Patients Undergoing Stress Echocardiography Research Articles

Right parasternal view in dobutamine stress echocardiography for aortic stenosis assessment.

Dobutamine stress echocardiography is an integral part of the evaluation of aortic stenosis (AS) severity in low-gradient AS. In transthoracic echocardiography, in 20% of the patients, the highest aortic valve peak transvalvular velocity and mean gradient are achieved with continuous wave Doppler, from the suprasternal or right parasternal view. We present a case of a 79-year-old-male, with low-gradient aortic stenosis, where the highest peak aortic valve velocity and mean gradient, were consistently obtained from the right parasternal view, during all stages of a dobutamine stress echocardiogram. Use of the right parasternal view was important in avoiding overestimation of aortic valve area and underestimation of aortic valve mean gradients and therefore AS severity at rest. Furthermore, it correctly identified significant increase of aortic valve mean gradients during stress and therefore confirmed the diagnosis of severe AS. This case report highlights the importance of routinely attempting right parasternal view, in patients undergoing stress echocardiography to ensure the maximum possible aortic valve gradient is obtained.

Informativeness of echocardiography in inferior myocardial infarction at different stages of observation

Aim. to evaluate the informativeness of echocardiographic parameters in patients with acute inferior wall myocardial infarction of the left ventricle, who have undergone primary percutaneous coronary intervention, at discharge from the hospital and in the long-term period.
 Material and methods. Echocardiographic data was analyzed using speckle tracking technology in 144 patients with acute inferior myocardial infarction of the left ventricle before discharge and 2 years later. In the post-infarction period, 10 patients underwent magnetic resonance imaging and 15 patients underwent stress echocardiography.
 Results. Using the tree construction method, critical values of 7 ultrasound parameters were identified (for the left ventricle - ejection fraction, end-systolic volume index, global longitudinal and circular strains, for the right ventricle - tricuspid S', global longitudinal strain, free wall strain), which with a probability of 89.4% predict repeat revascularization.
 Identification of possible areas of myocardial fibrosis in the remote period by speckle-tracking echocardiography has a sensitivity of 46-57%, specificity of 68-76%, and negative predictive value of 74-87% relative to the gold standard detection of postinfarction scarring by magnetic resonance imaging.
 According to the results of stress-echocardiography, new zones of local contractility impairment registered after exercise were not accompanied by changes in segmental longitudinal deformation.
 Conclusion. The results of echocardiographic screening of patients with acute inferior myocardial infarction of the left ventricle using speckle tracking technology have high prognostic significance in assessing the likelihood of repeated revascularization at discharge and diagnostic information for verifying post-infarction fibrous changes in the long-term period.

Abstract 11723: Predictors of Post-Operative Atrial Fibrillation in Patients Undergoing Stress Echocardiography Prior to Noncardiac Surgery

Background: Atrial fibrillation (a-fib) occurs in up to 40% of patients after noncardiac surgery and is associated with increased risk of adverse outcomes. Practice guidelines recommend stress testing, including stress echocardiography (SE) to assess for coronary artery disease in selected high-risk patients prior to noncardiac surgery. The utility of using SE findings for predicting postoperative a-fib is unknown. Hypothesis: Myocardial ischemia can contribute to arrhythmogenic potential; other echocardiographic variables are likely associated with a-fib. Findings on SE may identify patients at risk for a-fib after noncardiac surgery. Aims: To determine if certain SE findings predict a-fib following noncardiac surgery. Methods: The study included patients undergoing pharmacological and exercise SE before noncardiac surgery. The primary outcome was a-fib/flutter within 30 days after surgery. Multivariate analysis was adjusted for age, cardiovascular comorbidities, and markers of surgical risk. Results: This analysis included 2,376 patients (mean age 68 +/- 7 years; 60% male); 1,986 patients had no known history of a-fib/flutter. Of these, 48 (2.4%) developed postoperative a-fib/flutter. In multivariate analysis, SE variables associated with development of new a-fib/flutter included left ventricular dilation (OR 2.11, p=0.049), increased left atrial volume (OR 1.19, p=0.045), and increased left ventricular mass index (OR 1.13, p=0.043) on rest images. The presence of ischemia or infarct on stress echocardiogram was not associated with postoperative a-fib/flutter. A total of 390 patients had a history of paroxysmal a-fib/flutter and were in sinus rhythm at the time of surgery. Of these, 90 (23%) experienced recurrent a-fib/flutter within 30 days of surgery. Multivariate analysis did not reveal any SE variables significantly associated with recurrence, including presence of myocardial ischemia or infarct at the time of SE. Conclusions: All SE variables associated with postoperative a-fib following noncardiac surgery are available from resting images alone. Therefore, SE that includes comprehensive resting images may offer benefit in the pre-operative evaluation of selected patients.

Rest and Stress Left Atrial Dysfunction in Patients with Atrial Fibrillation.

Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress. This study sought to assess LA volume and function at rest and during stress across the spectrum of AF. In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients. LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m2, p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m2, p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001). In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress.

Sex differences in the evaluation and outcomes of multi-ethnic asian patients undergoing stress echocardiography

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Stress echocardiography is an important test used in the evaluation of myocardial ischemia. Despite this, not much is known about sex differences between men and women undergoing stress echocardiography, with regards to their characteristics and outcomes, especially in the Asian population. Methods We performed a retrospective cohort study of 1504 consecutive patients evaluated with dobutamine or exercise stress echocardiography performed for suspected coronary artery disease (CAD) or to evaluate the status of known CAD. We divided the patients into two groups: males and females. The tests were classified as positive, equivocal, or negative for ischemia, and the outcomes at 6 months follow-up was analysed. Results 48.1% (723) patients were males. The mean age of patients was 52.2 ± 14.9 years for males and 55.8 ± 12.5 years for females. The 3 most common indications for stress echocardiography in both males and females were for the assessment of symptoms for suspected CAD in 787 (52.3%), for the assessment of a prior abnormal test in 408 (27.1%) and for the assessment of the status of pre-existing CAD in 93 (6.2%). In terms of co-morbidities, males were more likely to have ischemic heart disease (&amp;lt;0.001), prior AMI (p&amp;lt;0.001), prior PCI (p&amp;lt;0.001) and CABG (p=0.002). Stress echocardiography was normal in 608 men (84.3%) and 643 women (82.3%). A positive result on stress echocardiography was obtained in 65 men (9.0%) and 63 women (8.1%), and equivocal result in 48 men (6.7%) and 75 women (9.6%). During a mean follow-up of 7.9 ± 0.2 years, 84 men (11.6%) and 44 women (5.6%) (p&amp;lt;0.001) experienced a cardiac event, of which there were 40 (2.7%) deaths, with 26 men (3.6%) and 14 women (1.8%) (p=0.030). 26 men (3.6%) and 6 women (0.8%) (p&amp;lt;0.001) experienced an acute myocardial infarction. Independent predictors of cardiac events in patients using a Cox proportional hazards regression analysis were age (hazard ratio (HR): 1.05 [range 1.03 to 1.07]), female gender (HR: 0.50 [range: 0.328 to 0.760]) and previous myocardial infarction (HR: 2.50 [range 1.28 to 4.86]) Conclusion Differences in mean age, prevalence of ischemic heart disease, prior myocardial infarction and prior PCI/CABG were noted between males and females who underwent stress echocardiography. Males experienced a higher incidence of cardiac events compared to females. Gender is an independent predictor of cardiac events in patients undergoing stress echocardiography, together with age and a history of myocardial infarction.

Association between Resting Global Longitudinal Strain and Clinical Outcome of Patients Undergoing Stress Echocardiography

Reduced global longitudinal strain (GLS) of the left ventricle is associated with adverse prognosis in healthy subjects and in different cardiovascular conditions. Resting GLS may enable risk assessment independently from stress echocardiography (SE). We assessed whether there is an association of GLS measured at rest before SE with long-term outcome, independent of clinical parameters or reversible wallmotion abnormalities and Doppler coronary flow velocity reserve. Five hundred thirty patients who underwent SE for ischemia evaluation between 2010 and 2012 and who had rest images available were selected. Resting GLS was measured off-line (absolute value <15% was considered abnormal). Cox models were used to examine the association between clinical variables, ejection fraction, SE variables, and resting GLS with mortality and cardiac events (cardiac death and nonfatal myocardial infarction). The independent prognostic value of GLS over known rest and stress variables was assessed. Over a median follow-up of 7.5years, 137 patients died from any cause and 50 had a nonfatal myocardial infarction. Patients with resting GLS <15% had significantly lower event-free survival (log-rank P<.0001). Resting GLS was significantly associated with risk of all-cause death and hard cardiac events, after adjustment for clinical risk factors, reversible wall motion abnormalities, and coronary flow velocity reserve. Adding resting GLS into a model with clinical, rest, and stress imaging variables significantly increased the model C index (P=.031). In a large cohort of patients with suspected coronary artery disease referred for SE, resting GLS <15% was independently associated with mortality and hard cardiac events, incremental to SE data. Model discrimination including resting GLS measurement was comparable to discrimination including SE results.

OR35. Exercise Effect on Global Myocardial Function Score in Patients with Refractory Angina Undergoing Extracorporeal Shockwave Myocardial Revascularization (ESMR): A Study focusing on Speckle Tracking and Exercise Stress Echocardiography

Abstract Aims Refractory angina pectoris (RAP) is defined as the occurrence of frequent angina attacks uncontrolled by optimal drug therapy. Extracorporeal shockwave myocardial revascularization (ESMR) is one of the alternative therapies that can be performed to treat RAP. Stress echocardiography is necessary to determine the inducible myocardial segments. To date, study evaluating the effect of exercise on myocardial function using WMSI and GLS was still limited. The aim of this study was to show the effect of exercise on global myocardial function evaluated using GLS and WMSI from echocardiography. Methods and Results This is a cross sectional and single center study of 9 Refractory Angina Pectoris patients underwent stress echocardiography from April - June 2021 in Mohammad Hoesin General Hospital, Palembang. Pre and post exercise WMSI and GLS were obtained and analyzed using McNemar non-parametric test. There were no significant differences between both pre and post GLS (p = 0.500) and WMSI (p = 0.250) through exercise stress echocardiography. Conclusion Our study showed no significant difference of global myocardial function evaluated by GLS and WMSI, pre and post exercise. Segmental myocardial function analysis seems to be more potential as useful assessment for RAP undergoing ESMR procedure.

Fully automated left ventricular ejection fraction and global longitudinal strain predicts obstructive coronary artery disease in patients undergoing stress echocardiography: a multi-centre study

Abstract Background Assessment of LVEF and myocardial deformation with GLS has shown promise in predicting CAD, which may add prognostic information for patients undergoing SE. However, selection bias precludes an accurate assessment of routine clinical SE workflow due to the exclusion of poor image quality and contrast enhanced studies. We hypothesise that an artificial intelligence (AI) pipeline capable of fully automated contouring of the left ventricle and GLS analysis of both non-contrast and contrast SE images is feasible and can predict CAD. Purpose The aim of this study was to evaluate the prediction of obstructive coronary artery disease (CAD) from fully automated left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) measures in a large multicentre population of patients undergoing stress echocardiography (SE). Methods 500 patients from five medical centres undergoing SE for the clinical evaluation of ischaemic heart disease were included in this study. LVEF and GLS was automatically calculated using AI in non-contrast and contrast images at rest and peak stress. The primary endpoint was CAD assessed using invasive coronary angiography. Results Patients with significant CAD demonstrated significantly reduced LVEF and GLS at rest and peak stress (all p&amp;lt;0.001) compared to those without CAD. Of the 130 patients who exhibited myocardial ischaemia at peak stress, patients without significant CAD (37%) had significantly reduced LVEF and GLS when compared to those who did. Multivariate analysis demonstrated that a peak LVEF (0.93; 95% CI 0.9–0.96) and peak GLS (1.15; 95% CI 1.07–1.24) were significant independent predictors of CAD. The addition of automated LVEF and GLS to basic models significantly improved the C statistic from 0.78 to 0.83 and 0.85 (both p&amp;lt;0.001), respectively. Conclusions Fully automated LVEF and GLS in non-contrast and contrast SE images is feasible and independently augment the prediction of obstructive CAD above and beyond traditional SE indexes. Funding Acknowledgement Type of funding sources: None.

Assessing the Stress Echocardiography in Women With Breast Arterial Calcification.

Objective: breast arterial calcification (BAC) is one of the most prevalent mammographic findings and has been debated as a marker of cardiovascular disease (CVDs). The present study aimed to assess the findings of stress echo in women with BAC. Materials and methods: This cross-sectional study was conducted on women who undergo mammography for routine breast cancer screening at Imam Reza hospital, western Iran from March 2018 to July 2018. The patients underwent stress echocardiography to evaluate the probability of myocardial ischemia (MI). Chi-square and independent t-tests were used to assess the differences between subgroups. Results: BAC was present in 61 (15.2%) women. The mean age of the patients with BAC was significantly higher than the patients without BAC (58.59± 7.82 vs. 55.32±6.57, p =0.003). Prevalence rates of the menopause (88.5% vs. 71.1%, p=0.009), hypertension (29.5% vs. 17.7%, p=0.032), and hypercholesterolemia (24.6% vs. 13.0, p=0.018) were significantly higher in the patients with BAC compared to the patients without BAC. The prevalence rate of MI symptoms in the patients with BAC was equal to 24.6%. Significantly, more women with BAC were positive for myocardial ischemia compared to the women without BAC (24.6% vs. 8.5%, p<0.001). The prevalence rates of the diabetes mellitus, hypertension, hypercholesterolemia, and history of CVDs were significantly higher in the patients who were positive for MI. Conclusion: It was found that BACs are correlated with an increased occurrence rate of CVDs. Our results illustrated that the patients who were positive for MI were more plausible to be diabetic, hyperlipidemic, hypertensive, and having a history of CVDs.

Evaluation of strain parameters during stress-echocardiography with physical exercise may be significant in detecting severe coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background. Assessment of the left ventricular strain during speckle-tracking stress echocardiography may be significant in diagnosing transient myocardial ischemia. So it is challenging to evaluate left ventricular global longitudinal strain (GLS) and post-systolic shortening indicators during stress-echocardiography and compare their diagnostic value with the data obtained with invasive methods of diagnosing coronary artery disease (CAD). Aim of the study. The aim of this study was to determine the diagnostic capabilities of the left ventricular GLS, delta GLS, left ventricular post-systolic index (PSI) and post-systolic time (PST) obtained during stress echocardiography with exercise on the treadmill in defining the presence and significance of CAD. Methods. The study included 113 patients (mean age 64.8 ± 9.4 years; 43 females) with known or suspected CAD. All patients underwent stress echocardiography with exercise on the treadmill. At rest and after treadmill-test, all patients were measured for the values of left ventricular GLS, left ventricular PSI and PST using the AFI (Automated functional imaging) algorithm. The delta of the left ventricular GLS values was also counted. The delta of the left ventricular GLS values was counted as the difference of the left ventricular GLS values after the load and at rest. All patients underwent coronary angiography, assessment of the severity of CAD was counted according to the Gensini score. According to the results of coronary angiography, the patients were divided into 3 groups: 41 patients without CAD, 53 patients with moderate CAD (≤34 points on the Gensini score) and 19 patients with severe CAD (&amp;gt;35 points on the Gensini score). Results. In the group of patients with severe CAD, values of left ventricular GLS after the load significantly differed from the group of patients without CAD (16,1 compared with 20,3; p = 0,003) and from the group of patients with moderate CAD (16,1 compared with 19,4; p = 0,003). At rest GLS values didn’t differ significantly between all groups. Left ventricular GLS delta in the group of patients with severe CAD differed significantly with the group of patients without CAD (-1,8 compared with 1,3; p = 0,003) and with the group of patients with moderate CAD (-1,8 compared with 0,6; p = 0,03). Left ventricular PSI differed significantly between the group of patients with severe CAD and the group of patients without CAD after the load (8,4 compared with 5,1; p = 0,03) and at rest didn’t differ significantly. Left ventricular PST values didn’t differ significantly at rest and after the load in all groups. Conclusions. Strain parameters such as left ventricular GLS, left ventricular GLS delta and left ventricular PSI assessed during stress-echocardiography on the treadmill may be useful in identifying patients with severe CAD. Left ventricular PST didn’t show significance in identifying CAD.

Prognostic Value of Intraplaque Neovascularization Detected by Carotid Contrast-Enhanced Ultrasound in Patients Undergoing Stress Echocardiography

Stress echocardiography (SE) is used for diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). Contrast-enhanced ultrasound (CEUS) detects carotid intraplaque neovascularization (IPN). The aim of this study was to test the hypothesis that combining SE with carotid CEUS in patients with known or suspected CAD might provide incremental prognostic value beyond clinical risk factors and either test alone for the occurrence of cardiovascular events. One hundred eighty-five patients (mean age, 69±8years; 79% men) with known or suspected CAD referred for SE and found to have carotid plaque on screening were recruited for carotid CEUS imaging. IPN was graded by presence and location within plaque. Patients were followed for cardiovascular events (CVEs) including cardiac death, myocardial infarction, unstable angina, and transient ischemic attack or stroke. A subset of patients (n=27) underwent carotid magnetic resonance imaging within 1month of CEUS; carotid plaque was assessed for lipid-rich necrotic core, loose matrix, and presence of intraplaque hemorrhage. Sixty-nine patients had abnormal findings on SE. IPN was identified in 112 patients; 52 patients had IPN localized to plaque shoulder (IPNS). Plaques with IPNS had larger lipid-rich necrotic cores and were more likely to have intraplaque hemorrhage. During follow-up (median, 31months), 26 CVEs occurred. Multivariate Cox proportional-hazard analysis showed IPN and IPNS to be predictors of CVEs (hazard ratios, 3.34 [95% CI, 1.25-8.93; P=.02] and 4.88 [95% CI, 1.77-13.49; P=.002], respectively). The presence of IPNS increased the likelihood of CVEs beyond SE and history of CAD (χ2=9.0, P=.02). Carotid IPN detected by CEUS and localized to plaque shoulder was an independent predictor of CVEs in patients referred for SE.

P1399 Global longitudinal systolic deformation of the left ventricle during stress echocardiography with physical exercise may identify patients with severe coronary artery disease

Abstract Background Assessment of longitudinal systolic deformation of the left ventricular myocardium during speckle tracking stress echocardiography can potentially be significant in the diagnosis of transient myocardial ischemia. In this regard, determination of the global longitudinal systolic deformation (GLSD) of the left ventricle during stress echocardiography is challenging and its diagnostic capabilities can be assessed by comparing them with the data obtained with invasive methods for diagnosing coronary artery disease (CAD). Aim of the study The aim of this study was to determine the diagnostic capabilities of the left ventricular GLSD obtained during stress echocardiography with exercise on the treadmill in defining the presence and significance of CAD. Methods The study included 80 patients (mean age 68.3 ± 7.8 years; 29 females). All patients underwent stress echocardiography with exercise on the treadmill. At rest and after treadmill-test, all patients were measured for the values of the left ventricular GLSD using the AFI (Automated functional imaging) algorithm. The delta of the left ventricular GLSD values was counted. The delta of the left ventricular GLSD values was counted as the difference of the left ventricular GLSD values at rest and after the exercise. All patients underwent coronary angiography, assessment of the severity of CAD was counted according to the Gensini score. According to the results of coronary angiography, the patients were divided into 3 groups: 21 patients without CAD, 45 patients with moderate CAD (&amp;lt;34 points on the Gensini score) and 14 patients with severe CAD (&amp;gt; 34 points on the Gensini score). Results In the group of patients with severe CAD, the value of the left ventricular GLSD delta at rest and after treadmill-test significantly differed from the groups of patients with moderate CAD and without CAD (-0.56 compared with 2.17; p = 0,009). In the group of patients without CAD, the value of the left ventricular GLSD delta at rest and after treadmill-test did not significantly differ from the group of patients with CAD (0.23 compared to -0.95; p = 0.199). Conclusions The delta of the left ventricular GLSD obtained during stress echocardiography with exercise on the treadmill showed a reliable significance in determining severe CAD, but did not demonstrate a reliable significance in identifying the absence of CAD.

Incremental Prognostic Value of Stress Echocardiography With Carotid Ultrasound for Suspected CAD

ObjectivesThis study hypothesized that ischemia and atherosclerosis assessment by ultrasound (US) may provide incremental prognostic information in patients with new-onset chest pain who do not have coronary artery disease (CAD). BackgroundThe clinical significance of atherosclerosis assessment by carotid US in patients undergoing stress echocardiography (SE) in such patients is unknown. MethodsConsecutive patients with suspected angina but no history of CAD underwent simultaneous SE and US prospectively to assess myocardial ischemia and carotid plaque burden (CPB), respectively. Patients were followed up for major adverse events (MAEs)—all-cause mortality, nonfatal myocardial infarction, and unplanned coronary revascularization. ResultsOf 591 recruited patients, 580 (men, 46%; mean age 59 ± 11 years) patients were available for follow-up. SE demonstrated myocardial ischemia in 12%, but prevalence of carotid plaques was 59%. During a mean follow-up of 1,117 ± 361 days, 40 first MAEs occurred. In the multivariable regression model, pre-test probability (PTP) of CAD (p = 0.001), abnormal SE (p < 0.0001), and CPB (p < 0.0001) predicted MAEs. MAE rates per year increased from 0.9% versus 1.97% versus 4.3% versus 9.7% in patients with no carotid plaque and normal SE versus patients who had plaque and normal SE versus those with no plaque and abnormal SE versus patients with plaque and abnormal SE, respectively (p < 0.0001). In hierarchical analysis, plaque burden provided incremental prognostic value over PTP of CAD and SE; likewise, SE was incremental to PTP-CAD and CPB (p < 0.0001 for both). ConclusionsIn patients with suspected stable angina without known CAD, simultaneous SE (for ischemia) and US (for atherosclerosis) provided incremental prognostic value.

Safety With Echocardiographic Contrast Agents.

In October 2007, the Food and Drug Administration mandated significant revisions to product labeling for the commercially available echocardiographic contrast agents (ECA) Definity and Optison after spontaneous healthcare provider reports of 4 patient deaths and ≈190 severe cardiopulmonary reactions occurring in close temporal relationship to ECA administration. Since then, multiple large ECA safety studies have been published and have included outpatients, hospitalized patients (including the critically ill), patients undergoing stress echocardiography, and patients with pulmonary hypertension. In addition, the Food and Drug Administration has convened 2 Advisory Committee meetings and the product labels for Optison and Definity have been substantially revised with a softening of safety restrictions. In this review, we will address the safety of ECA use in patients with serious cardiopulmonary conditions, patients with intracardiac shunts, and special patient populations including pulmonary hypertension, pediatrics, and pregnancy. In addition, we will discuss the confounding role of pseudocomplication in attribution of adverse events during diagnostic testing, the current status of the ECA Black Box Warning, and recommended safety precautions during ECA administration.

Global longitudinal strain from resting echocardiogram is associated with long-term adverse cardiac outcomes in patients with suspected coronary artery disease.

Measuring myocardial strain using two-dimensional speckle tracking echocardiography has emerged as a new tool to identify subclinical ventricular dysfunction. Abnormal strain has been shown to have superior sensitivity compared with dobutamine stress echocardiography for viability assessment; however, there is a paucity of data regarding the prediction of long-term major adverse cardiac events. We compared the prognostic ability of both global longitudinal strain (GLS) from resting echocardiograms to regional wall motion score index (WMSI) from stress echocardiograms in their ability to predict long-term major adverse cardiac events. Patients referred for stress echocardiography, who also underwent coronary angiography within 3 months of stress echo (n=122), were enrolled. Patients with reduced ejection fractions (<40%) were excluded. Patients were followed for a median of 3.4 years for major adverse cardiac events, readmissions and repeat cardiac testing. Patients with abnormal GLS (GLS <16.8%) from the resting echocardiogram obtained as part of the exercise echocardiogram experienced a significantly shorter time to major adverse cardiac events (p=0.026), first cardiovascular hospitalization and repeat cardiac testing (p=0.0011) compared to those with normal GLS. Abnormal GLS appears to be a better predictor than abnormal WMSI in predicting major adverse cardiac events (p=0.174) and time to first cardiovascular hospitalization or repeat cardiac testing (p=0.0093). GLS may be a better predictor of long-term major adverse cardiac events, readmissions and repeat cardiac testing than WMSI in patients undergoing stress echocardiography.

Myocardial Contrast Agents – Safety Considerations and Clinical Efficacy in Stress Echocardiography

Abstract Transthoracic echocardiographic examination is known to be a safe, non-invasive and reproducible method, used in every day clinical practice to obtain important information about cardiac structure and function. Unfortunately, a significant proportion of studies have highlighted the considerable technically difficultly in producing diagnostic images due to a poor acoustic window and more than 33% of patients undergoing stress echocardiography have suboptimal echocardiographic images. All these limitations have led to the use of contrast agents to improve the quality of standard ultrasound examination to provide a better delineation of left ventricle endocardial borders or to obtain information that cannot be achieved by using standard echocardiography, such as assessing myocardial microcirculation and therefore perfusion. This paper sought to review the clinical efficacy and safety of ultrasound contrast agents focusing on stress echocardiography.

SIMULTANEOUS CAROTID ULTRASONOGRAPHY PROVIDES INCREMENTAL PROGNOSTIC VALUE BEYOND CLINICAL AND STRESS ECHOCARDIOGRAPHY DATA IN PATIENTS WITH SUSPECTED ANGINA WITHOUT KNOWN CORONARY ARTERY DISEASE: A PROSPECTIVE STUDY

Carotid plaque burden (CPD) has been shown to predict cardiovascular risk beyond traditional risk factors. However, potential impact of CPD in patients undergoing stress echocardiography (SE) for new onset chest pain without known coronary artery disease (CAD) is unknown. Consecutive patients with

Abstract 135: Clinical Decision Making Utility of Stress Echocardiography in Contemporary Managed Patients with Suspected Coronary Artery Disease

Background: We have investigated outcomes of contemporary management in patients undergoing stress echocardiography for evaluation of chest pain. Methods: Records of 294 consecutive patients who underwent a stress echocardiogram at a single tertiary care center were reviewed. Demographic, clinical data, and outcomes were collected. ANOVA, chi-square, and logistic regression analyses were used. Mean follow up length was 37 months. The study was approved by the IRB. Results: This study cohort included 46% women, with an average age of 61 +/- 10.6 years old; 20% were current smokers, with history of CAD in 26%, CHF in 4%, hypertension in 40%, diabetes in 14%, and peripheral vascular disease in 4%. Baseline medical treatment included beta blockers in 46% and ACE inhibitors in 24%. The majority (94%) of these patients underwent a dobutamine stress echocardiogram. Fifty five of the 294 patients had ischemia during the test. Males were twice as likely to have ischemia during the stress test compared to females (24% vs. 12% p=0.009). There was a trend towards increased prevalence of ischemia in diabetics (26% vs. 17% p=0.175) and in smokers (24% vs. 17% p=0.262). The presence of ischemia was associated with a 40% increase in mortality (14.5% vs. 10.5%) and an approximately 3-fold increase in MI (9.1% vs. 2.9% p=0.0679). Patients with ischemia during stress testing were ten times more likely to have invasive cardiac evaluation and changes in medications compared to patients without ischemia during stress testing (41.5% vs. 4.1% p&lt;0.001) or undergo invasive evaluation without a change in medications (24.5% vs. 3.3% p&lt;0.001). Invasive evaluation was not associated with a reduction in mortality (13.4% vs. 10.4% p=0.349). However, change in medications alone was associated with increased mortality (16.7% vs. 9.7% p=0.04). Conclusions: In the majority of contemporary managed patients with suspected coronary artery disease, stress testing is likely to have a normal result. When abnormal, it typically leads to invasive evaluation and/or medication changes. The small sample size of patients with ischemia in our study limits our ability to discern the effects of invasive evaluation and/or medicine changes on outcomes. Additional studies of this important subject are needed.

Prognostic Value of Stress Echocardiography in Patients Presenting with Syncope.

Evaluation for ischemia is appropriate in patients at risk for or with a history of coronary artery disease presenting with syncope. The aim of this study is to determine the prognostic value of stress echocardiography in patients presenting with syncope. We examined our database of all patients undergoing stress echocardiography at our institution. Patients referred due to syncope were grouped as high risk based on any of the following: (1) known history of coronary artery disease, (2) left ventricular ejection fraction <50%, (3) moderate or severe mitral or aortic valve regurgitation, and (4) moderate mitral or aortic valve stenosis. The main outcomes were the presence of ischemia on stress imaging and all-cause mortality using the social security death index. A total of 225 patients were identified; mean age was 64.3 ± 14.5 years, the mean follow-up duration was 29.2 ± 13.8 months. There were 163 patients in the low-risk group and 62 patients in the high-risk group. On imaging, 7% of the overall cohort had ischemia. The low-risk group had 5 (3%) patients with ischemia and the high-risk group had 10 patients (16%) with ischemia (P < 0.01). The mortality rate was significantly higher in the high-risk group (3.99%/year vs. 1.02%/year; P = 0.02); this difference was not affected by the presence of ischemia. High-risk patients with syncope as defined by appropriateness criteria and existing evidence carry a higher risk of ischemia and all-cause mortality. The presence of ischemia may not be predictive of long-term outcome in this group.

Rest global longitudinal 2D strain to detect coronary artery disease in patients undergoing stress echocardiography: a comparison with wall-motion and coronary flow reserve responses.

Myocardium subtended by obstructive coronary artery disease (CAD) may show reduced left ventricle (LV) global longitudinal strain (GLS), as well as early systolic lengthening (ESL) before shortening; these can be measured at rest and may predict obstructive CAD. This study investigated whether baseline resting LV longitudinal strain measurements may be able to detect significant CAD in patients undergoing stress echocardiography (SE) and coronary angiography, who have normal resting wall motion. We selected patients with a clinical indication of coronary angiography who were previously referred for SE. Patients with known CAD, rest wall-motion (WM) abnormalities, or rhythm/conduction abnormalities were excluded. Speckle tracking strain analyses were retrospectively performed on digitally archived 2D video-loops, using vendor independent software. Peak GLS and duration of ESL were recorded. Diagnostic accuracy of each parameter to predict obstructive (≥50%) CAD was assessed and multivariate logistic regression models fitted and compared. Eighty-two patients were enrolled and 49 had significant CAD by quantitative angiography. Patients with CAD were more often male (P=0.01) and more frequently presented with typical angina (P<0.01). Among rest and stress variables, GLS showed a Youden index of 0.665, while SE WM assessment showed a Youden index of 0.599. These were the only two parameters that remained predictive in multivariate analyses. In conclusion, rest GLS demonstrated comparable accuracy with stress-echo data for prediction of angiographically obstructive CAD; it also added significant CAD prediction when combined with clinical data, similar to SE WM assessment.