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Woodward W, Dockerill C, McCourt A, Upton R, O'Driscoll J, Balkhausen K, Chandrasekaran B, Firoozan S, Kardos A, Wong K, Woodward G, Sarwar R, Sabharwal N, Benedetto E, Spagou N, Sharma R, Augustine D, Tsiachristas A, Senior R, Leeson P, Boardman H, d'Arcy J, Abraheem A, Banypersad S, Boos C, Bulugahapitiya S, Butts J, Coles D, Easaw J, Hamdan H, Jamil-Copley S, Kanaganayagam G, Mwambingu T, Pantazis A, Papachristidis A, Rajani R, Rasheed MA, Razvi NA, Rekhraj S, Ripley DP, Rose K, Scheuermann-Freestone M, Schofield R, Sultan A. Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study. Eur Heart J Cardiovasc Imaging 2021; 23:689-698. [PMID: 34148078 PMCID: PMC9016358 DOI: 10.1093/ehjci/jeab092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/04/2021] [Indexed: 12/22/2022] Open
Abstract
Aims Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography. Methods and results Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57–74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals. Conclusion Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.
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Affiliation(s)
- William Woodward
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Cameron Dockerill
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Annabelle McCourt
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Ross Upton
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK.,Ultromics Ltd, Wood Centre for Innovation, OxfordOX3 8SB, UK
| | - Jamie O'Driscoll
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK.,School of Human and Life Sciences, Canterbury Christ Church University, Canterbury CT1 1QU, UK
| | - Katrin Balkhausen
- Department of Cardiology, Royal Berkshire Hospitals NHS Foundation Trust, Reading RG1 5AN, UK
| | | | - Soroosh Firoozan
- Department of Cardiology, Buckinghamshire Healthcare NHS Trust, High Wycombe HP11 2TT, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes MK6 5LD, UK
| | - Kenneth Wong
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool FY3 8NP, UK
| | - Gary Woodward
- Ultromics Ltd, Wood Centre for Innovation, OxfordOX3 8SB, UK
| | - Rizwan Sarwar
- Ultromics Ltd, Wood Centre for Innovation, OxfordOX3 8SB, UK.,Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Nikant Sabharwal
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Elena Benedetto
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Nancy Spagou
- Ultromics Ltd, Wood Centre for Innovation, OxfordOX3 8SB, UK
| | - Rajan Sharma
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Daniel Augustine
- Department of Cardiology, Royal United Hospitals NHS Foundation Trust, Bath, BA1 3NG, UK
| | - Apostolos Tsiachristas
- Health Economic Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Roxy Senior
- National Heart and Lung Institute, Imperial College London, London SW3 6LY, UK.,Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NJ, UK.,Department of Cardiology, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Henry Boardman
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes MK6 5LD, UK.,Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Joanna d'Arcy
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Abraheem Abraheem
- Department of Cardiology, Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Sanjay Banypersad
- Department of Cardiology, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Christopher Boos
- Department of Cardiology, Poole Hospital NHS Foundation Trust, Poole, UK
| | | | - Jeremy Butts
- Department of Cardiology, Calderdale and Huddersfield NHS Foundation Trust, Calderdale, UK
| | - Duncan Coles
- Department of Cardiology, Mid Essex NHS Hospital Services NHS Trust, Broomfield, UK
| | - Jacob Easaw
- Department of Cardiology, Royal United Hospitals NHS Foundation Trust, Bath, BA1 3NG, UK
| | - Haytham Hamdan
- Department of Cardiology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Shahnaz Jamil-Copley
- Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Gajen Kanaganayagam
- Department of Cardiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Tom Mwambingu
- Department of Cardiology, The Mid Yorkshire Hospitals NHS Trust, Pinderfields, UK
| | - Antonis Pantazis
- Department of Cardiology, North Middlesex University Hospital NHS Trust, London, UK
| | | | - Ronak Rajani
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Naveed A Razvi
- Department of Cardiology, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Sushma Rekhraj
- Department of Cardiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - David P Ripley
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, North Tyneside, UK
| | - Kathleen Rose
- Department of Cardiology, Northampton General Hospital NHS Trust, Northampton, UK
| | | | - Rebecca Schofield
- Department of Cardiology, North West Anglia NHS Foundation Trust, Peterborough, UK
| | - Ayyaz Sultan
- Department of Cardiology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
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Peteiro J, Bouzas-Mosquera A. Time to climb 4 flights of stairs provides relevant information on exercise testing performance and results. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:354-355. [PMID: 33268317 DOI: 10.1016/j.rec.2020.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 09/15/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Jesus Peteiro
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain; Facultad de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain.
| | - Alberto Bouzas-Mosquera
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain; Facultad de Ciencias de la Salud, Universidad de A Coruña, A Coruña, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Spain
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3
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Peteiro J, Bouzas-Mosquera A. El tiempo en subir 4 tramos de escaleras da información relevante sobre la capacidad funcional y resultados en una prueba de ejercicio. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Smith L, Myc L, Watson D, Beller GA, Bourque JM. A high exercise workload of ≥ 10 METS predicts a low risk of significant ischemia and cardiac events in older adults. J Nucl Cardiol 2020; 27:1486-1496. [PMID: 30051345 PMCID: PMC6348049 DOI: 10.1007/s12350-018-1376-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients who achieve ≥ 10 METS during exercise SPECT myocardial perfusion imaging (MPI) have very low rates of significant ischemia and major adverse cardiac events (MACE). It is unknown how many older adults can achieve ≥ 10 METS, and if low risk extends to this subgroup. METHODS AND RESULTS We examined the workload achieved, prevalence and predictors of ischemia, and MACE (cardiac death, non-fatal MI, late revascularization) in a cohort of 382 patients ≥ 65 years of age who underwent exercise 99mTc SPECT MPI. The cohort was 64.4% male and 36.9% had known coronary artery disease (CAD). All achieved ≥ 85% of maximum age-predicted heart rate. A workload of ≥ 10 METS was achieved in 25.4%; 50.3% attained 7-9 METS, and 24.4% reached < 7 METS. There was a stepwise decrease in prevalence of any ischemia and significant ischemia (≥ 10% of the left ventricle (LV)) as workload increased (P = 0.037). Patients achieving ≥ 10 METS had a 3.1% prevalence of ≥ 10% LV ischemia (1.2% in those without ST depression). Cardiac death and MACE rates in the ≥ 10 METS subgroup were 0.6%/year and 2.6%/year over a median 7.0 years of follow-up. CONCLUSIONS A substantial proportion of older adults who undergo exercise SPECT MPI can achieve ≥ 10 METS. This subgroup has low rates of significant LV ischemia and MACE. The favorable diagnostic and prognostic implications of achieving a high workload in an older adult population suggest it is feasible, with certain exceptions, to include this subgroup in workload-based strategies of provisional imaging.
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Affiliation(s)
- LaVone Smith
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Lukasz Myc
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Denny Watson
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA
| | - George A Beller
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA
| | - Jamieson M Bourque
- Cardiovascular Division, Department of Internal Medicine, Cardiovascular Imaging Center, University of Virginia Health System, Box 800662, 1215 Lee Street, Charlottesville, VA, 22908, USA.
- Department of Radiology, University of Virginia Health System, Charlottesville, VA, USA.
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Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK. Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction. J Am Soc Echocardiogr 2020; 33:1490-1499. [PMID: 32981787 DOI: 10.1016/j.echo.2020.07.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography. METHODS Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm. RESULTS LASreservoir was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LASreservoir was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LASreservoir and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LASreservoir (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LASreservoir improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01). CONCLUSIONS LASreservoir has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.
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Affiliation(s)
- Zi Ye
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darwin F Yeung
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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6
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Beri N, Dang P, Bhat A, Venugopal S, Amsterdam EA. Usefulness of Excellent Functional Capacity in Men and Women With Ischemic Exercise Electrocardiography to Predict a Negative Stress Imaging Test and Very Low Late Mortality. Am J Cardiol 2019; 124:661-665. [PMID: 31300200 DOI: 10.1016/j.amjcard.2019.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.
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7
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Franklin BA, Brinks J, Berra K, Lavie CJ, Gordon NF, Sperling LS. Using Metabolic Equivalents in Clinical Practice. Am J Cardiol 2018; 121:382-387. [PMID: 29229271 DOI: 10.1016/j.amjcard.2017.10.033] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/17/2017] [Accepted: 10/23/2017] [Indexed: 11/24/2022]
Abstract
Metabolic equivalents, or METs, are routinely employed as a guide to exercise training and activity prescription and to categorize cardiorespiratory fitness (CRF). There are, however, inherent limitations to the concept, as well as common misapplications. CRF and the patient's capacity for physical activity are often overestimated and underestimated, respectively. Moreover, frequently cited fitness thresholds associated with the highest and lowest mortality rates may be misleading, as these are influenced by several factors, including age and gender. The conventional assumption that 1 MET = 3.5 mL O2/kg/min has been challenged in numerous studies that indicate a significant overestimation of actual resting energy expenditure in some populations, including coronary patients, the morbidly obese, and individuals taking β-blockers. These data have implications for classifying relative energy expenditure at submaximal and peak exercise. Heart rate may be used to approximate activity METs, resulting in a promising new fitness metric termed the "personal activity intelligence" or PAI score. Despite some limitations, the MET concept provides a useful method to quantitate CRF and define a repertoire of physical activities that are likely to be safe and therapeutic. In conclusion, for previously inactive adults, moderate-to-vigorous physical activity, which corresponds to ≥3 METs, may increase MET capacity and decrease the risk of future cardiac events.
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8
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Bourque JM, Beller GA. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies. JACC Cardiovasc Imaging 2016; 8:1309-21. [PMID: 26563861 DOI: 10.1016/j.jcmg.2015.09.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/15/2015] [Accepted: 09/23/2015] [Indexed: 02/07/2023]
Abstract
Exercise stress electrocardiography (ExECG) is underutilized as the initial test modality in patients with interpretable electrocardiograms who are able to exercise. Although stress myocardial imaging techniques provide valuable diagnostic and prognostic information, variables derived from ExECG can yield substantial data for risk stratification, either supplementary to imaging variables or without concurrent imaging. In addition to exercise-induced ischemic ST-segment depression, such markers as ST-segment elevation in lead aVR, abnormal heart rate recovery post-exercise, failure to achieve target heart rate, and poor exercise capacity improve risk stratification of ExECG. For example, patients achieving ≥10 metabolic equivalents on ExECG have a very low prevalence of inducible ischemia and an excellent prognosis. In contrast, cardiac imaging techniques add diagnostic and prognostic value in higher-risk populations (e.g., poor functional capacity, diabetes, or chronic kidney disease). Optimal test selection for symptomatic patients with suspected coronary artery disease requires a patient-centered approach factoring in the risk/benefit ratio and cost-effectiveness.
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Affiliation(s)
- Jamieson M Bourque
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia; Department of Radiology, University of Virginia Health System, Charlottesville, Virginia.
| | - George A Beller
- Cardiovascular Division and the Cardiovascular Imaging Center, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
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Abstract
Stress testing remains the cornerstone for noninvasive assessment of patients with possible or known coronary artery disease (CAD). The most important application of stress testing is risk stratification. Most patients who present for evaluation of stable CAD are categorized as low risk by stress testing. These low-risk patients have favorable clinical outcomes and generally do not require coronary angiography. Standard exercise treadmill testing is the initial procedure of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise.
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Affiliation(s)
- Todd D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA.
| | - J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
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Tweet MS, Arruda-Olson AM, Anavekar NS, Pellikka PA. Stress echocardiography: what is new and how does it compare with myocardial perfusion imaging and other modalities? Curr Cardiol Rep 2016; 17:43. [PMID: 25911442 DOI: 10.1007/s11886-015-0600-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality, and noninvasive strategies to diagnose and risk stratify patients remain paramount in the evaluative process. Stress echocardiography is a well-established, versatile, real-time imaging modality with advantages including lack of radiation exposure, portability, and affordability. Innovative techniques in stress echocardiography include myocardial contrast echocardiography, deformation imaging, three-dimensional (3D) echocardiography, and assessment of coronary flow reserve. Myocardial perfusion imaging with single-photon emission computed tomography (SPECT) or positron emission tomography (PET) are imaging alternatives, and stress cardiac magnetic resonance imaging and coronary computed tomography (CT) angiography, including CT perfusion imaging, are emerging as newer approaches. This review will discuss recent and upcoming developments in the field of stress testing, with an emphasis on stress echocardiography while highlighting comparisons with other modalities.
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Affiliation(s)
- Marysia S Tweet
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA,
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11
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Qamruddin S. False-Positive Stress Echocardiograms: A Continuing Challenge. Ochsner J 2016; 16:277-279. [PMID: 27660577 PMCID: PMC5024810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Stress echocardiography is an integral test in the cardiac diagnostic laboratory and has high sensitivity and specificity. Despite the excellent specificity of stress echocardiography, we continue to see a subset of patients with false-positive tests (defined as <50% diameter stenosis on subsequent coronary angiography). These false-positive findings present a management challenge because it remains unclear if and how to treat these patients. METHODS This article reviews relevant clinical studies and their outcomes. RESULTS Studies suggest that a group of patients develops a hypertensive response to exercise and therefore may have false-positive stress echocardiography. Hence, superior blood pressure control prior to stress echocardiography may prevent some false-positive tests. In addition, a subset of patients has microvascular abnormalities, vasomotor changes, endothelial dysfunction, and/or small vessel coronary disease that can lead to false-positive stress echocardiography. CONCLUSION The evidence is insufficient to state that a false-positive stress echocardiography in the absence of obstructive coronary artery disease portends a poor outcome, but considerable evidence shows that some of these patients have microvascular abnormalities and endothelial dysfunction and consequently may benefit from aggressive medical management and further testing.
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Affiliation(s)
- Salima Qamruddin
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
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12
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My patient wants to perform strenuous endurance exercise. What's the right advice? Int J Cardiol 2015; 197:248-53. [DOI: 10.1016/j.ijcard.2015.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/07/2015] [Accepted: 06/12/2015] [Indexed: 12/23/2022]
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Cardiac CT vs. Stress Testing in Patients with Suspected Coronary Artery Disease: Review and Expert Recommendations. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015; 8. [PMID: 26500716 DOI: 10.1007/s12410-015-9344-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diagnosis and management of coronary artery disease represent a major challenge to our health care systems affecting millions of patients each year. Until recently, the diagnosis of coronary artery disease could be conclusively determined only by invasive coronary angiography. To avoid risks from cardiac catheterization, many healthcare systems relied on stress testing as gatekeeper for coronary angiography. Advancements in cardiac computed tomography angiography technology now allows to noninvasively visualize coronary artery disease, challenging the role of stress testing as the default noninvasive imaging tool for evaluating patients with chest pain. In this review, we summarize current data on the clinical utility of cardiac computed tomography and stress testing in stable patients with suspected coronary artery disease.
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14
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Abstract
Stress testing remains the cornerstone for noninvasive assessment of patients with possible or known coronary artery disease (CAD). The most important application of stress testing is risk stratification. Most patients who present for evaluation of stable CAD are categorized as low risk by stress testing. These low-risk patients have favorable clinical outcomes and generally do not require coronary angiography. Standard exercise treadmill testing is the initial procedure of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise.
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Affiliation(s)
- Todd D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA.
| | - J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
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15
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Oja P, Titze S, Kokko S, Kujala UM, Heinonen A, Kelly P, Koski P, Foster C. Health benefits of different sport disciplines for adults: systematic review of observational and intervention studies with meta-analysis. Br J Sports Med 2015; 49:434-40. [DOI: 10.1136/bjsports-2014-093885] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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16
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Duvall WL, Savino JA, Levine EJ, Hermann LK, Croft LB, Henzlova MJ. Prospective evaluation of a new protocol for the provisional use of perfusion imaging with exercise stress testing. Eur J Nucl Med Mol Imaging 2014; 42:305-16. [PMID: 25367747 DOI: 10.1007/s00259-014-2864-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/10/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Previous literature suggests that myocardial perfusion imaging (MPI) adds little to the prognosis of patients who exercise >10 metabolic equivalents (METs) during stress testing. With this in mind, we prospectively tested a provisional injection protocol in emergency department (ED) patients presenting for the evaluation of chest pain in which a patient would not receive an injection of radioisotope if adequate exercise was achieved without symptoms and a negative ECG response. METHODS All patients who presented to the ED over a 5-year period who were referred for stress testing as part of their ED evaluation were included. Patients considered for a provisional protocol were: exercise stress, age <65 years, no known coronary artery disease, and an interpretable rest ECG. Criteria for not injecting included a maximal predicted heart rate ≥85%, ≥10 METs of exercise, no anginal symptoms during stress, and no ECG changes. Groups were compared based on stress test results, all-cause and cardiac mortality, follow-up cardiac testing, subsequent revascularization, and cost. RESULTS A total of 965 patients were eligible with 192 undergoing exercise-only and 773 having perfusion imaging. After 41.6 ± 19.6 months of follow-up, all-cause mortality was similar in the exercise-only versus the exercise plus imaging group (2.6% vs. 2.1%, p = 0.59). There were no cardiac deaths in the exercise-only group. At 1 year there was no difference in the number of repeat functional stress tests (1.6% vs. 2.1%, p = 0.43), fewer angiograms (0% vs. 4.0%, p = 0.002), and a significantly lower cost ($65 ± $332 vs $506 ± $1,991, p = 0.002; values are in US dollars) in the exercise-only group. The radiation exposure in the exercise plus imaging group was 8.4 ± 2.1 mSv. CONCLUSIONS A provisional injection protocol has a very low mortality, few follow-up diagnostic tests, and lower cost compared to standard imaging protocols. If adopted it would decrease radiation exposure, save time and decrease health-care costs without jeopardizing prognosis.
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Affiliation(s)
- W Lane Duvall
- Division of Cardiology (Henry Low Heart Center), Hartford Hospital, South Building 2nd Floor, Hartford, CT, 06102, USA,
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Duvall WL, Parker MW, Henzlova MJ. Improving Nuclear Cardiology Practice. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9271-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barnes JN, Joyner MJ. Physical activity and cardiovascular risk: 10 metabolic equivalents or bust. Mayo Clin Proc 2013; 88:1353-5. [PMID: 24290107 DOI: 10.1016/j.mayocp.2013.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 10/23/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Jill N Barnes
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
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