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Drop-off in positivity rate of stress echocardiography based on regional wall motion abnormalities over the last three decades. Int J Cardiovasc Imaging 2018; 35:627-632. [PMID: 30460582 DOI: 10.1007/s10554-018-1501-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/13/2018] [Indexed: 01/09/2023]
Abstract
Previous studies have suggested a decline in positivity of stress cardiac imaging based on regional wall motion abnormalities (RWMA). To assess the rate of RWMA positivity of stress echocardiography (SE) over 3 decades in the same primary care SE lab. We retrospectively assessed the rate of SE positivity in 7626 SE tests (dipyridamole in 5053, dobutamine in 2496, exercise in 77) in consecutive patients with known or suspected coronary artery disease and /or heart failure who performed SE in a primary care referral center from April 1991 to May 2018. Starting April 2005, SE based on RWMA was complemented by assessment of coronary flow velocity reserve (CFVR) of the left anterior descending coronary artery. Starting October 2016, we added left ventricular contractile reserve (LVCR). Starting October 2016, we also added B-lines by lung ultrasound. There was a progressive decline over time in the rate of SE positivity based on RWMA from 24% (1991-1999) to 10% (2000-2009) down to 4% (2010-2018) (p < 0.0001). Positivity rate was 29% with CFVR, 16% with LVCR, and 12% with B-lines. Over three decades, we observed a dramatic decline in SE positivity rate based on classical RWMA. In the last decade, the positivity rate rose sharply thanks to the stepwise introduction of CFVR, LVCR and B-lines as additional positivity criteria in integrated quadruple SE.
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152
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[Diagnosis and treatment of aortic valve stenosis]. Internist (Berl) 2018; 59:1279-1290. [PMID: 30413846 DOI: 10.1007/s00108-018-0519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aortic valve stenosis (AS) is the most frequently observed valvular heart disease. Once it is symptomatic the mortality rapidly increases. The diagnostic gold standard is transthoracic echocardiography. By measuring the maximum transvalvular velocity, mean transaortic pressure gradient and aortic valve opening area, classification of the type of stenosis can be defined. A differentiation is made between high-gradient AS, low-flow low gradient AS with reduced ventricular ejection fraction (<50%) and the paradoxical low-flow low-gradient AS with preserved ventricular function (≥50%). In some cases, additional diagnostic tools are necessary using dobutamine stress echocardiography, transesophageal echocardiography and cardiac computed tomography. The treatment follows an individualized approach. In cases of indications for valve replacement the multidisciplinary heart team takes into account the patient's age and individual risk for deciding whether an open surgical approach or transcatheter aortic valve implantation is indicated.
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153
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Franco-Gutiérrez R, Pérez-Pérez AJ, Franco-Gutiérrez V, Testa-Fernández AM, Vidal-Pérez RC, López-Reboiro ML, Puebla-Rojo VM, Santás-Álvarez M, Crespo-Leiro MG, González-Juanatey C. Usefulness of carotid ultrasonography in the diagnosis of coronary artery disease in patients undergoing exercise echocardiography. Cardiovasc Ultrasound 2018; 16:26. [PMID: 30296943 PMCID: PMC6176507 DOI: 10.1186/s12947-018-0143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Relationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear. The aim of the study is to evaluate whether carotid disease is associated with CAD in patients submitted to exercise echocardiography (EE) and if it improves the EE ability to predict CAD. METHODS We retrospectively studied 156 subjects without previous vascular disease who underwent EE, carotid ultrasonography and coronary angiography between 2002 and 2013. Positive EE was defined as exercise induced wall motion abnormalities, carotid disease according to Manheim and American Society of Echocardiography Consensus and significant CAD as stenosis ≥50%. RESULTS Eighty-nine (57.1%) subjects had significant CAD. Factors associated with CAD in multivariate analysis were fasting plasma glucose (odds ratio [OR] 1.02, p = 0.031), pre-test probability of CAD > 65% (OR 3.71, p < 0.001), positive EE (OR 10.51, p < 0.001) and carotid plaque (CP) presence (OR 2.95, p = 0.013). There was neither statistical significant difference in area under the curve after addition of CP to EE results (0.77 versus 0.81, p = 0.525) nor sensitivity, specificity, predictive values or efficiency. CP presence reclassified as very high-risk according to Systematic COronary Risk Evaluation 13 patients (34.2%) with negative EE and 22 (33.3%) without CAD. CONCLUSION CP is associated with CAD in patients undergoing EE, however its addition to EE does not improve CAD prediction, probably due to insufficient statistical power. CP reclassified one third of patients to very high-risk category despite negative EE or CAD absence, these subjects benefit from aggressive primary prevention interventions.
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Affiliation(s)
- Raúl Franco-Gutiérrez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Alberto José Pérez-Pérez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Virginia Franco-Gutiérrez
- Department of Otolaryngology, Hospital Universitario Marqués de Valdecilla, Avenida Valdecilla n° 25, Santander, 39008 Spain
| | - Ana María Testa-Fernández
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Rafael Carlos Vidal-Pérez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Manuel Lorenzo López-Reboiro
- Department of Internal Medicine, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, Lugo, 27003 Spain
| | - Víctor Manuel Puebla-Rojo
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Melisa Santás-Álvarez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - María Generosa Crespo-Leiro
- Department of Cardiology, Complejo Hospitalario Universitario A Coruña (CHUAC), As Xubias de Arriba n° 84, A Coruña, 15006 Spain
- Intitituto de Investigación Biomédica A Coruña (INIBIC), Xubias de Arriba n° 84, A Coruña, 15006 Spain
- Universidad de La Coruña (UDC), Calle de la Maestranza n° 9, A Coruña, 15001 Spain
| | - Carlos González-Juanatey
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
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154
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Picano E, Ciampi Q, Wierzbowska-Drabik K, Urluescu ML, Morrone D, Carpeggiani C. The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. Cardiovasc Ultrasound 2018; 16:22. [PMID: 30285774 PMCID: PMC6167852 DOI: 10.1186/s12947-018-0141-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The detection of regional wall motion abnormalities is the cornerstone of stress echocardiography. Today, stress echo shows increasing trends of utilization due to growing concerns for radiation risk, higher cost and stronger environmental impact of competing techniques. However, it has also limitations: underused ability to identify factors of clinical vulnerability outside coronary artery stenosis; operator-dependence; low positivity rate in contemporary populations; intermediate risk associated with a negative test; limited value of wall motion beyond coronary artery disease. Nevertheless, stress echo has potential to adapt to a changing environment and overcome its current limitations. INTEGRATED-QUADRUPLE STRESS-ECHO Four parameters now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-stress echo. They are: 1- regional wall motion abnormalities; 2-B-lines measured by lung ultrasound; 3-left ventricular contractile reserve assessed as the stress/rest ratio of force (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D); 4- coronary flow velocity reserve on left anterior descending coronary artery (with color-Doppler guided pulsed wave Doppler). IQ-Stress echo allows a synoptic functional assessment of epicardial coronary artery stenosis (wall motion), lung water (B-lines), myocardial function (left ventricular contractile reserve) and coronary small vessels (coronary flow velocity reserve in mid or distal left anterior descending artery). In "ABCD" protocol, A stands for Asynergy (ischemic vs non-ischemic heart); B for B-lines (wet vs dry lung); C for Contractile reserve (weak vs strong heart); D for Doppler flowmetry (warm vs cold heart, since the hyperemic blood flow increases the local temperature of the myocardium). From the technical (acquisition/analysis) viewpoint and required training, B-lines are the kindergarten, left ventricular contractile reserve the primary (for acquisition) and secondary (for analysis) school, wall motion the university, and coronary flow velocity reserve the PhD program of stress echo. CONCLUSION Stress echo is changing. As an old landline telephone with only one function, yesterday stress echo used one sign (regional wall motion abnormalities) for one patient with coronary artery disease. As a versatile smart-phone with multiple applications, stress echo today uses many signs for different pathophysiological and clinical targets. Large scale effectiveness studies are now in progress in the Stress Echo2020 project with the omnivorous "ABCD" protocol.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Quirino Ciampi
- Fatebenefratelli Hospital of Benevento, Viale Principe di Napoli, 12, 82100 Benevento, Italy
| | - Karina Wierzbowska-Drabik
- Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul Kniaziewicza 1/5, 91-347 Lodz, Poland
| | | | - Doralisa Morrone
- Cardiothoracic department, Cisanello Hospital, University of Pisa, Pisa, Italy
| | - Clara Carpeggiani
- Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
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155
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Comparison of Preoperative Assessment of Patient's Metabolic Equivalents (METs) Estimated from History versus Measured by Exercise Cardiac Stress Testing. Anesthesiol Res Pract 2018; 2018:5912726. [PMID: 30250484 PMCID: PMC6140009 DOI: 10.1155/2018/5912726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/29/2018] [Accepted: 08/12/2018] [Indexed: 11/17/2022] Open
Abstract
Background Preoperative anesthetic evaluations of patients before surgery traditionally involves assessment of a patient's functional capacity to estimate perioperative risk of cardiovascular complications and need for further workup. This is typically done by inquiring about the patient's physical activity, with the goal of providing an estimate of the metabolic equivalents (METs) that the patient can perform without signs of myocardial ischemia or cardiac failure. We sought to compare estimates of patients' METs between preoperative assessment by medical history with quantified assessment of METs via the exercise cardiac stress test. Methods A single-center retrospective chart review from 12/1/2005 to 5/31/2015 was performed on 492 patients who had preoperative evaluations with a cardiac stress test ordered by a perioperative anesthesiologist. Of those, a total of 170 charts were identified as having a preoperative evaluation note and an exercise cardiac stress test. The METs of the patient estimated by history and the METs quantified by the exercise cardiac stress test were compared using a Bland-Altman plot and Cohen's kappa. Results Exercise cardiac stress test quantified METs were on average 3.3 METS higher than the METs estimated by the preoperative evaluation history. Only 9% of patients had lower METs quantified by the cardiac stress test than by history. Conclusions The METs of a patient estimated by preoperative history often underestimates the METs measured by exercise stress testing. This demonstrates that the preoperative assessments of patients' METs are often conservative which errs on the side of patient safety as it lowers the threshold for deciding to order further cardiac stress testing for screening for ischemia or cardiac failure.
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156
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Scali MC, Ciampi Q, Picano E, Bossone E, Ferrara F, Citro R, Colonna P, Costantino MF, Cortigiani L, Andrea AD, Severino S, Dodi C, Gaibazzi N, Galderisi M, Barbieri A, Monte I, Mori F, Reisenhofer B, Re F, Rigo F, Trambaiolo P, Amor M, Lowenstein J, Merlo PM, Daros CB, de Castro e Silva Pretto JL, Miglioranza MH, Torres MAR, de Azevedo Bellagamba CC, Chaves DQ, Simova I, Varga A, Čelutkienė J, Kasprzak JD, Wierzbowska-Drabik K, Lipiec P, Weiner-Mik P, Szymczyk E, Wdowiak-Okrojek K, Djordjevic-Dikic A, Dekleva M, Stankovic I, Neskovic AN, Zagatina A, Di Salvo G, Perez JE, Camarozano AC, Corciu AI, Boshchenko A, Lattanzi F, Cotrim C, Fazendas P, Haberka M, Sobkowic B, Kosmala W, Witkowski T, Gosciniak P, Salustri A, Rodriguez-Zanella H, Leal LIM, Nikolic A, Gligorova S, Urluescu ML, Fiorino M, Novo G, Preradovic-Kovacevic T, Ostojic M, Beleslin B, Villari B, De Nes M, Paterni M, Carpeggiani C. Quality control of B-lines analysis in stress Echo 2020. Cardiovasc Ultrasound 2018; 16:20. [PMID: 30249305 PMCID: PMC6154410 DOI: 10.1186/s12947-018-0138-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 08/03/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.
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Affiliation(s)
- Maria Chiara Scali
- Cardiology Department, Nottola Hospital, Siena, Italy
- Cardiothoracic Department, University of Pisa, Pisa, Italy
| | - Quirino Ciampi
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Eugenio Picano
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Eduardo Bossone
- Cardiology Department, Ospedale santa Maria Incoronata dell’Olmo, cava de’ Tirreni, Salerno, Italy
| | - Francesco Ferrara
- Cardiology Department, Ospedale santa Maria Incoronata dell’Olmo, cava de’ Tirreni, Salerno, Italy
| | - Rodolfo Citro
- Cardiology Department and Echocardiography Lab, University Hospital “San Giovanni di Dio e Ruggi d’Aragona”, Salerno, Italy
| | - Paolo Colonna
- Cardiology Hospital, Policlinico of Bari, Bari, Italy
| | | | | | - Antonello D’. Andrea
- Cardiology Department, Echocardiography Lab, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Sergio Severino
- Cardiology Department, Echocardiography Lab, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Claudio Dodi
- Casa di Cura Figlie di San Camillo, Cremona, Italy
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Andrea Barbieri
- Cardiology Department, Modena University Hospital, Modena, Italy
| | - Ines Monte
- Cardio-Thorax-Vascular Department, Echocardiography lab, Policlinico Vittorio Emanuele, University of Catania, Catania, Italy
| | - Fabio Mori
- Cardiology Department, Careggi Hospital, Florence, Italy
| | - Barbara Reisenhofer
- Cardiology Division, Pontedera-Volterra Hospital, ASL Toscana 3 Nord-Ovest, Florence, Italy
| | - Federica Re
- Cardiology Department, San Camillo-Forlanini Hospital, Rome, Italy
| | - Fausto Rigo
- Cardiology Department, Ospedale dell’Angelo Mestre-Venice, Venice, Italy
| | | | - Miguel Amor
- Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina
| | | | | | | | | | - Marco A. R. Torres
- Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | | | - Iana Simova
- Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | - Albert Varga
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Jelena Čelutkienė
- Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Faculty of Medicine, Vilnius University, State Research Institute for Innovative Medicine, Vilnius, Lithuania
| | | | | | - Piotr Lipiec
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | - Paulina Weiner-Mik
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | - Eva Szymczyk
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | | | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Ivan Stankovic
- Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar N. Neskovic
- Department of Cardiology, Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Angela Zagatina
- Cardiology Department, University Hospital, Saint Petersburg, Russian Federation
| | | | - Julio E. Perez
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA
| | - Ana Cristina Camarozano
- Hospital de Clinicas UFPR, Medicine Department, Federal University of Paranà, Curitiba, Brazil
| | - Anca Irina Corciu
- Department of Cardiology, IRCCS Policlinico San Donato Clinic, Milan, Italy
| | - Alla Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Center of Russian Academy of Sciences, Tomsk, Russia
| | - Fabio Lattanzi
- Cardiothoracic Department, University of Pisa, Pisa, Italy
| | - Carlos Cotrim
- Heart Center, Hospital da Cruz Vermelha, Lisbon and Medical School of University of Algarve, Faro, Portugal
| | - Paula Fazendas
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Maciej Haberka
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Bozena Sobkowic
- Department of Cardiology, Medical University of Białystok, Białystok, Poland
| | - Wojciech Kosmala
- Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Witkowski
- Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Piotr Gosciniak
- Department of Cardiology, Provincial Hospital, Szczecin, Poland
| | | | | | | | | | | | - Madalina-Loredana Urluescu
- Cardiology Department, County Hospital Sibiu, Invasive and Non-Invasive Center for Cardiac and Vascular Pathology in Adults - CVASIC Sibiu, Faculty of Medicine, Sibiu, Romania
| | - Maria Fiorino
- Cardiology Division Ospedale Civico Di Cristina Benfratelli, Palermo, Italy
| | | | | | - Miodrag Ostojic
- Institute for Cardiovascular Diseases, Dedinje, Belgrade, Italy
- University Clinical Center, Banja Luka, Republic of Srpska Bosnia and Herzegovina
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Michele De Nes
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Marco Paterni
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Clara Carpeggiani
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
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157
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Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain. JACC Cardiovasc Imaging 2018; 11:1288-1297. [DOI: 10.1016/j.jcmg.2018.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 12/12/2022]
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158
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Chamsi-Pasha MA, Kurrelmeyer KM. Noninvasive Evaluation of Symptomatic Women with Suspected Coronary Artery Disease. Methodist Debakey Cardiovasc J 2018; 13:193-200. [PMID: 29744011 DOI: 10.14797/mdcj-13-4-193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in the United States, yet several factors make it challenging to diagnose in women. Although women have more frequent chest pain than men, atypical symptoms such as nausea, dyspnea, and fatigue make it difficult to determine their risk of coronary artery disease (CAD) before testing. Current guidelines recommend exercise electrocardiography (ex-ECG) as the initial test in symptomatic women with intermediate pretest probability who can exercise and have a normal resting ECG; however, treadmill ex-ECG testing has a significantly lower positive predictive value in women. In addition, women often have nonobstructive CAD in conjunction with microvascular dysfunction and other cardiovascular abnormalities that can decrease the accuracy of all noninvasive tests. The following provides an overview of exercise ECG, echocardiography, SPECT imaging, and various other available modalities and examines their effectiveness in diagnosing and managing symptomatic women with suspected CAD.
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Affiliation(s)
| | - Karla M Kurrelmeyer
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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159
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Minter S, Armour A, Tinnemore A, Strub K, Crowley AL, Bloomfield GS, Alexander JH, Douglas PS, Kisslo JA, Velazquez EJ, Samad Z. Crowdsourcing consensus: proposal of a novel method for assessing accuracy in echocardiography interpretation. Int J Cardiovasc Imaging 2018; 34:1725-1730. [PMID: 30128849 DOI: 10.1007/s10554-018-1389-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 06/04/2018] [Indexed: 12/22/2022]
Abstract
Quality in stress echocardiography interpretation is often gauged against coronary angiography (CA) data but anatomic obstructive coronary disease on CA is an imperfect gold standard for a stress induced wall motion abnormality. We examined the utility of crowd-sourcing a "majority-vote" consensus as an alternative 'gold standard' against which to evaluate the accuracy of an individual echocardiographer's interpretation of stress echocardiography studies. Participants independently interpreted baseline and post-exercise stress echocardiographic images of cases that had undergone follow up CA within 3 months of the stress echo in two surveys, 2 years apart. We examined the agreement of consensus on survey (survey participant response (> 60%) for one decision) with the stress echocardiography clinical read and with CA results. In the first survey, 29 participants reviewed and independently interpreted 14 stress echo cases. Consensus was reached in all 14 cases. There was good agreement between clinical and consensus (kappa = 0.57), survey participant response and consensus (kappa = 0.68) and consensus and CA results (kappa = 0.40). In the validation survey, the agreement between clinical reads and consensus (kappa = 0.75) and survey participant response and consensus (kappa = 0.81) remained excellent. Independent consensus is achievable and offers a fair comparison for stress echocardiographic interpretation. Future validation work, in other laboratories, and against hard outcomes, is necessary to test the feasibility and effectiveness of this approach.
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Affiliation(s)
- Stephanie Minter
- Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Alicia Armour
- Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Amanda Tinnemore
- Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Karen Strub
- Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Anna Lisa Crowley
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Gerald S Bloomfield
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Joseph A Kisslo
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA
| | - Eric J Velazquez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA.,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Zainab Samad
- Division of Cardiology, Department of Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Duke South, Orange Zone, Rm. 3347 A, Durham, NC, 27710, USA. .,Cardiac Diagnostic Unit, Duke University Medical Center, Durham, NC, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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Comparison of long-term clinical outcomes between revascularization versus medical treatment in patients with silent myocardial ischemia. Int J Cardiol 2018; 277:47-53. [PMID: 30093138 DOI: 10.1016/j.ijcard.2018.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/09/2018] [Accepted: 08/02/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND There have been limited and conflicting results regarding the prognostic impact of revascularization treatment on the long-term clinical outcomes of silent ischemia. The current study aimed to determine whether revascularization treatment compared with medical treatment (MT) alone reduces long-term risk of cardiac death of asymptomatic patients with objective evidence of inducible myocardial ischemia. METHODS A total of 1473 consecutive asymptomatic patients with evidence of inducible myocardial ischemia were selected from a prospective institutional registry. All patients showed at least 1 epicardial coronary stenosis with ≥50% diameter stenosis in coronary angiography. Patients were classified according to their treatment strategies. The primary outcome was cardiac death up to 10 years. RESULTS Among the total population, 709 patients (48.1%) received revascularization treatment including percutaneous coronary intervention (PCI, n = 558) or coronary artery bypass graft surgery (CABG, n = 151), with the remaining patients (764 patients, 51.9%) receiving MT alone. During the follow-up period, the revascularization treatment group showed a significantly lower risk of cardiac death compared with the MT alone group (25.4% vs. 33.7%, HR 0.624, 95%CI 0.498-0.781, p < 0.001). Among revascularized patients, patients with negative non-invasive stress test results after revascularization showed significantly lower risk of cardiac death compared to those with residual myocardial ischemia (8.9% vs. 18.7%, HR 0.406, 95% CI 0.175-0.942, p = 0.036). CONCLUSIONS In patients with silent myocardial ischemia, revascularization treatment was associated with significantly lower long-term risk of cardiac death compared with the MT alone group. The current results support contemporary practice of ischemia-directed revascularization, even in patients with silent myocardial ischemia.
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161
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Alsaied T, Niss O, Powell AW, Fleck RJ, Cnota JF, Chin C, Malik P, Quinn CT, Taylor MD. Diastolic dysfunction is associated with exercise impairment in patients with sickle cell anemia. Pediatr Blood Cancer 2018; 65:e27113. [PMID: 29781568 PMCID: PMC6019177 DOI: 10.1002/pbc.27113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/02/2018] [Accepted: 04/03/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Left ventricular diastolic dysfunction (DD) is an independent risk factor for mortality in sickle cell anemia (SCA) and is associated with increased extracellular volume (ECV) on cardiac MRI (CMR). Exercise impairment is common in SCA, but its causes and prognostic value are not well understood. OBJECTIVE To study the effects of DD and ECV on cardiopulmonary exercise test (CPET) in patients with SCA. METHODS AND RESULTS As part of a prospective study to characterize the cardiomyopathy of SCA (NCT02410811), 20 children and adults with SCA underwent CMR, echocardiography, and cycle ergometer CPET (age range 8-43 years). Maximum exercise was reached in 18 patients and 17 (94%) had reduced exercise capacity (%predicted VO2 less than 80%). Six patients had DD and none had systolic dysfunction. Patients with DD had lower exercise capacity compared to patients with normal diastolic function (%predicted VO2 48.2 ± 9.1% vs. 61.2 ± 11.7%; P = 0.01). The z-score of left ventricular lateral E/e' ratio, which is a marker of DD, was negatively associated with %predicted VO2 (r = -0.61, P = 0.01). All patients with moderate-to-severe exercise impairment (%predicted VO2 < 60%) had lateral E/e' z-score > 2. In a multivariate analysis, lateral E/e' z-score was independently associated with %predicted VO2 (P = 0.02). All participants had elevated ECV but the degree of elevation was not associated with exercise parameters. CONCLUSION Left ventricular DD is associated with decreased exercise capacity in SCA. Interventions to prevent or delay DD could improve exercise capacity, quality of life, and long-term outcomes in SCA.
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Affiliation(s)
- Tarek Alsaied
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Cardiac Imaging, Boston Children’s Hospital
| | - Omar Niss
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Adam W. Powell
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Robert J. Fleck
- Department of Radiology at Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - James F. Cnota
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Clifford Chin
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Punam Malik
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Division of Experimental Hematology and Cancer Biology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Charles T. Quinn
- Division of Hematology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Michael D. Taylor
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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162
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Mentias A, Alashi A, Naji P, Gillinov AM, Rodriguez LL, Mihaljevic T, Suri RM, Grimm RA, Svensson LG, Griffin BP, Desai MY. Exercise capacity in asymptomatic patients with significant primary mitral regurgitation: independent effect of global longitudinal left ventricular strain. Cardiovasc Diagn Ther 2018; 8:460-468. [PMID: 30214861 DOI: 10.21037/cdt.2018.05.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Despite preserved left ventricular ejection fraction (LVEF), patients with significant primary mitral regurgitation (MR) often have reduced exercise capacity. In asymptomatic patients with ≥3+ primary MR undergoing rest-stress echocardiography (RSE), we sought to evaluate the incremental impact of left ventricular global longitudinal strain (LV-GLS) on exercise capacity. Methods A total of 660 asymptomatic patients with ≥3+ primary MR, non-dilated LV and LVEF ≥60% (mean age, 57±14 years, 66% men, body mass index or BMI 25±4 kg/m2) who underwent RSE at our center between 2001 and 2013 were included. Standard RSE data were obtained. Average resting LV-GLS was measured using Velocity Vector Imaging. Results Mean mitral effective regurgitant orifice, resting right ventricular systolic pressure (RVSP) and LV-GLS were 0.45±0.2 cm2, 31±12 mmHg and -21.7%±2%, respectively; 28% had flail mitral leaflet. Mean metabolic equivalents (METs) and post-stress RVSP were 9.9±3, and 46±15 mmHg; 28% achieved <100% age-gender predicted METs. No patient had ischemia or significant arrhythmias. On logistic regression, resting LV-GLS [odds ratio (OR), 1.40, 95% confidence interval (CI): 1.21-1.55, BMI (OR, 1.11, 95% CI: 1.06-1.17)] and resting RVSP 1.22 (1.02-1.49) were independent predictors of exercise capacity. Area under the curve for association between 100% age-gender predicted METs and various factors were as follows: (I) BMI (0.60, 95% CI: 0.55-0.65, P<0.001); (II) resting RVSP (0.57, 95% CI: 0.52-0.62, P=0.006) and LV-GLS (0.66, 95% CI: 0.61-0.70, P<0.001). Conclusions In asymptomatic patients with ≥3+ primary MR, non-dilated LV and preserved LVEF, LV-GLS is independently associated with exercise capacity, beyond known predictors.
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Affiliation(s)
- Amgad Mentias
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alaa Alashi
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peyman Naji
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A Marc Gillinov
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L Leonardo Rodriguez
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tomislav Mihaljevic
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rakesh M Suri
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Richard A Grimm
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Svensson
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Griffin
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Milind Y Desai
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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163
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Patel KK, Young L, Carey W, Kohn KA, Grimm RA, Rodriguez LL, Griffin BP, Desai MY. Preoperative dobutamine stress echocardiography in patients undergoing orthotopic liver transplantation. Clin Cardiol 2018; 41:931-935. [PMID: 29781184 DOI: 10.1002/clc.22980] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/01/2018] [Accepted: 05/14/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Coronary artery disease (CAD) is associated with increased mortality in patients who undergo orthotopic liver transplantation (OLT). Chronic vasodilatory state and poor exercise tolerance in patients with end-stage liver disease make dobutamine stress echocardiography (DSE) preferred for preoperative evaluation of CAD prior to OLT. We studied the incidence of positive DSE results and the association between DSE results and perioperative and longer-term events. HYPOTHESIS DSE results pre-OLT will predict short and long term outcomes. METHODS We studied 460 patients who underwent DSE within 1 year prior to OLT between 2004 and 2011. Primary events included death and MI at 30 days post-OLT. We also recorded longer-term deaths. RESULTS Four patients (0.9%) had an ischemic response to DSE, 360 (78%) were normal, and 96 (21%) were nondiagnostic. Fourteen patients (3%) had a primary event at 30 days following OLT (13 deaths and 1 NSTEMI), and there were 108 (24%) deaths at 4.6±2 years of follow-up. No patient with ischemia on DSE had a 30-day event. The accuracy, sensitivity, specificity, and positive and negative predictive values of DSE that was not normal (ie, ischemic or nondiagnostic response) to predict 30-day post-OLT events were 76%, 14%, 78%, 2%, and 97%, respectively. On Cox survival analysis, only baseline left ventricular ejection fraction (HR: 0.90, 95% CI: 0.85-0.96, P < 0.001) was associated with longer-term deaths. CONCLUSIONS Patients undergoing pre-OLT DSE have very low incidence of an ischemic response on DSE, and it has no association with 30-day events.
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Affiliation(s)
- Krishna K Patel
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Laura Young
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - William Carey
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kathryn A Kohn
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard A Grimm
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - L Leonardo Rodriguez
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Stress Echocardiography Laboratory, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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164
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Porter TR. A physiologist observing and reporting supra-pharmacologic dobutamine stress testing: can we trust them, and can we trust the results? Echo Res Pract 2018; 5:E7-E8. [PMID: 30078786 PMCID: PMC6074816 DOI: 10.1530/erp-18-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/10/2018] [Indexed: 12/02/2022] Open
Abstract
In a study, published in this issue of Echo Research and Practice, Ntoskas et al. retrospectively analyzed the safety of a cardiac physiologist performing, and interpreting, Dobutamine stress echocardiography (DSE) in of 300 patients undergoing DSE for the detection of inducible reversible ischemia, myocardial viability and valvular heart disease. While safety during the tests themselves did not appear to be compromised with this unsupervised approach, the interpretation of these DSEs causes concerns regarding broad patient safety relative to misread results.
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165
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Löffler AI, Kramer CM. Myocardial Viability Testing to Guide Coronary Revascularization. Interv Cardiol Clin 2018; 7:355-365. [PMID: 29983147 DOI: 10.1016/j.iccl.2018.03.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Left ventricular dysfunction remains one of the best prognostic determinants of survival in patients with coronary artery disease. Revascularization has been shown to improve survival compared with medical therapy alone. Viability testing can help direct patients who will benefit the most from revascularization. Single-photon emission computed tomography, dobutamine stress echo, cardiac MRI, and PET imaging with F18-fluorodeoxyglucose are the most common modalities for assessing myocardial viability. Viability testing can help differentiate which patients benefit most from chronic total occlusion interventions.
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Affiliation(s)
- Adrián I Löffler
- Division of Cardiovascular Medicine, University of Virginia Health System, Box 800170, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Christopher M Kramer
- Division of Cardiovascular Medicine, University of Virginia Health System, Box 800170, 1215 Lee Street, Charlottesville, VA 22908, USA; Department of Radiology and Medical Imaging, Cardiovascular Imaging Center, University of Virginia Health System, Box 800170, 1215 Lee Street, Charlottesville, VA 22908, USA.
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166
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Beaudry RI, Samuel TJ, Wang J, Tucker WJ, Haykowsky MJ, Nelson MD. Exercise cardiac magnetic resonance imaging: a feasibility study and meta-analysis. Am J Physiol Regul Integr Comp Physiol 2018; 315:R638-R645. [PMID: 29949409 DOI: 10.1152/ajpregu.00158.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiac stress testing improves detection and risk assessment of heart disease. Magnetic resonance imaging (MRI) is the clinical gold-standard for assessing cardiac morphology and function at rest; however, exercise MRI has not been widely adapted for cardiac assessment because of imaging and device limitations. Commercially available magnetic resonance ergometers, together with improved imaging sequences, have overcome many previous limitations, making cardiac stress MRI more feasible. Here, we aimed to demonstrate clinical feasibility and establish the normative, healthy response to supine exercise MRI. Eight young, healthy subjects underwent rest and exercise cinematic imaging to measure left ventricular volumes and ejection fraction. To establish the normative, healthy response to exercise MRI we performed a comprehensive literature review and meta-analysis of existing exercise cardiac MRI studies. Results were pooled using a random effects model to define the left ventricular ejection fraction, end-diastolic, end-systolic, and stroke volume responses. Our proof-of-concept data showed a marked increase in cardiac index with exercise, secondary to an increase in both heart rate and stroke volume. The change in stroke volume was driven by a reduction in end-systolic volume, with no change in end-diastolic volume. These findings were entirely consistent with 17 previous exercise MRI studies (226 individual records), despite differences in imaging approach, ergometer, or exercise type. Taken together, the data herein demonstrate that exercise cardiac MRI is clinically feasible, using commercially available exercise equipment and vendor-provided product sequences and establish the normative, healthy response to exercise MRI.
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Affiliation(s)
- Rhys I Beaudry
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - T Jake Samuel
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - Jing Wang
- College of Nursing and Health Innovation, University of Texas at Arlington , Arlington, Texas
| | - Wesley J Tucker
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
| | - Mark J Haykowsky
- College of Nursing and Health Innovation, University of Texas at Arlington , Arlington, Texas
| | - Michael D Nelson
- Department of Kinesiology, University of Texas at Arlington , Arlington, Texas
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167
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Suzuki K, Hirano Y, Yamada H, Murata M, Daimon M, Takeuchi M, Seo Y, Izumi C, Akaishi M. Practical guidance for the implementation of stress echocardiography. J Echocardiogr 2018; 16:105-129. [PMID: 29876799 PMCID: PMC6132937 DOI: 10.1007/s12574-018-0382-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/07/2018] [Accepted: 05/16/2018] [Indexed: 01/01/2023]
Abstract
Exercise stress testing has been widely undertaken for the diagnosis of heart diseases. The accurate assessment of clinical conditions can be conducted by comparing the findings obtained from the results of stress echocardiography with the changes in the blood/heart rate and electrocardiograms. Numerous overseas studies have reported the utility of stress echocardiography in diagnosing myocardial ischemia; in Japan, the use of this modality for this purpose was included in the national health insurance reimbursable list in 2012. Nevertheless, stress echocardiography is far from being a widespread practice in Japan. This might be due to insufficient equipment (e.g., ergometers, space for test implementation) at each medical institution, shortage of technicians and sonographers who are well experienced and who are responsible for obtaining images during stress testing. The other possible reasons include the limited evidence available in Japan and the lack of a standardized testing protocol. Further dissemination of the practice of exercise stress echocardiography in this country is deemed necessary to establish satisfactory evidence for the use of stress echocardiography in the Japanese population. To this end, efforts are underway to develop a standardized protocol and report format to be adopted throughout Japan. We here present a guideline created by the Guideline Development Committee of the Japanese Society of Echocardiography that describes safe and effective stress echocardiography protocols and report formats. The readers are encouraged to perform exercise stress echocardiography using the proposed template for consensus document and report attached to this guideline.
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Affiliation(s)
- Kengo Suzuki
- Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yutaka Hirano
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Hirotsugu Yamada
- Department of Cardiology, Tokushima University Hospital, Tokushima, Japan
| | - Mitsushige Murata
- Department of Laboratory Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Masao Daimon
- Department of Clinical Laboratory, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihiro Seo
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Chisato Izumi
- National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Akaishi
- Tokai University Tokyo Hospital, 1-2-5 Yoyogi Shibuya-ku, Tokyo, Japan.
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168
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Dobutamine-induced takotsubo cardiomyopathy: A systematic review of the literature and case report. Anatol J Cardiol 2018; 19:412-416. [PMID: 29848925 PMCID: PMC5998857 DOI: 10.14744/anatoljcardiol.2018.78642] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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169
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Vasodilator Stress Single-Photon Emission Computed Tomography or Contrast Stress Echocardiography Association with Hard Cardiac Events in Suspected Coronary Artery Disease. J Am Soc Echocardiogr 2018; 31:683-691. [DOI: 10.1016/j.echo.2018.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Indexed: 11/19/2022]
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170
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Cortigiani L, Huqi A, Ciampi Q, Bombardini T, Bovenzi F, Picano E. 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. J Am Soc Echocardiogr 2018; 31:692-701. [DOI: 10.1016/j.echo.2017.11.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Indexed: 10/17/2022]
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171
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The hemodynamic response to constant dobutamine infusion: the effect of ADRB1 389 polymorphism and sex. Pharmacogenet Genomics 2018; 28:139-146. [PMID: 29768300 DOI: 10.1097/fpc.0000000000000338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVES Prolonged activation of the β-1 adrenergic receptor (ADRB1) is associated with receptor desensitization. This process has been suggested to have important pathophysiological and clinical implications in conditions such as congestive heart failure. The contribution of genetic factors to this process is a subject of ongoing research. We have previously shown that the ADRB1 389 polymorphism affects the response to incremental dose infusion of the ADRB agonist dobutamine. The aim of the current study was to determine whether the ADRB1 389 polymorphism affects the hemodynamic response to constant dose infusion of dobutamine in healthy patients. PATIENTS AND METHODS Healthy patients were recruited according to their ADRB1 49 and 389 genotypes [15 Arg389Arg, 10 Gly389Arg, and 10 Gly389Gly patients (all Ser49Ser), 21 men and 14 women]. Following a standardized protocol of dose increase, 6 mcg/kg/min dobutamine was infused over 2 h. Heart rate (HR), blood pressure (BP), and active plasma renin (PR) were measured. Standardized exercise (1 min) was performed at three time points during infusion. RESULTS In all patients, resting systolic BP was significantly decreased during infusion [144.4±11.5 vs. 140.3±12.2 mmHg (mean±SD), P=0.007]. There was no change in HR, and PR following 120 min of dobutamine infusion. ADRB1 389 genotypes were not associated with HR, systolic BP, and PR changes during dobutamine infusion (all P>0.05, repeated measures analysis of variance). Sex was associated with response to dobutamine. Among women, but not in men, resting HR significantly increased, and diastolic blood pressure (DBP) significantly decreased during dobutamine infusion [HR: 76.0±7.3 to 86.3±17.5 beats per minute (P=0.023), and DBP 78.5±8.49 mmHg to 72.36±6.16 (P=0.041) (repeated measures analysis of variance)]. CONCLUSION In healthy patients, the ADRB1 389 genotype was not associated with hemodynamic changes during constant dobutamine infusion. In women, but not in men, HR significantly increased and DBP decreased during 2 h of infusion.
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172
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Abdelmoneim SS, Ball CA, Mantovani F, Hagen ME, Eifert-Rain S, Wilansky S, Castello R, Pellikka PA, Best PJ, Mulvagh SL. Prognostic Utility of Stress Testing and Cardiac Biomarkers in Menopausal Women at Low to Intermediate Risk for Coronary ARTery Disease (SMART Study): 5-Year Outcome. J Womens Health (Larchmt) 2018; 27:542-551. [DOI: 10.1089/jwh.2017.6506] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Sahar S. Abdelmoneim
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Division of Cardiovascular Diseases, Assiut University, Assuit, Egypt
| | - Caroline A. Ball
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Francesca Mantovani
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Arcispedale Santa Maria Nuova (IRCCS), Reggio Emilia, Italy
| | - Mary E. Hagen
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Eifert-Rain
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan Wilansky
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, Arizona
| | | | - Patricia A. Pellikka
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Patricia J.M. Best
- Women's Heart Clinic, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Cardiovascular Catheterization Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sharon L. Mulvagh
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Women's Heart Clinic, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
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173
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Lu DY, Hailesealassie B, Ventoulis I, Liu H, Liang HY, Nowbar A, Pozios I, Canepa M, Cresswell K, Luo HC, Abraham MR, Abraham TP. Impact of peak provoked left ventricular outflow tract gradients on clinical outcomes in hypertrophic cardiomyopathy. Int J Cardiol 2018; 243:290-295. [PMID: 28747034 DOI: 10.1016/j.ijcard.2017.04.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/23/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is traditionally classified based on a left ventricular outflow tract (LVOT) pressure gradient of 30mmHg at rest or with provocation. There are no data on whether 30mmHg is the most informative cut-off value and whether provoked gradients offer any information regarding outcomes. METHODS Resting and provoked peak LVOT pressure gradients were measured by Doppler echocardiography in patients fulfilling guidelines criteria for HCM. A composite clinical outcome including new onset atrial fibrillation, ventricular tachycardia/fibrillation, heart failure, transplantation, and death was examined over a median follow-up period of 2.1years. RESULTS Among 536 patients, 131 patients had resting LVOT gradients greater than 30mmHg. Subjects with higher resting gradients were older with more cardiovascular events. For provoked gradients, a bi-modal risk distribution was found. Patients with provoked gradients >90mmHg (HR 3.92, 95% CI 1.97-7.79) or <30mmHg (HR 2.15, 95% CI 1.08-4.29) have more events compared to those with gradients between 30 and 89mmHg in multivariable analysis. The introduction of two cut-off points for provoked gradients allowed HCM to be reclassified into four groups: patients with "benign" latent HCM (provoked gradient 30-89mmHg) had the best prognosis, whereas those with persistent obstructive HCM had the worst outcome. CONCLUSIONS Provoked LVOT pressure gradients offer additional information regarding clinical outcomes in HCM. Applying cut-off points at 30 and 90mmHg to provoked LVOT pressure gradients further classifies HCM patients into low-, intermediate- and high-risk groups.
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Affiliation(s)
- Dai-Yin Lu
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Bereketeab Hailesealassie
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Johns Hopkins University, Baltimore, MD, United States
| | - Ioannis Ventoulis
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hongyun Liu
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hsin-Yueh Liang
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States; Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Alexandra Nowbar
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Iraklis Pozios
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Marco Canepa
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Kenneth Cresswell
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Hong-Chang Luo
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - M Roselle Abraham
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States
| | - Theodore P Abraham
- Johns Hopkins Hypertrophic Cardiomyopathy Center of Excellence, Baltimore, MD, United States.
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Huded CP, Masri A, Kusunose K, Goodman AL, Grimm RA, Gillinov AM, Johnston DR, Rodriguez LL, Popovic ZB, Svensson LG, Griffin BP, Desai MY. Outcomes in Asymptomatic Severe Aortic Stenosis With Preserved Ejection Fraction Undergoing Rest and Treadmill Stress Echocardiography. J Am Heart Assoc 2018; 7:JAHA.117.007880. [PMID: 29650708 PMCID: PMC6015416 DOI: 10.1161/jaha.117.007880] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background In asymptomatic patients with severe aortic stenosis and preserved left ventricular ejection fraction, we sought to assess the incremental prognostic value of resting valvuloarterial impedence (Zva) and left ventricular global longitudinal strain (LV‐GLS) to treadmill stress echocardiography. Methods and Results We studied 504 such patients (66±12 years, 78% men, 32% with coronary artery disease who underwent treadmill stress echocardiography between 2001 and 2012. Clinical and exercise variables (% of age‐sex predicted metabolic equivalents [%AGP‐METs]) were recorded. Resting Zva ([systolic arterial pressure+mean aortic valve gradient]/[LV‐stroke volume index]) and LV‐GLS (measured offline using Velocity Vector Imaging, Siemens) were obtained from the baseline resting echocardiogram. Death was the primary outcome. There were no major adverse cardiac events during treadmill stress echocardiography. Indexed aortic valve area, Zva, and LV‐GLS were 0.46±0.1 cm2/m2, 4.5±0.9 mm Hg/mL per m2 and −16±4%, respectively; only 50% achieved >100% AGP‐METs. Sixty‐four percent underwent aortic valve replacement. Death occurred in 164 (33%) patients over 8.9±3.6 years (2 within 30 days of aortic valve replacement). On multivariable Cox survival analysis, higher Society of Thoracic Surgeons score (hazard ratio or HR 1.06), lower % AGP‐METS (HR 1.16), higher Zva (HR 1.25) and lower LV‐GLS (HR 1.12) were associated with higher longer‐term mortality, while aortic valve replacement (HR 0.45) was associated with improved survival (all P<0.01). Sequential addition of ZVa and LV‐GLS to clinical model (Society of Thoracic Surgeons score and %AGP‐METs) increased the c‐statistic from 0.65 to 0.69 and 0.75, respectively, both P<0.001); findings were similar in the subgroup of patients who underwent aortic valve replacement. Conclusions In asymptomatic patients with severe aortic stenosis undergoing treadmill stress echocardiography, LV‐GLS and ZVa offer incremental prognostic value.
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Affiliation(s)
- Chetan P Huded
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmad Masri
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Kenya Kusunose
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Andrew L Goodman
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Richard A Grimm
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - A Marc Gillinov
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Douglas R Johnston
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - L Leonardo Rodriguez
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Zoran B Popovic
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lars G Svensson
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Brian P Griffin
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Milind Y Desai
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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175
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Picano E, Morrone D, Scali MC, Huqi A, Coviello K, Ciampi Q. Integrated quadruple stress echocardiography. Minerva Cardioangiol 2018; 67:330-339. [PMID: 29642694 DOI: 10.23736/s0026-4725.18.04691-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Stress echocardiography (SE) is an established diagnostic technique. For 40 years, the cornerstone of the technique has been the detection of regional wall motion abnormalities (RWMA), due to the underlying physiologically-relevant epicardial coronary artery stenosis. In the last decade, three new parameters (more objective than RWMA) have shown the potential to integrate and complement RWMA: 1) B-lines, also known as ultrasound lung comets, as a marker of extravascular lung water, measured using lung ultrasound with the 4-site simplified scan symmetrically of the antero-lateral thorax on the third intercostal space, from mid-axillary to anterior axillary and mid-clavicular line; 2) left ventricular contractile reserve (LVCR), assessed as the peak stress/rest ratio of left ventricular force, also known as elastance (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D echocardiography); 3) coronary flow velocity reserve (CFVR) on left anterior descending coronary artery, calculated as peak stress/rest ratio of diastolic peak flow velocity assessed using pulsed-wave Doppler. The 4 parameters (RWMA, B-lines, LVCR and CFVR) now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-SE. IQ-SE optimizes the versatility of SE to include in a one-stop shop the core "ABCD" (asynergy+B-lines+contractile reserve+Doppler flowmetry) protocol. It allows a synoptic assessment of parameters mirroring the epicardial artery stenosis (RWMA), interstitial lung water (B-lines), myocardial function (LVCR) and small coronary vessels (CFVR). Each variable has a clear clinical correlate, different and complementary to all others: RWMA identify an ischemic vs. non-ischemic heart; B-lines a wet vs. dry lung; LVCR a strong vs. weak heart; CFVR a warm vs. cold heart. IQ-SE is highly feasible, with minimal increase in the imaging and analysis time, and obvious diagnostic and prognostic impact also beyond coronary artery disease - especially in heart failure. Large scale effectiveness studies with IQ-SE are now under way with the Stress Echo 2020 Study, and will provide the necessary evidence base prior to large scale acceptance of the technique.
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Affiliation(s)
| | - Doralisa Morrone
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
| | | | - Alda Huqi
- Versilia Hospital, Viareggio, Lucca, Italy
| | - Katia Coviello
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
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Elhendy A. The power of stress echocardiography and myocardial perfusion scintigraphy in predicting long-term outcome. Nothing lasts forever. J Nucl Cardiol 2018; 25:480-482. [PMID: 27473219 DOI: 10.1007/s12350-016-0621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Abdou Elhendy
- Department of Cardiology, Marshfield Clinic, Marshfield, WI, USA.
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177
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ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease. J Am Soc Echocardiogr 2018; 31:381-404. [DOI: 10.1016/j.echo.2017.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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178
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Reynolds HR, Hausvater A, Carney K. Test Selection for Women with Suspected Stable Ischemic Heart Disease. J Womens Health (Larchmt) 2018; 27:867-874. [PMID: 29583082 DOI: 10.1089/jwh.2017.6587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Ischemic heart disease (IHD) is the leading cause of death and disability among women in the United States. Identifying IHD in women presenting with stable symptoms and stratifying their risk for an IHD event can be challenging for providers, with several different tests available. This article is meant to serve as a practical guide for clinicians treating women with potentially ischemic symptoms. Evidence and American Heart Association (AHA) recommendations regarding test selection are reviewed, with a focus on the information to be gained from each test. We outline suggested courses of action to be taken in the case of a positive or negative test. Regardless of the initial test result, clinicians should view a woman's symptom presentation as an opportunity to review and modify her risk of cardiovascular events.
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Affiliation(s)
- Harmony R Reynolds
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Anais Hausvater
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
| | - Kerrilynn Carney
- Soter Center for Women's Cardiovascular Research, Leon H. Charney Division of Cardiology, Department of Medicine, NYU School of Medicine , New York, New York
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179
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Exercise capacity in diabetes mellitus is predicted by activity status and cardiac size rather than cardiac function: a case control study. Cardiovasc Diabetol 2018; 17:44. [PMID: 29571290 PMCID: PMC5866526 DOI: 10.1186/s12933-018-0688-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 03/17/2018] [Indexed: 12/22/2022] Open
Abstract
Background The reasons for reduced exercise capacity in diabetes mellitus (DM) remains incompletely understood, although diastolic dysfunction and diabetic cardiomyopathy are often favored explanations. However, there is a paucity of literature detailing cardiac function and reserve during incremental exercise to evaluate its significance and contribution. We sought to determine associations between comprehensive measures of cardiac function during exercise and maximal oxygen consumption (\documentclass[12pt]{minimal}
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\begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak), with the hypothesis that the reduction in exercise capacity and cardiac function would be associated with co-morbidities and sedentary behavior rather than diabetes itself. Methods This case–control study involved 60 subjects [20 with type 1 DM (T1DM), 20 T2DM, and 10 healthy controls age/sex-matched to each diabetes subtype] performing cardiopulmonary exercise testing and bicycle ergometer echocardiography studies. Measures of biventricular function were assessed during incremental exercise to maximal intensity. Results T2DM subjects were middle-aged (52 ± 11 years) with a mean T2DM diagnosis of 12 ± 7 years and modest glycemic control (HbA1c 57 ± 12 mmol/mol). T1DM participants were younger (35 ± 8 years), with a 19 ± 10 year history of T1DM and suboptimal glycemic control (HbA1c 65 ± 16 mmol/mol). Participants with T2DM were heavier than their controls (body mass index 29.3 ± 3.4 kg/m2 vs. 24.7 ± 2.9, P = 0.001), performed less exercise (10 ± 12 vs. 28 ± 30 MET hours/week, P = 0.031) and had lower exercise capacity (\documentclass[12pt]{minimal}
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\begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak = 26 ± 6 vs. 38 ± 8 ml/min/kg, P < 0.0001). These differences were not associated with biventricular systolic or left ventricular (LV) diastolic dysfunction at rest or during exercise. There was no difference in weight, exercise participation or \documentclass[12pt]{minimal}
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\begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak in T1DM subjects as compared to their controls. After accounting for age, sex and body surface area in a multivariate analysis, significant positive predictors of \documentclass[12pt]{minimal}
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\begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak were cardiac size (LV end-diastolic volume, LVEDV) and estimated MET-hours, while T2DM was a negative predictor. These combined factors accounted for 80% of the variance in \documentclass[12pt]{minimal}
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\begin{document}$$\dot{V}O_{2}$$\end{document}V˙O2peak (P < 0.0001). Conclusions Exercise capacity is reduced in T2DM subjects relative to matched controls, whereas exercise capacity is preserved in T1DM. There was no evidence of sub-clinical cardiac dysfunction but, rather, there was an association between impaired exercise capacity, small LV volumes and sedentary behavior.
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180
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Rudski LG, Gargani L, Armstrong WF, Lancellotti P, Lester SJ, Grünig E, D'Alto M, Åström Aneq M, Ferrara F, Saggar R, Saggar R, Naeije R, Picano E, Schiller NB, Bossone E. Stressing the Cardiopulmonary Vascular System: The Role of Echocardiography. J Am Soc Echocardiogr 2018; 31:527-550.e11. [PMID: 29573927 DOI: 10.1016/j.echo.2018.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 01/06/2023]
Abstract
The cardiopulmonary vascular system represents a key determinant of prognosis in several cardiorespiratory diseases. Although right heart catheterization is considered the gold standard for assessing pulmonary hemodynamics, a comprehensive noninvasive evaluation including left and right ventricular reserve and function and cardiopulmonary interactions remains highly attractive. Stress echocardiography is crucial in the evaluation of many cardiac conditions, typically coronary artery disease but also heart failure and valvular heart disease. In stress echocardiographic applications beyond coronary artery disease, the assessment of the cardiopulmonary vascular system is a cornerstone. The possibility of coupling the left and right ventricles with the pulmonary circuit during stress can provide significant insight into cardiopulmonary physiology in healthy and diseased subjects, can support the diagnosis of the etiology of pulmonary hypertension and other conditions, and can offer valuable prognostic information. In this state-of-the-art document, the topic of stress echocardiography applied to the cardiopulmonary vascular system is thoroughly addressed, from pathophysiology to different stress modalities and echocardiographic parameters, from clinical applications to limitations and future directions.
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Affiliation(s)
- Lawrence G Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - William F Armstrong
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA-Cardiovascular Sciences, Liège, Belgium
| | - Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, University Hospital Heidelberg, Heidelberg, Germany
| | - Michele D'Alto
- Department of Cardiology, Second University of Naples-Monaldi Hospital, Naples, Italy
| | - Meriam Åström Aneq
- Department of Clinical Physiology, Institution of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Rajeev Saggar
- Lung Institute, Banner University Medical Center-Phoenix, University of Arizona, Phoenix, Arizona
| | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Nelson B Schiller
- Cardiovascular Research Institute, Health eHeart Study, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
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181
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Stillman AE, Oudkerk M, Bluemke DA, de Boer MJ, Bremerich J, Garcia EV, Gutberlet M, van der Harst P, Hundley WG, Jerosch-Herold M, Kuijpers D, Kwong RY, Nagel E, Lerakis S, Oshinski J, Paul JF, Slart RHJA, Thourani V, Vliegenthart R, Wintersperger BJ. Imaging the myocardial ischemic cascade. Int J Cardiovasc Imaging 2018; 34:1249-1263. [PMID: 29556943 DOI: 10.1007/s10554-018-1330-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/05/2018] [Indexed: 01/25/2023]
Abstract
Non-invasive imaging plays a growing role in the diagnosis and management of ischemic heart disease from its earliest manifestations of endothelial dysfunction to myocardial infarction along the myocardial ischemic cascade. Experts representing the North American Society for Cardiovascular Imaging and the European Society of Cardiac Radiology have worked together to organize the role of non-invasive imaging along the framework of the ischemic cascade. The current status of non-invasive imaging for ischemic heart disease is reviewed along with the role of imaging for guiding surgical planning. The issue of cost effectiveness is also considered. Preclinical disease is primarily assessed through the coronary artery calcium score and used for risk assessment. Once the patient becomes symptomatic, other imaging tests including echocardiography, CCTA, SPECT, PET and CMR may be useful. CCTA appears to be a cost-effective gatekeeper. Post infarction CMR and PET are the preferred modalities. Imaging is increasingly used for surgical planning of patients who may require coronary artery bypass.
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Affiliation(s)
- Arthur E Stillman
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA.
| | - Matthijs Oudkerk
- Center of Medical Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - David A Bluemke
- Department of Radiology and Imaging Sciences, National Institute of Biomedical Imaging and Bioengineering, Bethesda, MD, USA
| | - Menko Jan de Boer
- Department of Cardiology, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Jens Bremerich
- Department of Radiology, University of Basel Hospital, Basel, Switzerland
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | - Matthias Gutberlet
- Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Pim van der Harst
- Department of Genetics, University Medical Center Groningen, Groningen, The Netherlands
| | - W Gregory Hundley
- Departments of Internal Medicine & Radiology, Wake Forest University, Winston-Salem, NC, USA
| | | | - Dirkjan Kuijpers
- Department of Radiology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Raymond Y Kwong
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, DZHK Centre for Cardiovascular Imaging, University Hospital, Frankfurt/Main, Germany
| | | | - John Oshinski
- Department of Radiology and Imaging Sciences, Emory University, 1365 Clifton Rd NE, Atlanta, GA, 30322, USA
| | | | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Vinod Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
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Aggarwal NR, Bond RM, Mieres JH. The role of imaging in women with ischemic heart disease. Clin Cardiol 2018; 41:194-202. [PMID: 29505091 DOI: 10.1002/clc.22913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 12/24/2022] Open
Abstract
Substantial advances and insights in medical technology and treatment strategies, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, ischemic heart disease (IHD) remains the leading cause of cardiovascular morbidity and mortality of women in the Western world. Advances in cardiovascular imaging, over the past 4 decades, have significantly improved the evaluation and management of the full spectrum of coronary atherosclerosis, which contributes to ischemic heart disease. The development of contemporary and novel diagnostic imaging techniques and tools have assumed an expanded role in the evaluation of symptomatic women to detect not only flow-limiting epicardial coronary stenosis and nonobstructive atherosclerosis, but also ischemia resulting from microvascular dysfunction. IHD is now diagnosed early and with greater accuracy, leading to improved risk assessment and timely therapies in women. In this article, we review the available evidence on the role of contemporary diagnostic imaging techniques in the evaluation of women with suspected IHD.
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Affiliation(s)
| | - Rachel M Bond
- Zucker School of Medicine at Hofstra Northwell, New York
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183
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Xu B, Dobson L, Mottram PM, Nasis A, Cameron J, Moir S. Is exercise stress echocardiography useful in patients with suspected obstructive coronary artery disease who have resting left bundle branch block? Clin Cardiol 2018; 41:360-365. [PMID: 29574887 PMCID: PMC6490042 DOI: 10.1002/clc.22875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/23/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Current guidelines support exercise stress echocardiography (ESE) for evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Data regarding the diagnostic utility of ESE in patients with LBBB are limited. HYPOTHESIS We hypothesized that the diagnostic performance of ESE for the assessment of suspected OCAD is reduced in the context of LBBB. METHODS We studied 191 consecutive patients with resting LBBB undergoing ESE for the investigation of suspected OCAD between 2008 and 2015 at our center. The studies were categorized as inconclusive, normal, or abnormal. Patients with an abnormal response were subcategorized as regional ischemic response or globally abnormal. RESULTS Eighty-two patients (43%) demonstrated a normal left ventricular contractile response (LVCR) to exercise; 92 (48%) developed an abnormal LVCR to exercise, including 70 patients with globally abnormal and 22 patients with regional ischemic responses. Of the patients with abnormal responses, 62 patients had anatomic imaging, only 29 of whom had significant OCAD, conferring an overall specificity of ESE for significant OCAD of 21% and accuracy of 52%. Of patients who developed a regionally abnormal response, 89% had significant OCAD. CONCLUSIONS For patients with LBBB who develop a globally abnormal LVCR during ESE, the specificity of ESE for reliably excluding significant OCAD is significantly reduced. ESE appears to be a suboptimal test for the evaluation of OCAD in patients with resting LBBB, as about 50% of patients will have an abnormal response, the majority due to globally abnormal contraction where OCAD cannot be reliably diagnosed. Alternative testing should be considered for the investigation of suspected OCAD in patients with resting LBBB.
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Affiliation(s)
- Bo Xu
- MonashHeart, Monash HealthClaytonVictoriaAustralia
| | - Laura Dobson
- MonashHeart, Monash HealthClaytonVictoriaAustralia
| | | | - Arthur Nasis
- MonashHeart, Monash HealthClaytonVictoriaAustralia
| | | | - Stuart Moir
- MonashHeart, Monash HealthClaytonVictoriaAustralia
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Rest and Stress Longitudinal Systolic Left Ventricular Mechanics in Hypertrophic Cardiomyopathy: Implications for Prognostication. J Am Soc Echocardiogr 2018; 31:578-586. [PMID: 29426649 DOI: 10.1016/j.echo.2017.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Exercise intolerance is the most common symptom in hypertrophic cardiomyopathy (HCM). We examined whether inability to augment myocardial mechanics during exercise would influence functional performance and clinical outcomes in HCM. METHODS Ninety-five HCM patients (32 nonobstructive, 32 labile-obstructive, 31 obstructive) and 26 controls of similar age and gender distribution were recruited prospectively. They underwent rest and treadmill stress strain echocardiography, and 61 of them underwent magnetic resonance imaging. Mechanical reserve (MRES) was defined as percent change in systolic strain rate (SR) immediately postexercise. RESULTS Global strain and SR were significantly lower in HCM patients at rest (strain: nonobstructive, -15.6 ± 3.0; labile-obstructive, -15.9 ± 3.0; obstructive, -13.8 ± 2.9; control, -17.7% ± 2.1%, P < .001; SR: nonobstructive, -0.92 ± 0.20; labile-obstructive, -0.94 ± 0.17; obstructive, -0.85 ± 0.18; control, -1.04 ± 0.14 s-1, P = .002); and immediately postexercise (strain: nonobstructive, -15.6 ± 3.0; labile-obstructive, -17.6 ± 3.6; obstructive, -15.6 ± 3.6; control, -19.2 ± 3.1%; P = .001; SR: nonobstructive, -1.41 ± 0.37; labile-obstructive, -1.64 ± 0.38; obstructive, -1.32 ± 0.29; control, -1.82 ± 0.29 s-1, P < .001). MRES was lower in nonobstructive and obstructive compared with labile-obstructive and controls (51% ± 29%, 54% ± 31%, 78% ± 38%, 77% ± 30%, P = .001, respectively). Postexercise SR and MRES were associated with exercise capacity (r = 0.47 and 0.42, P < .001 both, respectively). When adjusted for age, gender, body mass index, E/e', and resting peak instantaneous systolic gradient, postexercise SR best predicted exercise capacity (r = 0.74, P = .003). Postexercise SR was correlated with extent of late gadolinium enhancement (r = 0.34, P = .03). By Cox regression, exercise SR and MRES predicted ventricular tachycardia/ventricular fibrillation (VT/VF) even after adjustment for age, gender, family history of sudden cardiac death, septum ≥ 3 cm and abnormal blood pressure response (P = .04 and P = .046, respectively). CONCLUSIONS Nonobstructive and obstructive patients have reduced MRES compared with labile-obstructive and controls. Postexercise SR correlates with LGE and exercise capacity. Exercise SR and MRES predict VT/VF.
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185
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Shah BN, MacNab A, Lynch J, Hampson R, Senior R, Steeds RP. Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation. Echo Res Pract 2018; 5:E1-E6. [PMID: 29358185 PMCID: PMC5795358 DOI: 10.1530/erp-17-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 01/09/2018] [Indexed: 11/20/2022] Open
Abstract
Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.
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Affiliation(s)
- Benoy N Shah
- Wessex Cardiac CentreUniversity Hospital Southampton, Southampton, UK
| | - Anita MacNab
- University Hospital of South ManchesterManchester, UK
| | - Jane Lynch
- University Hospital of South ManchesterManchester, UK
| | | | - Roxy Senior
- Northwick Park HospitalHarrow, UK.,National Heart and Lung InstituteImperial College, London, UK
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Capotosto L, Massoni F, De Sio S, Ricci S, Vitarelli A. Early Diagnosis of Cardiovascular Diseases in Workers: Role of Standard and Advanced Echocardiography. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7354691. [PMID: 29560362 PMCID: PMC5820578 DOI: 10.1155/2018/7354691] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/04/2017] [Indexed: 12/30/2022]
Abstract
Cardiovascular disease (CVD) still remains the main cause of morbidity and mortality and consequently early diagnosis is of paramount importance. Working conditions can be regarded as an additional risk factor for CVD. Since different aspects of the job may affect vascular health differently, it is important to consider occupation from multiple perspectives to better assess occupational impacts on health. Standard echocardiography has several targets in the cardiac population, as the assessment of myocardial performance, valvular and/or congenital heart disease, and hemodynamics. Three-dimensional echocardiography gained attention recently as a viable clinical tool in assessing left ventricular (LV) and right ventricular (RV) function, volume, and shape. Two-dimensional (2DSTE) and, more recently, three-dimensional speckle tracking echocardiography (3DSTE) have also emerged as methods for detection of global and regional myocardial dysfunction in various cardiovascular diseases and applied to the diagnosis of subtle LV and RV dysfunction. Although these novel echocardiographic imaging modalities have advanced our understanding of LV and RV mechanics, overlapping patterns often show challenges that limit their clinical utility. This review will describe the current state of standard and advanced echocardiography in early detection (secondary prevention) of CVD and address future directions for this potentially important diagnostic strategy.
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Barbieri A, Mantovani F, Bursi F, Bartolacelli Y, Manicardi M, Lauria MG, Boriani G. 12-year Temporal Trend in Referral Pattern and Test Results of Stress Echocardiography in a Tertiary Care Referral Center with Moderate Volume Activities and Cath-lab Facility. J Cardiovasc Echogr 2018; 28:32-38. [PMID: 29629257 PMCID: PMC5875133 DOI: 10.4103/jcecho.jcecho_48_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Data on stress echocardiography (SE) time-related changes in referral patterns and diagnostic yield for detection of inducible ischemia could enhance Echo Lab quality benchmarks and performance measures. Aim This study aims to evaluate temporal trends in SE test results among ambulatory patients with suspected or known coronary artery disease (CAD) in a tertiary care referral center with moderate (>100/year) volume SE activities and Cath-Lab facility. Methods From January 2004 to December 2015, 1954 patients (mean age 62 ± 12 years, 42% women, 27% with known CAD) underwent SE (1673 exercise SE, 86%, 246 pharmacological SE, 12%, 35 pacing SE, 2%). Time was grouped into three 4 year periods, where clinical data and test results were evaluated. Results Our series comprised low-to-intermediate pretest probability of CAD throughout the observation period (overall pretest probability of CAD 19% ± 15%). A progressive decline over time in the rate of pharmacological SE instead of a dramatic increment of exercise SE (79%-96%, P < 0.0001) was noted. The use of beta-blockers increased (from 43% to 66%, P < 0.0001), while the use of nitrates decreased (from 11% to 4%, P < 0.0001) over time. We noted a very uncommon occurrence of abnormal test results with a further decrease in the last period (from 11% to 3%, P < 0.0001). Conclusions We observed, over a 12-year period, a progressive decrease in the frequency of inducible myocardial ischemia among patients with known or suspected CADe referred to our Echo Lab for SE with Cath-Lab facility, and this trend was parallel to changes in SE referral practice. These findings are particularly relevant if we consider the practical implications on diagnostic SE accuracy and risk assessment.
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Affiliation(s)
- Andrea Barbieri
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Mantovani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesca Bursi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Ylenia Bartolacelli
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Manicardi
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Giulia Lauria
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Boriani
- Department of Cardiology, Azienda Ospedaliero-Univarsitaria Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
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Hyun D, Abou-Elkacem L, Perez VA, Chowdhury SM, Willmann JK, Dahl JJ. Improved Sensitivity in Ultrasound Molecular Imaging With Coherence-Based Beamforming. IEEE TRANSACTIONS ON MEDICAL IMAGING 2018; 37:241-250. [PMID: 29293430 PMCID: PMC5764183 DOI: 10.1109/tmi.2017.2774814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Ultrasound molecular imaging (USMI) is accomplished by detecting microbubble (MB) contrast agents that have bound to specific biomarkers, and can be used for a variety of imaging applications, such as the early detection of cancer. USMI has been widely utilized in preclinical imaging in mice; however, USMI in humans can be challenging because of the low concentration of bound MBs and the signal degradation caused by the presence of heterogenous soft tissue between the transducer and the lesion. Short-lag spatial coherence (SLSC) beamforming has been proposed as a robust technique that is less affected by poor signal quality than standard delay-and-sum (DAS) beamforming. In this paper, USMI performance was assessed using contrast-enhanced ultrasound imaging combined with DAS (conventional CEUS) and with SLSC (SLSC-CEUS). Each method was characterized by flow channel phantom experiments. In a USMI-mimicking phantom, SLSC-CEUS was found to be more robust to high levels of additive thermal noise than DAS, with a 6dB SNR improvement when the thermal noise level was +6dB or higher. However, SLSC-CEUS was also found to be insensitive to increases in MB concentration, making it a poor choice for perfusion imaging. USMI performance was also measured in vivo using VEGFR2-targeted MBs in mice with subcutaneous human hepatocellular carcinoma tumors, with clinical imaging conditions mimicked using a porcine tissue layer between the tumor and the transducer. SLSC-CEUS improved the SNR in each of ten tumors by an average of 41%, corresponding to 3.0dB SNR. These results indicate that the SLSC beamformer is well-suited for USMI applications because of its high sensitivity and robust properties under challenging imaging conditions.
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Patel H, Mazur W, Williams KA, Kalra DK. Myocardial viability–State of the art: Is it still relevant and how to best assess it with imaging? Trends Cardiovasc Med 2018; 28:24-37. [DOI: 10.1016/j.tcm.2017.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 06/30/2017] [Accepted: 07/04/2017] [Indexed: 10/19/2022]
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Pierard LA. The Role of Stress in Valvular Heart Disease. Echocardiography 2018. [DOI: 10.1007/978-3-319-71617-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Carpeggiani C, Landi P, Michelassi C, Andreassi MG, Sicari R, Picano E. Stress Echocardiography Positivity Predicts Cancer Death. J Am Heart Assoc 2017; 6:e007104. [PMID: 29233827 PMCID: PMC5779024 DOI: 10.1161/jaha.117.007104] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 10/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stress echocardiography (SE) predicts cardiac death, but an increasing share of cardiac patients eventually die of cancer. The aim of the study was to assess whether SE positivity predicts cancer death. METHODS AND RESULTS In a retrospective analysis of prospectively acquired single-center, observational data, we evaluated 4673 consecutive patients who underwent SE from 1983 to 2009. All patients were cancer-free at index SE and were followed up for a median of 131 months (interquartile range 134). We separately analyzed predetermined end points: cardiovascular, cancer, and noncardiovascular, noncancer death, with and without competing risk. SE was positive in 1757 and negative in 2916 patients; 869 cardiovascular, 418 cancer, and 625 noncardiovascular, noncancer deaths were registered. The 25-year mortality was higher in SE-positive than in SE-negative patients, considering cardiovascular (40% versus 31%; P<0.001) and cancer mortality (26% versus 17%; P<0.01). SE positivity was a strong predictor of cancer (cause-specific hazard ratio 1.19; 95% confidence interval, 1.16-1.73; P=0.05) and cardiovascular mortality (1.18; 95% confidence interval, 1.03-1.35; P=0.02). Fine-Gray analysis to account for competing risk gave similar results. Cancer risk diverged after 15 years, whereas differences were already significant at 5 years for cardiovascular risk. CONCLUSIONS SE results predict cardiovascular and cancer mortality. SE may act as a proxy of the shared risk factor milieu for cancer or cardiovascular death.
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Affiliation(s)
| | | | | | | | - Rosa Sicari
- CNR Institute of Clinical Physiology, Pisa, Italy
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Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Nucl Cardiol 2017; 24:2043-2063. [PMID: 29067561 DOI: 10.1007/s12350-017-1070-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This document is 1 of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. This document addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas the second, companion document addresses this topic with regard to structural heart disease. Although there is clinical overlap, the documents addressing valvular and structural heart disease are published separately, albeit with a common structure. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of valvular and structural heart disease, encompassing multiple imaging modalities.Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association guidelines.A separate, independent rating panel scored the 92 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations where diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.
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Affiliation(s)
| | - Smadar Kort
- American Society of Echocardiography, Morrisville, NC, USA
| | - Roxana Mehran
- Society for Cardiovascular Angiography and Interventions, Washington, DC, USA
| | | | - Prem Soman
- American Society of Nuclear Cardiology, Bethesda, MD, USA
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Popovic D, Martic D, Djordjevic T, Pesic V, Guazzi M, Myers J, Mohebi R, Arena R. Oxygen consumption and carbon-dioxide recovery kinetics in the prediction of coronary artery disease severity and outcome. Int J Cardiol 2017; 248:39-45. [DOI: 10.1016/j.ijcard.2017.06.107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 06/22/2017] [Accepted: 06/27/2017] [Indexed: 10/19/2022]
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Role of Exercise Testing in Hypertrophic Cardiomyopathy. JACC Cardiovasc Imaging 2017; 10:1374-1386. [DOI: 10.1016/j.jcmg.2017.07.016] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/28/2017] [Accepted: 07/27/2017] [Indexed: 01/06/2023]
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Cortigiani L, Carpeggiani C, Sicari R, Michelassi C, Bovenzi F, Picano E. Simple six-item clinical score improves risk prediction capability of stress echocardiography. Heart 2017; 104:760-766. [DOI: 10.1136/heartjnl-2017-312122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectivesTo assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE).MethodsStudy includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups.ResultsDuring a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001).ConclusionsSimple clinical variables may be able to optimise SE risk stratification.
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Go G, Davies KT, O'Callaghan C, Senior W, Kostner K, Fagermo N, Prasad SB. Negative predictive value of dobutamine stress echocardiography for perioperative risk stratification in patients with cardiac risk factors and reduced exercise capacity undergoing non-cardiac surgery. Intern Med J 2017; 47:1376-1384. [PMID: 28967164 DOI: 10.1111/imj.13629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/06/2017] [Accepted: 09/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidelines recommend functional testing for myocardial ischaemia in the perioperative setting in patients with greater than one recognised cardiac risk factor and self-reported reduced exercise capacity. AIM To determine the clinical utility of dobutamine stress echocardiography (DSE) for perioperative risk stratification in patients undergoing major non-cardiac surgery. METHODS Data on 79 consecutive patients undergoing DSE for perioperative risk stratification at a single centre were retrospectively reviewed to determine rates of major adverse cardiac events (MACE) during the index hospitalisation and 30 days post-discharge. Echocardiography and outcome data were obtained through a folder audit and echolab database. RESULTS Out of the 79 DSE performed for perioperative risk stratification, 11 (14%) were positive (DSE +ve) and 68 (86%) were negative (DSE -ve). Management in the DSE +ve group included medical optimisation without invasive intervention (n = 7(64%)), diagnostic coronary angiography (n = 3(27%)) and coronary artery bypass graft (n = 1(9%)). None of the patients underwent percutaneous coronary intervention preoperatively. Perioperative MACE in the DSE +ve group was 36% compared to 4% in the DSE-ve group (P = 0.006). DSE +ve was a powerful predictor of perioperative inpatient MACE (OR 12.4, 95% CI 2.3-67, P = 0.003). The positive predictive value of DSE +ve status was 36%, whereas the negative predictive value of DSE-ve status for perioperative MACE was 96%. CONCLUSION DSE for perioperative risk stratification had a high clinical utility in patients undergoing major non-cardiac surgery. In particular, a normal DSE had a high negative predictive value for perioperative MACE.
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Affiliation(s)
- Gus Go
- Department of Internal Medicine, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Kathy T Davies
- Department of Cardiology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Cara O'Callaghan
- Department of Internal Medicine, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Wendy Senior
- Department of Cardiology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Karam Kostner
- Department of Cardiology, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Narelle Fagermo
- Department of Internal Medicine, Mater Hospital Brisbane, Brisbane, Queensland, Australia
| | - Sandhir B Prasad
- Department of Cardiology, Mater Hospital Brisbane, Brisbane, Queensland, Australia.,Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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197
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Thibodeau DT. Evaluation of Chest Pain in the Primary Care Setting. PHYSICIAN ASSISTANT CLINICS 2017. [DOI: 10.1016/j.cpha.2017.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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198
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Quality control of regional wall motion analysis in stress Echo 2020. Int J Cardiol 2017; 249:479-485. [PMID: 28986062 DOI: 10.1016/j.ijcard.2017.09.172] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/13/2017] [Accepted: 09/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The trial "Stress Echo (SE) 2020" evaluates novel applications of SE beyond coronary artery disease. The aim of the study was control quality and harmonize reading criteria. METHODS One reader from 78 centers of the SE 2020 network asked for credentials to read a set of 20 SE video-clips selected by the core lab. All aspiring centers met the pre-requisite of high-volume and the years of experience in SE ranged from 5 to 31years (mean value 18years). The diagnostic gold standard was a reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%). RESULTS Of the initial 78 who started, 57 completed the first attempt: individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor correlation between years of experience and the reader's score on first attempt (r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it again after the web-based session and their accuracy improved (74% vs. 96%, p<0.001). The kappa inter-observer agreement before and after web-based training was 0.59 on first attempt and rose to 0.91 on the last attempt. CONCLUSIONS In SE reading, the volume of activity or years of experience is not synonymous with diagnostic quality. Qualitative analysis and operator-dependence can become a limiting weakness in clinical practice, in the absence of strict pathways of learning, credentialing and audit.
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Nishikii-Tachibana M, Pargaonkar VS, Schnittger I, Haddad F, Rogers IS, Tremmel JA, Wang PJ. Myocardial bridging is associated with exercise-induced ventricular arrhythmia and increases in QT dispersion. Ann Noninvasive Electrocardiol 2017; 23:e12492. [PMID: 28921787 PMCID: PMC6931813 DOI: 10.1111/anec.12492] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 07/27/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND A myocardial bridge (MB) has been associated with ventricular arrhythmia and sudden death during exercise. QT dispersion (QTd) is a measure of abnormal repolarization and may predict ventricular arrhythmia. We investigated the frequency of ventricular arrhythmias during exercise and the QTd at rest and after exercise, in patients with an MB compared to a normal cohort. METHODS We studied the rest and stress ECG tracings of patients with an MB suspected by focal septal buckling on exercise echocardiography (EE) (Echo-MB group, N = 510), those with an MB confirmed by another examination (MB group, N = 110), and healthy controls (Control group, N = 198). RESULTS The frequency of exercise-induced premature ventricular contractions (PVCs) was significantly higher in the Echo-MB and MB groups compared with the Control group (both p < .001). In all, 25 patients (4.9%) in the Echo-MB group, seven patients (6.4%) in the MB group and no patients in the Control group had exercise-induced non-sustained ventricular tachycardia (NSVT). There was no difference in the baseline QTd between the groups. In the Echo-MB and MB groups, QTd postexercise increased significantly when compared with baseline (both p < .001). Patients with NSVT had a higher frequency of male gender and an even greater increase in QTd with exercise compared with the non-NSVT group. DISCUSSION There is an increased frequency of exercise-induced PVCs and NSVT in patients with MBs. Exercise significantly increases QTd in MB patients, with an even greater increase in QTd in MB patients with NSVT. Exercise in MB patients results in ventricular arrhythmias and abnormalities in repolarization.
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Affiliation(s)
- Makiko Nishikii-Tachibana
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Cardiovascular Division, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Vedant S Pargaonkar
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ingela Schnittger
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francois Haddad
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ian S Rogers
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer A Tremmel
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Paul J Wang
- The Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
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ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2017; 70:1647-1672. [PMID: 28870679 DOI: 10.1016/j.jacc.2017.07.732] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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