Exercise Echocardiographic Results Research Articles

Diagnosis of heart failure with preserved ejection fraction based on exercise stress echocardiography in real-world practice

Abstract Aims The diagnostic difficulty of heart failure with preserved ejection fraction (HFpEF) is related to the fact that many patients develop abnormal hemodynamics only during exercise. Exercise stress echocardiography is a first-line test to unmask such abnormalities, but exercise protocols and diagnostic criteria have not been established. It remains unclear how cardiologists diagnose HFpEF by exercise echocardiography in real-world practice. Methods and Results An international web-based survey was performed on 87 cardiologists, 59% of whom had ≥ 6 years of experience with exercise echocardiography. A retrospective cohort of 652 dyspneic patients who underwent exercise echocardiography was used to determine the impact of different diagnostic criteria on the proportion of HFpEF diagnosis. The most commonly used exercise echocardiography criterion for the HFpEF diagnosis was the HFA-PEFF algorithm (48%), followed by the ASE/EACVI criteria (24%) and some combinations of multiple parameters (22%). A retrospective study found that the proportion of HFpEF diagnosis varied substantially between the criteria used: 20.1% for the ASE/EACVI criteria and 44.3% for the HFA-PEFF algorithm. A survey demonstrated that 54% of the participating cardiologists would initiate sodium-glucose co-transporter 2 inhibitors based on exercise echocardiography results. Conclusion In real-world practice, exercise echocardiography criteria for HFpEF diagnosis vary among cardiologists. While many cardiologists consider initiating pharmacological treatment on exercise echocardiography results, the frequency of HFpEF diagnosis varies substantially depending on the diagnostic criteria used. The lack of universal diagnostic criteria may limit the delivery of evidence-based treatment to patients with HFpEF.

P358 Prevalence of suicide in a cohort of subjects submitted to exercise echocardiography: clinical characteristics and exercise echocardiography results

Abstract Patients with clinical symptoms and morbidities might be more prone to commit suicide. Suicidal rate reaches up to 25-30/100.000 subjects in the countries most affected by this problem. We aimed to establish the rate of suicides among a large cohort of patients submitted to Exercise echocardiography (ExE), and also to study their clinical and ExE results, to better understand possible explanations. Methods Retrospective analysis of prospectively collected data on 12,615 patients (age 62 ± 12 years, 63% men) with a first treadmill ExE performed in our center for known/suspected coronary artery disease. Exclusion criteria were significant valve disease, cardiomyopathy, congenital heart disease, and age <18 year-old. Ischemia was defined as the development of new wall motion abnormalities (WMAs) with exercise; abnormal ExE as ischemia or resting WMAs. Results During a follow-up of 4.7± 4.8 years (interquartil range 0.1-8.0 years) there were 2,578 deaths, including 21 due to suicide (rate 166/100.000 subjects). We compare clinical characteristics and ExE results between patients that committed suicide (S), patients that died of other causes (OC), and patients that survived (Surv). The worst clinical and ExE characteristics were found in patients that died of non-suicidal causes, whereas patients that committed suicide were in an intermediate risk position (Table). In conclusion, suicidal rate seems to be very high among patients with a clinically indicated ExE. Clinical characteristics and ExE results of suicidal subjects are worse than in survivor patients and could in part explain this event. Surv S OC P value Age, y 61 ± 12 65 ± 11 69 ± 9 <0.001 Male 60% 86% 72% <0.001 Diabetes Mellitus 17.5% 24% 31% <0.001 Achieved METS 9.7 ± 3.2 8.3 ± 3.6 7.6 ± 2.9 <0.001 Good functional capacity (≥10 METs) 55% 52% 29% <0.001 Symptoms during ExE 16% 14% 19% 0.01 Maximal double product 25.0 ± 5.9 22.5 ± 6.4 22.9 ± 6.0 <0.001 Submaximal test 20% 31% 32% <0.001 Ischemia 27% 38% 44% <0.001 ExE abnormal 37% 50% 63% <0.001 LVEF at rest 59 ± 7 53 ± 13 54 ± 11 <0.001 LVEF at peak 64 ± 11 60 ± 16 55 ± 15 <0.001

Abnormal exercise echocardiography plus abnormal E/e′ ratio at exercise portends worse outcome in patients with dyspnea

BackgroundThe role of exercise echocardiography (ExE) for the assessment of patients with dyspnea is promising. We aimed to analyze the clinical characteristics and outcome of patients with this condition referred for ExE. MethodsA total of 505 patients (66 ± 11 years, 57% women) referred for evaluation of dyspnea were considered. Mitral regurgitation, ratio of early left ventricular inflow wave to early diastolic annulus wave (E/e′), and wall motion abnormalities (WMAs) were measured at rest and at exercise. Considered events were overall mortality, non-fatal myocardial infarction, late revascularization, and admission for heart failure. ResultsIschemia was observed in 102 patients (20%), whereas WMAs were already present at rest in 55 patients (11%). A percent achieved of predicted metabolic equivalents >100% was found for most of the patients (70%). During a median follow-up of 3.50 years, 66 patients had events (annualized event rate 3.5%). An E/e′ value of 13 at post-exercise was the best cut-off value to predict events. After adjustment by clinical and ExE variables, the combination of an abnormal ExE and E/e′ values at post-exercise ≥13 was an independent predictor of events (hazard ratio = 3.67, 95% confidence interval = 2.11–6.38, p < 0.001). The worse outcome corresponded to patients with abnormal ExE and raised E/e′ values at post-exercise (annualized event rate 17.2%). Patients with normal E/e′ values at post-exercise had better outcome irrespective of the ExE results (annualized event rate 2.2% with normal ExE and 2.9% with abnormal ExE), whereas patients with high E/e′ values at post-exercise but normal ExE results were at intermediate risk (annualized event rate 5.0%). ConclusionsDespite favorable ExE results, event rate remains high among patients with dyspnea referred for ExE, which may have a role to predict outcome in this setting. Patients with both raised E/e′ values at post-exercise and abnormal ExE results are at the highest event risk.

Left ventricular torsion and circumferential strain responses to exercise in patients with ischemic coronary artery disease.

LV torsion during exercise in patients with coronary artery disease (CAD) is not well known. Circumferential strain (CS) and left ventricular (LV) torsion (Tor) have not been evaluated during ischemia in these patients. We aimed to assess the effect of ischemia during exercise echocardiography (ExE) on CS and Tor. We studied a group of 73 patients with true positive ExE results (Ischemic group: ischemia plus an abnormal coronary angiogram) and a matched control group of 66 patients with negative ExE and either normal coronary angiography or low post-test probability of CAD. Basal rotation (Rot) and apical rotation and basal and apical CS were studied by speckle tracking at rest and exercise. Apical CS and apical and basal Rot values were similar between groups at rest, except basal CS which was already worse in the ischemic group. At exercise, all rotational and CS parameters were impaired in the ischemic in comparison with the control group (basal CS: -18 ± 5 vs. -25 ± 7 %, p < 0.001; apical CS: -31 ± 11 vs. - 43 ± 9 %, p < 0.001; time to basal CS: 52 ± 6 vs. 48 ± 7 %, p = 0.001; time to apical CS: 55 ± 7 vs. 49 ± 6 %, p < 0.001; basal rotation: -0.7 ± 6.5° vs. -6.2 ± 8.5°, p < 0.001; LV twist 13.0 ± 10.4° vs.19.7 ± 11.5°, p < 0.001; LV-Tor 1.9 ± 1.6°/cm vs. 2.8 ± 1.7˚/cm, p = 0.001) with the exception of apical rotation which was similar (12.3 ± 7.4° vs. 13.4 ± 7.7°, p = NS). Basal and apical CS and basal rotation impair during exercise-induced ischemia. LV-Tor decreases with ischemia due to worsening of basal rotation, whereas apical rotation does not impair, suggesting the existence of an apical compensatory mechanism.

Hypertension is strongly associated with false-positive bicycle exercise stress echocardiography testing results

Introduction: Exercise echocardiography is a reliable routine test in patients with known or suspected coronary artery disease. However, in ∼15% of all patients, stress echocardiography leads to false-positive stress echocardiography results. We aimed to investigate the impact of hypertension on stress echocardiographic results.Methods: We performed a retrospective study of patients with suspected or known stable coronary artery disease who underwent a bicycle exercise stress echocardiography. Patients with false-positive stress results were compared with those with appropriate results.Results: 126 patients with suspected or known coronary artery disease were included in this retrospective study. 23 patients showed false-positive stress echocardiography results. Beside comparable age, gender distribution and coronary artery status, hypertension was more prevalent in patients with false-positive stress results (95.7% vs. 67.0%, p = 0.0410). Exercise peak load revealed a borderline-significance with lower loads in patients with false-positive results (100.0 (IQR 75.0/137.5) vs. 125.0 (100.0/150.0) W, p = 0.0601). Patients with false-positive stress results showed higher systolic (2.05 ± 0.69 vs. 1.67 ± 0.39 mmHg/W, p = 0.0193) and diastolic (1.03 ± 0.38 vs. 0.80 ± 0.28 mmHg/W, p = 0.0165) peak blood pressure (BP) per wattage. In a multivariate logistic regression test, hypertension (OR 17.6 [CI 95% 1.9–162.2], p = 0.0115), and systolic (OR 4.12 [1.56–10.89], p = 0.00430) and diastolic (OR 13.74 [2.46–76.83], p = 0.00285) peak BP per wattage, were associated with false-positive exercise results. ROC analysis for systolic and diastolic peak BP levels per wattage showed optimal cut-off values of 1.935mmHg/W and 0.823mmHg/W, indicating false-positive exercise echocardiographic results with AUCs of 0.660 and 0.664, respectively.Conclusions: Hypertension is a risk factor for false-positive stress exercise echocardiographic results in patients with known or suspected coronary artery disease. Presence of hypertension was associated with 17.6-fold elevated risk of false-positive results.

Temporal changes in the use and results of exercise echocardiography.

Limited data are available regarding changes over time in referral patterns and outcomes of non-invasive cardiac stress testing. Our aim was to evaluate the temporal changes in the use and results of exercise echocardiography in our area of reference. A total of 12 339 patients referred to our unit for exercise echocardiography between 1997 and 2012 were included. We divided the 16-year period into four quadrennia and evaluated the changes in clinical data, results of the tests, referrals for invasive management and outcomes. We observed a gradual decrease in the frequency of detection of myocardial ischaemia from 35.3% in1997-2000 to 25.4% in 2009-12 (P < 0.001). There was also a progressive increase in the prevalence of cardiovascular risk factors and in the frequency of non-ischaemic chest pain and dyspnoea, while the proportion of patients with prior myocardial infarction and non-interpretable electrocardiograms declined. The rate of referral to coronary angiography within 6 months decreased from 24.8% in 1997-2000 to 19.6% in 2009-12 (P < 0.001), but the rate of coronary revascularization remained almost unchanged (13.1 to 11.7%, P for the trend = 0.16). We also observed a progressive decrease in the 1-year mortality rate from 3.4 to 1% (P < 0.001). Over a 16-year period, there was a gradual decrease in the frequency of myocardial ischaemia among patients referred to our unit for exercise echocardiography, which was parallel to changes in their clinical profile. However, this was not accompanied by a significant reduction in the rate of coronary revascularization.

Prognostic Value of Normal Exercise Echocardiography in a One-Year Follow-up

Background: Exercise echocardiography is a well-validated technique for the diagnosis of coronary artery disease. In addition to the diagnostic role, it also provides useful prognostic information. Objectives: The aim of this cross sectional study was to assess the prognosis of patients with negative exercise echocardiographic results over a one-year period follow-up. Patients and Methods: The outcomes of 336 patients who had normal exercise echocardiograms were examined. All clinical and exercise echocardiogram parameters were recorded. Patients were followed up for 1 year. End points were defined as cardiac death, non-fatal myocardial infarction, hospital admission for coronary artery disease, and coronary revascularization. Results: Mean age was 54.55 ± 10.34 years. 63.4 % were women. The most frequent risk factor was hypertension. There was no significant statistical difference between men and women regarding the prevalence of systemic hypertension, diabetes mellitus, and history of coronary artery bypass grafting. 5.67% of men and 8.9 % of women had positive exercise tolerance test for ischemia. Hemodynamic parameters, diastolic function, severity of mitral regurgitation, pulmonary artery pressures, peak strain rate were not significantly different between men and women, but rest strain rates were significantly lower in women. Total exercise times and exercise capacity were higher in men. After a 1-year follow-up there was no cardiac events and mortality. Conclusions: Patients with normal exercise echocardiogram results regardless of ischemia or chest pain during the test had excellent outcomes over a one-year follow-up.

Exercise Echocardiography and Multidetector Computed Tomography for the Evaluation of Acute Chest Pain

Introduction and objectivesUp to 4% of patients with acute chest pain, normal electrocardiogram, and negative troponins present major adverse cardiac events as a result of undiagnosed acute coronary syndrome. Our aim was to compare the diagnostic performance of multidetector computed tomography and exercise echocardiography in patients with a low-to-intermediate probability of coronary artery disease. MethodsWe prospectively included 69 patients with acute chest pain, normal electrocardiogram, and negative troponins who underwent coronary tomography angiography and exercise echocardiography. Patients with coronary stenosis ≥ 50% or Agatston calcium score ≥ 400 on coronary tomography angiography or positive exercise echocardiography, or with inconclusive results, were admitted to rule out acute coronary syndrome. ResultsAn acute coronary syndrome was confirmed in 17 patients (24.6%). This was lower than the suspected 42% based on coronary tomography angiography (P<.05) and not significantly different than the suspected 29% based on the results of exercise echocardiography (P=.56). Exercise echocardiography was normal in up to 37% of patients with pathological findings on coronary tomography angiography. The latter technique provided a higher sensitivity (100% vs 82.3%; P=.21) but lower specificity (76.9% vs 88.4%; P=.12) than exercise echocardiography for the diagnosis of acute coronary syndrome, although without reaching statistical significance. Increasing the stenosis cutoff point to 70% increased the specificity of coronary tomography angiography to 88.4%, while maintaining high sensitivity. ConclusionsCoronary tomography angiography offers a valid alternative to exercise echocardiography for the diagnosis of acute coronary syndrome among patients with low-to-intermediate probability of coronary artery disease. A combination of both techniques could improve the diagnosis of acute coronary syndrome.

Evaluación del dolor torácico agudo mediante ecocardiografía de ejercicio y tomografía computarizada multidetectores

Introduction and objectivesUp to 4% of patients with acute chest pain, normal electrocardiogram, and negative troponins present major adverse cardiac events as a result of undiagnosed acute coronary syndrome. Our aim was to compare the diagnostic performance of multidetector computed tomography and exercise echocardiography in patients with a low-to-intermediate probability of coronary artery disease. MethodsWe prospectively included 69 patients with acute chest pain, normal electrocardiogram, and negative troponins who underwent coronary tomography angiography and exercise echocardiography. Patients with coronary stenosis ≥ 50% or Agatston calcium score ≥ 400 on coronary tomography angiography or positive exercise echocardiography, or with inconclusive results, were admitted to rule out acute coronary syndrome. ResultsAn acute coronary syndrome was confirmed in 17 patients (24.6%). This was lower than the suspected 42% based on coronary tomography angiography (P<.05) and not significantly different than the suspected 29% based on the results of exercise echocardiography (P=.56). Exercise echocardiography was normal in up to 37% of patients with pathological findings on coronary tomography angiography. The latter technique provided a higher sensitivity (100% vs 82.3%; P=.21) but lower specificity (76.9% vs 88.4%; P=.12) than exercise echocardiography for the diagnosis of acute coronary syndrome, although without reaching statistical significance. Increasing the stenosis cutoff point to 70% increased the specificity of coronary tomography angiography to 88.4%, while maintaining high sensitivity. ConclusionsCoronary tomography angiography offers a valid alternative to exercise echocardiography for the diagnosis of acute coronary syndrome among patients with low-to-intermediate probability of coronary artery disease. A combination of both techniques could improve the diagnosis of acute coronary syndrome.Full English text available from:www.revespcardiol.org/en

Characteristics and Outcomes of Patients Who Achieve High Workload (≥10 Metabolic Equivalents) During Treadmill Exercise Echocardiography

To determine the frequency and prognostic significance of abnormal exercise echocardiographic results for patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise echocardiography. Patients who underwent treadmill exercise echocardiography from November 1, 2003, through December 31, 2008, and exercised for 9 or more minutes using the Bruce protocol (N=7236) were included. Clinical and exercise echocardiographic characteristics and outcomes were evaluated. Variables associated with abnormal exercise echocardiographic results and mortality were identified. Exercise echocardiographic results were positive for ischemia in 862 patients (12%). Extensive ischemia developed in 265 patients (4%). For patients with normal exercise echocardiographic results, all-cause and cardiovascular mortality rates were 0.30% and 0.05% per person-year of follow-up, respectively. For patients who had extensive ischemia, all-cause and cardiovascular mortality rates were 0.84% and 0.25% per person-year of follow-up, respectively. Patients at highest risk were those who had extensive and severe regional wall motion abnormalities at rest (n=58), and their all-cause and cardiovascular mortality rates were 2.65% and 0.76% per person-year of follow-up. Exercise echocardiographic variables did not identify sizable patient subgroups at risk for death and did not provide incremental prognostic information (C statistic was 0.74 compared with 0.73 for the clinical plus exercise electrocardiography model). Patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise testing do not often have extensive ischemic abnormalities on exercise echocardiography. Although exercise echocardiographic results provide some prognostic information, it is not of incremental value for these patients, whose short-term and medium-term prognosis is excellent.

Value of an Exercise Workload ≥10 Metabolic Equivalents for Predicting Inducible Myocardial Ischemia

We sought to identify extensive ischemia on exercise echocardiography (ExE) relative to workload in patients without known coronary artery disease and to investigate whether ExE is useful in predicting outcomes in those with high exercise capacity (≥10 metabolic equivalents [METs]) plus a maximal test (≥85% of their maximal age-predicted heart rate [MAPHR]). The analysis was performed on 4269 patients who underwent ExE, of whom 3995 achieved ≥85% of their MAPHR. These patients were divided according to the reached workload (<7, 7-9, or ≥10 METs) and compared for ExE results. Outcomes in the group achieving ≥10 METs plus ≥85% of their MAPHR (n=2221) were specifically assessed. Ischemia was defined as new/worsening wall motion abnormalities with exercise. ExE results were different between groups because the METs were lower. Still, among patients achieving ≥10 METs plus ≥85% of their MAPHR, 9.3% had extensive ischemia and 6% multiterritory disease. During follow-up in this subgroup, 108 patients died and 42 had a major cardiac event. Annualized mortality and major cardiac event rates were 0.84% and 0.32% in patients without ischemia versus 2.26% and 0.84% in those with ischemia, respectively (P<0.001 and P=0.002, respectively). Ischemia was an independent predictor of mortality (hazard ratio, 1.88; 95% confidence interval, 1.23-2.89; P=0.004) and major cardiac event (hazard ratio, 2.39; 95% confidence interval, 1.22-4.71; P=0.01). Patients without known coronary artery disease achieving ≥10 METs plus ≥85% of their MAPHR may still have ischemia. However, the low event rates even in those with ischemia limit the usefulness of imaging for assessing outcomes in this group.

Value of an exercise workload higher or equal to 10 metabolic equivalents for predicting low risk of inducible myocardial ischemia

Objectives: To identify the prevalence of extensive ischemia on exercise echocardiography (ExE) relative to workload in patients without known coronary artery disease (CAD), and to investigate whether ExE is useful to assess outcome in those with high exercise capacity (≥10 metabolic equivalents (METs) plus a maximal test (≥85% of their Maximal Age-Predicted Heart Rate (MAPHR). Background: Recent work has suggested low reach of imaging in patients who achieve ≥10 METs and ≥85% of their MAPHR during exercise. Methods: Retrospective analysis on 4,269 patients who underwent ExE, of whom 3,995 achieved ≥85% of their MAPHR. These patients were divided according to the reached workload (<7, 7 to 9, or ≥10 METs) and were compared for ExE results, particularly the prevalence of extensive ischemia (≥3 ischemic segments). Outcome in the group achieving ≥10 METs plus ≥85% of their MAPHR (n=2,221) was specifically assessed. Ischemia was defined as the development of new/worsening wall motion abnormalities with exercise. Results: ExE results were significantly different between groups as the achieved METs were lower. Still, among patients achieving ≥10 METs plus ≥85% of their MAPHR, 6% had extensive ischemia and 9.3% multiterritory disease. During follow-up of 4.3±3.4 years in this group, 108 patients died and 42 had a MACE. The 5-year mortality and MACE rates were 4.2% and 1.6% in patients without ischemia vs. 11.3% and 4.2% in those with ischemia (p <0.001, and p=0.002, respectively). Ischemia was an independent predictor of mortality (hazard ratio [HR] 1.88, 95% confidence interval [CI] 1.23-2.89, p=0.004) and MACE (HR 2.39, 95% CI 1.22-4.71, p=0.01). Conclusions: Patients with theoretically good prognosis by exercise testing, such those without known CAD achieving ≥10 METs plus ≥85% of their MAPHR may still have significant risk. Switching these patients to exercise ECG testing alone could deny important medical treatment or revascularization procedures.

An Exaggerated Blood Pressure Response to Treadmill Exercise does not Increase the Likelihood that Exercise Echocardiograms are Abnormal in Men or Women

Some experts have suggested that patients with exaggerated blood pressure responses during exercise echocardiography are more likely to have abnormal exercise echocardiographic findings and less likely to have angiographically significant coronary artery disease than patients with normal blood pressure responses. The aim of this study was to evaluate the impact of exercise blood pressure on exercise echocardiographic findings and subsequent angiographic results in men and women. In this retrospective study, clinical, exercise, and echocardiographic characteristics of patients who underwent treadmill exercise echocardiography over a 2-year period were examined, and the angiographic findings of the subgroup of patients who subsequently underwent coronary angiography within 30 days were analyzed. Among the 7,015 patients (mean age, 61 ± 13 years), 3,992 were men (57%). The likelihood of patients' having abnormal exercise echocardiographic results was similar at all levels of exercise blood pressure, except in men who had low peak systolic blood pressures (<120 mm Hg); they had the highest rate of abnormal exercise echocardiographic findings. Of the 3,225 patients without histories of hypertension or coronary artery disease, 3,098 had peak systolic blood pressures of 120 to 219 mm Hg (a "normal" blood pressure response), and 59 had peak systolic blood pressures ≥ 220 mm Hg (an exaggerated blood pressure response). These patients with exaggerated blood pressure responses were just as likely to have normal exercise echocardiographic results as those who had normal blood pressure responses (85% vs 83%, P > .99). A subgroup of 508patients underwent coronary angiography. The rate of false-positive findings was similar for patients who had exaggerated blood pressure responses and those who had normal blood pressure responses. The false-positive rate tended to be lower in patients who had low blood pressure responses. Patients who have exaggerated blood pressure responses to exercise are not more likely to have abnormal exercise echocardiographic findings than those with normal blood pressure responses. The majority of patients who have echocardiographic abnormalities and subsequently undergo coronary angiography have substantial (≥50% stenosis) coronary artery disease.

Prognostic Value of Exercise Echocardiography in Patients With Left Bundle Branch Block

Our aim was to evaluate the role of exercise echocardiography for predicting outcome in a cohort of patients with left bundle branch block (LBBB). Although the prognostic value of exercise echocardiography has been well established in several subgroups of patients, it has not been specifically assessed in patients with LBBB. Of the 8,050 patients who underwent treadmill exercise echocardiography, 618 demonstrated complete LBBB. Nine patients were lost to follow-up and 609 patients were included in this study. Wall motion score index (WMSI) was evaluated at rest and at peak exercise, and the difference (DeltaWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (including cardiac death, myocardial infarction, or cardiac transplantation). Mean follow-up was 4.6 +/- 3.4 years. Mean age was 66 +/- 10 years, and 331 patients (54%) were men. A total of 177 patients (29%) developed ischemia with exercise. During follow-up, 124 deaths occurred, and 74 patients had a major cardiac event before any revascularization procedure. Patients with ischemia had a greater 5-year mortality rate (24.6% vs. 12.6%, p < 0.001) and 5-year major cardiac events rate (18.1% vs. 9.7%, p = 0.003). In multivariate analysis, DeltaWMSI remained an independent predictor of mortality (hazard ratio: 2.42, 95% confidence interval: 1.21 to 4.82, p = 0.012) and major cardiac events (hazard ratio: 3.38, 95% confidence interval: 1.30 to 8.82, p = 0.013). Exercise echocardiographic results also provided incremental value over clinical, resting echocardiographic, and treadmill exercise data for the prediction of mortality (p = 0.014) and major cardiac events (p = 0.017). Exercise echocardiography provides significant prognostic information for predicting outcome in patients with LBBB. As compared to patients with normal exercise echocardiograms, patients with abnormal results are at increased risk of mortality and major cardiac events.

How to improve noninvasive coronary artery disease diagnostics in premenopausal women?: The influence of menstrual cycle on ST depression, left ventricle contractility, and chest pain observed during exercise echocardiography in women with angina and normal coronary angiogram

The aim was to assess the influence of menstrual cycle on results of exercise echocardiography and electrocardiography. Premenopausal women (n=28) with regular monthly menses, presented typical angina, positive electrocardiogram (ECG) exercise stress test, and normal coronary angiogram were recruited. Exercise supine bicycle echocardiography with simultaneous recording of 12-lead ECG was performed once a week for 4 consecutive weeks. Occurrence of angina, time to angina, time to significant ST deviation, and segmental myocardial contractility were analyzed. Blood samples were drawn to estimate follicle-stimulating hormone, luteinizing hormone, beta-estradiol, progesterone concentration and confirm the position in menstrual cycle. In correlation analysis, linear and logistic regression were used as appropriate. Qualitative variables were categorized into quartiles in logistic regression analysis. Exercise ST depression was more frequently observed in both luteal phases (early luteal 78%, late luteal 86%) compared to the late follicular phase (50%, P<.05). Time to ST depression was significantly longer in late follicular phase compared to other phases. The rate of segmental exercise left ventricular hypokinesis was low and not significantly related to menstrual cycle. Using linear regression, significant positive correlation was found between estradiol-progesterone ratio and time to ST depression. Using multiple logistic regression, we confirmed that progesterone level is independent factor influencing the presence of ST depression. In women with typical angina and normal coronary angiogram, the position in menstrual cycle influences the ST depression but not myocardial contractility during exercise echocardiography.

Usefulness of High Functional Capacity in Patients With Exercise-Induced ST-Depression to Predict a Negative Result on Exercise Echocardiography and Low Prognostic Risk

Although exercise electrocardiography (ExECG) is commonly used to detect coronary artery disease, the diagnostic accuracy and reliability of positive (ischemic) results of ExECG in low- and intermediate-risk populations are limited. Accordingly, many patients with positive results of ExECG undergo secondary evaluation using noninvasive stress imaging such as exercise echocardiography. Functional capacity is a strong predictor of prognosis and, indirectly, of high-risk coronary artery disease. It was hypothesized that high functional capacity in patients with positive results of ExECG would predict (1) negative results on subsequent exercise echocardiography and (2) a low risk for late mortality. Results were analyzed in 104 consecutive patients (79 men, 25 women; mean age 49 years, range 27 to 76) referred for exercise echocardiography after positive results of ExECG with a treadmill workload of > or =10 METs. Late all-cause mortality was also determined in these patients. Exercise echocardiographic results were negative in 93% of patients (97 of 104; 92% of men [73 of 79] and 100% of women [25 of 25]) and positive in 7% (7 of 104). During a mean follow-up period of 7.2 +/- 1.9 years, there was 1 death. In conclusion, high functional capacity in patients with positive results of ExECG is associated with negative exercise echocardiographic results in most patients and very low late mortality. Patients with ischemic ST-segment response on ExECG who achieve workloads of > or =10 METs infrequently require additional noninvasive or invasive evaluation.

Prognostic value of exercise echocardiographyin 5,798 patients: is there a gender difference?

ObjectivesThis study was designed to determine the effect of gender on the prognostic value of exercise echocardiography. BackgroundLimited information exists regarding gender differences in prognostic value of exercise echocardiography. MethodsWe obtained follow-up (3.2 ± 1.7 years) in 5,798 consecutive patients who underwent exercise echocardiography for evaluation of known or suspected coronary artery disease. ResultsThere were 3,322 men (mean age 62 ± 12 years) and 2,476 women (mean age 62 ± 12 years) (p = 0.7). New or worsening wall motion abnormalities developed with exercise in 35% of men and 25% of women (p = 0.001). Cardiac events, including cardiac death (107 patients) and nonfatal myocardial infarction (148 patients), occurred in 5.3% of men and 3.1% of women (p = 0.001). Addition of the percentage of ischemic segments to the clinical and rest echocardiographic model provided incremental information in predicting cardiac events for both men (X2= 137 to 143, p = 0.014) and women (X2= 72 to 76, p = 0.046). By multivariate analysis, exercise electrocardiographic and exercise echocardiographic predictors of cardiac events in both men and women were workload and exercise wall motion score index. There was no significant interaction effect of rest echocardiography (p = 0.79), exercise electrocardiography (p = 0.38) or exercise echocardiography (p = 0.67) with gender. ConclusionsAlthough cardiac events occurred more frequently in men, the incremental value of exercise echocardiography was comparable in both genders. Of all exercise electrocardiographic and exercise echocardiographic variables, workload and exercise wall motion score index had the strongest association with outcome. The results of exercise echocardiography have comparable implications in both men and women.

Effect of Left Ventricular Global Systolic Function, Mitral Regurgitation, and Left Ventricular Inflow Pattern on Exercise Echocardiography Results

Diagnosis of coronary artery disease (CAD) by exercise echocardiography is usually based on rest or exercise-induced regional wall-motion abnormalities. Mitral regurgitation (MR), left ventricular (LV) global systolic function, and LV inflow measurements can be assessed during exercise echocardiography; however, their diagnostic value has not been analyzed consistently. Treadmill exercise echocardiography and coronary angiography were performed in 120 patients (94 male, 26 female; mean age 61 +/- 10 years [+/- 1 SD]) to evaluate known or suspected CAD. Positive exercise echocardiography was defined either as a rest- or exercise-induced regional wall-motion abnormalities. An abnormal response of LV ejection fraction (EF), LV volumes, MR (as assessed by color Doppler), and LV inflow pattern was defined as a fall in LVEF, a LV end-diastolic volume increase, a LV end-systolic volume increase, a new or increased MR, or a change from an impaired relaxation pattern (E < A) to a "pseudonormalized" pattern (E > A) from rest to exercise, respectively. CAD (> or = 50% luminal narrowing in at least one vessel) was found in 89 (74%) patients. EE-based regional wall-motion abnormality analysis was positive in 95 (79%) patients and negative in 25 (21%) patients. Feasible images for regional wall-motion abnormalities, LVEF and volumes, LV inflow, and MR measurements were acquired in 90% of patients. Regional wall-motion abnormality analysis and LVEF decrease provided the greatest sensitivities for CAD (94% and 75%, respectively), while the highest specificity was given by a new or increased MR (90%), the development of a pseudonormalized pattern (88%), and the appearance of angina (87%). A positive electrocardiogram (ECG) finding in patients with interpretable ECGs provided good sensitivity and specificity (67% and 85%, respectively). In conclusion, a complete rest and exercise Doppler echocardiography approach is feasible in most patients. Regional wall-motion abnormalities are the most accurate exercise echocardiography variable for diagnosing CAD, whereas exercise ECG remains a good test in patients with interpretable ECGs. Exercise echocardiography, exercise ECG, newly developed or increased MR, and change to a pseudonormalized LV inflow pattern are highly specific.

Hypertensive response to exercise: a potential cause for new wall motion abnormality in the absence of coronary artery disease

ObjectivesWe sought to characterize patients with a hypertensive response during exercise echocardiography and its effect on results of the test. BackgroundA hypertensive response to exercise has been shown to cause false-positive results in perfusion imaging, radionuclide angiography and exercise electrocardiography, but its influence on exercise echocardiography has not been reported. MethodsWe identified 548 of 6,686 patients who had coronary angiography within four weeks after exercise echocardiography from 1992 through 1996. Echocardiographic results from 132 patients (24%) with a hypertensive response to exercise, defined as systolic blood pressure (SBP) >220 mm Hg for men and SBP >190 mm Hg for women or as an increase in diastolic blood pressure (DBP) >10 mm Hg or DBP >90 mm Hg during exercise echocardiography, were compared with those from 416 patients without a hypertensive response. ResultsOf 132 patients with a hypertensive response to exercise, 108 patients had exercise echocardiographic results positive for ischemia. Of these patients, 24 (22%) were found to have no significant coronary artery disease (CAD). In contrast, of 320 patients with positive exercise echocardiographic results without a hypertensive response, 39 (12%) patients did not have significant CAD. Among the false-positive results, new wall motion abnormalities were extensive in 15 of 24 (63%) hypertensive responders involving >25% of segments compared with 14 of 39 nonhypertensive responders (36%, p = 0.012). ConclusionsAn excessive rise in blood pressure during exercise is associated with a greater likelihood of new or worsening abnormalities with exercise, which may be observed in the absence of angiographically significant coronary artery stenosis.

Prediction of mortality by exercise echocardiography: a strategy for combination with the duke treadmill score.

In studies generally involving short follow-up, exercise echocardiography has been shown to predict composite end points. We sought to study the prediction of mortality with this test and to devise a strategy for combination with standard exercise testing. Clinical, exercise testing, and echocardiographic data were collected in 5375 patients (aged 54+/-14 years, 3880 men) undergoing exercise echocardiography. The Duke treadmill score was derived from the results of treadmill exercise testing. Resting left ventricular (LV) function and the presence and severity of ischemia were interpreted by expert observers. Follow-up at 10.6 years (mean 5.5+/-1.9 years) was complete in 5211 patients (97%). The Duke score classified 59% of patients as low risk, 39% as intermediate risk, and 2% as high risk. Resting LV dysfunction was present in 1445 patients (27%), and the exercise echocardiogram was abnormal in 2525 patients (47%). Death occurred in 649 patients (12%). Over the first 6 years of follow-up, those with normal exercise echocardiograms had a mortality of 1% per year. Ischemia was an independent predictor of mortality. In sequential Cox models, the predictive power of clinical data was strengthened by adding the Duke score, resting LV function, and the results of exercise echocardiography. Exercise echocardiography was able to substratify patients with intermediate-risk Duke scores into groups with a yearly mortality of 2% to 7%. A normal exercise echocardiogram confers a low risk of death, and positive results are an independent predictor of death; ischemia is incremental to other data. This test may be particularly useful in patients with intermediate-risk Duke treadmill scores.