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Kumar K, Seetharam K, Rani T, Mir P, Mir T, Shetty V, Shani J. Evolution of Stress Echocardiogram in the Era of CT Angiography. Cureus 2023; 15:e39501. [PMID: 37378169 PMCID: PMC10292127 DOI: 10.7759/cureus.39501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
The ideal diagnostic modality for acute chest pain is a highly debated topic in the cardiovascular community. With the rapid rise of coronary computed tomography angiography (CTA) and the fall of functional testing, stress echocardiography (SE) is at a delicate crossroads. Though there are many advantages of coronary CTA, it is not without its flaws. The exact realm of SE needs to be clearly defined, as well as which patients need diagnostic testing. The emergence of additional parameters will propel the evolution of modern SE. In this review article, we explore the role of SE, guidelines, comparison of SE versus CTA, and additional parameters in the coronary CTA era.
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Affiliation(s)
- Kelash Kumar
- Internal Medicine, Maimonides Medical Center, New York, USA
| | | | - Teesha Rani
- Medicine and Surgery, Ziauddin University, Karachi, PAK
| | - Parvez Mir
- Internal Medicine and Pulmonology, Wyckoff Heights Medical Center, New York, USA
| | - Tanveer Mir
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Vijay Shetty
- Internal Medicine and Cardiology, Maimonides Medical Center, New York, USA
| | - Jacob Shani
- Cardiology, Maimonides Medical Center, New York, USA
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Gaibazzi N, Tuttolomondo D, Guaricci AI, De Marco F, Pontone G. Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide. J Cardiovasc Med (Hagerstown) 2022; 23:12-21. [PMID: 34366402 DOI: 10.2459/jcm.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.
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Affiliation(s)
| | | | | | - Federico De Marco
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese
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Baessato F, Guglielmo M, Muscogiuri G, Baggiano A, Fusini L, Scafuri S, Babbaro M, Mollace R, Collevecchio A, Guaricci AI, Pontone G. Stress CMR in Known or Suspected CAD: Diagnostic and Prognostic Role. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6678029. [PMID: 33511208 PMCID: PMC7822671 DOI: 10.1155/2021/6678029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/23/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022]
Abstract
The recently published 2019 guidelines on chronic coronary syndromes (CCS) focus on the need for noninvasive imaging modalities to accurately establish the diagnosis of coronary artery disease (CAD) and assess the risk of clinical scenario occurrence. Appropriate patient management should rely on controlling symptoms, improving prognosis, and guiding each therapeutic strategy as well as monitoring disease progress. Among the noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) has gained broad acceptance in past years due to its unique features in providing a complete assessment of CAD through data on cardiac anatomy and function and myocardial viability, with high spatial and temporal resolution and without ionizing radiation. In detail, evaluation of the presence and extent of myocardial ischemia through stress CMR (S-CMR) has shown a high rule-in power in detecting functionally significant coronary artery stenosis in patients suspected of CCS. Moreover, S-CMR technique may add significant prognostic value, as demonstrated by different studies which have progressively evidenced the valuable power of this multiparametric imaging modality in predicting adverse cardiac events. The latest scientific progress supports a greater expansion of S-CMR with improvement of quantitative myocardial perfusion analysis, myocardial strain, and native mapping within the same examination. Although further study is warranted, these techniques, which are currently mostly restricted to the research field, are likely to become increasingly prevalent in the clinical setting with the scope of increasing accuracy in the selection of patients to be sent to invasive revascularization. This review investigates the diagnostic and prognostic role of S-CMR in the context of CAD, by analysing a strong, long-standing, scientific evidence together with an appraisal of new advanced techniques which may potentially enrich CAD management in the next future.
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Affiliation(s)
- Francesca Baessato
- Department of Cardiology, San Maurizio Regional Hospital, Bolzano, Italy
| | - Marco Guglielmo
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Giuseppe Muscogiuri
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Andrea Baggiano
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Laura Fusini
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Stefano Scafuri
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Mario Babbaro
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Rocco Mollace
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Ada Collevecchio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Andrea I. Guaricci
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital Policlinico of Bari, Bari, Italy
| | - Gianluca Pontone
- Cardiovascular Imaging Department, Centro Cardiologico Monzino IRCCS, Milan, Italy
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Gaibazzi N, Barbieri A, Boriani G, Benatti G, Codazzo G, Manicardi M, Bursi F, Siniscalchi C. Imaging functional stress test for stable chest pain symptoms in patients at low pretest probability of coronary artery disease: Current practice and long-term outcome. Echocardiography 2019; 36:1095-1102. [PMID: 31038795 DOI: 10.1111/echo.14352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 03/29/2019] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Stress testing in patients with low pretest probability (PTP) of coronary artery disease (CAD) has become an increasing practice, potentially leading to underestimation of its true clinical value. Our aim was to describe the current use of most employed imaging functional tests and their prognostic value. METHODS AND RESULTS We selected patients with low PTP of CAD (CAD consortium clinical score < 15%) who underwent exercise or dipyridamole stress echocardiography or single photon emission computed tomography for suspected angina. Main exclusions were age < 45, known CAD, and abnormal rest wall motion. Of the 2279 subjects undergoing stress test, 883 (39%) had low PTP, and 91 (10.3%) had a positive test for ischemia. After a median follow-up of 5.8 years, 36 patients had events (21 died, 14 had nonfatal myocardial infarction). The percentage of events in the abnormal and normal stress test groups were similar (5 [5.5%] vs 31 [3.9%], P = ns), as the annualized event rate (0.87% vs 0.62%, P = ns). Age was the only variable associated with outcome in the regression analysis (hazard ratio 1.072, 95% CI 1.034-1.113, P < 0.001). An abnormal result was not associated with worse outcome in each of the subgroups of functional tests. CONCLUSIONS In our geographical area, a considerable proportion of patients undergoing imaging functional tests for stable chest pain have a low estimated PTP of CAD. Of these, 1 in 10 resulted positive for inducible ischemia. However, none of the most common imaging functional tests, single photon emission computed tomography (SPECT), and stress echocardiography offer prognostic information in these patients.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Andrea Barbieri
- Department of Cardiology, Modena University Hospital, Modena, Italy
| | - Giuseppe Boriani
- Department of Cardiology, Modena University Hospital, Modena, Italy
| | - Giorgio Benatti
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | | | | | - Francesca Bursi
- Department of Cardiology, Modena University Hospital, Modena, Italy
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Gaibazzi N. Stress Echocardiography: Need to Optimize its Appropriate Use in Suspected Angina and a Review of Available Additional Tools for its Clinical Application in 2018: First do no Harm! Second do it at the Highest Possible Accuracy. J Cardiovasc Echogr 2018; 28:154-159. [PMID: 30306018 PMCID: PMC6172890 DOI: 10.4103/jcecho.jcecho_16_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
There is a need to reassess the most appropriate indications for stress echocardiography in the current era, in patients with suspect or known coronary artery disease (CAD), and also the most helpful additional parameters that can be easily calculated in clinical practice to increase the known suboptimal sensitivity for obstructive CAD of this test. The current review tries to clarify what is and what should be the proper role for functional testing in general, but specifically regarding modern stress echocardiography in the current practice, for suspected CAD and/or atypical chest pain. Few candidate additional parameters beyond wall motion assessment are here suggested to improve diagnostic accuracy of stress echocardiography, and pertinent literature is briefly reviewed, together with a more personal view of the author regarding the characteristics of each parameter, as far as ease of acquisition, cost, and true diagnostic or prognostic clinical usefulness are concerned. The reviewed additional parameters, which can be acquired during stress echocardiography, are Doppler coronary flow reserve in the left anterior descending artery, cardiac calcium score, global longitudinal strain, ventricular elastance, and contrast myocardial perfusion. Each of them finds a potential place in the current practice or may find a place in the future practice of stress echocardiography.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy
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Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancellotti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging 2018; 18:1205-1205af. [PMID: 28950366 DOI: 10.1093/ehjci/jex182] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 12/16/2022] Open
Abstract
Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.
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Affiliation(s)
- Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Imperial College, Sydney Street, London SW3 6NP, UK
| | | | | | | | - Jose Zamorano
- CIBERCV, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | - Patrizio Lancellotti
- University of Liege Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liege, Belgium
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Karogiannis N, Senior R. Contrast echocardiography for detection of myocardial perfusion abnormalities. Herz 2017; 42:287-294. [DOI: 10.1007/s00059-017-4536-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Effect of Pharmacologic Stress Test Results on Outcomes in Obese versus Nonobese Subjects Referred for Stress Perfusion Echocardiography. J Am Soc Echocardiogr 2016; 29:899-906. [DOI: 10.1016/j.echo.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Indexed: 01/27/2023]
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9
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Porter TR, Xie F. Therapeutic Uses of Contrast Microbubbles. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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10
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schroeder J, Hamada S, Gründlinger N, Rubeau T, Altiok E, Ulbrich K, Keszei A, Marx N, Becker M. Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy. Clin Res Cardiol 2015; 105:248-56. [PMID: 26349786 DOI: 10.1007/s00392-015-0916-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor. METHODS 2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission. RESULTS Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p < 0.001) caused the greatest increment in model power (χ (2) = 43.4, p < 0.001). Optimal cut-off value was calculated as -21.7 % for GCS (sensitivity 87 %, specificity 76 %) to differentiate between these patients. CONCLUSIONS In patients with suspected ACS but without ECG changes or myocardial enzyme abnormalities, myocardial deformation imaging can identify patients at risk. This approach may be applied to improve decision guidance at the CPU for fast discharge of patients with non-cardiac chest pain or prompt cardiological allocation of patients with CAD. CLINICAL TRIAL REGISTRATION NCT 02357641.
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Affiliation(s)
- Joerg Schroeder
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sandra Hamada
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nina Gründlinger
- Department of Internal Medicine, Hospital St. Brigida, Simmerath, Germany
| | - Tanja Rubeau
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ertunc Altiok
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Katrin Ulbrich
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andras Keszei
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Michael Becker
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
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Romero J, Husain SA, Holmes AA, Kelesidis I, Chavez P, Mojadidi MK, Levsky JM, Wever-Pinzon O, Taub C, Makani H, Travin MI, Piña IL, Garcia MJ. Non-invasive assessment of low risk acute chest pain in the emergency department: A comparative meta-analysis of prospective studies. Int J Cardiol 2015; 187:565-80. [DOI: 10.1016/j.ijcard.2015.01.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 01/14/2015] [Indexed: 10/24/2022]
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Streitberger A, Hocke V, Modler P. Measurement of pulmonary transit time in healthy cats by use of ultrasound contrast media "Sonovue®": feasibility, reproducibility, and values in 42 cats. J Vet Cardiol 2013; 15:181-7. [PMID: 23933477 DOI: 10.1016/j.jvc.2013.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 05/01/2013] [Accepted: 05/06/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the feasibility of measuring pulmonary transit time (PTT) in healthy cats by transthoracic echocardiography using the ultrasound contrast agent Sonovue(®). To determine normalized PTT (nPTT) values in 42 healthy cats and to estimate the interobserver variability and the within-day repeatability of nPTT measurements. ANIMALS Forty-two privately owned healthy cats of different breeds, gender and age presented for cardiac examination. METHODS A bolus injection of contrast agent (Sonovue(®)) was administered intravenously. The right parasternal short axis echocardiographic view was used to record the contrast agent's transit time from the pulmonary artery to the left atrium. Pulmonary transit time and nPTT were determined independently by three examiners with different levels of experience. RESULTS Normalized PTT was 4.12 ± 1.0 (mean ± SD) in our population. The median interobserver variability across our population was 6.8%, the median within-day variability for the three observers were 13.1%, 12.7% and 13%. No effect of the observer's experience on nPTT measurement was identified. Age, sex and body weight did not significantly influence nPTT. CONCLUSIONS This study demonstrates that nPTT measurement is feasible in cats using ultrasound and the blood pool contrast media Sonovue(®). Measurements of nPTT can be performed in a clinical setting. Normalized PTT values in healthy cats are comparable with those reported in healthy dogs.
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Affiliation(s)
- Brian P Davidson
- Division of Cardiovascular Medicine, Oregon Health & Science University, Portland, 97239, USA
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16
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Squeri A, Gaibazzi N, Reverberi C, Caracciolo MM, Ardissino D, Gherli T. Ejection fraction change and coronary artery disease severity: a vasodilator contrast stress-echocardiography study. J Am Soc Echocardiogr 2012; 25:454-9. [PMID: 22243999 DOI: 10.1016/j.echo.2011.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND An important goal of noninvasive stress testing is the identification of patients with left main coronary artery or three-vessel disease, because coronary artery disease extension and severity are major prognostic factors in ischemic heart disease. Wall motion abnormalities during vasodilator stress echocardiography become apparent in more than one coronary territory only in a small number of patients with multivessel disease. The aim of this study was to assess the value of change in left ventricular ejection fraction change (ΔLVEF) to identify patients with multivessel obstructive coronary artery disease during dipyridamole stress echocardiography. METHODS All dipyridamole stress echocardiographic studies performed at the authors' institution from October 2007 through March 2010 were retrospectively reviewed, and 150 patients who underwent coronary angiography within the next 60 days were selected. Left ventricular end-diastolic volume and end-systolic volume were measured at baseline and at the end of high-dose dipyridamole; ΔLVEF was calculated as stress ejection fraction minus rest ejection fraction. Patients were divided into four groups (controls and patients with single-vessel, two-vessel, and three-vessel disease) on the basis of coronary angiographic results. RESULTS The mean LVEF increased significantly from rest to peak stress in all groups except the three-vessel disease group. Mean ΔLVEF was negative in patients with three-vessel or left main coronary artery disease (-2.8 ± 5.1%) and significantly lower compared with all other angiographic groups (10.2 ± 5.1% and 6.2 ± 4.1%, respectively, for single-vessel and two-vessel disease). The negative value of ΔLVEF for three-vessel disease was due mainly to increased end-systolic volume at peak stress. Receiver operating characteristic curves demonstrated excellent accuracy of ΔLVEF compared with change in wall motion score index in identifying patients with multivessel disease, with areas under the curves of 0.96 and 0.62, respectively. CONCLUSIONS ΔLVEF is significantly lower in patients with severe coronary artery disease compared with those with single-vessel or two-vessel disease; reduced ΔLVEF identifies high-risk patients, who are likely to benefit from a more aggressive therapeutic strategy.
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Affiliation(s)
- Angelo Squeri
- U.O. Cardiologia, Dipartimento Cardio-Nefro-Polmonare, Azienda Ospedaliero, Universitaria di Parma, Via Gramsci 14, Parma, Italy.
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Le DE, Bragadeesh T, Zhao Y, Wang YG, Zha D, Kaul S. Detection of coronary stenosis with myocardial contrast echocardiography using regadenoson, a selective adenosine A2A receptor agonist. Eur Heart J Cardiovasc Imaging 2011; 13:298-308. [DOI: 10.1093/ejechocard/jer232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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18
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Gaibazzi N, Squeri A, Reverberi C, Molinaro S, Lorenzoni V, Sartorio D, Senior R. Contrast stress-echocardiography predicts cardiac events in patients with suspected acute coronary syndrome but nondiagnostic electrocardiogram and normal 12-hour troponin. J Am Soc Echocardiogr 2011; 24:1333-41. [PMID: 22014426 DOI: 10.1016/j.echo.2011.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND No large study has demonstrated that any stress test can risk-stratify future hard cardiac events (cardiac death or myocardial infarction) in patients with suspected acute coronary syndromes (ACS), nondiagnostic electrocardiographic (ECG) findings, and normal troponin levels. The aim of this study was to test the hypothesis that combined contrast wall motion and myocardial perfusion echocardiographic assessment (cMCE) during stress echocardiography can predict long-term hard cardiac events in patients with suspected ACS, nondiagnostic ECG findings, and normal troponin. METHODS A total of 545 patients referred for contrast stress echocardiography from the emergency department for suspected ACS but nondiagnostic ECG findings and normal troponin levels at 12 hours were followed up for cardiac events. Patients underwent dipyridamole-atropine echocardiography with adjunctive myocardial perfusion imaging using a commercially available ultrasound contrast medium (SonoVue). RESULTS During a median follow-up period of 12 months, 25 cardiac events (4.6%) occurred (no deaths, 12 nonfatal myocardial infarctions, 13 episodes of unstable angina). Abnormal findings on cMCE were the most significant predictor of both hard cardiac events (hazard ratio, 22.8; 95% confidence interval, 2.9-176.7) and the combined (cardiac death, myocardial infarction, or unstable angina requiring revascularization) end point (hazard ratio, 10.7; 95% confidence interval, 3.7-31.3). The inclusion of the cMCE variable significantly improved multivariate models, determining lower Akaike information criterion values and higher discrimination ability. CONCLUSIONS cMCE during contrast stress echocardiography provided independent information for predicting hard and combined cardiac events beyond that predicted by stress wall motion abnormalities in patients with suspected ACS, nondiagnostic ECG findings, and normal troponin levels.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy.
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19
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Quaia E. Assessment of tissue perfusion by contrast-enhanced ultrasound. Eur Radiol 2010; 21:604-15. [PMID: 20927527 DOI: 10.1007/s00330-010-1965-6] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 08/13/2010] [Accepted: 08/17/2010] [Indexed: 12/11/2022]
Abstract
Contrast-enhanced ultrasound (CEUS) with microbubble contrast agents is a new imaging technique for quantifying tissue perfusion. CEUS presents several advantages over other imaging techniques in assessing tissue perfusion, including the use of microbubbles as blood-pool agents, portability, availability and absence of exposure to radiation or nuclear tracers. Dedicated software packages are necessary to quantify the echo-signal intensity and allow the calculation of the degree of tissue contrast enhancement based on the accurate distinction between microbubble backscatter signals and native tissue background. The measurement of organ transit time after microbubble injection and the analysis of tissue reperfusion kinetics represent the two fundamental methods for the assessment of tissue perfusion by CEUS. Transit time measurement has been shown to be feasible and has started to become accepted as a clinical tool, especially in the liver. The loudness of audio signals from spectral Doppler analysis is used to generate time-intensity curves to follow the wash-in and wash-out of the microbubble bolus. Tissue perfusion may be quantified also by analysing the replenishment kinetics of the volume of microbubbles after their destruction in the imaged slice. This allows to obtain semiquantitative parameters related to local tissue perfusion, especially in the heart, brain, and kidneys.
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Affiliation(s)
- Emilio Quaia
- Department of Radiology, Cattinara Hospital, University of Trieste, Strada di Fiume 447, Trieste, 34149, Italy.
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Gaibazzi N, Rigo F, Squeri A, Ugo F, Reverberi C. Incremental value of contrast myocardial perfusion to detect intermediate versus severe coronary artery stenosis during stress-echocardiography. Cardiovasc Ultrasound 2010; 8:16. [PMID: 20459632 PMCID: PMC2877655 DOI: 10.1186/1476-7120-8-16] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 05/06/2010] [Indexed: 11/10/2022] Open
Abstract
Background We aimed to compare the incremental value of contrast myocardial perfusion imaging (MPI) for the detection of intermediate versus severe coronary artery stenosis during dipyridamole-atropine echocardiography (DASE). Wall motion (WM) assessment during stress-echocardiography demonstrates suboptimal sensitivity to detect coronary artery disease (CAD), particularly in patients with isolated intermediate (50%-70%) coronary stenosis. Methods We performed DASE with MPI in 150 patients with a suspected chest pain syndrome who were given clinical indication to coronary angiography. Results and discussion When CAD was defined as the presence of a ≥50% stenosis, the addition of MPI increased sensitivity (+30%) and decreased specificity (-14%), with a final increase in total diagnostic accuracy (+16%, p < 0.001). The addition of MPI data substantially increased the sensitivity to detect patients with isolated intermediate stenosis from 37% to 98% (p < 0.001); the incremental sensitivity was much lower in patients with severe stenosis, from 85% to 96% (p < 0.05), at the expense of a higher decrease in specificity and a final decrease in total diagnostic accuracy (-18%, p < 0.001). Conclusions The addition of MPI on top of WM analysis during DASE increases the diagnostic sensitivity to detect obstructive CAD, whatever its definition (≥50% or > 70% stenosis), but it is mainly driven by the sensitivity increase in the intermediate group (50%-70% stenosis). The total diagnostic accuracy increased only when defining CAD as ≥50% stenosis, since in patients with severe stenosis (> 70%) the decrease in specificity is not counterbalanced by the minor sensitivity increase.
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Affiliation(s)
- Nicola Gaibazzi
- Cardiology Division, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Parato VM, Mehta A, Delfino D, Amabili S, Partemi M, Grossi P, Nardini E. Resting Echocardiography for the Early Detection of Acute Coronary Syndromes in Chest Pain Unit Patients. Echocardiography 2010; 27:597-602. [DOI: 10.1111/j.1540-8175.2010.01166.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Dawson D, Kaul S, Peters D, Rinkevich D, Schnell G, Belcik JT, Wei K. Prognostic value of dipyridamole stress myocardial contrast echocardiography: comparison with single photon emission computed tomography. J Am Soc Echocardiogr 2009; 22:954-60. [PMID: 19553084 DOI: 10.1016/j.echo.2009.04.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2008] [Indexed: 12/21/2022]
Abstract
BACKGROUND Dipyridamole stress myocardial contrast echocardiography (MCE) can be used to detect coronary artery disease (CAD). Because it measures myocardial blood flow velocity in addition to measuring myocardial blood volume, it was hypothesized that it should have greater prognostic utility than single photon-emission computed tomography (SPECT), which measures only myocardial blood volume. Because blood flow mismatch precedes wall thickening (WT) abnormalities during demand ischemia, it was also postulated that perfusion on MCE would be superior to WT abnormalities on echocardiography for this purpose. METHODS The incidence of nonfatal myocardial infarction and cardiac death was determined in 261 patients with known or suspected CAD over a mean follow-up period of 14 months who underwent simultaneous dipyridamole stress MCE and 99mTc-sestamibi SPECT. Comparisons of survival curves were conducted with stratified (and unstratified) log-rank tests. RESULTS Abnormal results on MCE were found to be the best predictor of an adverse outcome (odds ratio, 23; 95% confidence interval, 6-201; P<.0001) and provided incremental prognostic value over clinical variables (age>60 years, the presence of >or=3 cardiac risk factors, known peripheral vascular disease, prior myocardial infarction, and left ventricular systolic function), inducible WT abnormalities, and SPECT. Prognoses were worst in patients who had both abnormal results on MCE and inducible WT abnormalities and best in those who had neither. Patients with abnormal results on MCE but no inducible WT abnormalities had intermediate outcomes. CONCLUSION In patients with known or suspected CAD undergoing dipyridamole stress, MCE provides powerful prognostic information that is superior to clinical variables, electrocardiography, left ventricular systolic function, WT analysis, and SPECT. MCE may therefore serve as a method of choice for myocardial perfusion assessment in patients with known or suspected CAD. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Dana Dawson
- Division of Cardiovascular Medicine, Oregon Health & Science University, Portland, Oregon 97239, USA
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Gaibazzi N, Squeri A, Ardissino D, Reverberi C. Safety of contrast flash-replenishment stress echocardiography in 500 patients with a chest pain episode of undetermined origin within the last 5 days. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:726-32. [DOI: 10.1093/ejechocard/jep078] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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