatile applications of Stress Echocardiography can be tailored to the individual patient with aortic or mitral valve disease, both before and after valve replacement or repair. Hence, exercise-induced changes in valve hemodynamics, ventricular function, and pulmonary artery pressure, together with exercise capacity and symptomatic responses to exercise, provide the clinician with diagnostic and prognostic information that can contribute to subsequent clinical decisions. Nevertheless, there is a lack of convincing evidence that the results of Stress Echocardiography lead to clinical decisions that result in better outcomes, and therefore large-scale prospective randomized studies focusing on patient outcomes are needed in the future.
Patricia A Pellikka - One of the best experts on this subject based on the ideXlab platform.
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applicability of appropriateness criteria for Stress imaging similarities and differences between Stress Echocardiography and single photon emission computed tomography myocardial perfusion imaging criteria
Circulation-cardiovascular Imaging, 2009Co-Authors: Robert B Mccully, Patricia A Pellikka, David O Hodge, Philip A Araoz, Todd D Miller, Raymond J GibbonsAbstract:Background— Appropriateness criteria for Stress imaging have been published to promote the effective use of Stress nuclear scintigraphy and Stress Echocardiography. We sought to evaluate the application of the Stress Echocardiography appropriateness criteria to patients undergoing Stress Echocardiography in an academic medical center. Methods and Results— The Stress Echocardiography criteria were applied to 298 consecutive patients who underwent Stress Echocardiography. Patients were rated as appropriate, uncertain, inappropriate, or not classifiable. Results were compared with those of a previous analysis in the same patients using the single-photon computed tomography myocardial perfusion imaging (SPECT MPI) criteria. The level of agreement between 2 cardiac nurse abstractors for categorizing appropriateness by the Stress Echocardiography criteria was good (κ=0.72). Overall, 54% of patients were classified as appropriate, 8% as uncertain, and 19% as inappropriate; 19% were not classifiable. By the SPECT MPI criteria, 64% of patients were classified as appropriate, 9% as uncertain, and 18% as inappropriate; 9% were not classifiable ( P <0.001 compared with Stress Echocardiography criteria). By the Stress Echocardiography criteria, 6 clinical situations or indications accounted for more than 90% of the inappropriate tests; most of these involved asymptomatic patients. Conclusions— Applying Stress Echocardiography appropriateness criteria to a patient population is feasible, although 1 in 5 of our patients was not classifiable. Overall, the Stress Echocardiography criteria classified patients differently compared with the SPECT MPI criteria. Future refinements of the appropriateness criteria for Stress imaging should address gaps in the criteria and disparities between the Stress Echocardiography and SPECT MPI criteria. Received June 10, 2008; accepted January 26, 2009.
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american society of Echocardiography recommendations for performance interpretation and application of Stress Echocardiography
Journal of The American Society of Echocardiography, 2007Co-Authors: Patricia A Pellikka, Cathryn A Kuehl, Abdou Elhendy, Sherif F Nagueh, Stephen G SawadaAbstract:Methodology...... 1021 Imaging Equipment and Technique 1021 Stress Testing Methods...... 1022 Training Requirements and Maintenance of Competency...... 1023 Image Interpretation 1024 Table 1. Normal and Ischemic Responses for Various Modalities of Stress 1025 Quantitative Analysis Methods 1025 Accuracy...... 1026 False-negative Studies...... 1026 False-positive Studies...... 1027 Assessment of Myocardial Viability 1027 Assessment of Patients With Dyspnea, Pulmonary Hypertension, and Valvular Heart Disease...... 1028 Dyspnea 1028 Pulmonary Hypertension 1029 Mitral Valve Disease...... 1029 Aortic Valve Disease...... 1029 Evaluation of Prosthetic Valves 1030 Stress Echocardiography for Risk Stratification 1030 Table 2. Summary of Studies Evaluating the Value of Stress Echocardiography in Predicting Outcome...... 1031 Table 3. Stress Echocardiography Predictors of Risk 1032 Women 1032 After Acute Myocardial Infarction...... .........1032 Elderly 1033 Patients With Diabetes Mellitus...... 1033 Before Noncardiac Surgery...... 1033 After Coronary Revascularization...... .........1033 Patients With Angina...... 1033 Comparison With Radionuclide Imaging...... ....1033 Recent and Future Developments...... .........1034 Strain and Strain Rate Echocardiograpy...... ......1034 Three-Dimensional Echocardiography...... ........1034 Myocardial Contrast Perfusion Imaging...... ......1034 Summary...... 1034 References 1034 Advances since the 1998 publication of the Recommendations for Performance and Interpretation of Stress Echocardiography include improvements in imaging equipment, refinements in Stress testing protocols and standards for image interpretation, and important progress toward quantitative analysis. Moreover, the roles of Stress Echocardiography for cardiac risk stratification and for assessment of myocardial viability are now well documented. Specific recommendations and main points are identified in bold.
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contrast dobutamine Stress Echocardiography clinical practice assessment in 300 consecutive patients
Journal of The American Society of Echocardiography, 2001Co-Authors: Andrew J Rainbird, Douglas W Mahoney, Robert B Mccully, Sharon L Mulvagh, Kyle W Klarich, Clarence Shub, Patricia A PellikkaAbstract:In this study we compared non-contrast imaging with contrast imaging of the left ventricle during dobutamine Stress Echocardiography (DSE). Wall segment visualization, image quality, and confidence of interpretation were determined with and without the use of intravenous Optison, a second-generation echocardiographic contrast agent, in 300 consecutive patients undergoing rest and peak DSE. At rest and at peak Stress, the percentage of wall segments visualized, image quality, and confidence of interpretation were better with contrast compared with non-contrast imaging. No significant decrease was seen in wall segment visualization, image quality, or confidence of interpretation from rest to peak Stress in images obtained with contrast, unlike the images obtained without contrast from rest to peak Stress. The use of the intravenous echocardiographic contrast agent Optison during DSE significantly improved wall segment visualization and image quality at rest and at peak Stress, resulting in improved confidence of interpretation.
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role of dobutamine Stress Echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease
Circulation, 1998Co-Authors: Seng Chye Chuah, Patricia A Pellikka, Robert B Mccully, Veronique L Roger, James B SewardAbstract:Background—Increasingly, dobutamine Stress Echocardiography has been used for detection of coronary artery disease. Less information exists regarding the incremental prognostic value of the test, including semiquantitative wall scoring, compared with clinical and rest echocardiographic variables. Methods and Results—Follow-up information was obtained from 860 patients who underwent dobutamine Stress Echocardiography over a 2-year period. To determine the value of dobutamine Stress Echocardiography in predicting cardiac events, including cardiac death and myocardial infarction, clinical and rest and Stress echocardiographic data were considered in a stepwise Cox multivariate regression model. During follow-up of up to 52 months, 72 patients underwent coronary revascularization before any cardiac event and were censored. Eighty-six patients had cardiac events, including nonfatal myocardial infarction in 36 and cardiac death in 50. In a multivariate model, a history of congestive heart failure, the percentag...
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Stress Echocardiography recommendations for performance and interpretation of Stress Echocardiography
Journal of The American Society of Echocardiography, 1998Co-Authors: William F Armstrong, Patricia A Pellikka, Thomas J Ryan, Linda Crouse, William A ZoghbiAbstract:Cardiovascular Stress testing remains the mainstay of provocative evaluation for patients with known or suspected coronary artery disease. Stress Echocardiography has become a valuable means of cardiovascular Stress testing. It plays a crucial role in the initial detection of coronary disease, in determining prognosis, and in therapeutic decision making. The purpose of this document is to outline the recommended methodology for Stress Echocardiography with respect to personnel and equipment as well as the clinical use of this recently developed technique. Specific limitations will also be discussed.
D Poldermans - One of the best experts on this subject based on the ideXlab platform.
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Stress Echocardiography expert consensus statement executive summary european association of Echocardiography eae a registered branch of the esc
European Heart Journal, 2008Co-Authors: Rosa Sicari, D Poldermans, Patrizio Lancellotti, Jensuwe Voigt, Petros Nihoyannopoulos, Arturo Evangelista, J D Kasprzak, Jose ZamoranoAbstract:Stress Echocardiography is the combination of Echocardiography with a physical, pharmacological, or electrical Stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during Stress. Stress Echocardiography provides similar diagnostic and prognostic accuracy to radionuclide Stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different Stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological Stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast Echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler Echocardiography adds another potentially important dimension to Stress Echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler Stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operator's training, Stress Echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 Stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …
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Stress Echocardiography expert consensus statement european association of Echocardiography eae a registered branch of the esc
European Journal of Echocardiography, 2008Co-Authors: Rosa Sicari, D Poldermans, Jaroslaw D Kasprzak, Patrizio Lancellotti, Petros Nihoyannopoulos, Arturo Evangelista, Jenuwe Voigt, Jose ZamoranoAbstract:Stress Echocardiography is the combination of 2D Echocardiography with a physical, pharmacological or electrical Stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during Stress. Stress Echocardiography provides similar diagnostic and prognostic accuracy as radionuclide Stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different Stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological Stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast Echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding – coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler Echocardiography adds another potentially important dimension to Stress Echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler Stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator’s training, Stress Echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.
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noninvasive evaluation of ischaemic heart disease myocardial perfusion imaging or Stress Echocardiography
European Heart Journal, 2003Co-Authors: Arend F L Schinkel, Abdou Elhendy, Eric Boersma, Jeroen J Bax, Jos R T C Roelandt, M L Geleijnse, D PoldermansAbstract:Stress Echocardiography and myocardial perfusion imaging are commonly used noninvasive imaging modalities for the evaluation of ischaemic heart disease. Both modalities have proved clinically useful in the entire spectrum of coronary artery disease. Both techniques can detect coronary artery disease and provide prognostic information. Both techniques can identify low-risk and high-risk subsets among patients with known or suspected coronary artery disease and thus guide patient management decisions. In patients with acute myocardial infarction, both techniques have been used to identify residual viable tissue and predict improvement of function over time. In patients with chronic ischaemic left ventricular (LV) dysfunction, viability assessment with either modality can be used to predict improvement of function after revascularisation and thus guide patient treatment.
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doppler tissue velocity sampling improves diagnostic accuracy during dobutamine Stress Echocardiography for the assessment of viable myocardium in patients with severe left ventricular dysfunction
European Heart Journal, 2000Co-Authors: Riccardo Rambaldi, Abdou Elhendy, D Poldermans, J J Bax, E Boersma, Wim B Vletter, J R T C Roelandt, Roelf ValkemaAbstract:Background Both nuclear imaging with F18-fluorodeoxyglucose and dobutamine Stress Echocardiography have been used to identify viable myocardium, although dobutamine–Stress Echocardiography has been demonstrated to be the less sensitive of the two. Aim To compare the accuracy of pulsed-wave Doppler tissue sampling with dobutamine–Stress Echocardiography for the detection of viable myocardium, using F18-fluorodeoxyglucose imaging as a reference. Methods Forty patients with chronic coronary artery disease and left ventricular dysfunction (mean ejection fraction 33±11%), underwent F18-fluorodeoxyglucose imaging, dobutamine–Stress Echocardiography and pulsed-wave Doppler tissue sampling. Evaluation was performed using a six-segment model. Results Visual assessment by resting echo was feasible in 230 out of 240 segments (96%); 177 (77%) segments showed severe dyssynergy at rest. F18-fluorodeoxyglucose imaging showed viability in 95 (54%) segments while 82 (46%) were non-viable. Ejection phase velocity at rest was not significantly different; ejection velocities during low-dose and peak-dose dobutamine, however, were significantly higher in viable myocardium (8·6±2·9 vs 6·0±1·8 and 9·3±31 vs 6·2±2·1cm.s−1). Using receiver operating characteristic curves the optimal cut-off value for viability assessment was an increase in the ejection phase velocity low-dose of 1±0·5cm.s−1, while 0±0·5cm.s−1predicted non-viability. The sensitivity and specificity (95%CI) of pulsed-wave Doppler tissue sampling and dobutamine–Stress Echocardiography for the prediction of viability was respectively 87% (82–92) vs 75% (67–81) ( P <0·05) and 52% (44–59) vs 51% (45–59) ( P =ns). Conclusions The sensitivity of pulsed-wave Doppler tissue sampling is superior to dobutamine–Stress Echocardiography for the assessment of myocardial viability.
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stroke volume changes during dobutamine atropine Stress Echocardiography the influence of heart rate and ischaemia
International Journal of Cardiac Imaging, 1999Co-Authors: D Poldermans, Abdou Elhendy, Riccardo Rambaldi, Wim B Vletter, Eric Boersma, Stephane Carlier, Jeroen J Bax, Arie Man In J T Veld, Jos R T C RoelandtAbstract:Background: A decrease in stroke volume during dobutamine-atropine Stress Echocardiography heralds ischaemia and possible hypotension. Hypotension results from worsening of LV-function (as a result of ischaemia) left ventricular outflow tract obstruction or hypovolemia, while an increase of stroke volume indicates the preservation of myocardial contractile reserve. Objective: To assess stroke volume changes during dobutamine Stress Echocardiography in relation to heart rate and occurrence of ischaemia and to validate a new automated cardiac output measurement device. Methods: In fifty patients, the stroke volume was assessed using the echocardiographic biplane discs method during a Stress Echocardiography. These data were reference values for the validation of a new automated cardiac output measurement using the first method as a reference. Results: Stroke volume measured by the biplane discs method and automated cardiac output device decreased from rest to peak Stress, respectively, from 54 ± 16 to 34 ± 9 (63%) ml and 63 ± 17 to 38 ± 15 (60%) ml (p < 0.001). Stroke volume decreased with increased heart rate and Stress-induced ischaemia when assessed by the biplane discs method, but with the automated device it decreased only with increased heart rate. Conclusions: Both increased heart rate and myocardial ischaemia during dobutamine Stress Echocardiography cause a reduction of stroke volume. However, the automated device did not detect the effects of Stress-induced ischaemia on stroke volume. It appears that the biplane discs method is more sensitive for evaluating the effect of ischaemia.
Rosa Sicari - One of the best experts on this subject based on the ideXlab platform.
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prediction of mortality by Stress Echocardiography in 2835 diabetic and 11 305 nondiabetic patients
Circulation-cardiovascular Imaging, 2015Co-Authors: Lauro Cortigiani, Francesco Bovenzi, Eugenio Picano, Sabrina Molinaro, Lucia Borelli, Mauro Raciti, Rosa SicariAbstract:Background— To compare the capability by Stress Echocardiography results to predict overall mortality in a large unselected cohort of diabetic and nondiabetic patients. Methods and Results— The study group comprised 14 140 patients (2835 diabetics and 11 305 nondiabetics) who underwent Stress Echocardiography for evaluation of known (n=5671) or suspected (n=8469) coronary artery disease. Ischemia at Stress Echocardiography was observed in 768 (27%) diabetics and 2644 (23%) nondiabetics. During a median follow-up of 30 months (first quartile, 9; third quartile, 63), 1213 patients died. In diabetics, multivariable indicators of mortality were age (hazard ratio [HR], 1.07, 95% confidence interval [CI], 1.06–1.09), rest wall motion abnormality (HR, 2.43; 95% CI, 1.83–3.22), and ischemia at Stress Echocardiography (HR, 1.71; 95% CI, 1.34–2.18). In nondiabetics, multivariable indicators of mortality were age (HR, 1.07; 95% CI, 1.06–1.08), rest wall motion abnormality (HR, 2.19; 95% CI, 1.86–2.57), male sex (HR, 1.65; 95% CI, 1.41–1.93), ischemia at Stress Echocardiography (HR, 1.54; 95% CI, 1.32–1.80), and antischemic therapy at the time of test (HR, 1.15; 95% CI, 1.00–1.32). In Stress echo negative subjects for ischemia, antischemic therapy showed increased annual mortality in nondiabetic patients with (3.8% versus 3.1%; P =0.04) or without rest wall motion abnormality (1.6% versus 0.9%; P <0.0001); it failed to do so in diabetic patients with (5.7% versus 5.8%; P =0.89) or without rest wall motion abnormality (2.6% versus 1.9%; P =0.10). Conclusions— Ischemia at Stress Echocardiography is a strong and independent predictor of total mortality in diabetic as well as nondiabetic patients. Antischemic therapy markedly affects the negative predictive value of Stress Echocardiography in nondiabetic patients, whereas it is prognostically neutral in the diabetic population.
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End-Systolic Elastance and Ventricular-Arterial Coupling Reserve Predict Cardiac Events in Patients with Negative Stress Echocardiography
BioMed Research International, 2013Co-Authors: Tonino Bombardini, Marco Fabio Costantino, Quirino Ciampi, Lorenza Pratali, Rosa Sicari, Eugenio PicanoAbstract:Background. A maximal negative Stress echo identifies a low-risk subset for coronary events. However, the potentially prognostically relevant information on cardiovascular hemodynamics for heart-failure-related events is unsettled. Aim of this study was to assess the prognostic value of Stress-induced variation in cardiovascular hemodynamics in patients with negative Stress Echocardiography. Methods. We enrolled 891 patients (593 males mean age 63 ± 12, ejection fraction 48 ± 17%), with negative (exercise 172, dipyridamole 482, and dobutamine 237) Stress Echocardiography result. During Stress we assessed left ventricular end-systolic elastance index (ELVI), ventricular arterial coupling (VAC) indexed by the ratio of the ELVI to arterial elastance index (EaI), systemic vascular resistance (SVR), and pressure-volume area (PVA). Changes from rest to peak Stress (reserve) were tested as predictors of main outcome measures: combined death and heart failure hospitalization. Results. During a median followup of 19 months (interquartile range 8–36), 50 deaths and 84 hospitalization occurred. Receiver-operating-characteristic curves identified as best predictors ELVI reserve for exercise (AUC = 0.871) and dobutamine (AUC = 0.848) and VAC reserve (AUC = 0.696) for dipyridamole. Conclusions. Patients with negative Stress Echocardiography may experience an adverse outcome, which can be identified by assessment of ELVI reserve and VAC reserve during Stress echo.
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coronary flow reserve during dipyridamole Stress Echocardiography predicts mortality
Jacc-cardiovascular Imaging, 2012Co-Authors: Lauro Cortigiani, Sonia Gherardi, Francesco Bovenzi, Fausto Rigo, Eugenio Picano, Sabrina Molinaro, Rosa SicariAbstract:Objectives The goal of this study was to evaluate the ability of coronary flow reserve (CFR) over regional wall motion to predict mortality in patients with known or suspected coronary artery disease (CAD). Background CFR evaluated using pulsed Doppler Echocardiography testing on left anterior descending artery is the state-of-the-art method during vasodilatory Stress Echocardiography. Methods In a prospective, multicenter, observational study, we evaluated 4,313 patients (2,532 men; mean age 65 ± 11 years) with known (n = 1,547) or suspected (n = 2,766) CAD who underwent high-dose dipyridamole (0.84 mg/kg over 6 min) Stress Echocardiography with CFR evaluation of left coronary descending artery (LAD) by Doppler. Overall mortality was the only endpoint analyzed. Results Stress Echocardiography was positive for ischemia in 765 (18%) patients. Mean CFR was 2.35 ± 0.68. At individual patient analysis, 1,419 (33%) individuals had CFR ≤2. During a median follow-up of 19 months (1st quartile 8; 3rd quartile 36), 146 patients died. The 4-year mortality was markedly higher in subjects with CFR ≤2 than in those with CFR >2, both considering the group with ischemia (39% vs. 7%; p Conclusions CFR on LAD is a strong and independent indicator of mortality, conferring additional prognostic value over wall motion analysis in patients with known or suspected CAD. A negative result on Stress Echocardiography with a normal CFR confers an annual risk of death
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Stress Echocardiography expert consensus statement executive summary european association of Echocardiography eae a registered branch of the esc
European Heart Journal, 2008Co-Authors: Rosa Sicari, D Poldermans, Patrizio Lancellotti, Jensuwe Voigt, Petros Nihoyannopoulos, Arturo Evangelista, J D Kasprzak, Jose ZamoranoAbstract:Stress Echocardiography is the combination of Echocardiography with a physical, pharmacological, or electrical Stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during Stress. Stress Echocardiography provides similar diagnostic and prognostic accuracy to radionuclide Stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different Stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological Stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast Echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler Echocardiography adds another potentially important dimension to Stress Echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler Stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operator's training, Stress Echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease. In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 Stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …
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Stress Echocardiography expert consensus statement european association of Echocardiography eae a registered branch of the esc
European Journal of Echocardiography, 2008Co-Authors: Rosa Sicari, D Poldermans, Jaroslaw D Kasprzak, Patrizio Lancellotti, Petros Nihoyannopoulos, Arturo Evangelista, Jenuwe Voigt, Jose ZamoranoAbstract:Stress Echocardiography is the combination of 2D Echocardiography with a physical, pharmacological or electrical Stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during Stress. Stress Echocardiography provides similar diagnostic and prognostic accuracy as radionuclide Stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different Stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological Stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast Echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding – coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler Echocardiography adds another potentially important dimension to Stress Echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler Stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator’s training, Stress Echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.