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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024:ehae177. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [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: 09/04/2024] Open
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Baweja P, Sweeney MJ, López-Candales A. A Reminder That Stress Echocardiography Is Useful in Diagnosing Myocardial Ischemia in Nonobstructive Coronary Artery Disease: Case Series. Cureus 2021; 13:e17763. [PMID: 34659974 PMCID: PMC8493938 DOI: 10.7759/cureus.17763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/05/2022] Open
Abstract
Identification of ischemia remains critical when assessing individuals presenting with atypical symptoms or in patients with known coronary artery disease (CAD). Several imaging modalities are currently available to attain this diagnostic goal. Unfortunately, not all case presentations are straightforward, particularly when microvascular dysfunction (MVD) is the cause of symptoms in the absence of identifiable epicardial luminal stenosis. Specifically, in such cases, current imaging guidelines do not include stress echocardiography (SE) as a recommended tool when assessing these patients. We present three cases that highlight the utility of SE for identifying MVD and provide mechanistic explanations. We believe that SE should not be completely discarded as an inadequate testing modality; we highlight the potential utility of this imaging modality not only in diagnosing CAD and pre-surgical evaluation of patients but also in identifying patients with MVD.
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Affiliation(s)
- Paramdeep Baweja
- Cardiovascular Medicine, University of Missouri Kansas City, Kansas City, USA
| | - Michael J Sweeney
- Cardiovascular Medicine, University of Missouri Kansas City, Kansas City, USA
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Qian L, Xie F, Xu D, Porter TR. Long-term prognostic value of stress myocardial perfusion echocardiography in patients with coronary artery disease: a meta-analysis. Eur Heart J Cardiovasc Imaging 2021; 22:553-562. [PMID: 32125367 DOI: 10.1093/ehjci/jeaa026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/17/2019] [Accepted: 02/06/2020] [Indexed: 01/18/2023] Open
Abstract
AIMS To evaluate the prognostic value of myocardial perfusion (MP) imaging during contrast stress echocardiography (cSE) in patients with known or suspected coronary artery disease (CAD). METHODS AND RESULTS A search in PubMed, Embase databases, and the Cochrane library was conducted through May 2019. The Cochran Q statistic and the I2 statistic were used to assess heterogeneity, and the results were analysed by RevMan V5.3 and Stata V15.1 software. Twelve studies (seven dipyridamole and five exercise/dobutamine) without evidence of patient overlap (same institution publishing results over a similar time period) enrolling 5953 subjects (47% female, 8-80 months of follow-up) were included in the analysis. In all studies, total adverse cardiovascular events were defined as either cardiac death, non-fatal myocardial infarction (NFMI), or need for urgent revascularization. Hazard ratios (HRs) revealed that a MP abnormality [pooled HR 4.75; 95% confidence interval (CI) 2.47-9.14] was a higher independent predictor of total events than abnormal wall motion (WM, pooled HR 2.39; 95% CI 1.58-3.61) and resting left ventricular ejection fraction (LVEF, pooled HR 1.92; 95% CI 1.44-2.55) with significant subgroup differences (P = 0.002 compared with abnormal WM and 0.01 compared with abnormal LVEF). Abnormal MP was associated with higher risks for death [Risk ratio (RR) 5.24; 95% CI 2.91-9.43], NFMI (RR 3.09; 95% CI 1.84-5.21), and need for coronary revascularization (RR 16.44; 95% CI 6.14-43.99). CONCLUSION MP analysis during stress echocardiography is an effective prognostic tool in patients with known or suspected CAD and provides incremental value over LVEF and WM in predicting clinical outcomes.
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Affiliation(s)
- Lijun Qian
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Xie
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, 69198-1165, USA
| | - Di Xu
- Department of Geriatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - T R Porter
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, 69198-1165, USA
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Troy AM, Cheng HM. Human microvascular reactivity: a review of vasomodulating stimuli and non-invasive imaging assessment. Physiol Meas 2021; 42. [PMID: 34325417 DOI: 10.1088/1361-6579/ac18fd] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/29/2021] [Indexed: 11/11/2022]
Abstract
The microvasculature serves an imperative function in regulating perfusion and nutrient exchange throughout the body, adaptively altering blood flow to preserve hemodynamic and metabolic homeostasis. Its normal functioning is vital to tissue health, whereas its dysfunction is present in many chronic conditions, including diabetes, heart disease, and cognitive decline. As microvascular dysfunction often appears early in disease progression, its detection can offer early diagnostic information. To detect microvascular dysfunction, one uses imaging to probe the microvasculature's ability to react to a stimulus, also known as microvascular reactivity (MVR). An assessment of MVR requires an integrated understanding of vascular physiology, techniques for stimulating reactivity, and available imaging methods to capture the dynamic response. Practical considerations, including compatibility between the selected stimulus and imaging approach, likewise require attention. In this review, we provide a comprehensive foundation necessary for informed imaging of MVR, with a particular focus on the challenging endeavor of assessing microvascular function in deep tissues.
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Affiliation(s)
- Aaron M Troy
- Institute of Biomedical Engineering, University of Toronto, Toronto, CANADA
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Tiwari N, Margapuri J, Katamreddy A, Jubbal S, Madan N. Diagnostic accuracy of cardiac testing for coronary artery disease in potential liver transplant recipients: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2021; 32:100714. [PMID: 33521238 PMCID: PMC7820133 DOI: 10.1016/j.ijcha.2021.100714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/29/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022]
Abstract
Background The incidence of coronary artery disease (CAD) in Liver transplant (LT) patients is much higher than prior estimates and the morbidity and mortality are significant in this group of patients. Coronary angiography is the gold standard for detection of CAD, a non-invasive test that allows appropriate risk stratification would be preferred. In this systematic review and meta-analysis, we sought to assess the pooled diagnostic accuracy of various noninvasive cardiac imaging tests in detecting CAD in patients listed for LT. Methods We performed a systematic review and meta-analysis of studies comparing sensitivity and specificity of non-invasive tests to that of coronary angiography in diagnosing coronary artery disease in patients undergoing liver transplantation. Results Five studies (616 participants) evaluated myocardial perfusion imaging (MPI); five studies (1243 participants) dobutamine stress echocardiography (DSE); and three (87 participants), other tests. MPI had a pooled sensitivity of 0.62 (95% CI 0.37, 0.83), specificity of 0.60 (95% CI 0.39, 0.79), diagnostic odds ratio (DOR) of 2.5 (95% CI 1.7, 5.64) and Area under the curve (AUC) 0.649. DSE had a pooled sensitivity of 0.25 (95%CI 0.09, 0.51), specificity of 0.68 (95% CI 0.44, 0.84) and DOR of 0.7 (95% CI 0.12, 3.84). Conclusions Our results show that both MPI and DSE are not effective screening tools for detecting CAD in patients with end-stage liver disease (ESLD). Future studies are needed to evaluate the role of real-time myocardial contrast echocardiography (RTMCE) and coronary artery calcium score (CAC) with coronary CT angiography in patients with ESLD.
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Affiliation(s)
- Nidhish Tiwari
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Adarsh Katamreddy
- Jacobi Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sandeep Jubbal
- University of Massachusetts Medical School, Worcester, MA, USA
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Garçon P. [Myocardial perfusion assessment with contrast echocardiography, a promising old technique?]. Ann Cardiol Angeiol (Paris) 2020; 69:268-272. [PMID: 32980084 DOI: 10.1016/j.ancard.2020.09.007] [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: 08/20/2020] [Accepted: 09/03/2020] [Indexed: 06/11/2023]
Abstract
Myocardial perfusion assessment with contrast echocardiography has been studied for more than 25 years. It is a feasible and safe technique. Rather it has an additional value in pharmacologic stress test remains unclear. However, with adequate settings (using both low and very low mechanical index), perfusion analysis can be very useful for the diagnosis of apical thrombus or tumor, viability assessment, and acute coronary syndrome with non-informative ECG.
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Affiliation(s)
- P Garçon
- Service de cardiologie, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Vasiljevic-Pokrajcic Z, Trifunovic D, Krljanac G, Zdravkovic M. Role of Coronary Microcirculation in No-Reflow Phenomenon in Myocardial Infarction with ST Segment Elevation. Microcirculation 2020. [DOI: 10.1007/978-3-030-28199-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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9
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Shock-Wave Therapy Improves Myocardial Blood Flow Reserve in Patients with Refractory Angina: Evaluation by Real-Time Myocardial Perfusion Echocardiography. J Am Soc Echocardiogr 2019; 32:1075-1085. [PMID: 31235421 DOI: 10.1016/j.echo.2019.04.420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/31/2019] [Accepted: 04/09/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Cardiac shock-wave therapy (CSWT) has been demonstrated as an option for the treatment of patients with refractory angina (RA), promoting immediate vasodilatory effects and, in the long-term, neoangiogenic effects that would be responsible for reducing the myocardial ischemic load. The aim of this study was to determine the effects of CSWT on myocardial blood flow reserve (MBFR) assessed by quantitative real-time myocardial perfusion echocardiography in patients with RA. METHODS Fifteen patients (mean age 61.5 ± 12.8 years) with RA who underwent CSWT during nine sessions, over 3 months of treatment, were prospectively studied. A total of 32 myocardial segments with ischemia were treated, while another 31 did not receive therapy because of technical limitations. Myocardial perfusion was evaluated at rest and after dipyridamole stress (0.84 mg/kg) before and 6 months after CSWT, using quantitative real-time myocardial perfusion echocardiography. Clinical effects were evaluated using Canadian Cardiovascular Society grading of angina and the Seattle Angina Questionnaire. RESULTS The ischemic segments treated with CSWT had increased MBFR (from 1.33 ± 0.22 to 1.74 ± 0.29, P < .001), a benefit that was not observed in untreated ischemic segments (1.51 ± 0.29 vs 1.54 ± 0.28, P = .47). Patients demonstrated increased global MBFR (from 1.78 ± 0.54 to 1.89 ± 0.49, P = .017). Semiquantitative single-photon emission computed tomographic analysis of the treated ischemic segments revealed a score reduction from 2.10 ± 0.87 to 1.68 ± 1.19 (P = .024). There was improvement in Canadian Cardiovascular Society score (from 3.20 ± 0.56 to 1.93 ± 0.70, P < .05) and in Seattle Angina Questionnaire score (from 42.3 ± 12.99 to 71.2 ± 14.29, P < .05). No major cardiovascular events were recorded during follow-up. CONCLUSIONS CSWT improved MBFR in ischemic segments, as demonstrated by quantitative real-time myocardial perfusion echocardiography. These results suggest that CSWT has the potential to increase myocardial blood flow, with an impact on symptoms and quality of life in patients with RA.
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Sonothrombolysis in ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2019; 73:2832-2842. [PMID: 30894317 DOI: 10.1016/j.jacc.2019.03.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/25/2019] [Accepted: 03/06/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Preclinical studies have demonstrated that high mechanical index (MI) impulses from a diagnostic ultrasound transducer during an intravenous microbubble infusion (sonothrombolysis) can restore epicardial and microvascular flow in acute ST-segment elevation myocardial infarction (STEMI). OBJECTIVES This study tested the clinical effectiveness of sonothrombolysis in patients with STEMI. METHODS Patients with their first STEMI were prospectively randomized to either diagnostic ultrasound-guided high MI impulses during an intravenous Definity (Lantheus Medical Imaging, North Billerica, Massachusetts) infusion before, and following, emergent percutaneous coronary intervention (PCI), or to a control group that received PCI only (n = 50 in each group). A reference first STEMI group (n = 203) who arrived outside the randomization window was also analyzed. Angiographic recanalization before PCI, ST-segment resolution, infarct size by magnetic resonance imaging, and systolic function (LVEF) at 6 months were compared. RESULTS ST-segment resolution occurred in 16 (32%) high MI PCI versus 2 (4%) PCI-only patients before PCI, and angiographic recanalization was 48% in high MI/PCI versus 20% in PCI only and 21% in the reference group (p < 0.001). Infarct size was reduced (29 ± 22 g high MI/PCI vs. 40 ± 20 g PCI only; p = 0.026). LVEF was not different between groups before treatment (44 ± 11% vs. 43 ± 10%), but increased immediately after PCI in the high MI/PCI group (p = 0.03), and remained higher at 6 months (p = 0.015). Need for implantable defibrillator (LVEF ≤30%) was reduced in the high MI/PCI group (5% vs. 18% PCI only; p = 0.045). CONCLUSIONS Sonothrombolysis added to PCI improves recanalization rates and reduces infarct size, resulting in sustained improvements in systolic function after STEMI. (Therapeutic Use of Ultrasound in Acute Coronary Artery Disease; NCT02410330).
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Affiliation(s)
- Jonathan R Lindner
- Knight Cardiovascular Institute and Oregon National Primate Research Center, Oregon Health & Science University, Portland, OR
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Kutty S, Bisselou Moukagna KS, Craft M, Shostrom V, Xie F, Porter TR. Clinical Outcome of Patients With Inducible Capillary Blood Flow Abnormalities During Demand Stress in the Presence or Absence of Angiographic Coronary Disease. Circ Cardiovasc Imaging 2018; 11:e007483. [DOI: 10.1161/circimaging.117.007483] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Shelby Kutty
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Karl Stessy Bisselou Moukagna
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Mary Craft
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Valerie Shostrom
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Feng Xie
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
| | - Thomas R. Porter
- Division of Cardiology and Pediatric Cardiology, Departments of Internal Medicine and Pediatrics, University of Nebraska Medical Center, Omaha, NE
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Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, Nihoyannopoulos P, Edvardsen T, Lancellotti P. Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017. Eur Heart J Cardiovasc Imaging 2018; 18:1205-1205af. [PMID: 28950366 DOI: 10.1093/ehjci/jex182] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/20/2017] [Indexed: 12/16/2022] Open
Abstract
Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.
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Affiliation(s)
- Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, Imperial College, Sydney Street, London SW3 6NP, UK
| | | | | | | | - Jose Zamorano
- CIBERCV, University Hospital Ramón y Cajal, Madrid, Spain
| | | | | | | | - Patrizio Lancellotti
- University of Liege Hospital, GIGA Cardiovascular Science, Heart Valve Clinic, Imaging Cardiology, Liege, Belgium
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Porter TR. A physiologist observing and reporting supra-pharmacologic dobutamine stress testing: can we trust them, and can we trust the results? Echo Res Pract 2018; 5:E7-E8. [PMID: 30078786 PMCID: PMC6074816 DOI: 10.1530/erp-18-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 07/10/2018] [Indexed: 12/02/2022] Open
Abstract
In a study, published in this issue of Echo Research and Practice, Ntoskas et al. retrospectively analyzed the safety of a cardiac physiologist performing, and interpreting, Dobutamine stress echocardiography (DSE) in of 300 patients undergoing DSE for the detection of inducible reversible ischemia, myocardial viability and valvular heart disease. While safety during the tests themselves did not appear to be compromised with this unsupervised approach, the interpretation of these DSEs causes concerns regarding broad patient safety relative to misread results.
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Elhendy A. The power of stress echocardiography and myocardial perfusion scintigraphy in predicting long-term outcome. Nothing lasts forever. J Nucl Cardiol 2018; 25:480-482. [PMID: 27473219 DOI: 10.1007/s12350-016-0621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Abdou Elhendy
- Department of Cardiology, Marshfield Clinic, Marshfield, WI, USA.
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Gurunathan S, Ahmed A, Vamvakidou A, Ramzy IS, Akhtar M, Ali A, Karogiannis N, Zidros S, Balaji G, Young G, Elghamaz A, Senior R. Diagnostic Concordance and Clinical Outcomes in Patients Undergoing Fractional Flow Reserve and Stress Echocardiography for the Assessment of Coronary Stenosis of Intermediate Severity. J Am Soc Echocardiogr 2017; 31:180-186. [PMID: 29246509 DOI: 10.1016/j.echo.2017.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The ischemic consequences of coronary artery stenosis can be assessed by invasive fractional flow reserve (FFR) or by noninvasive imaging. We sought to determine (1) the concordance between wall thickening assessment during clinically indicated stress echocardiography (SE) and FFR measurements and (2) the factors associated with hard events in these patients. METHODS Two hundred twenty-three consecutive patients who underwent SE and invasive FFR measurements in close succession were analyzed retrospectively for diagnostic concordance and clinical outcomes. RESULTS At the vessel level, the sensitivity, specificity, positive predictive value, and negative predictive value of SE for identifying significant disease as assessed by FFR was 68%, 75%, 43%, and 89%, respectively. The greatest discordance was seen in patients with wall thickening abnormalities (WTAs) and negative FFR. During a follow-up of 3.6 ± 2.2 years, there were 23 cardiovascular (CV) events (death and nonfatal myocardial infarction). The number of wall segments with inducible WTAs emerged as the strongest factor associated with CV events (hazard ratio, 1.18 [1.05-1.34]; P = .008). FFR was not associated with outcome. There was a significant increase in event rate in patients with WTA/negative FFR versus no WTA/negative FFR (P = .01), but no significant difference versus WTA/positive FFR (P = .85). CONCLUSIONS In a patient population with significant CV risk factors, a normal SE had a high negative predictive value for excluding abnormal FFR. WTAs were associated with outcomes regardless of FFR value, suggesting that this is a superior marker of ischemia to FFR.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Asrar Ahmed
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Anastasia Vamvakidou
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ihab S Ramzy
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Mohammed Akhtar
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Aamir Ali
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Nikos Karogiannis
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Spiros Zidros
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | | | - Grace Young
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Ahmed Elghamaz
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom
| | - Roxy Senior
- Department of Cardiology, Northwick Park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, London, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Aggeli C, Polytarchou K, Felekos I, Zisimos K, Venieri E, Verveniotis A, Varvarousis D, Toutouzas K, Tsiamis E, Tousoulis D. Effect of gender on the prognostic value of dobutamine stress myocardial contrast echocardiography. Hellenic J Cardiol 2017; 58:419-424. [DOI: 10.1016/j.hjc.2017.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 04/04/2017] [Accepted: 04/12/2017] [Indexed: 12/18/2022] Open
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Abstract
PURPOSE OF REVIEW Stress echocardiography (SE) is a well-established technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). This review article summarizes the status of SE in CAD, including testing protocols, clinical efficacy and current use of newer technologies: myocardial perfusion, strain imaging, three-dimensional echocardiography and adjunctive carotid ultrasonography. RECENT FINDINGS Recent major findings in SE include the clinical value of myocardial perfusion imaging in multicentre studies, as well as when added to left ventricular (LV) wall motion assessment in clinical service. Additionally, SE has been shown to be more cost-effective than exercise ECG in patients with low-intermediate pre-test probability of CAD. Adjunctive atherosclerosis imaging by carotid ultrasonography (CU) to ischaemia testing by SE provides synergistic prognostic value, equivalent to hybrid imaging by PET-CT. Despite the development of newer and more expensive imaging modalities, SE remains the cornerstone for the assessment of CAD and has excellent clinical efficacy, is safe and is cost-effective.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK
| | - Roxy Senior
- Department of Cardiology, Northwick Park Hospital, Harrow, UK.
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK.
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Gaibazzi N, Porter T, Lorenzoni V, Pontone G, De Santis D, De Rosa A, Guaricci AI. Effect of Coronary Revascularization on the Prognostic Value of Stress Myocardial Contrast Wall Motion and Perfusion Imaging. J Am Heart Assoc 2017; 6:JAHA.117.006202. [PMID: 28566297 PMCID: PMC5669203 DOI: 10.1161/jaha.117.006202] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The assessment of myocardial perfusion (MP) and wall motion (WM) using contrast dipyridamole echocardiography (cSE‐WMP) improves the sensitivity to detect coronary artery disease and the stratification of cardiac events, but its long‐term value for fatal and nonfatal ischemic cardiac events, also with respect to patients undergoing revascularization or not, remains to be determined. Methods and Results One‐thousand three‐hundred and twenty‐nine patients with suspect or known CAD who underwent cSE‐WMP were followed for a median 5.5 years. The independent prognostic value of cSE‐WMP regarding cardiac death or nonfatal myocardial infarction was related to stress WM and MP, rest ejection fraction, clinical risk factors, and medications. Patients revascularized after cSE‐WMP were separately analyzed to determine whether the procedure influenced outcome and whether this depends on cSE‐WMP results. A total of 125 cardiac fatal and nonfatal ischemic events (9.4%) occurred during the follow‐up (61 deaths, 64 myocardial infarctions). The 5‐year event rate with normal MP and WM was 5.9%, 9.9% with isolated MP defects (normal WM), and 15.5% with both MP and WM abnormalities. In patients not undergoing revascularization (n=1111), reversible MP defects added discrimination value over WM response and clinical factors/medication data (P=0.001), while in the cohort undergoing revascularization (n=218), cSE‐WMP results did not influence outcome. Conclusions cSE‐WMP, with both contrast MP and WM assessments, provides independent, incremental prognostic information regarding ischemic cardiac events at 5 years in patients with known or suspected coronary artery disease. Revascularization reduces cardiac events after an abnormal cSE‐WMP, resulting in outcomes not different from those in patients with normal cSE‐WMP.
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Prognostic Value of Myocardial Perfusion Analysis in Patients with Coronary Artery Disease: A Meta-Analysis. J Am Soc Echocardiogr 2017; 30:270-281. [DOI: 10.1016/j.echo.2016.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 01/28/2023]
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Mattoso AAA, Tsutsui JM, Kowatsch I, Cruz VYL, Sbano JCN, Ribeiro HB, Kalil Filho R, Porter TR, Mathias W. Prognostic value of dobutamine stress myocardial perfusion echocardiography in patients with known or suspected coronary artery disease and normal left ventricular function. PLoS One 2017; 12:e0172280. [PMID: 28234978 PMCID: PMC5325237 DOI: 10.1371/journal.pone.0172280] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 02/02/2017] [Indexed: 01/13/2023] Open
Abstract
Objective We sought to determine the prognostic value of qualitative and quantitative analysis obtained by real-time myocardial perfusion echocardiography (RTMPE) in patients with known or suspected coronary artery disease (CAD). Background Quantification of myocardial blood flow reserve (MBFR) in patients with CAD using RTMPE has been demonstrated to further improve accuracy over the analysis of wall motion (WM) and qualitative analysis of myocardial perfusion (QMP). Methods From March 2003 to December 2008, we prospectively studied 168 patients with normal left ventricular function (LVF) who underwent dobutamine stress RTMPE. The replenishment velocity reserve (β) and MBFR were derived from RTMPE. Acute coronary events were: cardiac death, myocardial infarction and unstable angina with need for urgent coronary revascularization. Results During a median follow-up of 34 months (5 days to 6.9 years), 17 acute coronary events occurred. Abnormal β reserve in ≥2 coronary territories was the only independent predictor of events hazard ratio (HR) = 21, 95% CI = 4.5–99; p<0.001). Both, abnormal β reserve and MBFR added significant incremental value in predicting events over qualitative analysis of WM and MP (χ2 = 6.6 and χ2 = 24.6, respectively; p = 0.001 and χ2 = 6.6 and χ2 = 15.5, respectively; p = 0.012, respectively). When coronary angiographic data was added to the multivariate analysis model, β reserve remained the only predictor of events with HR of 21.0 (95% CI = 4.5–99); p<0.001. Conclusion Quantitative dobutamine stress RTMPE provides incremental prognostic information over clinical variables, qualitative analysis of WM and MP, and coronary angiography in predicting acute coronary events.
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Affiliation(s)
- Angele A. A. Mattoso
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Jeane M. Tsutsui
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
- * E-mail:
| | - Ingrid Kowatsch
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Vitória Y. L. Cruz
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - João C. N. Sbano
- University of Nebraska Medical Center, Omaha, United States of America
| | - Henrique B. Ribeiro
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Roberto Kalil Filho
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Thomas R. Porter
- University of Nebraska Medical Center, Omaha, United States of America
| | - Wilson Mathias
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Karogiannis N, Senior R. Contrast echocardiography for detection of myocardial perfusion abnormalities. Herz 2017; 42:287-294. [DOI: 10.1007/s00059-017-4536-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Effect of Pharmacologic Stress Test Results on Outcomes in Obese versus Nonobese Subjects Referred for Stress Perfusion Echocardiography. J Am Soc Echocardiogr 2016; 29:899-906. [DOI: 10.1016/j.echo.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Indexed: 01/27/2023]
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Wu J, Barton D, Xie F, O’Leary E, Steuter J, Pavlides G, Porter TR. Comparison of Fractional Flow Reserve Assessment With Demand Stress Myocardial Contrast Echocardiography in Angiographically Intermediate Coronary Stenoses. Circ Cardiovasc Imaging 2016; 9:CIRCIMAGING.116.004129. [DOI: 10.1161/circimaging.116.004129] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/23/2016] [Indexed: 11/16/2022]
Abstract
Background—
Real-time myocardial contrast echocardiography (RTMCE) directly measures capillary flow (CBF), which in turn is a major regulator of coronary flow and resistance during demand or hyperemic stress. Although fractional flow reserve (FFR) was developed to assess the physiological relevance of an epicardial stenosis, it assumes maximal microvascular vasodilation and minimal resistance during vasodilator stress. Therefore, we sought to determine the relationship between CBF assessed with RTMCE during stress echocardiography and FFR in intermediate coronary lesions.
Methods and Results—
Sixty-seven vessels with 50% to 80% diameter stenoses by quantitative coronary angiography in 58 consecutive patients were examined with FFR and RTMCE (mean age, 60±13 years). RTMCE was performed using an incremental dobutamine (n=32) or exercise (n=26) stress protocol, and myocardial perfusion was assessed using a continuous infusion of ultrasound contrast. The presence or absence of inducible perfusion defects and wall motion abnormalities were correlated with FFR. Mean percent diameter stenosis was 60±9%. Eighteen stenoses (27%) had an FFR ≤ 0.8. Although 17 of the 18 stenoses that were FFR+ had abnormal CBF during RTMCE, 28 of the 49 stenoses (57%) that were FFR had abnormal CBF, and 24 (49%) had abnormal wall motion in the corresponding coronary artery territory during stress echocardiography.
Conclusions—
In a significant percentage of intermediate stenoses with normal FFR values, CBF during demand stress is reduced, resulting in myocardial ischemia.
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Affiliation(s)
- Juefei Wu
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - David Barton
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - Feng Xie
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - Edward O’Leary
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - John Steuter
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - Gregory Pavlides
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
| | - Thomas R. Porter
- From the Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China (J.W.); Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha (D.B., F.X., E.O’L., G.P., T.R.P.); and Nebraska Heart, Lincoln (J.S.)
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Mathias W, Tsutsui JM, Tavares BG, Xie F, Aguiar MO, Garcia DR, Oliveira MT, Soeiro A, Nicolau JC, Lemos PA, Rochitte CE, Ramires JA, Kalil R, Porter TR. Diagnostic Ultrasound Impulses Improve Microvascular Flow in Patients With STEMI Receiving Intravenous Microbubbles. J Am Coll Cardiol 2016; 67:2506-15. [DOI: 10.1016/j.jacc.2016.03.542] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 03/17/2016] [Indexed: 10/21/2022]
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Barletta G, Del Bene MR. Myocardial perfusion echocardiography and coronary microvascular dysfunction. World J Cardiol 2015; 7:861-874. [PMID: 26730291 PMCID: PMC4691812 DOI: 10.4330/wjc.v7.i12.861] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 09/04/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023] Open
Abstract
Our understanding of coronary syndromes has evolved in the last two decades out of the obstructive atherosclerosis of epicardial coronary arteries paradigm to include anatomo-functional abnormalities of coronary microcirculation. No current diagnostic technique allows direct visualization of coronary microcirculation, but functional assessments of this circulation are possible. This represents a challenge in cardiology. Myocardial contrast echocardiography (MCE) was a breakthrough in echocardiography several years ago that claimed the capability to detect myocardial perfusion abnormalities and quantify coronary blood flow. Research demonstrated that the integration of quantitative MCE and fractional flow reserve improved the definition of ischemic burden and the relative contribution of collaterals in non-critical coronary stenosis. MCE identified no-reflow and low-flow within and around myocardial infarction, respectively, and predicted the potential functional recovery of stunned myocardium using appropriate interventions. MCE exhibited diagnostic performances that were comparable to positron emission tomography in microvascular reserve and microvascular dysfunction in angina patients. Overall, MCE improved echocardiographic evaluations of ischemic heart disease in daily clinical practice, but the approval of regulatory authorities is lacking.
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The Incremental Prognostic Value of the Incorporation of Myocardial Perfusion Assessment into Clinical Testing with Stress Echocardiography Study. J Am Soc Echocardiogr 2015; 28:1358-65. [DOI: 10.1016/j.echo.2015.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Indexed: 01/08/2023]
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Abstract
Ultrasound enhancing agents (UEAs) are being utilized for a growing number of applications with real-time very low mechanical index (MI) techniques in clinical cardiology today. This article will review recent developments on the safety of UEAs and their effectiveness in myocardial perfusion imaging, three-dimensional quantification of left ventricular function, and vascular imaging. UEAs are now being utilized in all age groups, with new indications that add incremental value to the currently approved by the Food and Drug Administration. These include the incremental value in cardiac imaging, where the off-label analysis of myocardial perfusion observed with UEAs adds to the enhanced endocardial border delineation. In carotid artery imaging, UEAs improve the detection of plaque but also can examine plaque neovascularization. Vascular surgeons now utilize UEAs in the evaluation of endovascular repair to detect endoleaks without the need of ionizing radiation. Newer applications are emerging in the detection of left atrial appendage thrombi and quantification of myocardial blood flow and volume in transplant patients.
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Affiliation(s)
- Thomas R Porter
- Division of Cardiology, University of Nebraska Medical Center, Omaha, NE, 68198, USA,
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Schroeder J, Hamada S, Gründlinger N, Rubeau T, Altiok E, Ulbrich K, Keszei A, Marx N, Becker M. Myocardial deformation by strain echocardiography identifies patients with acute coronary syndrome and non-diagnostic ECG presenting in a chest pain unit: a prospective study of diagnostic accuracy. Clin Res Cardiol 2015; 105:248-56. [PMID: 26349786 DOI: 10.1007/s00392-015-0916-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Clinical assessment often cannot risk stratify patients hospitalized with chest pain and non-diagnostic electrocardiography (ECG) or myocardial enzymes. An inappropriate admission of patients with non-cardiac chest pain is an enormous cost factor. METHODS 2315 patients who presented in the chest pain unit (CPU) with symptoms suggestive of acute coronary syndrome (ACS) were screened. All patients with relevant changes in ECG or myocardial enzymes were excluded. 268 consecutive patients (mean 58 ± 7 years, 88 men) were prospectively included and underwent echocardiography for left ventricular ejection fraction (LVEF), wall motion score index (WMSI) and strain parameter and a coronary angiography (CA) within 2 ± 1 days after admission. RESULTS Anatomically obstructive coronary artery disease (CAD) (≥70 % diameter stenosis) was present in 110 patients (41 %). The incremental value of LVEF, WMSI, and strain parameters to relevant clinical variables was determined in nested Cox models. Baseline clinical data associated with relevant CAD were age [hazard ratio (HR) 1.31, p = 0.03], arterial hypertension (HR 1.39, p = 0.03) and diabetes (HR 1.46, p = 0.001). The addition of endocardial global circumferential strain (GCS) (HR 1.57, p < 0.001) caused the greatest increment in model power (χ (2) = 43.4, p < 0.001). Optimal cut-off value was calculated as -21.7 % for GCS (sensitivity 87 %, specificity 76 %) to differentiate between these patients. CONCLUSIONS In patients with suspected ACS but without ECG changes or myocardial enzyme abnormalities, myocardial deformation imaging can identify patients at risk. This approach may be applied to improve decision guidance at the CPU for fast discharge of patients with non-cardiac chest pain or prompt cardiological allocation of patients with CAD. CLINICAL TRIAL REGISTRATION NCT 02357641.
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Affiliation(s)
- Joerg Schroeder
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sandra Hamada
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nina Gründlinger
- Department of Internal Medicine, Hospital St. Brigida, Simmerath, Germany
| | - Tanja Rubeau
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ertunc Altiok
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Katrin Ulbrich
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andras Keszei
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Michael Becker
- Department of Cardiology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany.
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Stress-echocardiography is underused in clinical practice: a nationwide survey in Austria. Wien Klin Wochenschr 2015; 127:514-20. [PMID: 26162465 DOI: 10.1007/s00508-015-0828-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 06/06/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The wide area of application, including coronary artery disease, valvular heart disease, or pulmonary hypertension makes stress echocardiography (SE) a powerful, cost-effective imaging modality in cardiology. The role of this technique in clinical practice in Austria is unknown. METHODS A nationwide survey included all departments for cardiology and/or internal medicine in the years 2008 and 2013. By electronic questionnaire demographics, indication for the test, the numbers of examined cases per year, operators, and various applied techniques of SE were interrogated and completed by telephone interviews. RESULTS Data could be obtained from all 117 departments. In the year 2007 in 58 (50%) and in 2012 57 (49%) departments SE was available in Austrian hospitals. More than 100 SEs per year were performed by only four (7%) units in the year 2007 and by five (8%) in 2012. Physical exercise, dobutamine, and dipyridamole SE were available in 27 (46%), 52 (90%), and six (10%) units in 2007, and in 15 (27%), 52 (91%), and five (9%) units in 2012, respectively. In 2007 41 (71%) and in 2012 26 (46%) echo-labs administered contrast agents during SE. Transesophageal SE and 3D-echo was performed in one (2%) and three (5%) units in 2007, and in six (10%) and four (7%) echo-labs in 2012. CONCLUSIONS This representative survey demonstrates the underuse of SE in clinical practice in Austria. Even in established application fields performance is low, examination frequencies as recommended by the cardiology societies are fulfilled only by a minority of institutions.
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Uenishi EK, Caldas MA, Tsutsui JM, Abduch MCD, Sbano JCN, Kalil Filho R, Mathias W. Evaluation of cardiac masses by real-time perfusion imaging echocardiography. Cardiovasc Ultrasound 2015; 13:23. [PMID: 25933602 PMCID: PMC4424545 DOI: 10.1186/s12947-015-0018-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/23/2015] [Indexed: 11/10/2022] Open
Abstract
Background Diagnosis of cardiac masses is still challenging by echocardiography and distinguishing tumors from thrombi has important therapeutical implications. We sought to determine the diagnostic value of real-time perfusion echocardiography (RTPE) for cardiac masses characterization. Methods We prospectively studied 86 patients, 23 with malignant tumors (MT), 26 with benign tumors (BT), 33 with thrombi and 6 with pseudotumors who underwent RTPE. Mass perfusion was analyzed qualitatively and blood flow volume (A), blood flow velocity (β), and microvascular blood flow (A x β) were determined by quantitative RTPE. Results Logistic regression models showed that the probability of having a tumor increased by 15.8 times with a peripheral qualitative perfusion pattern, and 34.5 times with a central perfusion pattern, in comparison with the absence of perfusion. Using quantitative RTPE analysis, thrombi group had parameters of blood flow lower than tumor group. A values for thrombi, MT, and BT were 0.1 dB (0.01-0.22), 2.78 dB (1–7) and 2.58 dB (1.44-5), respectively; p < 0.05, while A x β values were 0.0 dB/s−1 (0.01–0.14), 2.00 dB/s−1 (1–6), and 1.18 dB/s−1 (0.52–3), respectively; p < 0.05. At peak dipyridamole stress, MT had greater microvascular blood volume than BT [A = 4.18 dB (2.14-7.93) versus A = 2.04 dB (1.09-3.55); p < 0.05], but no difference in blood flow [Axβ = 2.46 dB/s−1 (1.42–4.59) versus Axβ = 1.55 dB/s [1] (0.51-4.08); p = NS]. An A value >3.28 dB at peak dipyridamole stress predicted MT (AUC = 0.75) and conferred 5.8-times higher chance of being MT rather than BT. Conclusion RTPE demonstrated that cardiac tumors have greater microvascular blood volume and regional blood flow when compared with thrombi. Dipyridamole stress was useful in differentiating MT from BT.
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Affiliation(s)
- Eliza K Uenishi
- Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Márcia A Caldas
- Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Jeane M Tsutsui
- Heart Institute (InCor), University of Sao Paulo Medical School and Fleury Group, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, 05403-000, Brazil.
| | - Maria C D Abduch
- Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - João C N Sbano
- Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Roberto Kalil Filho
- Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
| | - Wilson Mathias
- Heart Institute (InCor), University of Sao Paulo Medical School and Fleury Group, Av. Dr. Enéas de Carvalho Aguiar, 44, São Paulo, 05403-000, Brazil.
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Vasu S, Little WC, Morgan TM, Stacey RB, Ntim WO, Hamilton C, Thohan V, Chiles C, Hundley WG. Mechanism of decreased sensitivity of dobutamine associated left ventricular wall motion analyses for appreciating inducible ischemia in older adults. J Cardiovasc Magn Reson 2015; 17:26. [PMID: 25885436 PMCID: PMC4389511 DOI: 10.1186/s12968-015-0131-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 03/13/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dobutamine associated left ventricular (LV) wall motion analyses exhibit reduced sensitivity for detecting inducible ischemia in individuals with increased LV wall thickness. This study was performed to better understand the mechanism of this reduced sensitivity in the elderly who often manifest increased LV wall thickness and risk factors for coronary artery disease. METHODS During dobutamine cardiovascular magnetic resonance (DCMR) stress testing, we assessed rate pressure product (RPP), aortic pulse wave velocity (PWV), LV myocardial oxygen demand (pressure volume area, PVA, mass, volumes, concentricity, and the presence of wall motion abnormalities (WMA) and first pass gadolinium enhanced perfusion defects (PDs) indicative of ischemia in 278 consecutively recruited individuals aged 69 ± 8 years with pre-existing or known risk factors for coronary artery disease. Each variable was assessed independently by personnel blinded to participant identifiers and analyses of other DCMR or hemodynamic variables. RESULTS Participants were 80% white, 90% hypertensive, 43% diabetic and 55% men. With dobutamine, 60% of the participants who exhibited PDs had no inducible WMA. Among these participants, myocardial oxygen demand was lower than that observed in those who had both wall motion and perfusion abnormalities suggestive of ischemia (p = 0.03). Relative to those with PDs and inducible WMAs, myocardial oxygen demand remained different in these individuals with PDs without an inducible WMA after accounting for LV afterload and contractility (p = 0.02 and 0.03 respectively), but not after accounting for either LV stress related end diastolic volume index (LV preload) or resting concentricity (p = 0.31-0.71). CONCLUSIONS During dobutamine stress testing, elderly patients experience increased LV concentricity and declines in LV preload and myocardial oxygen demand, all of which are associated with an absence of inducible LV WMAs indicative of myocardial ischemia. These findings provide insight as to why dobutamine associated wall motion analyses exhibit reduced sensitivity for identifying inducible ischemia in elderly. TRIAL REGISTRATION This study was registered with Clinicaltrials.gov (NCT00542503).
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Affiliation(s)
- Sujethra Vasu
- Department of Internal medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
| | - William C Little
- Department of Internal Medicine, University of Mississippi, Jackson, Mississippi, 39216, USA.
| | - Timothy M Morgan
- Department of Biostatistical sciences, Wake Forest School of Medicine, Winston Salem North Carolina, 27157, USA.
| | - Richard B Stacey
- Department of Internal medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
| | - William O Ntim
- Mid Carolina Cardiology, Charlotte North Carolina, 28204, USA.
| | - Craig Hamilton
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
| | - Vinay Thohan
- Aurora Cardiovascular Services, Milwaukee, Wisconsin, 53215, USA.
| | - Caroline Chiles
- Department of Radiology, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
| | - William Gregory Hundley
- Department of Internal medicine, Section on Cardiology, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
- Department of Radiology, Wake Forest School of Medicine, Winston Salem, North Carolina, 27157, USA.
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Gardin JM. Can Calcium Supplementation Improve Stress Echocardiography? JACC Cardiovasc Imaging 2015; 8:397-399. [DOI: 10.1016/j.jcmg.2014.12.021] [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: 12/16/2014] [Revised: 12/17/2014] [Accepted: 12/18/2014] [Indexed: 11/26/2022]
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Abstract
Microbubbles are an excellent intravascular tracer, and both the rate of myocardial opacification (analogous to coronary microvascular perfusion) and contrast intensity (analogous to myocardial blood volume) provide unique insights into myocardial perfusion. A strong evidence base has been accumulated to show comparability with nuclear perfusion imaging and incremental diagnostic and prognostic value relative to wall motion analysis. This technique also provides the possibility to measure myocardial perfusion at the bedside. Despite all of these advantages, the technique is complicated, technically challenging, and has failed to scale legislative and financial hurdles. The development of targeted imaging and therapeutic interventions will hopefully rekindle interest in this interesting modality.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Thomas H Marwick
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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Laiq Z, Smith LM, Xie F, Chamsi-Pasha M, Porter TR. Differences in patient outcomes after conventional versus real time perfusion stress echocardiography in men versus women: a prospective randomised trial. Heart 2015; 101:559-64. [PMID: 25608747 DOI: 10.1136/heartjnl-2014-306869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The purpose of our study was to determine whether sex affects the predictive value of perfusion and wall motion imaging obtained with real time myocardial contrast echocardiography (RTMCE) when compared with conventional stress echocardiography (CSE). METHODS We prospectively enrolled 1649 age-matched men and women with intermediate pretest probability of coronary artery disease (CAD) undergoing stress echocardiography for suspicion of CAD. Patients with known CAD were excluded. Those who consented to participate in the study were randomised to undergo either CSE or RTMCE. Events were defined as death, non-fatal myocardial infarction (MI) and need for revascularisation. RESULTS Median follow-up was 2.6 years (927 women, 722 men). Mean age was 58±13 years in both sexes. There were a total of 62 deaths, 12 MIs and 85 revascularisations with a 2-year event rate of 3.5% (95% CI 2.7% to 4.7%). Male sex was a significant independent predictor of adverse outcome (death, non-fatal MI) in both CSE and RTMCE (CSE HR 2.07, 95% CI 1.07 to 4.02, RTMCE HR 2.14; 95% CI 1.04 to 4.33). Higher 2-year event rates were noted in men in comparison with women after a normal CSE (men 5.4%, women 1.6%, p=0.02), but not after a normal RTMCE (men 5.8%, women 3.7%, p=0.41). Event rates were also significantly higher in men after an abnormal RTMCE (men 34.8%, women 16.4%, p=0.02) but no difference in outcome between sexes was observed after an abnormal CSE (men 17.8%, women 18.6%, p=0.90). CONCLUSIONS The addition of perfusion imaging with RTMCE improves the predictive value of stress echocardiography in men with no known CAD, but does not improve the predictive value in age-matched women.
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Affiliation(s)
- Zenab Laiq
- Department of Internal Medicine, University of Nebraska Medical Center, 983332 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Lynette M Smith
- College of Public Health Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Feng Xie
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mohammed Chamsi-Pasha
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Thomas R Porter
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, Nebraska, USA
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Echocardiographic Evaluation of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_10] [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: 10/23/2022]
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Shah BN, Chahal NS, Bhattacharyya S, Li W, Roussin I, Khattar RS, Senior R. The feasibility and clinical utility of myocardial contrast echocardiography in clinical practice: results from the incorporation of myocardial perfusion assessment into clinical testing with stress echocardiography study. J Am Soc Echocardiogr 2014; 27:520-30. [PMID: 24637056 DOI: 10.1016/j.echo.2014.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Indexed: 01/30/2023]
Abstract
BACKGROUND This prospective study investigated whether the incorporation of myocardial contrast echocardiography (MCE) into a clinical stress echocardiography service reproduces the benefits of assessing myocardial perfusion proved previously in research studies. METHODS MCE was performed during physiologic and pharmacologic clinical stress echocardiographic studies, and the value of myocardial perfusion to the reporting echocardiologists was categorized as of benefit (subclassified as incremental benefit over wall motion [WM] or greater confidence with WM) or of no added benefit. The presence and extent of inducible ischemia by WM and myocardial perfusion were documented and correlated with angiographic results in patients who underwent cardiac catheterization. RESULTS In total, 220 patients underwent simultaneous MCE during stress echocardiography by eight different operators. Overall, MCE was of benefit in 193 patients (88%), providing incremental benefit over WM in 25% and greater confidence with WM evaluation in 62%. MCE provided no added benefit in 27 patients (12%). MCE detected significantly more cases of ischemia than WM in the left anterior descending coronary artery territory (65% vs 53%, P = .02) and detected a greater ischemic burden than WM on a per patient basis (median, 5 [interquartile range, 3-8] vs 4 [interquartile range, 2-7] segments; P < .001) and across all coronary territories. MCE correctly identified a greater proportion of patients with multivessel disease than WM (76% vs 56%, P = .02) and a greater ischemic burden in patients with multivessel disease (median, 7 [interquartile range, 4-9] vs 5 [interquartile range, 1-8] segments; P < .001). CONCLUSIONS This prospective study is the first to demonstrate that the excellent feasibility and diagnostic utility of MCE, which have been documented in the research arena, are reproducible in the clinical arena.
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Affiliation(s)
- Benoy N Shah
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Navtej S Chahal
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | | | - Wei Li
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | - Isabelle Roussin
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
| | - Rajdeep S Khattar
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Bhattacharyya S, Senior R. The current state of myocardial contrast echocardiography: what can we read between the lines? Reply. Eur Heart J Cardiovasc Imaging 2013; 15:351-2. [PMID: 24520155 DOI: 10.1093/ehjci/jet249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Sanjeev Bhattacharyya
- Department of Cardiology and Echocardiography Laboratory, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Bhattacharyya S, Chehab O, Khattar R, Lloyd G, Senior R. Stress echocardiography in clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2013; 15:158-63. [DOI: 10.1093/ehjci/jet082] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Comparison of sulfur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography with gated single-photon emission computed tomography for detection of significant coronary artery disease: a large European multicenter study. J Am Coll Cardiol 2013; 62:1353-61. [PMID: 23770168 DOI: 10.1016/j.jacc.2013.04.082] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 04/05/2013] [Accepted: 04/23/2013] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The purpose of this study was to compare sulfur hexafluoride microbubble (SonoVue)-enhanced myocardial contrast echocardiography (MCE) with single-photon emission computed tomography (SPECT) relative to coronary angiography (CA) for assessment of coronary artery disease (CAD). BACKGROUND Small-scale studies have shown that myocardial perfusion assessed by SonoVue-enhanced MCE is a viable alternative to SPECT for CAD assessment. However, large multicenter studies are lacking. METHODS Patients referred for myocardial ischemia testing at 34 centers underwent rest/vasodilator SonoVue-enhanced flash-replenishment MCE, standard (99m)Tc-labeled electrocardiography-gated SPECT, and quantitative CA within 1 month. Myocardial ischemia assessments by 3 independent, blinded readers for MCE and 3 readers for SPECT were collapsed into 1 diagnosis per patient per technique and were compared to CA (reference standard) read by 1 independent blinded reader. RESULTS Of 628 enrolled patients who received SonoVue (71% males; mean age: 64 years; >1 cardiovascular [CV] risk factor in 99% of patients) 516 patients underwent all 3 examinations, of whom 161 (31.2%) had ≥70% stenosis (131 had single-vessel disease [SVD]; 30 had multivessel disease), and 310 (60.1%) had ≥50% stenosis. Higher sensitivity was obtained with MCE than with SPECT (75.2% vs. 49.1%, respectively; p < 0.0001), although specificity was lower (52.4% vs. 80.6%, respectively; p < 0.0001) for ≥70% stenosis. Similar findings were obtained for patients with ≥50% stenosis. Sensitivity levels for detection of SVD and proximal disease for ≥70% stenosis were higher for MCE (72.5% vs. 42.7%, respectively; p < 0.0001; 80% vs. 58%, respectively; p = 0.005, respectively). CONCLUSIONS SonoVue-enhanced MCE demonstrated superior sensitivity but lower specificity for detection of CAD compared to SPECT in a population with a high incidence of CV risk factors and intermediate-high prevalence of CAD. (A phase III study to compare SonoVue® enhanced myocardial echocardiography [MCE] to single photon emission computerized tomography [ECG-GATED SPECT], at rest and at peak of low-dose Dipyridamole stress test, in the assessment of significant coronary artery disease [CAD] in patients with suspect or known CAD using Coronary Angiography as Gold Standard-SonoVue MCE vs SPECT; EUCTR2007-003492-39-GR).
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Porter TR, Smith LM, Wu J, Thomas D, Haas JT, Mathers DH, Williams E, Olson J, Nalty K, Hess R, Therrien S, Xie F. Patient outcome following 2 different stress imaging approaches: a prospective randomized comparison. J Am Coll Cardiol 2013; 61:2446-2455. [PMID: 23643501 DOI: 10.1016/j.jacc.2013.04.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 04/11/2013] [Accepted: 04/16/2013] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The study sought to prospectively compare patient outcome after stress real-time myocardial contrast echocardiography (RTMCE) versus conventional stress echo (CSE), where contrast is used to optimize wall motion (WM) analysis. BACKGROUND Myocardial perfusion imaging with RTMCE may improve the detection of coronary artery disease (CAD), and predict patient outcome. METHODS Patients with intermediate to high pre-test probability referred for dobutamine or exercise stress echocardiography were prospectively randomized to either RTMCE or CSE. Definity contrast was used for CSE only when endocardial border delineation was inadequate (63% of studies). Studies were interpreted by either an experienced contrast reviewer (R1; n = 1257), or 4 Level 3 echocardiographers (R2) with basic contrast training (n = 806). Death, nonfatal myocardial infarction (MI), and revascularizations were recorded at follow-up. RESULTS Follow-up was available in 2,014 patients (median 2.6 years). Mean age was 59 ± 13 years (53% women). An abnormal RTMCE was more frequently observed than an abnormal CSE (p < 0.001), and more frequently resulted in revascularization (p = 0.004). Resting WM abnormalities were also more frequently seen with RTMCE (p < 0.01), and were an independent predictor of death/nonfatal MI (p = 0.005) for RTMCE, but not CSE. The predictive value of a positive study, whether with CSE or RTMCE, was significant for both R1 and R2 reviewers in predicting the combined endpoint, but R1 was better than R2 at predicting patients at risk for death or nonfatal MI. CONCLUSIONS Perfusion imaging with RTMCE improves the detection of CAD during stress echocardiography, and identifies those more likely to undergo revascularization following an abnormal study.
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Affiliation(s)
- Thomas R Porter
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Lynette M Smith
- College of Public Health Biostatistics, University of Nebraska Medical Center, Omaha, Nebraska
| | - Juefei Wu
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Deepak Thomas
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - John T Haas
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Daniel H Mathers
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Eric Williams
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Joan Olson
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kevin Nalty
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Roberta Hess
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Stacey Therrien
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Feng Xie
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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Mattoso AA, Kowatsch I, Tsutsui JM, de la Cruz VY, Ribeiro HB, Sbano JC, Ramires JA, Kalil Filho R, Porter TR, Mathias W. Prognostic Value of Qualitative and Quantitative Vasodilator Stress Myocardial Perfusion Echocardiography in Patients with Known or Suspected Coronary Artery Disease. J Am Soc Echocardiogr 2013; 26:539-47. [DOI: 10.1016/j.echo.2013.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Indexed: 10/27/2022]
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Lima MF, Mathias W, Sbano JC, de la Cruz VY, Abduch MC, Lima MS, Bocchi EA, Hajjar LA, Ramires JA, Kalil Filho R, Tsutsui JM. Prognostic Value of Coronary and Microvascular Flow Reserve in Patients with Nonischemic Dilated Cardiomyopathy. J Am Soc Echocardiogr 2013; 26:278-87. [DOI: 10.1016/j.echo.2012.12.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Indexed: 11/16/2022]
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Cosyns B, Roossens B, Hernot S, El Haddad P, Lignian H, Pierard L, Lancellotti P. Use of contrast echocardiography in intensive care and at the emergency room. Curr Cardiol Rev 2013; 7:157-62. [PMID: 22758614 PMCID: PMC3263480 DOI: 10.2174/157340311798220467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 03/04/2011] [Accepted: 04/07/2011] [Indexed: 12/13/2022] Open
Abstract
Bedside echocardiography in emergency room (ER) or in intensive care unit (ICU) is an important tool for managing critically ill patients, to obtain a timely accurate diagnosis and to immediately stratify the risk to the patient’s life. It may also render invasive monitoring unnecessary. In these patients, contrast echocardiography may improve quality of imaging and also may provide additional information, especially regarding myocardial perfusion in those with suspected coronary artery disease. This article focuses on the principle of contrast echocardiography and the clinical information that can be obtained according to the most frequent presentations in ER and ICU.
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Affiliation(s)
- Bernard Cosyns
- UZ Brussel, Cardiology, Free University of Brussels, Belgium.
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Jaarsma C, Nagel E, Schalla S. A Critical Review of Different Imaging Methods for the Assessment of Myocardial Ischemia. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-012-9185-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Gaibazzi N, Rigo F, Lorenzoni V, Molinaro S, Bartolomucci F, Reverberi C, Marwick TH. Comparative prediction of cardiac events by wall motion, wall motion plus coronary flow reserve, or myocardial perfusion analysis: a multicenter study of contrast stress echocardiography. JACC Cardiovasc Imaging 2012; 6:1-12. [PMID: 23219414 DOI: 10.1016/j.jcmg.2012.08.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 07/12/2012] [Accepted: 08/02/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to determine whether the increasing difficulty of assessing wall motion (WM), Doppler coronary flow reserve on the left anterior descending coronary artery (CFR-LAD), and myocardial perfusion (MP) during stress echocardiography (SE) was justified by increasing prognostic information in patients with known or suspected coronary artery disease. BACKGROUND The use of echocardiographic contrast agents during SE permits the assessment of both CFR-LAD and MP, but their relative incremental prognostic value is undefined. METHODS This study followed a multicenter cohort of 718 patients for 16 months after high-dose dipyridamole contrast SE for evaluation of known or suspected coronary artery disease. The ability of WM, CFR-LAD, and MP to predict cardiac events was studied by multivariable models and risk reclassification. RESULTS Abnormal SE was detected as a reversible WM abnormality in 18%, reversible MP defect in 27%, and CFR-LAD <2 in 38% of subjects. Fifty cardiac events occurred (annualized event rate 6.0%). A normal MP stress test had a 1-year hard event rate of 1.2%. The C-index of outcomes prediction based on clinical data was improved with MP (p < 0.001) and WM/CFR-LAD (p = 0.037), and MP (p = 0.003) added to clinical and WM data. Net risk reclassification was improved by adding MP (p < 0.001) or CFR-LAD (net reclassification improvement p = 0.001) in addition to clinical and WM data. The model including clinical data, WM/CFR-LAD, and MP performed better than that without MP did (p = 0.012). CONCLUSIONS The multiparametric assessment of WM, CFR-LAD and MP during stress testing in patients with known or suspected coronary artery disease is feasible. Contrast SE allowed better prognostication, irrespective of the use of CFR-LAD or MP. The addition of either CFR-LAD or MP assessment to standard WM analysis and clinical parameters yielded progressively higher values for the prediction of cardiac events and may be required in today's intensively treated patients undergoing SE, because their average low risk of future cardiac events requires methods with higher predictive sensitivity than that available with standalone WM assessment.
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Toutouzas K, Sfikakis PP, Karanasos A, Aggeli C, Felekos I, Kitas G, Zampeli E, Protogerou A, Stefanadis C. Myocardial ischaemia without obstructive coronary artery disease in rheumatoid arthritis: hypothesis-generating insights from a cross-sectional study. Rheumatology (Oxford) 2012. [PMID: 23185038 DOI: 10.1093/rheumatology/kes349] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE RA is associated with increased cardiovascular events, reportedly to equal diabetes mellitus (DM). The presence of myocardial ischaemia was assessed in asymptomatic high-risk RA patients and compared with patients with DM and a healthy control group. METHODS Eighteen consecutive non-diabetic RA patients without known cardiovascular disease who developed a new carotid atheromatic plaque during the last 3 years were matched 1:1 for traditional cardiovascular risk factors with asymptomatic type 2 DM patients and 1:2 with asymptomatic non-RA, non-DM control subjects. After dobutamine stress contrast echocardiography with wall-motion and perfusion evaluation, coronary angiography was performed in those with positive stress tests. RESULTS Ischaemia by echocardiography was found in 67% of RA patients; this was significantly higher than controls (31%, P = 0.019) but comparable to those with DM (78%, P = 0.71). Angiography performed in eight consenting RA patients was normal in four, revealed non-flow-limiting coronary atheromatic lesions in two and significant lesions in two patients. RA patients with ischaemia had CRP serum levels significantly higher by six-fold compared with those with normal stress echocardiography. CONCLUSION Asymptomatic RA patients may display myocardial ischaemia at similar levels to DM patients but with low prevalence of obstructive coronary artery disease. Microvascular abnormalities associated with increased inflammatory response may account for these findings. Their exact nature and significance require further evaluation.
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Affiliation(s)
- Konstantinos Toutouzas
- 1st Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece.
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Falcão SNDRS, Rochitte CE, Junior WM, Quaglia L, Lemos PA, Sbano JCN, Ramires JAF, Filho RK, Tsutsui JM. Incremental Value of Perfusion over Wall-Motion Abnormalities with the Use of Dobutamine-Atropine Stress Myocardial Contrast Echocardiography and Magnetic Resonance Imaging for Detecting Coronary Artery Disease. Echocardiography 2012; 30:45-54. [DOI: 10.1111/j.1540-8175.2012.01820.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | | | | | - Luiz Quaglia
- Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
| | - Pedro Alves Lemos
- Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
| | | | | | - Roberto Kalil Filho
- Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
| | - Jeane Mike Tsutsui
- Fleury Group; Heart Institute (InCor); University of São Paulo Medical School; São Paulo; Brazil
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Thomas D, Xie F, Smith LM, O'Leary E, Smith K, Olson J, Nalty K, Hess R, Graham M, Therrien S, Porter TR. Prospective randomized comparison of conventional stress echocardiography and real-time perfusion stress echocardiography in detecting significant coronary artery disease. J Am Soc Echocardiogr 2012; 25:1207-14. [PMID: 22998856 DOI: 10.1016/j.echo.2012.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although retrospective studies have suggested that myocardial perfusion and wall motion analysis with real-time myocardial contrast echocardiography (RTMCE) improves the detection of coronary artery disease (CAD) during dobutamine or exercise stress echocardiography, a prospective randomized comparison with conventional stress echocardiography that did not use RTMCE has not been performed. METHODS A total of 1,776 patients with preserved resting left ventricular wall motion undergoing dobutamine or exercise stress echocardiography for suspicion of CAD were randomized to either non-RTMCE, for which contrast was used only for the approved indication of enhancing left ventricular opacification, or RTMCE, for which contrast infusion was used in all cases to examine both wall motion and myocardial perfusion. Comparisons in test positivity, and positive predictive value in those subsequently referred for quantitative coronary angiography, were performed. RESULTS Patients randomized to RTMCE had significantly higher test positivity (22% for RTMCE vs 15% with non-RTMCE, P = .0002). The increased test positivity occurred without a difference in positive predictive value in predicting >50% diameter stenoses by quantitative coronary angiography (67% for non-RTMCE, 73% for RTMCE). The mechanism for increased detection of CAD with RTMCE was mostly due to the detection of subendocardial wall thickening abnormalities that would have gone undetected when examining transmural wall thickening. CONCLUSIONS RTMCE improves the detection of CAD during dobutamine and exercise stress echocardiography, mainly by the detection of subendocardial ischemia.
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Affiliation(s)
- Deepak Thomas
- Department of Cardiology, Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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