Exercise Stress Echocardiography Research Articles

Breath analysis combined with cardiopulmonary exercise testing and echocardiography for monitoring heart failure patients: the AEOLUS protocol

This paper describes the AEOLUS pilot study which combines breath analysis with cardiopulmonary exercise testing (CPET) and an echocardiographic examination for monitoring heart failure (HF) patients. Ten consecutive patients with a prior clinical diagnosis of HF with reduced left ventricular ejection fraction were prospectively enrolled together with 15 control patients with cardiovascular risk factors, including hypertension, type II diabetes or chronic ischemic heart disease. Breath samples were collected at rest and during CPET coupled with exercise stress echocardiography (CPET-ESE) protocol by means of needle trap micro-extraction and were analyzed through gas-chromatography coupled with mass spectrometry. The protocol also involved using of a selected ion flow tube mass spectrometer for a breath-by-breath isoprene and acetone analysis during exercise. At rest, HF patients showed increased breath levels of acetone and pentane, which are related to altered oxidation of fatty acids and oxidative stress, respectively. A significant positive correlation was observed between acetone and the gold standard biomarker NT-proBNP in plasma (r = 0.646, p < 0.001), both measured at rest. During exercise, some exhaled volatiles (e.g., isoprene) mirrored ventilatory and/or hemodynamic adaptation, whereas others (e.g., sulfide compounds and 3-hydroxy-2-butanone) depended on their origin. At peak effort, acetone levels in HF patients differed significantly from those of the control group, suggesting an altered myocardial and systemic metabolic adaptation to exercise for HF patients. These preliminary data suggest that concomitant acquisition of CPET-ESE and breath analysis is feasible and might provide additional clinical information on the metabolic maladaptation of HF patients to exercise. Such information may refine the identification of patients at higher risk of disease worsening.

The effect of cardiac rehabilitation on left ventricular diastolic functions assessed by exercise stress echocardiography in patients with acute coronary syndrome

Objective: The aim of our study is to investigate the impact of cardiac rehabilitation on left ventricular (LV) diastolic function in acute&#x0D; coronary syndrome (ACS) patients.&#x0D; Patients and Methods: Patients were selected consecutively among ACS patients who underwent primary percutaneous intervention&#x0D; and were found eligible for cardiac rehabilitation program from May 2014 to May 2015. Forty-four patients were included in cardiac&#x0D; rehabilitation group and recruited to 30 sessions of Phase-3 cardiac rehabilitation program six weeks after discharge. Twenty&#x0D; consecutive patients were included as control group. LV diastolic functions were assessed by resting and stress echocardiography.&#x0D; Results: There were not any significant differences in characteristics between the groups. Resting and stress E velocities and resting&#x0D; lateral e’ velocity significantly increased after rehabilitation program. Left atrial volume index, resting and stress A velocities and&#x0D; average E/e’ ratios were significantly lower while stress lateral e’ velocity was significantly higher in rehabilitation group after program&#x0D; compared to controls. The number of patients with diastolic dysfunction decreased after rehabilitation program. Final resting and&#x0D; stress echocardiography revealed significantly lower frequency of diastolic dysfunction in rehabilitation group.&#x0D; Conclusion: Cardiac rehabilitation improves diastolic functions in ACS patients, which may be detected by stress echocardiography.

Complications of exercise and pharmacologic stress echocardiography.

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).

Paradoxical increase in global longitudinal strain by handgrip exercise despite left ventricular diastolic dysfunction.

Although global longitudinal strain (GLS) is recognized as a sensitive marker of intrinsic left ventricular (LV) dysfunction, its afterload dependency has also been pointed. We hypothesized that decrease in GLS during handgrip exercise could be more sensitive marker of intrinsic myocardial dysfunction. Handgrip exercise-stress echocardiography was performed in 90 cardiovascular disease patients with preserved LV ejection fraction. LV diastolic function was graded according to the guidelines. Diastolic wall stress (DWS) and ratio of left atrial (LA) volume index to late-diastolic mitral annular velocity (LAVI/a') were measured at rest as LV stiffness. As well, LA strains were measured to assess LA function. GLS was expressed as absolute value and significant changes in GLS by handgrip exercise was defined as changes over prespecified mean absolute test-retest variability (2.65%). While mean value of GLS did not change by the exercise, substantial patients showed significant changes in GLS: decreased (group I, n=28), unchanged (group II, n=34), and increased (group III, n=28). Unexpectedly, patients in group I did not show any clinical and echocardiographic characteristics, while those in group III were characterized by elevated natriuretic peptide levels, blunted heart rate response to handgrip exercise, and advanced LV diastolic dysfunction. Multivariable analyses revealed that DWS, left atrial booster strain, and grade II or more diastolic dysfunction determined the increase in GLS even after adjustment for elevated natriuretic peptides and the changes in heart rate by the exercise. In contrast to our hypothesis, paradoxical increase in GLS by handgrip exercise could be associated with advanced LV diastolic dysfunction in cardiovascular patients with preserved LV ejection fraction. Our findings suggest that HG exercise for heart failure patients does not enhance the afterload straightforward, resulting in variable changes of GLS according to the individual conditions.

Characterization and prognostic importance of chronotropic incompetence in heart failure with preserved ejection fraction

BackgroundExercise intolerance is the primary symptom of patients with heart failure with preserved ejection fraction (HFpEF). Chronotropic incompetence has been considered to be common and contribute to poor exercise capacity in HFpEF. However, clinical characteristics, pathophysiology, and outcomes of chronotropic incompetence in HFpEF remain poorly understood. MethodsPatients with HFpEF (n = 246) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. The patients were divided into two groups based on the presence of chronotropic incompetence, which was defined by heart rate reserve <0.80. ResultsChronotropic incompetence was common in HFpEF (n = 112, 41 %). Compared to HFpEF patients with a normal chronotropic response (n = 134), those with chronotropic incompetence had higher body mass index, a higher prevalence of diabetes, more frequent β-blocker use, and worse New York Heart Association class. During peak exercise, patients with chronotropic incompetence demonstrated less increase in cardiac output and arterial oxygen delivery (cardiac output × saturation × hemoglobin × 1.34 × 10), higher metabolic work (peak oxygen consumption [VO2]/watt), an inability to increase arteriovenous oxygen difference, and poorer exercise capacity (lower peak VO2) than those without. Chronotropic incompetence was associated with higher rates of a composite of all-cause mortality or worsening HF events (hazard ratio, 2.66, 95 % confidence intervals, 1.16–6.09, p = 0.02). ConclusionChronotropic incompetence is common in HFpEF, and is associated with unique pathophysiologic characteristics during exercise and clinical outcomes.

The Utility of Preoperative Exercise Stress Echocardiography to Predict Perioperative Major Adverse Cardiovascular Events in Kidney Transplantation

The Utility of Preoperative Exercise Stress Echocardiography to Predict Perioperative Major Adverse Cardiovascular Events in Kidney Transplantation

SMART-3D: A Novel Scoring System to Predict Non-Diagnostic Exercise Stress Echocardiography in Renal Transplant Candidates

SMART-3D: A Novel Scoring System to Predict Non-Diagnostic Exercise Stress Echocardiography in Renal Transplant Candidates

Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65.

The prognosis of patients with chest pain after a negative exercise test is good, but some adverse events occur in this low-risk group. The aim of our study was to identify predictors of long-term adverse events after a negative exercise test in patients with chest pain and a lower intermediate (15-65%) pre-test probability of coronary artery disease (CAD) and to assess the prognostic value of exercise electrocardiography and exercise stress echocardiography in this group of patients. We identified from our stress test laboratory database 862 patients with chest pain without previously known CAD and with a pre-test probability of CAD ranging from 15 to 65% (mean 41 ± 14%) who underwent exercise testing. Patients were followed for the occurrence of death, non-fatal myocardial infarction (MI) and clinically guided revascularization. During the median follow-up of 94 months, 87 patients (10.1%) had an adverse event (AE). A total of 30 patients died (3.5%), 23 patients suffered non-fatal MI (2.7%) and 34 patients (3.9%) had clinically guided revascularization (20 patients percutaneous and 14 patients surgical revascularizations). Male gender, age, the presence of diabetes and a slow heart rate recovery (HRR) in the first minute after exercise were independently related to the occurrence of AEs. Adverse events occurred in 10.3% of patients who were tested by exercise stress echocardiography and in 10.0% of those who underwent stress electrocardiography (p = 0.888). The risk of AEs after negative exercise testing in patients with a pre-test probability of CAD of 15-65% is low. Male patients with a history of diabetes and slow HRR in the first minute after exercise have an increased risk of an adverse outcome.

The wide spectrum of determinants of false-positive results on exercise stress echocardiography.

The wide spectrum of determinants of false-positive results on exercise stress echocardiography.

Clinical and Prognostic Implications of Cardiopulmonary Exercise Stress Echocardiography in Asymptomatic Degenerative Mitral Regurgitation

The current guidelines recommend intervention in severe degenerative mitral regurgitation (MR) in symptomatic patients or asymptomatic patients with left ventricular dilatation or dysfunction. The insidious onset of symptoms may mean that patients do not report their symptoms. The role of systematic exercise testing for symptoms in MR is not clearly defined. A total of 97 patients with moderate to severe asymptomatic MR underwent exercise echocardiography combined with cardiopulmonary exercise testing. The predictors of exercise-induced dyspnea, symptom-free survival, and mitral valve intervention were identified. A total of 18 patients (19%) developed limiting dyspnea on exercise. Spontaneous symptom-free survival at 24months was significantly higher in those without exercise-induced symptoms than those with exercise-induced symptoms, p <0.0001. The only independent predictors of spontaneous symptoms at 2years were effective regurgitant orifice area (odds ratio 27.45, 95% confidence interval [CI] 1.43 to 528.40, p=0.03) and exercise-induced symptoms (odds ratio 11.56, 95% CI 1.71 to 78.09, p=0.01). The only independent predictor of surgery was indexed left ventricular systolic volumes (odds ratio 1.17, 95% CI 1.04 to 1.30, p=0.006). Where only the patients who underwent surgery due to symptoms were included, the only independent predictor was exercise-induced symptoms (odds ratio 13.94, 95% CI 1.39 to 140.27, p=0.025). In conclusion, in patients with primary asymptomatic degenerative MR, 1/5 develop revealed symptoms during exercise. This predicts a subsequent development of spontaneous symptoms and mitral valve intervention due to symptoms.

Association of cardiac functional reserve with body weight in heart failure with preserved ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Impaired cardiovascular functional reserve is believed to contribute to adverse outcomes in heart failure with preserved ejection fraction (HFpEF). However, overweight and mild to moderate obesity is associated with substantially improved survival compared to normal weight patients, a phenomenon known as the "obesity paradox". Aim We sought to investigate the association between LA and LV strain response to exercise and BMI in patient with heart failure with HFpEF. Methods A group of 140 subjects (54 ± 12 yrs) with symptomatic HFpEF underwent clinical evaluation and resting and exercise stress echocardiography (including peak atrial longitudinal strain [PALS], peak atrial contractile strain [PACS] and LV global longitudinal strain [GLS] assessment). Results Patients were divided into 3 groups according to BMI ( group A: BMI &amp;lt; 25 kg/m2, group B: BMI 25–30 kg/m2, group C: BMI ≥ 30 kg/m2). The subset with normal weight demonstrated greater changes from rest to exercise in GLS compared to overweight and obese patients (Table). No significant differences were shown for other components of cardiac reserve. Significant correlations were found between BMI and GLS and PACS exercise reserve (r=0.15; p&amp;lt;0.05, and r=0.19; p&amp;lt;0.02, respectively). Conclusions In patients with HFpEF, among LV and LA functional reserve parameters, GLS is most predisposed to the detrimental effect of weight excess. The profiles of changes in cardiac reserve parameters across the BMI strata do not indicate that better cardiac reserve should be considered as an explanation for the obesity paradox.

Clinical and prognostic implications of cardiopulmonary exercise stress echocardiography in asymptomatic degenerative mitral regurgitation

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Saudi Arabian Cultural Bureau. Background Current guidelines recommend intervention in severe degenerative mitral regurgitation (MR) in symptomatic patients or asymptomatic patients with left ventricular dilatation or dysfunction. The insidious onset of symptoms may mean patients do not report symptoms. The role of systematic exercise testing for symptoms in MR is not clearly defined. Methods 97 patients with moderate to severe, asymptomatic MR underwent exercise echocardiography combined with cardiopulmonary exercise testing. Predictors of exercise-induced dyspnoea, symptom-free survival and mitral valve intervention were identified. Results 18 (19%) patients developed limiting dyspnoea on exercise. Spontaneous symptom free survival at 24 months was significantly higher in those without exercise-induced symptoms compared to those with exercise-induced symptoms, p &amp;lt;0.0001. The only independent predictors of spontaneous symptoms at 2 years were effective regurgitant orifice area (odds ratio 27.45 (95% CI 1.43 – 528.40), p = 0.03) and exercise-induced symptoms (odds ratio 11.56 (95% CI 1.71 – 78.09), p = 0.01). The only independent predictor of surgery was indexed left ventricular systolic volumes (Odds ratio 1.17 (95% CI 1.04 – 1.30), p = 0.006). Where only patients undergoing surgery due to symptoms were included, the only independent predictor was exercise-induced symptoms (Odds ratio 13.94 (95% CI 1.39 – 140.27), p = 0.025). Conclusion In patients with primary asymptomatic degenerative MR, one fifth develop symptoms on exercise. This predicts subsequent development of spontaneous symptoms and mitral valve intervention due to symptoms.

Role of Exercise Stress Echocardiography in Pulmonary Hypertension.

Resting and exercise right heart catheterisation is the gold standard method to diagnose and differentiate types of pulmonary hypertension (PH). As it carries technical challenges, the question arises if non-invasive exercise stress echocardiography may be used as an alternative. Exercise echocardiography can unmask exercise PH, detect the early stages of left ventricular diastolic dysfunction, and, therefore, differentiate between pre- and post-capillary PH. Regardless of the underlying aetiology, a developed PH is associated with increased mortality. Parameters of overt right ventricle (RV) dysfunction, including RV dilation, reduced RV ejection fraction, and elevated right-sided filling pressures, are detectable with resting echocardiography and are associated with worse outcome. However, these measures all fail to identify occult RV dysfunction. Echocardiographic measures of RV contractile reserve during exercise echocardiography are very promising and provide incremental prognostic information on clinical outcome. In this paper, we review pulmonary haemodynamic response to exercise, briefly describe the modalities for assessing pulmonary haemodynamics, and discuss in depth the contemporary key clinical application of exercise stress echocardiography in patients with PH.

Discovering HFpEF in symptomatic and asymptomatic elderly outpatients to prevent hospital admission.

Transthoracic echocardiography plays an important role as an imaging tool for the evaluation of heart failure with preserved ejection fraction (HFpEF). Among the imaging findings, the E/e' ratio, a surrogate for left atrial (LA) filling pressure, is a robust indicator that supports the diagnosis of HFpEF. Other findings such as left ventricular (LV) early diastolic tissue velocity (e'), LA volume, LA strain and LV global longitudinal strain are also related to LA filling pressure, and these parameters are useful for the diagnosis of HFpEF. Although some patients with HFpEF do not have abnormalities in these indices at rest, they may develop abnormalities in LA filling pressure exclusively during exercise.1 Therefore, HFpEF is difficult to diagnose in symptomatic elderly outpatients with limited exercise capacity (Figure 1). There are two types of probability tests in which HFpEF is present in patients with dyspnoea based on the findings obtained in clinical settings: the H2FPEF score2 and the HFA-PEFF score.3 Although both scores included echocardiographic indices, the H2FPEF score focuses on comorbidities, whereas the HFA-PEFF score includes natriuretic peptide levels. Most patients with HFpEF have a history of hypertension, and their blood pressure levels may no longer be elevated by medications at the time of evaluation.4 Furthermore, most patients with HFpEF show a high BMI, which is not the case in older patients.5 Because natriuretic peptide levels are occasionally within normal limits in patients with HFpEF, they may not be necessary for the diagnosis of HFpEF.2 Haemodynamic exercise tests play a key role when one cannot make a definitive decision of developing HFpEF. Noninvasive exercise testing does not discriminate between patients with cardiac and non-cardiac causes of dyspnoea.6 Although exercise echocardiography is a useful tool in place of invasive stress testing, there are contradictory results regarding the significance of the E/e' ratio for LA filling pressure.7, 8 Since LV diastolic function is affected by afterload, we recently evaluated LV diastolic function as a vascular resistance-integrated index: the ratio of LV diastolic elastance (Ed) to arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure).9 This noninvasive index shows the ratio of LA filling pressure to LV end-systolic pressure and is a significant index of all-cause mortality in a multivariate Cox proportional hazards regression analysis performed by adjusting for age, comorbidities, natriuretic peptide levels and echocardiographic indices in elderly patients with HFpEF.10, 11 Stress tests cause an elevation of systolic blood pressure, and the extent of the change in blood pressure is different in each patient. Using an index such as Ed/Ea, the conflicting consequences described above may disappear. For the diagnosis of heart failure (HF), patients are aware of certain symptoms such as exertional dyspnoea, chest discomfort and fatigue. However, the symptoms are sometimes obscured in older patients. In clinical settings, it is important to identify patients with latent HFpEF who will likely be admitted for HF treatment in the near future. When populations with asymptomatic hypertension undergo invasive exercise stress or exercise echocardiography, some portions may exhibit an elevated LA filling pressure during exercise. We may call these populations ‘pre-HFpEF’ patients in terms of clinical entity.12 Asymptomatic LV hypertrophy is a potent risk factor for HFpEF.13 The main pathologies of HFpEF include cardiomyocyte remodelling and interstitial collagen deposition resulting from endothelial dysfunction and microvascular inflammatory changes.14-16 These latent populations might have treatment as ‘pre-HFpEF’ to avoid admission for HF. The diagnosis and treatment of asymptomatic elderly outpatients without a history of admission for HF, who possibly show exercise-induced elevation of LA filling pressure, remain to be defined. Recently, emerging differences in the phenotyping of HFpEF have been shown.17, 18 Asymptomatic patients with certain phenotypes must undergo stress echocardiography to diagnose pre-HFpEF. Under these conditions, the measurement of the Ed/Ea ratio may play a key role in the discrimination of several phenotypes in a multivariate model. As the medications and prognosis for HFpEF may be different from its phenotype,19, 20 it is urgent to elucidate the type of HFpEF or pre-HFpEF that should be medicated according to treatment type to reduce the incidence of admission for HF and mortality in the era of a super-ageing society. Among elderly clinic patients, we must detect symptomatic outpatients with possible HFpEF as well as asymptomatic ‘pre-HFpEF’ outpatients to reduce admission for HF in the near future and to conserve resources in the era of a super-ageing society. A vascular resistance-integrated LV diastolic index, (E/e')/(0.9 × systolic blood pressure), may play a role in revealing these patients in addition to possible comorbidities. None. No funding was received in relation to this article.

Sex-Specific Impairment of Cardiac Functional Reserve in HFpEF: Insights From the HFpEF Stress Trial

BackgroundHeart failure with preserved ejection fraction (HFpEF) has been observed to have a twice as high prevalence in women compared to men with similar predisposing risk factors between both sexes. ObjectivesThis study aimed to identify sex-specific pathophysiological features in HFpEF using rest and exercise stress right heart catheterization (RHC), echocardiography and cardiovascular magnetic resonance imaging (CMR). MethodsSeventy-five patients with exertional dyspnea, preserved ejection fraction (EF) (≥50%), and signs of diastolic dysfunction on echocardiography were prospectively recruited in the HFpEF Stress Trial. Patients underwent RHC, echocardiography and CMR at rest and during exercise stress. Patients were diagnosed with HFpEF and noncardiac dyspnea according to RHC measurements. ResultsAfter exclusion, the final study cohort comprised 68 patients (females n = 44, males n = 24) with a mean age of 66.9 ± 9.7 years. Compared to men, women with HFpEF revealed lower right ventricular stroke volumes during exercise stress (females 38.1 vs males 50.4 mL/m2 BSA; P = 0.011). This was accompanied by a decreasing left atrial EF in women but not men comparing resting to exercise conditions (females −2.7% vs males 2.5%, P = 0.020) and impaired left ventricular filling (females 35.5 vs males 44.2 mL/m2 BSA, P = 0.017) in women with HFpEF during exercise stress. These sex-specific differences were not present in noncardiac dyspnea. ConclusionsWomen with HFpEF demonstrate sex-specific functional alterations of right ventricular, left atrial, and left ventricular function during exercise stress. This unique pathophysiology represents a sex-specific diagnostic target, which may allow early identification of women with HFpEF for future individualized therapeutic approaches.

Exercise-induced B-lines for the diagnosis of heart failure with preserved ejection fraction: a two-centre study.

Diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging despite the use of scores/algorithms. This study intended to assess the diagnostic value of exercise lung ultrasound (LUS) for HFpEF diagnosis. We studied two independent case-control studies of HFpEF patients and control subjects undergoing different exercise protocols: (i) submaximal exercise stress echocardiography (ESE) with LUS performed by expert cardiologists (N = 116, HFpEF = 65.5%), and (ii) maximal cycle ergometer test (CET) (N = 54, HFpEF = 50%) with LUS performed by unexperienced physicians shortly trained for the study. B-line kinetics (i.e. peak values and their changes from rest) were assessed. In the ESE cohort, the C-index (95% CI) of peak B-lines for HFpEF diagnosis was 0.985 (0.968-1.000), whereas the C-index of rest and exercise HFA-PEFF scores (i.e. including stress echo findings) were < 0.90 (CI 0.823-0.949), and that of H2FPEF score was < 0.70 (CI 0.558-0.764). The C-index increase of peak B-lines on top of the above-mentioned scores was significant (C-index increase > 0.090 and P-value < 0.001 for all). Similar results were observed for change B-lines. Peak B-lines > 5 (sensitivity = 93.4%, specificity = 97.5%) and change B-lines > 3 (sensitivity = 94.7%, specificity = 87.5%) were the best cutoffs for HFpEF diagnosis. Adding peak or change B-lines on top of HFpEF scores and BNP significantly improved diagnostic accuracy. Peak B-lines showed a good diagnostic accuracy in the LUS beginner-led CET cohort (C-index = 0.713, 0.588-0.838). Exercise LUS showed excellent diagnostic value for HFpEF diagnosis regardless of different exercise protocols/level of expertise, with additive diagnostic accuracy on top of available scores and natriuretic peptides.

Evaluation of the relationship between left atrial strain and exercise tolerance in patients with hypertrophic cardiomyopathy by treadmill stress echocardiography.

The aim of this study is to evaluate the left atrial strain (LAS) in patients with hypertrophic cardiomyopathy (HCM) by treadmill exercise stress echocardiography, combined with three-dimensional speckle tracking technology, for predicting exercise tolerance. A total of 97 patients with HCM who underwent treadmill exercise stress echocardiography were recruited in Sichuan Provincial People's Hospital between January 2018 and January 2021, and 30 control subjects were selected to be included in the normal group. HCM patients with their metabolic equivalents (METS) ≤ 6.0 were included in the HCM-1 group, while those with METS > 6.0 were included in the HCM-2 group. The LAS and exercise tolerance were analyzed. The ultrasound parameters that could predict a decrease in exercise tolerance were screened, and a predictive model was constructed. It was found that METS, Rest-LASr, Rest-LAScd, and Rest-LASct were significantly lower in HCM patients than those in normal controls. There was a significant difference in age, Target_HR, LVMI, LAVI, E/e'-Rest, E/e'-Peak, Rest-LASr, Rest-LAScd, and Rest-LASct between the HCM-1 and the HCM-2 groups. LASr is an independent resting echocardiographic predictor of METS ≤ 6.0. LASr remained significant for predicting different subtypes (AHCM, asymmetric HCM, and obstructive HCM). Rest-LASr (AUC 0.990) was better at predicting METS ≤ 6.0 than Peak-E/e' (AUC 0.753). A multivariate model (LASr + Age + Target_HR) was established for METS prediction. Left atrial reservoir strain (LASr) has the strongest association with METS ≤ 6.0. The LASr is an independent resting predictor of METS ≤ 6.0 and has a good performance record in predicting different subtypes of HCM. Compared with the traditional parameters, Peak-E/e' and Rest-E/e', Rest-LASr is the best predictor. Rest-LASr can serve as a reliable method for HCM patients who are unable to undergo exercise testing but require an urgent evaluation of their METS, which provides a basis for clinical treatment decision-making and treatment effect evaluation.

Assessment of left ventricular energy loss in patients with mild coronary artery stenosis by using vector flow mapping combined with exercise stress echocardiography.

To evaluate the left ventricular energy loss (EL), energy loss reserve (EL-r), and energy loss reserve rate in patients with mild coronary artery stenosis by using vector flow mapping (VFM) combined with exercise stress echocardiography. A total of 34 patients (case group) with mild coronary artery stenosis and 36 sex and age matched patients (control group) without coronary artery stenosis according to coronary angiogram were prospectively enrolled. The total energy loss (ELt), basal segment energy loss (ELb), middle segment energy loss (ELm), apical segment energy loss (ELa), energy loss reserve (EL-r), and energy loss reserve rate were recorded in the isovolumic systolic period (S1), rapid ejection period (S2), slow ejection period (S3), isovolumic diastolic period (D1), rapid filling period (D2), slow filling period (D3), and atrial contraction period (D4). Compared with the control group, some of the EL in the resting case group were higher; some of the EL in the case group were lower after exercise, and those during D1 ELb and D3 ELb were higher. Compared with the resting state, the total EL and the EL within the time segment in the control group were higher after exercise, except during D2 ELb. In the case group, except for during D1 ELt, ELb and D2 ELb, the total and segmental EL of each phase was mostly higher after exercise (p<.05). Compared with the control group, most of the EL-r and EL reserve rates in the case group were lower (p<.05). The EL, EL-r, and energy loss reserve rate have a certain value in the evaluation of cardiac function in patients with mild coronary artery stenosis.

Diagnostic significance of myocardial and multimodal contrast exercise stress echocardiography in the detection of hemodynamically significant coronary artery stenosis in stable angina pectoris

Aim. To evaluate the diagnostic significance of myocardial contrast stress echocardiography (MCSE) and multimodal contrast stress echocardiography (MMSE) with dosed exercise in detecting hemo­dynamically significant coronary artery stenosis in patients with stable coronary heart disease (CAD) without impaired regional left ventricular contractility at rest.Material and methods. MCSE and MMSE were performed in 61 pa­­tients with suspected or stable CAD (mean age, 62,9±8,9 years). All patients underwent coronary angiography. During MCSE, perfusion and regional contractility were assessed. With MMSE, regional contractility was assessed. Sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios for MCSE and MMSE were assessed in com­parison with coronary angiography.Results. The sensitivity of MCSE with perfusion assessment was 82% (CI, 67-92%) with specificity of 70% (35-92%), LR+ — 2,74, LR- — 0,26. Sensitivity of MCSE with assessment of perfusion and regional contractility was 67% (50-81%) with specificity of 90% (65-99%), LR+ — 6,67, LR- — 0,37. The sensitivity of MCSE with an estimate of regional contractility of 74% (58-87%) with a specificity of 90% (56-98%), LR+ — 7,4, LR- — 0,28. The sensitivity of MMSE in the mode of cavitary and myocardial contrasting was 72% (55-85%) with a specificity of 90% (56-99%), LR+ — 7,18, LR- — 0,31.Conclusion. MCSE with an assessment of regional contractility and MMSE are of diagnostic importance in the detection of CAD, a positive result of which increases the post-test probability of hemodynamically significant coronary artery stenosis. A positive result of MCSE with dosed exercise with isolated perfusion assessment does not have a diagnostically significant effect on the post-test probability of CAD.

Combining cardiopulmonary exercise testing with echocardiography: a multiparametric approach to the cardiovascular and cardiopulmonary systems.

Exercise intolerance is a prominent feature of several cardiovascular conditions. However, the physical effort requires the intertwined adaptation of several factors, namely the cardiovascular system, the lungs, and peripheral muscles. Several abnormalities in each domain may be present in a given patient. Cardiopulmonary exercise testing (CPET) has been used to investigate metabolic and ventilatory alterations responsible for exercise intolerance but does not allow for direct evaluation of cardiovascular function. However, this can readily be obtained by concomitant exercise-stress echocardiography (ESE). The combined CPET-ESE approach allows for precise and thorough phenotyping of the pathophysiologic mechanisms underpinning exercise intolerance. Thus, it can be used to refine the diagnostic workup of patients with dyspnoea of unknown origin, as well as improve risk stratification and potentially guide the therapeutic approach in specific conditions, including left and right heart failure or valvular heart disease. However, given its hitherto sporadic use, both the conceptual and technical aspects of CPET-ESE are often poorly known by the clinician. Improving knowledge in this field could significantly aid in anticipating individual disease trajectories and tailoring treatment strategies accordingly. Therefore, we designed this review to revise the pathophysiologic correlates of exercise intolerance, the practical principles of the combined CPET-ESE examination, and its main applications according to current literature.