ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).

Abstract

The previous guideline for the use of echocardiography was published in March 1997. Since that time, there have been significant advances in the technology of echocardiography and growth in its clinical use and in the scientific evidence leading to recommendations for its proper use. Each section has been reviewed and updated in evidence tables, and where appropriate, changes have been made in recommendations. A new section on the use of intraoperative transesophageal echocardiography (TEE) is being added to update the guidelines published by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists. There are extensive revisions, especially of the sections on ischemic heart disease; congestive heart failure, cardiomyopathy, and assessment of left ventricular (LV) function; and screening and echocardiography in the critically ill. There are new tables of evidence and extensive revisions in the ischemic heart disease evidence tables. Because of space limitations, only those sections and evidence tables with new recommendations will be printed in this summary article. Where there are minimal changes in a recommendation grouping, such as a change from Class IIa to Class I, only that change will be printed, not the entire set of recommendations. Advances for which the clinical applications are still being investigated, such as the use of myocardial contrast agents and three-dimensional echocardiography, will not be discussed. The original recommendations of the 1997 guideline are based on a Medline search of the English literature from 1990 to May 1995. The original search yielded more than 3000 references, which the committee reviewed. For this guideline update, literature searching was conducted in Medline, EMBASE, Best Evidence, and the Cochrane Library for English-language meta-analyses and systematic reviews from 1995 through September 2001. Further searching was conducted for new clinical trials on the following topics: echocardiography in adult congenital heart disease, echocardiography for evaluation of chest pain in the emergency department, and intraoperative echocardiography. The new searches yielded more than 1000 references that were reviewed by the writing committee. This document includes recommendations for the use of echocardiography in both adult and pediatric patients. The pediatric guidelines also include recommendations for fetal echocardiography, an increasingly important field. The guidelines include recommendations for the use of echocardiography in both specific cardiovascular disorders and the evaluation of patients with frequently observed cardiovascular symptoms and signs, common presenting complaints, or findings of dyspnea, chest discomfort, and cardiac murmur. In this way, the guidelines will provide assistance to physicians regarding the use of echocardiographic techniques in the evaluation of such common clinical problems. The recommendations concerning the use of echocardiography follow the indication classification system (eg, Class I, II, and III) used in other American College of Cardiology/American Heart Association (ACC/AHA) guidelines: Class I:Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective.Class II:Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.IIa:Weight of evidence/opinion is in favor of usefulness/efficacy.IIb:Usefulness/efficacy is less well established by evidence/opinion.Class III:Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful/effective and in some cases may be harmful. Evaluation of the clinical utility of a diagnostic test such as echocardiography is far more difficult than assessment of the efficacy of a therapeutic intervention because the diagnostic test can never have the same direct impact on patient survival or recovery. Nevertheless, a series of hierarchical criteria are generally accepted as a scale by which to judge worth.1Smith Jr, S.C. Dove J.T. Jacobs A.K. et al.ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty.J Am Coll Cardiol. 2001; 37: 2215-2239Abstract Full Text Full Text PDF PubMed Scopus (466) Google Scholar, 2Mintz G.S. Nissen S.E. Anderson W.D. et al.American College of Cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS) a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.J Am Coll Cardiol. 2001; 37: 1478-1492Abstract Full Text Full Text PDF PubMed Scopus (1019) Google Scholar, 3Eagle KA, Berger PB, Calkins, H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Available at: http//www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm. Accessed June 12, 2002Google Scholar •Technical capacity•Diagnostic performance•Impact on diagnostic and prognostic thinking•Therapeutic impact•Health-related outcomes Because there are essentially no randomized trials assessing health outcomes for diagnostic tests, the committee has not ranked the available scientific evidence in an A, B, and C fashion (as in other ACC/AHA documents) but rather has compiled the evidence in tables. The evidence tables have been extensively revised and updated. All recommendations are thus based on either this evidence from observational studies or on the expert consensus of the committee. The definition of echocardiography used in this document incorporates Doppler analysis, M-mode echocardiography, two-dimensional transthoracic echocardiography (TTE), and, when indicated, TEE. Intravascular ultrasound is not considered but is reviewed in the ACC/AHA Guidelines for Percutaneous Coronary Intervention1Smith Jr, S.C. Dove J.T. Jacobs A.K. et al.ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty.J Am Coll Cardiol. 2001; 37: 2215-2239Abstract Full Text Full Text PDF PubMed Scopus (466) Google Scholar (available at http://www. acc.org/clinical/guidelines/percutaneous/dirIndex.htm) and the Clinical Expert Consensus Document on intravascular ultrasound2Mintz G.S. Nissen S.E. Anderson W.D. et al.American College of Cardiology clinical expert consensus document on standards for acquisition, measurement and reporting of intravascular ultrasound studies (IVUS) a report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.J Am Coll Cardiol. 2001; 37: 1478-1492Abstract Full Text Full Text PDF PubMed Scopus (1019) Google Scholar (available at http://www.acc.org/clinical/consensus/standards/standard12.htm). Echocardiography for evaluating the patient with cardiovascular disease for noncardiac surgery is considered in the ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery.3Eagle KA, Berger PB, Calkins, H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery update: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Available at: http//www.acc.org/clinical/guidelines/perio/update/periupdate_index.htm. Accessed June 12, 2002Google Scholar The techniques of three-dimensional echocardiography are still in the developmental stages and are not considered here. New techniques that are still rapidly evolving and improvements that are purely technological in echo-Doppler instrumentation, such as color Doppler imaging and digital echocardiography, are not going to be separately discussed in the clinical recommendations addressed in this document. Tissue Doppler imaging, both pulsed and color, which detects low Doppler shift frequencies of high energy generated by the contracting myocardium and consequent wall motion, are proving very useful in evaluating systolic and diastolic myocardial function. However, these technological advances will also not be separately discussed in the clinical recommendations.4Sutherland G.R. Stewart M.J. Groundstroem K.W. et al.Color Doppler myocardial imaging a new technique for the assessment of myocardial function.J Am Soc Echocardiogr. 1994; 7: 441-458PubMed Google Scholar, 5Isaaz K. Pulsed Doppler tissue imaging (letter).Am J Cardiol. 1998; 81: 663Google Scholar. Echocardiographic-contrast injections designed to assess myocardial perfusion to quantify myocardium at risk and perfusion beds also were not addressed. These guidelines address recommendations about the frequency with which an echocardiographic study is repeated. If the frequency with which studies are repeated could be decreased without adversely affecting the quality of care, the economic savings realized would likely be significant. With a noninvasive diagnostic study and no known complications, the potential for repeating the study unnecessarily exists. It is easier to state when a repeat echocardiogram is not needed then when and how often it should be repeated, because no studies in the literature address this question. How often an echocardiogram should be done depends on the individual patient and must be left to the judgment of the physician until evidence-based data addressing this issue are available. The ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography includes several significant changes in the recommendations and in the supporting narrative portion. In this summary, we list the updated recommendations, as well as commentary on some of the changes. All new or revised language in recommendations appears in boldface type. Only the references supporting the new recommendations are included in this article. The reader is referred to the full-text version of the guidelines posted on the American College of Cardiology (www.acc.org), American Heart Association (www.americanheart.org), and American Society for Echocardiography (www.asecho.org) World Wide Web sites for a more detailed exposition of the rationale for these changes. Comment: New references.6Bonow R.O. Carabello B.A. Cheitlin M.D. American College of Cardiology/American Heart Association practice guidelines for the management of patients with valvular heart disease.J Am Coll Cardiol. 1998; 32: 1486-1588Abstract Full Text Full Text PDF PubMed Google Scholar, 7Jick H. Heart valve disorders and appetite-suppressant drugs (editorial).JAMA. 2000; 283: 1738-1740Crossref Google Scholar 2.Dobutamine echocardiography for the evaluation of patients with low-gradient aortic stenosis and ventricular dysfunction. Comment: Literature on valvular effects of anorectic drugs and references to echocardiographic predictors of prognosis after aortic and mitral valve surgery have been added.6Bonow R.O. Carabello B.A. Cheitlin M.D. American College of Cardiology/American Heart Association practice guidelines for the management of patients with valvular heart disease.J Am Coll Cardiol. 1998; 32: 1486-1588Abstract Full Text Full Text PDF PubMed Google Scholar, 7Jick H. Heart valve disorders and appetite-suppressant drugs (editorial).JAMA. 2000; 283: 1738-1740Crossref Google Scholar, 8Corti R. Binggeli C. Turina M. et al.Predictors of long-term survival after valve replacement for chronic aortic regurgitation is M-mode echocardiography sufficient?.Eur Heart J. 2001; 22: 866-873Crossref PubMed Scopus (23) Google Scholar, 9Gardin J.M. Schumacher D. Constantine G. et al.Valvular abnormalities and cardiovascular status following exposure to dexfenfluramine or phentermine/fenfluramine.JAMA. 2000; 283: 1703-1709Crossref PubMed Google Scholar, 10Flemming M.A. Oral H. Rothman E.D. et al.Echocardiographic markers for mitral valve surgery to preserve left ventricular performance in mitral regurgitation.Am Heart J. 2000; 140: 476-482Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar 7.Assessment of the effects of medical therapy on the severity of regurgitation and ventricular compensation and function when it might change medical management.8.Assessment of valvular morphology and regurgitation in patients with a history of anorectic drug use, or the use of any drug or agent known to be associated with valvular heart disease, who are symptomatic, have cardiac murmurs, or have a technically inadequate auscultatory examination. 2.Routine repetition of echocardiography in past users of anorectic drugs with normal studies or known trivial valvular abnormalities. Comment: The Duke Criteria for the diagnosis of infective endocarditis have been added, as well as the value of TEE in the setting of a negative transthoracic echocardiogram when there is high clinical suspicion or when a prosthetic valve is involved.11Durack D.T. Lukes A.S. Bright D.K. New criteria for diagnosis of infective endocarditis–utilization of specific echocardiographic findings. Duke Endocarditis Service.Am J Med. 1994; 96: 200-209Abstract Full Text PDF PubMed Google Scholar, 12Rosen A.B. Fowler Jr, V.G. Corey G.R. et al.Cost-effectiveness of transesophageal echocardiography to determine the duration of therapy for intravascular catheter-associated Staphylococcus aureus bacteremia.Ann Intern Med. 1999; 130: 810-820Crossref PubMed Google Scholar 6.If TTE is equivocal, TEE evaluation of staphylococcus bacteremia without a known source. 1.Evaluation of persistent nonstaphylococcus bacteremia without a known source. *TEE may frequently provide incremental value in addition to information obtained by TTE. The role of TEE in first-line examination awaits further study. *TEE may frequently provide incremental value in addition to information obtained by TTE. The role of TEE in first-line examination awaits further study. 1.Evaluation of transient fever without evidence of bacteremia or new murmur. 3.Use of echocardiography (especially TEE) inguiding the performance of interventional techniques and surgery (eg, balloon valvotomy and valve repair) for valvular disease. Comment: Movement of a recommendation from Class IIa to Class I and minor wording change. 4.Assessment of myocardial viability when required to define potential efficacy of revascularization. *Dobutamine stress echocardiography. 2.Moved to Class I (see above). 1.Assessment of late prognosis (greater than or equal to 2 years after acute myocardial infarction). Comment: There are new sections on stress echocardiography in the detection of coronary disease in the transplanted heart and stress echocardiography in the detection of coronary disease in women. There is one new Class I recommendation and three new Class IIa recommendations. Recommendations have been renumbered for clarity. 2.Exercise echocardiography for diagnosis of myocardial ischemia in selected patients (those for whom ECG assessment is less reliable because of digoxin use, LVH or with more than 1 mm ST depression at rest on the baseline ECG, those with pre-excitation [Wolff-Parkinson-White] syndrome, complete left bundle-branch block) with an intermediate pretest likelihood of CAD. 1.Prognosis of myocardial ischemia in selected patients (those in whom ECG assessment is less reliable) with the following ECG abnormalities: pre-excitation (Wolff-Parkinson-White) syndrome, electronically paced ventricular rhythm, more than 1 mm of ST depression at rest, complete left bundle-branch block. *Exercise or pharmacological stress echocardiogram. *Exercise or pharmacological stress echocardiogram.2.Detection of coronary arteriopathy in patients who have undergone cardiac transplantation. †Dobutamine stress echocardiography.†Dobutamine stress echocardiography.3.Detection of myocardial ischemia in women with a low or intermediate pretest likelihood of CAD. *Exercise or pharmacological stress echocardiogram. 1.Moved to Class IIa. One new Class IIa recommendation has been added. 1.Assessment of LV function in patients with previous myocardial infarction when needed to guide possible implantation of implantable cardioverter-defibrillator (ICD) in patients with known or suspected LV dysfunction. Table 1, Table 2, Table 3, Table 4, Table 5, Table 6 are new tables that relate to CAD.Table 1Evaluation of myocardial viability with DSE in patients with chronic CAD and impaired systolic LV function to detect hibernating myocardiumFirst Author, YearRef.StressTotal PatientsCriteriaSensitivity %Specificity %PPV %NPV %Accuracy %Marzullo, 199313Marzullo P. Parodi O. Reisenhofer B. et al.Value of rest thallium-201/technetium-99m sestamibi scans and dobutamine echocardiography for detecting myocardial viability.Am J Cardiol. 1993; 71: 166-172Abstract Full Text PDF PubMed Scopus (153) Google ScholarLD-DSE14Imp. WM*Wall motion analyzed by segment.8292957385Cigarroa, 199314Cigarroa C.G. deFilippi C.R. Brickner M.E. et al.Dobutamine stress echocardiography identifies hibernating myocardium and predicts recovery of left ventricular function after coronary revascularization.Circulation. 1993; 88: 430-436Crossref PubMed Google ScholarLD-DSE25Imp. WM†wall motion analyzed by patient.8286828684Alfieri, 199315Alfieri O. La Canna G. Giubbini R. et al.Recovery of myocardial function the ultimate target of coronary revascularization.Eur J Cardiothorac Surg. 1993; 7: 325-330Crossref PubMed Google ScholarLD-DSE14Imp. WM*Wall motion analyzed by segment.9178927688La Canna, 199416La Canna G. Alfieri O. Giubbini R. et al.Echocardiography during infusion of dobutamine for identification of reversibly dysfunction in patients with chronic coronary artery disease.J Am Coll Cardiol. 1994; 23: 617-626Abstract Full Text PDF PubMed Google ScholarLD-DSE33Imp. WM*Wall motion analyzed by segment.8782907785Charney, 199417Charney R. Schwinger M.E. Chun J. et al.Dobutamine echocardiography and resting-redistribution thallium-201 scintigraphy predicts recovery of hibernating myocardium after coronary revascularization.Am Heart J. 1994; 128: 864-869Abstract Full Text PDF Google ScholarLD-DSE17Imp. WM*Wall motion analyzed by segment.7193927481Afridi, 199518Afridi I. Kleiman N.S. Raizner A.E. et al.Dobutamine echocardiography in myocardial hibernation optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty.Circulation. 1995; 81: 663-670Crossref Google ScholarDSE20Imp. WM†wall motion analyzed by patient.8090898285Perrone-Filardi, 199519Perrone-Filardi P. Pace L. Prastaro M. et al.Dobutamine echocardiography predicts improvement of hypoperfused dysfunctional myocardium after revascularization in patients with coronary artery disease.Circulation. 1995; 91: 2556-2565Crossref PubMed Google ScholarLD-DSE18Imp. WM*Wall motion analyzed by segment.8887918287Senior, 199520Senior R. Glenville B. Basu S. et al.Dobutamine echocardiography and thallium-201 imaging predict functional improvement after revascularisation in severe ischaemic left ventricular dysfunction.Br Heart J. 1995; 74: 358-364Crossref PubMed Google ScholarLD-DSE22Imp. WM*Wall motion analyzed by segment.8782927386Haque, 199521Haque T. Furukawa T. Takahashi M. et al.Identification of hibernating myocardium by dobutamine stress echocardiography comparison with thallium-201 reinjection imaging.Am Heart J. 1995; 130: 553-563Abstract Full Text PDF Google ScholarLD-DSE26Imp. WM*Wall motion analyzed by segment.9480948091Arnese, 199522Arnese M. Cornel J.H. Salustri A. et al.Prediction of improvement of regional left ventricular function after surgical revascularization a comparison of low-dose dobutamine echocardiography with 201Tl single-photon emission computed tomography.Circulation. 1995; 91: 2748-2752Crossref PubMed Google ScholarLD-DSE38Imp. WM*Wall motion analyzed by segment.7496859391deFilippi, 199523deFilippi C.R. Willett D.L. Irani W.N. et al.Comparison of myocardial contrast echocardiography and low-dose dobutamine stress echocardiography in predicting recovery of left ventricular function after coronary revascularization in chronic ischemic heart disease.Circulation. 1995; 92: 2863-2868Crossref PubMed Google ScholarLD-DSE23Imp. WM*Wall motion analyzed by segment.9775879389Iliceto, 199624Iliceto S. Galiuto L. Marchese A. et al.Analysis of microvascular integrity, contractile reserve, and myocardial viability after acute myocardial infarction by dobutamine echocardiography and myocardial contrast echocardiography.Am J Cardiol. 1996; 77: 441-445Abstract Full Text PDF Scopus (76) Google ScholarLD-DSE16Imp. WM*Wall motion analyzed by segment.7188738783Varga, 199625Varga A. Ostojic M. Djordjevic-Dikic A. et al.Infra-low dose dipyridamole test a novel dose regimen for selective assessment of myocardial viability by vasodilator stress echocardiography.Eur Heart J. 1996; 17: 629-634Crossref Google ScholarLD-DSE19Imp. WM*Wall motion analyzed by segment.7494937884Baer, 199626Baer F.M. Voth E. Deutsch H.J. et al.Predictive value of low dose dobutamine transesophageal echocardiography and fluorine-18 fluorodeoxyglucose positron emission tomography for recovery of regional left ventricular function after successful revascularization.J Am Coll Cardiol. 1996; 28: 60-69Abstract Full Text PDF PubMed Scopus (116) Google ScholarLD-DSE42Imp. WM†wall motion analyzed by patient.9288928890Vanoverschelde, 199627Vanoverschelde J.L. D'Hondt A.M. Marwick T. et al.Head-to-head comparison of exercise-redistribution-reinjection thallium single-photon emission computed tomography and low dose dobutamine echocardiography for prediction of reversibility of chronic left ventricular ischemic dysfunction.J Am Coll Cardiol. 1996; 28: 432-442PubMed Google ScholarLD-DSE73Imp. WM†wall motion analyzed by patient.8877848284Gerber, 199628Gerber B.L. Vanoverschelde J.L. Bol A. et al.Myocardial blood flow, glucose uptake, and recruitment of inotropic reserve in chronic left ventricular ischemic dysfunction implications for the pathophysiology of chronic myocardial hibernation.Circulation. 1996; 94: 651-659Crossref PubMed Google ScholarLD-DSE39Imp. WM*Wall motion analyzed by segment.7187896577Bax, 199629Bax J.J. Cornel J.H. Visser F.C. et al.Prediction of recovery of myocardial dysfunction after revascularization comparison of fluorine-18 fluorodeoxyglucose/thallium-201 SPECT, thallium-201 stress-reinjection SPECT and dobutamine echocardiography.J Am Coll Cardiol. 1996; 28: 558-564Abstract Full Text PDF Google ScholarLD-DSE17Imp. WM*Wall motion analyzed by segment.8563499170Perrone-Filardi, 199630Perrone-Filardi P. Pace L. Prastaro M. et al.Assessment of myocardial viability in patients with chronic coronary artery disease rest-4-hour-24-hour 201Tl tomography versus dobutamine echocardiography.Circulation. 1996; 94: 2712-2719Crossref PubMed Google ScholarLD-DSE18Imp. WM*Wall motion analyzed by segment.7983926581Qureshi, 199731Qureshi U. Nagueh S.F. Afridi I. et al.Dobutamine echocardiography and quantitative rest-redistribution 201Tl tomography in myocardial hibernation relation of contractile reserve to 201Tl uptake and comparative prediction of recovery of function.Circulation. 1997; 95: 626-635Crossref Google ScholarLD-DSE34Imp. WM*Wall motion analyzed by segment.8668519273Qureshi, 199731Qureshi U. Nagueh S.F. Afridi I. et al.Dobutamine echocardiography and quantitative rest-redistribution 201Tl tomography in myocardial hibernation relation of contractile reserve to 201Tl uptake and comparative prediction of recovery of function.Circulation. 1997; 95: 626-635Crossref Google ScholarDSE34Biphasic resp*Wall motion analyzed by segment.7489728985Nagueh, 199732Nagueh S.F. Vaduganathan P. Ali N. et al.Identification of hibernating myocardium comparative accuracy of myocardial contrast echocardiography, rest-redistribution thallium-201 tomography and dobutamine echocardiography.J Am Coll Cardiol. 1997; 29: 985-993Abstract Full Text Full Text PDF PubMed Scopus (142) Google ScholarLD-DSE18Imp. WM*Wall motion analyzed by segment.9166619375Nagueh, 199732Nagueh S.F. Vaduganathan P. Ali N. et al.Identification of hibernating myocardium comparative accuracy of myocardial contrast echocardiography, rest-redistribution thallium-201 tomography and dobutamine echocardiography.J Am Coll Cardiol. 1997; 29: 985-993Abstract Full Text Full Text PDF PubMed Scopus (142) Google ScholarDSE18Biphasic resp*Wall motion analyzed by segment.6883708277Furukawa, 199733Furukawa T. Haque T. Takahashi M. et al.An assessment of dobutamine echocardiography and end-diastolic wall thickness for predicting post-revascularization functional recovery in patients with chronic coronary artery disease.Eur Heart J. 1997; 18: 798-806Crossref Google ScholarLD-DSE53Imp. WM*Wall motion analyzed by segment.7972767576Cornel, 199734Cornel J.H. Bax J.J. Fioretti P.M. et al.Prediction of improvement of ventricular function after revascularization18F-fluorodeoxyglucose single-photon emission computed tomography vs low-dose dobutamine echocardiography.Eur Heart J. 1997; 18: 941-948Crossref Google ScholarLD-DSE30Imp. WM*Wall motion analyzed by segment.8982749385DSE indicates dobutamine stress echocardiography (dobutamine infused at both low and high doses); CAD, coronary artery disease; LV, left ventricular; Ref. reference number; Stress, DSE protocol used for pharmacological stress; Total Patients, number of patients with chronic CAD and LV dysfunction in whom DSE studies were analyzed; Criteria, findings on DSE considered as a “positive” indicator of viability; PPV, positive predictive value (likelihood that presence of viability by DSE is indicative of subsequent functional recovery after revascularization); NPV, negative predictive value (likelihood that absence of viability by DSE is indicative of lack of functional recovery after revascularization); LD-DSE, low dose DSE; Imp. WM, improved wall motion during dobutamine stress in a previously asynergic segment; and Biphasic resp, biphasic response, defined as improvement in wall motion during LD-DSE followed by worsening at high dose.In these patients, percutaneous or surgical revascularization was performed after DSE testing. Those patients demonstrating improved wall motion on follow-up resting transthoracic echocardiography were considered to have had impaired LV function due to hibernating myocardium, whereas those demonstrating no improvement despite revascularization were considered to have had impaired LV function due to necrotic myocardium.* Wall motion analyzed by segment.† wall motion analyzed by patient. Open table in a new tab Table 2Prognostic value of stress echocardiography in various patient populations*Prognostic value of inducible ischemia, detected with different forms of stress echocardiography, in patients with chronic ischemic heart disease and patients after cardiac transplantation.First Author, YearReferenceStressTotal PtsAvg F/U, moEventsAnnualized Event Rate, %IschemiaNo IschemiaNormalChronic ischemic heart diseasePicano, 198935Picano E. Severi S. Michelassi C. et al.Prognostic importance of dipyridamole-echocardiography test in coronary artery disease.Circulation. 1989; 80: 450-457Crossref PubMed Google ScholarDIP†New wall motion abnormality considered “positive” for inducible ischemia.53936D, MI2.30.7…Sawada, 199036Sawada S.G. Ryan T. Conley M.J. et al.Prognostic value of a normal exercise echocardiogram.Am Heart J. 1990; 120: 49-55Abstract Full Text PDF PubMed Scopus (88) Google ScholarNL TME14828.4D, MI……0.6Mazeika, 199337Mazeika P.K. Nadazdin A. Oakley C.M. Prognostic value of dobutamine echocardiography in patients with high pretest likelihood of coronary artery disease.Am J Cardiol. 1993; 71: 33-39Abstract Full Text PDF PubMed Scopus (73) Google ScholarDSE†New wall motion abnormality considered “positive” for inducible ischemia.5124D, MI, UA163.8…Krivokapich, 199338Krivokapich J. Child J.S. Gerber R.S. et al.Prognostic usefulness of positive or negative exercise stress echocardiography for predicting coronary events in ensuing twelve months.Am J Cardiol. 1993; 71: 646-651Abstract Full Text PDF PubMed Scopus (87) Google ScholarTME†New wall motion abnormality considered “positive” for inducible ischemia.360≈12D, MI10.83.1…Afridi, 199439Afridi I. Quinones M.A. Zoghbi W.A. et al.Dobutamine stress echocardiography sensitivity, specificity, and predictive value for future cardiac events.Am Heart J. 1994; 127: 1510-1515Abstract Full Text PDF Scopus (72) Google ScholarDSE†New wall motion abnormality considered “positive” for inducible ischemia.7710D, MI488.93Poldermans, 199440Poldermans D. Fioretti P.M. Boersma E. et al.Dobutamine-atropine stress echocardiography and clinical data for predicting late cardiac events in patients with suspected coronary artery disease.Am J Med. 1994; 97: 119-125Abstract Full Text PDF PubMed Scopus (70) Google ScholarDSE†New wall motion abnormality considered “positive” for inducible ischemia.43017D, MI6.63.4…Coletta, 199541Coletta C. Galati A. Greco G. et al.Prognostic value of high dose dipyridamole echocardiography in patients with chronic coronary artery disease and preserved left ventricular function.J Am Coll Cardiol. 1995; 26: 887-894Abstract Full Text PDF Scopus (23) Goog