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Donelli D, Antonelli M, Gurgoglione FL, Lazzeroni D, Niccoli G, Cortigiani L, Gaibazzi N. Effects of left bundle branch block on echocardiographic coronary flow assessment: A systematic review. Echocardiography 2024; 41:e15864. [PMID: 38889092 DOI: 10.1111/echo.15864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/13/2024] [Accepted: 05/30/2024] [Indexed: 06/20/2024] Open
Abstract
This systematic review investigates the diagnostic and prognostic utility of coronary flow reserve (CFR) assessment through echocardiography in patients with left bundle branch block (LBBB), a condition known to complicate the clinical evaluation of coronary artery disease (CAD). The literature search was performed on PubMed, EMBASE, Web of Science, Scopus, and Google Scholar, was guided by PRISMA standards up to March 2024, and yielded six observational studies that met inclusion criteria. These studies involved a diverse population of patients with LBBB, employing echocardiographic protocols to clarify the impact of LBBB on coronary flow dynamics. The findings emphasize the importance of CFR in stratifying cardiovascular risk and guiding clinical decision-making in patients with LBBB. Pooled results reveal that patients with LBBB and significant left anterior descending (LAD) artery stenosis exhibited a marked decrease in stress-peak diastolic velocity (MD = -19.03 [-23.58; -14.48] cm/s; p < .0001) and CFR (MD = -.60 [-.71; -.50]; p < .0001), compared to those without significant LAD lesions, suggesting the efficacy of stress echocardiography CFR assessment in the identification of clinically significant CAD among the LBBB population. This review highlights the clinical relevance of echocardiography CFR assessment as a noninvasive tool for evaluating CAD and stratifying risk in the presence of LBBB and underscores the need for standardized protocols in CFR measurement.
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Affiliation(s)
- Davide Donelli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Cardiology Unit, University Hospital of Parma, Parma, Italy
| | - Michele Antonelli
- Department of Public Health, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Filippo Luca Gurgoglione
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Cardiology Unit, University Hospital of Parma, Parma, Italy
| | - Davide Lazzeroni
- Prevention and Rehabilitation Unit, IRCCS Fondazione Don Gnocchi, Parma, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Cardiology Unit, University Hospital of Parma, Parma, Italy
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Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L, Van De Heyning CM, Celutkiene J, Gaibazzi N, Ciampi Q, Senior R, Neskovic AN, Henein M. The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. Eur Heart J Cardiovasc Imaging 2024; 25:e65-e90. [PMID: 37798126 DOI: 10.1093/ehjci/jead250] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology of the National Research Council, CNR, Via Moruzzi 1, 56124 Pisa, Italy
| | - Luc Pierard
- University of Liège, Walloon Region, Belgium
| | - Jesus Peteiro
- CHUAC-Complexo Hospitalario Universitario A Coruna, CIBER-CV, University of A Coruna, 15070 La Coruna, Spain
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Centre of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center UPMC Heart & Vascular Institute, Pittsburgh, PA, USA
| | | | | | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, 43100 Parma, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy
| | - Roxy Senior
- Imperial College, UK
- Royal Brompton Hospital Imperial College London, UK
- Northwick Park Hospital, London, UK
| | - Aleksandar N Neskovic
- Department of Cardiology, University Clinical Hospital Center Zemun-Belgrade Faculty of Medicine, University of Belgrade, Serbia
| | - Michael Henein
- Department of Public Health and Clinical Medicine Units: Section of Medicine, Umea University, Umea, Sweden
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Xu R, Yang H, Zhang J, Chen S, Pang L, Wu Y, Pei Z, Shi H, Li C, Ge J. Dynamic perfusion SPECT for functional evaluation in symptomatic patients with myocardial bridging. J Nucl Cardiol 2023; 30:2058-2067. [PMID: 37095328 DOI: 10.1007/s12350-023-03241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/28/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility and diagnostic value of myocardial flow reserve (MFR) assessed by rest/stress myocardial perfusion imaging with dynamic single-photon emission computed tomography (SPECT) in the functional evaluation of myocardial bridge (MB). METHODS From May 2017 to July 2021, patients with angiographically confirmed isolated MB on the left anterior descending artery (LAD) who underwent dynamic SPECT myocardial perfusion imaging were retrospectively included. The assessment of semiquantitative indices of myocardial perfusion (summed stress scores, SSS) and quantitative parameters (MFR) was performed. RESULTS A total of 49 patients were enrolled. The mean age of the subjects was 61.0 ± 9.0 years. All of the patients were symptomatic, and 16 cases (32.7%) presented with typical angina. SPECT-derived MFR showed a borderline significantly negative correlation with SSS (r = 0.261, P = .070). There was a trend of higher prevalence of impaired myocardial perfusion defined as MFR < 2 than as SSS ≥ 4 (42.9% vs 26.5%; P = .090). CONCLUSION Our data support that SPECT MFR may be a useful parameter for the functional assessment of MB. In patients with MB, the use of dynamic SPECT could be a potential method for hemodynamic assessment.
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Affiliation(s)
- Rende Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hao Yang
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Jie Zhang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Shuguang Chen
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Lifang Pang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yizhe Wu
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhiqiang Pei
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Chenguang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
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Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, Rajkumar CA, Shun-Shin MJ, Ahmad Y, Sen S, Al-Lamee R, Petraco R. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J 2022; 43:1582-1593. [PMID: 34849697 PMCID: PMC9020988 DOI: 10.1093/eurheartj/ehab775] [Citation(s) in RCA: 126] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
AIMS This meta-analysis aims to quantify the association of reduced coronary flow with all-cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. METHODS AND RESULTS We systematically identified all studies between 1 January 2000 and 1 August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios (HRs) using a random-effects model. Seventy-nine studies with a total of 59 740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality [HR: 3.78, 95% confidence interval (CI): 2.39-5.97] and a higher incidence of MACE (HR 3.42, 95% CI: 2.92-3.99). Each 0.1 unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR: 1.16, 95% CI: 1.04-1.29) and MACE (per 0.1 CFR unit HR: 1.08, 95% CI: 1.04-1.11). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR: 5.44, 95% CI: 3.78-7.83) and MACE (HR: 3.56, 95% CI: 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR: 3.76, 95% CI: 2.35-6.00), heart failure (HR: 6.38, 95% CI: 1.95-20.90), heart transplant (HR: 3.32, 95% CI: 2.34-4.71), and diabetes mellitus (HR: 7.47, 95% CI: 3.37-16.55). CONCLUSION Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice, to target aggressive vascular risk modification for individuals at higher risk.
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Affiliation(s)
- Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Haseeb Rahman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, Connecticut 06510, USA
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
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Zagatina A, Zhuravskaya N, Caprnda M, Shiwani HA, Gazdikova K, Rodrigo L, Kruzliak P, Shmatov D. Should we routinely assess coronary artery Doppler in daily echocardiography practice? Acta Cardiol 2021; 77:573-579. [PMID: 34538214 DOI: 10.1080/00015385.2021.1973771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A lot of people with coronary artery disease do not have specific symptoms, and myocardial infarction or death are the first manifestation of the disease. New accurate, non-invasive and safe screening methods are required that can assess the prognosis of patients during routine examinations performed on millions of people. The aim of this review was to discuss the current literature regarding the utility of non-invasive ultrasound imaging of the coronary artery in assessing a patient's prognosis in daily practice. Assessment of coronary artery flow during common stress echocardiography or echocardiography can provide additive incremental prognostic information without the burden of radiation. Exercise or pharmacologic stress echocardiography tests combined with coronary flow velocity reserve assessment has advantages over stress tests based only on regional wall motion abnormalities. Scanning of main coronary arteries as an addition to routine echocardiography can reveal patients at high risk of adverse cardiac events in the near future.
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Affiliation(s)
- Angela Zagatina
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Nadezhda Zhuravskaya
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Martin Caprnda
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Haaris A. Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Trust, Lancaster, United Kingdom
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia
- Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Luis Rodrigo
- Faculty of Medicine, University of Oviedo, Central University Hospital of Asturias (HUCA), Oviedo, Spain
| | - Peter Kruzliak
- 2nd Department of Surgery, Faculty of Medicine, Masaryk University and St. Annés University Hospital, Brno, Czech Republic
| | - Dmitry Shmatov
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
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6
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Donal E, Delgado V, Bucciarelli-Ducci C, Galli E, Haugaa KH, Charron P, Voigt JU, Cardim N, Masci PG, Galderisi M, Gaemperli O, Gimelli A, Pinto YM, Lancellotti P, Habib G, Elliott P, Edvardsen T, Cosyns B, Popescu BA. Multimodality imaging in the diagnosis, risk stratification, and management of patients with dilated cardiomyopathies: an expert consensus document from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2020; 20:1075-1093. [PMID: 31504368 DOI: 10.1093/ehjci/jez178] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is defined by the presence of left ventricular or biventricular dilatation and systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to explain these changes. This is a heterogeneous disease frequently having a genetic background. Imaging is important for the diagnosis, the prognostic assessment and for guiding therapy. A multimodality imaging approach provides a comprehensive evaluation of all the issues related to this disease. The present document aims to provide recommendations for the use of multimodality imaging according to the clinical question. Selection of one or another imaging technique should be based on the clinical condition and context. Techniques are presented with the aim to underscore what is 'clinically relevant' and what are the tools that 'can be used'. There remain some gaps in evidence on the impact of multimodality imaging on the management and the treatment of DCM patients where ongoing research is important.
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Affiliation(s)
- Erwan Donal
- Service de Cardiologie et CIC-IT INSERM 1414, CHU Pontchaillou, 2 rue Henri Le Guilloux, Rennes, France.,LTSI, Université de Rennes 1, INSERM, UMR, Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden RC, The Netherlands
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, University of Bristol, University Hospitals Bristol NHS Foundation Trust, Malborough St, Bristol, UK
| | - Elena Galli
- Service de Cardiologie et CIC-IT INSERM 1414, CHU Pontchaillou, 2 rue Henri Le Guilloux, Rennes, France.,LTSI, Université de Rennes 1, INSERM, UMR, Rennes, France
| | - Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Philippe Charron
- Centre de Référence pour les Maladies Cardiaques Héréditaires, APHP, ICAN, Hôpital de la Pitié Salpêtrière, Paris, France.,Université Versailles Saint Quentin & AP-HP, CESP, INSERM U1018, Service de Génétique, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Nuno Cardim
- Cardiology Department, Hospital da Luz, Av. Lusíada, n° 100, Lisbon, Portugal
| | - P G Masci
- HeartClinic, Hirslanden Hospital Zurich, Witellikerstrasse 32, CH Zurich, Switzerland
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Oliver Gaemperli
- HeartClinic, Hirslanden Hospital Zurich, Witellikerstrasse 32, CH Zurich, Switzerland
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, Italy
| | - Yigal M Pinto
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, Domaine Universitaire du Sart Tilman, B Liège, Belgium
| | - Gilbert Habib
- Cardiology Department, APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille, France.,Aix Marseille University, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Boulevard Jean Moulin, Marseille, France
| | - Perry Elliott
- Institute of Cardiovascular Science, University College London, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thor Edvardsen
- Department of Cardiology, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Bernard Cosyns
- Centrum voor Hart en Vaatziekten (CHVZ), Unversitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussel, Belgium
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila"- Euroecolab, Emergency Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos. Fundeni 258, Sector 2, Bucharest, Romania
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Cortigiani L, Ciampi Q, Lombardo A, Rigo F, Bovenzi F, Picano E. Age- and Gender-Specific Prognostic Cutoff Values of Coronary Flow Velocity Reserve in Vasodilator Stress Echocardiography. J Am Soc Echocardiogr 2019; 32:1307-1317. [DOI: 10.1016/j.echo.2019.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/18/2019] [Accepted: 05/25/2019] [Indexed: 01/09/2023]
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Sicari R, Cortigiani L, Arystan AZ, Fettser DV. [The Clinical use of Stress Echocardiography in Ischemic Heart Disease Cardiovascular Ultrasound (2017)15:7. Translation authors: Arystan A.Zh., Fettser D.V.]. ACTA ACUST UNITED AC 2019; 59:78-96. [PMID: 30990145 DOI: 10.18087/cardio.2019.3.10244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 04/13/2019] [Indexed: 01/08/2023]
Abstract
Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows detecting myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependence on operator expertise, the lack of outcome data (a widespread problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.
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Affiliation(s)
| | | | - A Zh Arystan
- Medical Centre Hospital of President's Affairs Administration of the RK, Astana
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9
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Zagatina A, Zhuravskaya N. The additive prognostic value of coronary flow velocity reserve during exercise echocardiography. Eur Heart J Cardiovasc Imaging 2018; 18:1179-1184. [PMID: 27502295 DOI: 10.1093/ehjci/jew164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/13/2016] [Indexed: 02/06/2023] Open
Abstract
Aims The aim of the study was to assess the additive prognostic value of coronary flow velocity reserve (CFVR) alongside wall motion analysis during exercise echocardiography in patients with known or suspected coronary artery disease (CAD). Methods and results In a prospective, single-centre, observational study, we evaluated 689 patients (449 males; 56 + 9 years) who underwent supine bicycle stress echo (ESE) with CFVR evaluation of the left anterior descending artery (LAD) by Doppler. ESE was positive for regional wall motion abnormalities in 359 (52%) patients. Mean CFVR was 1.9 ± 0.8. During a median follow-up of 36.6 months, there were 200 patients with major adverse cardiac events (MACE): 15 deaths, 17 non-fatal myocardial infarctions [11 of them also had percutaneous coronary intervention with stenting (PCI) or/and coronary artery bypass graft surgery (CABG)] and 179 patients underwent revascularization. The 37 months' event-free survival showed the best outcome for those patients with negative ESE by wall motion criteria and normal CFVR, and the worst outcome for patients with positive ESE by wall motion and abnormal CVFR (99 vs. 42%, P < 0.0001). At multivariable analysis, CFVR in LAD (OR 0.53, 95% CI 0.35-0.79, P < 0.0001), positivity for regional wall motion abnormalities during testing (OR 0.10, 95% CI 0.04-0.25, P < 0.000), previous PCI (OR 0.38, 95% CI 0.16-0.90, P < 0.003), male sex (OR 0.44, 95% CI 0.27-0.71, P < 0.0009), and heart rate reached during exercise (OR 0.98, 95% CI 0.96-0.99, P < 0.02) were independent prognostic predictors of MACE. Conclusion In patients with known or suspected CAD, exercise stress tests measuring wall motion criteria and CFVR are additive and complementary for the identification of patients at risk of experiencing major adverse events.
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Affiliation(s)
- Angela Zagatina
- Medika Cardiology Clinic, 8-2, Dundicha St., Saint Petersburg 192283, Russia
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Brainin P, Frestad D, Prescott E. The prognostic value of coronary endothelial and microvascular dysfunction in subjects with normal or non-obstructive coronary artery disease: A systematic review and meta-analysis. Int J Cardiol 2018; 254:1-9. [DOI: 10.1016/j.ijcard.2017.10.052] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/09/2017] [Indexed: 01/02/2023]
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Cortigiani L, Carpeggiani C, Sicari R, Michelassi C, Bovenzi F, Picano E. Simple six-item clinical score improves risk prediction capability of stress echocardiography. Heart 2017; 104:760-766. [DOI: 10.1136/heartjnl-2017-312122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/03/2017] [Accepted: 10/04/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectivesTo assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE).MethodsStudy includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups.ResultsDuring a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001).ConclusionsSimple clinical variables may be able to optimise SE risk stratification.
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Ahmed B, Creager MA. Alternative causes of myocardial ischemia in women: An update on spontaneous coronary artery dissection, vasospastic angina and coronary microvascular dysfunction. Vasc Med 2017; 22:146-160. [DOI: 10.1177/1358863x16686410] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Bina Ahmed
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Mark A Creager
- Dartmouth-Hitchcock Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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13
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Sicari R, Cortigiani L. The clinical use of stress echocardiography in ischemic heart disease. Cardiovasc Ultrasound 2017; 15:7. [PMID: 28327159 PMCID: PMC5361820 DOI: 10.1186/s12947-017-0099-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/15/2017] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows to detect myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependance on operator expertise, the lack of outcome data (a widesperad problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.
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Affiliation(s)
- Rosa Sicari
- CNR, Institute of Clinical Physiology, Via G. Moruzzi, 1, 56124, Pisa, Italy.
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14
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Wiegerinck EMA, van de Hoef TP, Rolandi MC, Yong Z, van Kesteren F, Koch KT, Vis MM, de Mol BAJM, Piek JJ, Baan J. Impact of Aortic Valve Stenosis on Coronary Hemodynamics and the Instantaneous Effect of Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv 2016; 8:e002443. [PMID: 26245891 DOI: 10.1161/circinterventions.114.002443] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Aortic valve stenosis (AS) induces compensatory alterations in left ventricular hemodynamics, leading to physiological and pathological alterations in coronary hemodynamics. Relief of AS by transcatheter aortic valve implantation (TAVI) decreases ventricular afterload and is expected to improve microvascular function immediately. We evaluated the effect of AS on coronary hemodynamics and the immediate effect of TAVI. METHODS AND RESULTS Intracoronary pressure and flow velocity were simultaneously assessed at rest and at maximal hyperemia in an unobstructed coronary artery in 27 patients with AS before and immediately after TAVI and in 28 patients without AS. Baseline flow velocity was higher and baseline microvascular resistance was lower in patients with AS as compared with controls, which remained unaltered post-TAVI. In patients with AS, hyperemic flow velocity was significantly lower as compared with controls (44.5±14.5 versus 54.3±18.6 cm/s; P=0.04). Hyperemic microvascular resistance (expressed in mm Hg·cm·s(-1)) was 2.10±0.69 in patients with AS as compared with 1.80±0.60 in controls (P=0.096). Coronary flow velocity reserve in patients with AS was lower, 1.9±0.5 versus 2.7±0.7 in controls (P<0.001). Improvement in coronary hemodynamics after TAVI was most pronounced in patients without post-TAVI aortic regurgitation. In these patients (n=20), hyperemic flow velocity increased significantly from 46.24±15.47 pre-TAVI to 56.56±17.44 cm/s post-TAVI (P=0.003). Hyperemic microvascular resistance decreased from 2.03±0.71 to 1.66±0.45 (P=0.050). Coronary flow velocity reserve increased significantly from 1.9±0.4 to 2.2±0.6 (P=0.009). CONCLUSIONS The vasodilatory reserve capacity of the coronary circulation is reduced in AS. TAVI induces an immediate decrease in hyperemic microvascular resistance and a concomitant increase in hyperemic flow velocity, resulting in immediate improvement in coronary vasodilatory reserve.
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Affiliation(s)
- Esther M A Wiegerinck
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tim P van de Hoef
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M Cristina Rolandi
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - ZeYie Yong
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Floortje van Kesteren
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T Koch
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije M Vis
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas A J M de Mol
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- From the AMC Heartcenter, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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15
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Mair L, Warriner D, Payne G. Assessment of an incidental finding of left bundle-branch block. Br J Hosp Med (Lond) 2015; 76:196-9. [PMID: 25853348 DOI: 10.12968/hmed.2015.76.4.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Incidental left bundle-branch block occurs in up to 1.5% of healthy adults without symptoms or signs of cardiovascular disease. It may be found during investigation for non-cardiac disease, during preoperative assessment, private health screening or inpatient monitoring. This article outlines how to assess these patients.
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Affiliation(s)
- Luke Mair
- Senior House Officer in the Department of Critical Care, Doncaster Royal Infirmary, Doncaster, South Yorkshire DN2 5LT
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16
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Stoebe S, Pfeiffer D, Hagendorff A. Feasibility of 3D4D echocardiography for the detection of colour-coded flow in the left anterior descending artery. Echo Res Pract 2014; 1:23-30. [PMID: 26693289 PMCID: PMC4676465 DOI: 10.1530/erp-14-0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/23/2014] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to test the feasibility of the visualisation of 3D4D coronary flow in detectable segments of coronary arteries. Regarding the feasibility of this new approach, the hypothesis was proposed that the flow signals of the course of detectable coronary arteries can be better visualised by 3D4D echocardiography than by the conventional 2D approach. A total of 30 consecutive patients with sinus rhythm, in whom the distal left anterior descending artery (LAD) was visualised by 2D colour-coded Doppler echocardiography, were selected for 3D4D scanning procedures. All measurements were performed using a Vivid 7 or E9. All segments visualised by 2D colour-coded Doppler echocardiography were also examined by 3D4D echocardiography. Using defined settings, the width of the colour-coded flow signal differs significantly between 2D- and 3D4D echocardiography. The length of larger segments of the visualised colour-coded flow signal of the coronary flow could be better detected with 2D imaging. Small segments of coronary artery flow (<11 mm), however, could be significantly better visualised by 3D4D echocardiography. The main advantage of 3D4D echocardiography of the coronary artery flow is the visualisation of the proportions of vessels with complex morphology. 3D4D echocardiography of LAD flow by colour-coded Doppler echocardiography raises new possibilities for the direct flow visualisation of the detectable segments of coronaries. With its sufficiently high spatial and temporal resolution, this new method has the potential to be implemented in clinical scenarios. The possible application to the quantification of stenoses by the flow visualisation has to be evaluated in further studies.
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Affiliation(s)
- Stephan Stoebe
- Division of Cardiology and Angiology, Department of Internal Medicine Neurology and Dermatology, University of Leipzig , Liebigstr. 2004103, Leipzig , Germany
| | - Dietrich Pfeiffer
- Division of Cardiology and Angiology, Department of Internal Medicine Neurology and Dermatology, University of Leipzig , Liebigstr. 2004103, Leipzig , Germany
| | - Andreas Hagendorff
- Division of Cardiology and Angiology, Department of Internal Medicine Neurology and Dermatology, University of Leipzig , Liebigstr. 2004103, Leipzig , Germany
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17
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Varho V, Karjalainen PP, Ylitalo A, Airaksinen JK, Mikkelsson J, Sia J, Pietilä M, Kiviniemi TO. Transthoracic echocardiography for non-invasive assessment of coronary vasodilator function after DES implantation. Eur Heart J Cardiovasc Imaging 2014; 15:1029-34. [PMID: 24755162 DOI: 10.1093/ehjci/jeu059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIMS Coronary vasodilator dysfunction has been reported after drug-eluting stent (DES) implantation. Recent ESC guidelines suggest that transthoracic echocardiography (TTE) may be considered for assessment of coronary flow reserve (CFR) and microvascular disease in patients with stable angina, but its reliability has not been tested in patients with DES. We sought to assess the agreement between TTE (CFRTTE) and invasive thermodilution-derived CFR (CFRThermodilution) as well as their association with index of microcirculatory resistance (IMR) in mid-term follow-up after percutaneous coronary intervention for acute coronary syndrome. METHODS AND RESULTS CFRTTE and CFRThermodilution were assessed 3 months after DES implantation in the left anterior descending artery in 24 patients. Patients with haemodynamically significant epicardial stenosis (fractional flow reserve <0.75) were excluded. Correlation between the two methods was good (r = 0.71, P < 0.001), but CFRThermodilution (mean ± SD) tended to be higher (3.17 ± 1.00 vs. 2.87 ± 0.72; mean difference 0.29, 95% confidence interval -0.06 to 0.59). In Bland-Altman analysis, there was a trend towards a greater difference in the range of higher invasive values. Nevertheless, TTE was successful in discriminating moderately impaired CFR (≤2.5) (P = 0.001) and severely impaired CFR (≤2.0) (P < 0.001) when compared with an invasive method. No association between either CFR measurements vs. IMR measurement was detected, suggesting that in addition to microcirculatory function, CFR also accounts for epicardial vasodilator function in the absence of haemodynamically significant stenosis. CONCLUSION TTE is a feasible and reliable method for the assessment of CFR and vasodilator dysfunction after DES implantation. Values obtained with this method successfully find abnormal CFR confirmed with the invasive thermodilution method.
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Affiliation(s)
- Ville Varho
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | | | - Antti Ylitalo
- Department of Cardiology, Satakunta Central Hospital, Pori, Finland
| | - Juhani K Airaksinen
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | - Jussi Mikkelsson
- Department of Cardiology, Satakunta Central Hospital, Pori, Finland
| | - Jussi Sia
- Department of Cardiology, Central Ostrobothnia Central Hospital, Kokkola, Finland
| | - Mikko Pietilä
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
| | - Tuomas O Kiviniemi
- Heart Centre Turku University Hospital and University of Turku, Hämeentie 9, Turku 20520, Finland
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18
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Abstract
This article focuses on some of the most important studies published in the year 2013 in cardiac imaging related to ischemic heart disease. Many of the studies across the various imaging techniques addressed the prognostic impact of imaging data on outcome in patients with this disease.
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Affiliation(s)
- Udo Sechtem
- Department of Cardiology, Robert-Bosch-Krankenhaus Stuttgart, Auerbachstraße 110, Stuttgart 70376, Germany
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19
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Karjalainen P. Neointimal coverage and vasodilator response to titanium-nitride-oxide-coated bioactive stents and everolimus-eluting stents in patients with acute coronary syndrome: insights from the BASE-ACS trial. Int J Cardiovasc Imaging 2013; 29:1693-703. [DOI: 10.1007/s10554-013-0285-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 08/24/2013] [Indexed: 10/26/2022]
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