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Palermi S, Sperlongano S, Mandoli GE, Pastore MC, Lisi M, Benfari G, Ilardi F, Malagoli A, Russo V, Ciampi Q, Cameli M, D’Andrea A. Exercise Stress Echocardiography in Athletes: Applications, Methodology, and Challenges. J Clin Med 2023; 12:7678. [PMID: 38137747 PMCID: PMC10743501 DOI: 10.3390/jcm12247678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
This comprehensive review explores the role of exercise stress echocardiography (ESE) in assessing cardiovascular health in athletes. Athletes often exhibit cardiovascular adaptations because of rigorous physical training, making the differentiation between physiological changes and potential pathological conditions challenging. ESE is a crucial diagnostic tool, offering detailed insights into an athlete's cardiac function, reserve, and possible arrhythmias. This review highlights the methodology of ESE, emphasizing its significance in detecting exercise-induced anomalies and its application in distinguishing between athlete's heart and other cardiovascular diseases. Recent advancements, such as LV global longitudinal strain (GLS) and myocardial work (MW), are introduced as innovative tools for the early detection of latent cardiac dysfunctions. However, the use of ESE also subsumes limitations and possible pitfalls, particularly in interpretation and potential false results, as explained in this article.
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Affiliation(s)
- Stefano Palermi
- Public Health Department, University of Naples Federico II, 80131 Naples, Italy;
| | - Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (S.S.); (V.R.)
| | - Giulia Elena Mandoli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.E.M.); (M.C.P.); (M.L.); (M.C.)
| | - Maria Concetta Pastore
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.E.M.); (M.C.P.); (M.L.); (M.C.)
| | - Matteo Lisi
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.E.M.); (M.C.P.); (M.L.); (M.C.)
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, 37126 Verona, Italy;
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy;
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, University of Modena and Reggio Emilia, 41126 Modena, Italy;
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (S.S.); (V.R.)
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | - Matteo Cameli
- Division of Cardiology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (G.E.M.); (M.C.P.); (M.L.); (M.C.)
| | - Antonello D’Andrea
- Department of Cardiology, Umberto I Hospital, 84014 Nocera Inferiore, Italy
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Oh JK, Miranda WR, Kane GC. Diagnosis of Heart Failure With Preserved Ejection Fraction Relies on Detection of Increased Diastolic Filling Pressure, But How? J Am Heart Assoc 2023; 12:e028867. [PMID: 36892047 PMCID: PMC10111525 DOI: 10.1161/jaha.122.028867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Affiliation(s)
- Jae K Oh
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Garvan C Kane
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Zhang X, Cerna AEU, Stough JV, Chen Y, Carry BJ, Alsaid A, Raghunath S, vanMaanen DP, Fornwalt BK, Haggerty CM. Generalizability and quality control of deep learning-based 2D echocardiography segmentation models in a large clinical dataset. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1685-1697. [PMID: 35201510 DOI: 10.1007/s10554-022-02554-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/04/2022] [Indexed: 11/26/2022]
Abstract
Use of machine learning (ML) for automated annotation of heart structures from echocardiographic videos is an active research area, but understanding of comparative, generalizable performance among models is lacking. This study aimed to (1) assess the generalizability of five state-of-the-art ML-based echocardiography segmentation models within a large Geisinger clinical dataset, and (2) test the hypothesis that a quality control (QC) method based on segmentation uncertainty can further improve segmentation results. Five models were applied to 47,431 echocardiography studies that were independent from any training samples. Chamber volume and mass from model segmentations were compared to clinically-reported values. The median absolute errors (MAE) in left ventricular (LV) volumes and ejection fraction exhibited by all five models were comparable to reported inter-observer errors (IOE). MAE for left atrial volume and LV mass were similarly favorable to respective IOE for models trained for those tasks. A single model consistently exhibited the lowest MAE in all five clinically-reported measures. We leveraged the tenfold cross-validation training scheme of this best-performing model to quantify segmentation uncertainty. We observed that removing segmentations with high uncertainty from 14 to 71% studies reduced volume/mass MAE by 6-10%. The addition of convexity filters improved specificity, efficiently removing < 10% studies with large MAE (16-40%). In conclusion, five previously published echocardiography segmentation models generalized to a large, independent clinical dataset-segmenting one or multiple cardiac structures with overall accuracy comparable to manual analyses-with variable performance. Convexity-reinforced uncertainty QC efficiently improved segmentation performance and may further facilitate the translation of such models.
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Affiliation(s)
- Xiaoyan Zhang
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA
| | - Alvaro E Ulloa Cerna
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA
| | | | - Yida Chen
- Computer Science, Bucknell University, Lewisburg, PA, USA
| | | | - Amro Alsaid
- Heart Institute, Geisinger, Danville, PA, USA
| | - Sushravya Raghunath
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA
| | - David P vanMaanen
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA
| | - Brandon K Fornwalt
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA
- Heart Institute, Geisinger, Danville, PA, USA
- Department of Radiology, Geisinger, Danville, PA, USA
| | - Christopher M Haggerty
- Department of Translational Data Science and Informatics, Geisinger, 100 North Academy Avenue, Danville, PA, 17822, USA.
- Heart Institute, Geisinger, Danville, PA, USA.
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Speckle tracking evaluation in endurance athletes: the “optimal” myocardial work. Int J Cardiovasc Imaging 2020; 36:1679-1688. [DOI: 10.1007/s10554-020-01871-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/27/2020] [Indexed: 10/24/2022]
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Abstract
PURPOSE OF REVIEW Diastolic stress echocardiography may help facilitate the attribution of exertional dyspnea to cardiac and non-cardiac disease. It represents a non-invasive hemodynamic test to assess the patients with unexplained dyspnea. It can improve the diagnosis of heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure. RECENT FINDINGS A number of studies have validated exercise E/e' as a measure of left ventricular (LV) filling pressure against invasively measured LV filling pressure using simultaneous exercise echocardiography-catheterization studies. Addition of E/e' during exercise echocardiography improved sensitivity for diagnosis of HFpEF compared with resting assessment alone, and its specificity can be improved if tricuspid regurgitation velocity also increases above the normal range with exercise. The independent prognostic value of exercise E/e' has also been well delineated in a number of studies. Diastolic stress exercise echocardiography should be considered for all patients with unexplained or exertional dyspnea and normal diastolic filling pressure or grade 1 diastolic dysfunction on resting echocardiography. Addition of diastolic assessment with exercise echocardiography improves the sensitivity of the test in patients with dyspnea and there are sufficient data to integrate diastolic exercise test into our clinical practice.
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Affiliation(s)
- Kyung-Hee Kim
- Department of Cardiovascular Medicine, Division of Cardiovascular Ultrasound, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Division of Cardiovascular Disease, Sejong General Hospital, Bucheon, Kyunggido, South Korea
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Division of Cardiovascular Ultrasound, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Christina L Luong
- Department of Cardiovascular Medicine, Division of Cardiovascular Ultrasound, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jae K Oh
- Department of Cardiovascular Medicine, Division of Cardiovascular Ultrasound, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Park S, Moon YJ, Nam GB, Kim YJ. Changes in Doppler echocardiography depending on type of elite athletes immediately after maximal exercise. J Sports Med Phys Fitness 2019; 59:524-529. [DOI: 10.23736/s0022-4707.18.08445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rundqvist L, Engvall J, Faresjö M, Blomstrand P. Left ventricular diastolic function is enhanced after peak exercise in endurance-trained adolescents as well as in their non-trained controls. Clin Physiol Funct Imaging 2018; 38:1054-1061. [PMID: 29947056 DOI: 10.1111/cpf.12534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022]
Abstract
The aims of the study were to explore the temporal change of cardiac function after peak exercise in adolescents, and to investigate how these functional changes relate to maximal oxygen uptake (VO2max ). The cohort consisted of 27 endurance-trained adolescents aged 13-19 years, and 27 controls individually matched by age and gender. Standard echocardiography and colour tissue Doppler were performed at rest, and immediately after as well as 15 min after a maximal cardio pulmonary exercise test (CPET) on a treadmill. The changes in systolic and diastolic parameters after exercise compared to baseline were similar in both groups. The septal E/e'-ratio increased immediately after exercise in both the active and the control groups (from 9·2 to 11·0; P<0·001, and from 8·7 to 10·2; P = 0·008, respectively). In a comparison between the two groups after CPET, the septal E/e'-ratio was higher in the active group both immediately after exercise and 15 min later compared to the control group (P = 0·007 and P = 0·006, respectively). We demonstrated a positive correlation between VO2max and cardiac function including LVEF and E/e' immediately after CPET, but the strongest correlation was found between VO2max and LVEDV (r = 0·67, P<0·001) as well as septal E/e' (r = 0·34, P = 0·013). Enhanced diastolic function was found in both groups, but this was more pronounced in active adolescents. The cardiac functional response to exercise, in terms of LVEF and E/e', correlates with the increase in VO2 uptake. These findings in trained as well as un-trained teenagers have practical implications when assessing cardiac function.
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Affiliation(s)
- Louise Rundqvist
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Jan Engvall
- Department of Clinical Physiology, Linköping University, Linköping, Sweden
- Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
- Centre for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Maria Faresjö
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden
- The Academy of Health and Care, Region Jönköping County, Jönköping, Sweden
| | - Peter Blomstrand
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Department of Clinical Physiology, Region Jönköping County, Jönköping, Sweden
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Takagi T. Diastolic stress echocardiography. J Echocardiogr 2017; 15:99-109. [PMID: 28271289 DOI: 10.1007/s12574-017-0335-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Revised: 02/17/2017] [Accepted: 02/24/2017] [Indexed: 01/28/2023]
Abstract
Evaluation of diastolic dysfunction and diagnosis of heart failure with preserved ejection fraction (HFpEF) by echocardiography are routinely performed at rest. However, many patients with modest HFpEF develop symptoms such as dyspnea only during exercise. Therefore, echocardiographic analysis at rest could be insufficient to identify these patients. Recent studies have demonstrated the utility of diastolic stress echocardiography to evaluate diastolic dysfunction during exercise. This review attempts to summarize and discuss current studies in diastolic stress echocardiography.
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Affiliation(s)
- Tsutomu Takagi
- Takagi Cardiology Clinic, Mibu Kayogosho-cho 3-3, Nakagyo-ku, Kyoto, 604-8811, Japan.
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Mansour MJ, Aljaroudi W, Mroueh A, Hamoui O, Honeine W, Khoury N, Nassif JA, Chammas E. Stress-induced Worsening of Left Ventricular Diastolic Function as a Marker of Myocardial Ischemia. J Cardiovasc Echogr 2017; 27:45-51. [PMID: 28465992 PMCID: PMC5412746 DOI: 10.4103/jcecho.jcecho_44_16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Echocardiography has been the subject of interest in diagnosing diastolic dysfunction and estimating left ventricular filling pressures (LVFPs). The present study is set to estimate the correlation between the worsening of diastolic parameters and the evidence of inducible ischemia during an exercise stress echocardiography (SE) in comparison with the results of coronary computed tomographic angiogram (CCTA). Methods: A total of 191 consecutive patients from the executive screening program who underwent exercise SE followed by CCTA were evaluated. Baseline demographics, heart rate, and blood pressure measurements were extracted for analysis. Standard two-dimensional and tissue Doppler imaging parameters were analyzed. Diastolic function was graded at rest and peak exercise. Results: Patients who had worsening of diastolic function by at least one grade had had 2–3-fold higher odds of having abnormal SE. In addition, patients with worsening of diastolic function had higher stress LVFPs (E/e’ = 11.7 ± 2.7 vs. E/e’ 8.0 ± 2.0; P < 0.0001), more E/e’ change >25% (48% vs. 22%, P = 0.012), and were more likely to have obstructive coronary artery disease (CAD) on CCTA (23.8% vs. 9.2%; P = 0.045). A change in E/e’ >25% (stress-rest) was highly associated with a positive stress test and abnormal CCTA result. Patients with no change or improvement in diastolic function with stress had a 92% negative predictive value of having normal SE and 91% of normal/nonobstructive CCTA. Conclusion: A worsening of diastolic function and a change in E/e’ >25% (stress-rest) were associated with abnormal SE, positive stress test, and obstructive CAD when compared to CCTA results.
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Affiliation(s)
- Mohamad Jihad Mansour
- Division of Cardiology, Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon.,Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Wael Aljaroudi
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Ali Mroueh
- Division of Cardiology, Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon
| | - Omar Hamoui
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Walid Honeine
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Nada Khoury
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Jinane Abi Nassif
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Elie Chammas
- Division of Cardiology, Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon.,Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
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Schiano-Lomoriello V, Santoro C, de Simone G, Trimarco B, Galderisi M. Diastolic bicycle stress echocardiography: Normal reference values in a middle age population. Int J Cardiol 2015; 191:181-3. [DOI: 10.1016/j.ijcard.2015.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/04/2015] [Accepted: 05/05/2015] [Indexed: 11/25/2022]
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Authors’ Reply. J Am Soc Echocardiogr 2015; 28:377. [DOI: 10.1016/j.echo.2014.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 11/20/2022]
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Oh JK, Kane GC. Response to the Letter to the Editor by Hammoudi et al. J Am Soc Echocardiogr 2015; 28:377-8. [DOI: 10.1016/j.echo.2015.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hammoudi N, Achkar M, Isnard R. Exercise E/e' for the assessment of left ventricular filling pressures: with caution in clinical practice? J Am Soc Echocardiogr 2014; 28:376-7. [PMID: 25510308 DOI: 10.1016/j.echo.2014.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Nadjib Hammoudi
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France; University Paris 6, Faculté de Médecine Pierre et Marie Curie, Paris, France
| | - Marc Achkar
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France
| | - Richard Isnard
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Paris, France; University Paris 6, Faculté de Médecine Pierre et Marie Curie, Paris, France
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Diastolic Stress Echocardiography: The Time Has Come for Its Integration into Clinical Practice. J Am Soc Echocardiogr 2014; 27:1060-3. [DOI: 10.1016/j.echo.2014.08.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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