Contrast Stress Echocardiography Research Articles

CONTRAST STRESS ECHOCARDIOGRAPHY FINDINGS IN MYOCARDIAL BRIDGING COMPARED TO NORMAL CORONARY COURSE, WITH AND WITHOUT CORONARY ARTERY DISEASE

Abstract Background Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD). Methods We evaluated all consecutive patients who underwent contrast stress echocardiography and coronary computed tomography angiography (CCTA) due to suspected symptoms of CAD within 3 months in Parma Hospital. Coronary computed tomography angiography served as the reference standard for detecting MB and obstructive CAD. The patients were divided into 3 groups: (1) MB and no evidence of obstructive CAD (MB group, N = 64), (2) no evidence of obstructive CAD or MB (NoCAD group, N = 135), (3) obstructive CAD without MB (CAD group, N = 68). Results The coronary flow velocity reserve in the LAD (CFVR–LAD) was reduced in the MB and CAD groups, measuring 1.91 ± 0.21 and 1.82 ± 0.28, respectively, whereas it was 2.27 ± 0.34 in the NoCAD group (P < .001). The MB and CAD groups exhibited a higher prevalence of reversible myocardial perfusion defects (rMPDs) compared to the NoCAD group (57.8% vs 64.7% vs 3.7%, P < .001). Reversible wall motion abnormalities were frequently observed in the CAD group and rarely found in the MB and NoCAD groups (47.1% vs 18.8% vs 4.4%, P < .001). In multivariable analyses, the presence of MB was independently associated with reduced CFVR–LAD (odds ratio = 14.55; 95% CI, 6.84–30.93; P < .001) and the presence of rMPD (odds ratio = 37.96; 95% CI, 13.49–106.84; P < .001). Patients with deep MB (>2 mm depth) and very deep MB (≥5 mm depth) exhibited significantly greater CFVR–LAD reduction and rMPD than those with superficial MB. Conclusions Myocardial bridging is capable of inducing rMPD and reducing CFVR–LAD similar to obstructive CAD. The depth of the MB correlates with the abnormalities found in the stress echo evaluation. Contrast stress echo may serve as a valuable noninvasive tool for evaluating patients with MB.

Contrast Stress Echocardiography Findings in Myocardial Bridging Compared to Normal Coronary Course, With and Without Coronary Artery Disease

Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD). We evaluated all consecutive patients who underwent contrast stress echocardiography and coronary computed tomography angiography (CCTA) due to suspected symptoms of CAD within 3months in Parma Hospital. Coronary computed tomography angiography served as the reference standard for detecting MB and obstructive CAD. The patients were divided into 3 groups: (1) MB and no evidence of obstructive CAD (MB group, N=64), (2) no evidence of obstructive CAD or MB (NoCAD group, N=135), (3) obstructive CAD without MB (CAD group, N=68). The coronary flow velocity reserve in the LAD (CFVR-LAD) was reduced in the MB and CAD groups, measuring 1.91±0.21 and 1.82±0.28, respectively, whereas it was 2.27±0.34 in the NoCAD group (P<.001). The MB and CAD groups exhibited a higher prevalence of reversible myocardial perfusion defects (rMPDs) compared to the NoCAD group (57.8% vs 64.7% vs 3.7%, P<.001). Reversible wall motion abnormalities were frequently observed in the CAD group and rarely found in the MB and NoCAD groups (47.1% vs 18.8% vs 4.4%, P<.001). In multivariable analyses, the presence of MB was independently associated with reduced CFVR-LAD (odds ratio= 14.55; 95% CI, 6.84-30.93; P<.001) and the presence of rMPD (odds ratio= 37.96; 95% CI, 13.49-106.84; P<.001). Patients with deep MB (>2 mm depth) and very deep MB (≥5 mm depth) exhibited significantly greater CFVR-LAD reduction and rMPD than those with superficial MB. Myocardial bridging is capable of inducing rMPD and reducing CFVR-LAD similar to obstructive CAD. The depth of the MB correlates with the abnormalities found in the stress echo evaluation. Contrast stress echo may serve as a valuable noninvasive tool for evaluating patients with MB.

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.

Early diagnosis of coronary microvascular dysfunction by myocardial contrast stress echocardiography.

Coronary microvascular dysfunction (CMD) is one of the basic mechanisms of myocardial ischemia. Myocardial contrast echocardiography (MCE) is a bedside technique that utilises microbubbles which remain entirely within the intravascular space and denotes the status of microvascular perfusion within that region. Some pilot studies suggested that MCE may be used to diagnose CMD, but without further validation. This study is aimed to investigate the diagnostic performance of MCE for the evaluation of CMD. MCE was performed at rest and during adenosine triphosphate stress. ECG triggered real-time frames were acquired in the apical 4-chamber, 3-chamber, 2-chamber, and long-axis imaging planes. These images were imported into Narnar for further processing. Eighty-two participants with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. Thermodilution was used as the gold standard to diagnose CMD. CMD was present in 23 (28%) patients. Myocardial blood flow reserve (MBF) was assessed using MCE. CMD was defined as MBF reserve < 2. The MCE method had a high sensitivity (88.1%) and specificity (95.7%) in the diagnosis of CMD. There was strong agreement with thermodilution (Kappa coefficient was 0.727; 95% CI: 0.57-0.88, p < 0.001). However, the correlation coefficient (r = 0.376; p < 0.001) was not high.

Plasma hydroxyanthranilic acid as a predictor of stress induced myocardial ischemia in non-obstructive coronary artery disease

Abstract Background The tryptophan catabolite hydroxyanthranilic acid (HAA) has potent immunomodulatory and vasoactive effects. HAA is also a precursor in the synthesis of nicotinamide adenine dinucleotide (NAD), a crucial cofactor in energy-metabolism. We have previously demonstrated that elevated plasma HAA predicted risk of myocardial infarction. Purpose To explore if plasma HAA is associated with stress induced myocardial ischemia in non-obstructive coronary artery disease (CAD). Methods In 132 patients with chest pain and non-obstructive CAD by coronary computed tomography angiography (CCTA), plasma HAA was analyzed by gas chromatography tandem mass spectrometry. All participants underwent myocardial contrast stress echocardiography. Myocardial ischemia was assessed as delayed contrast replenishment at peak dobutamine stress during real-time low mechanical index imaging and destruction replenishment. The extent of ischemia was defined as the number of segments with delayed contrast enhancement using a 17-segment left ventricular model. Associations of plasma HAA with myocardial ischemia was evaluated in a multivariate adjusted linear regression model. Results Mean (SD) age at inclusion was 63 (8) years and 56% were women. At CCTA, the median (25th, 75th percentile) coronary artery calcium (CAC) score was 42 (13–107) Agatston units, whereas the mean (SD) segment involvement score (SIS) was 2.6 (1.6). Myocardial ischemia was found in 52% of patients with on average 5 (3) ischemic segments per patient. Serum HAA did not correlate with the CAC score or SIS (p&amp;gt;0.29). After multivariate adjustment including age, sex, body mass index, systolic blood pressure, diabetes, current smoking, and LDL cholesterol, the odds ratio and 95% confidence interval for myocardial ischemia was 1.55 (1.04–2.32), P=0.03, per SD increment of plasma HAA levels (log transformed). Plasma HAA was also associated with the extent of myocardial ischemia with a multivariate adjusted β of 0.26, P=0.004. Conclusion Plasma HAA is associated with the extent of myocardial ischemia in non-obstructive CAD. Potential roles of this metabolite in atherogenesis, vascular dysfunction and as a predictor of myocardial ischemia should be further elucidated. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Western Norway Regional Health Authority

Total coronary atherosclerotic plaque burden is associated with myocardial ischemia in non-obstructive coronary artery disease.

AimWhether the total coronary atherosclerotic plaque burden is independently associated with myocardial ischemia in non-obstructive coronary artery disease (CAD) is not well established. We aimed to test the association of total plaque burden quantified by coronary computed tomography angiography (CCTA) with myocardial ischemia in patients with chronic coronary syndrome and non-obstructive CAD.MethodsWe included 125 patients (age 62 ± 9 years, 58% women) with chronic coronary syndrome and non-obstructive CAD (stenosis < 50%) by CCTA, who were grouped according to presence or absence of myocardial ischemia by myocardial contrast stress echocardiography. Total plaque burden was quantified by CCTA as the total plaque volume in the main coronary arteries, and positive remodelling was defined as remodelling index > 1.10.ResultsPatients with myocardial ischemia (n = 66) had higher total plaque burden (847 ± 245 mm3 vs. 758 ± 251 mm3, p = 0.049) and higher left ventricular (LV) mass index (42.1 ± 9.9 g/m2.7 vs. 37.3 ± 8.0 g/m2.7, p = 0.004), while age, sex, prevalence of hypertension, diabetes, calcium score and positive remodelling did not differ between the groups (all p > 0.05). In multivariable regression analysis, total plaque burden remained associated with presence of myocardial ischemia (OR 1.02, 95% CI 1.00–1.04, p = 0.045) independent of age, sex, hypertension, diabetes, LV mass index, coronary calcium score and positive remodelling.ConclusionTotal coronary artery plaque burden by CCTA was independently associated with myocardial ischemia in patients with non-obstructive CAD. Whether plaque quantification is useful for clinical management of patients with non-obstructive CAD should be tested in prospective studies.ClinicalTrials.gov: Identifier NCT01853527.

Using deep learning to extract novel and quantitative imaging features from perfluoropropane contrast, sulphur hexafluoride contrast and non-contrast stress echocardiography images

Abstract Background Stress echocardiography has become established as the most widely applied non-invasive imaging test for diagnosis of coronary artery disease within the UK. However, stress echocardiography has been substantially qualitative, rather than quantitative, based on visual wall motion assessment. For the first time, we have identified and validated quantitative descriptors of cardiac geometry and motion, extracted from ultrasound images acquired using contrast agents in an automated way. Purpose To establish whether these novel imaging features can be generated in an automated, quantifiable and reproducible way from images acquired with perfluoropropane contrast, as well as investigating how these extracted measures compare to those extracted from sulphur hexafluoride contrast and non-contrast studies. Methods 100 patients who received perfluoropropane contrast during their stress echocardiogram were recruited. Their stress echocardiography images were processed through a deep learning algorithm. Novel feature values were recorded and a subset of 10 studies were repeated. The automated measures of global longitudinal strain (GLS) and ejection fraction (EF) extracted from these images were compared to values previously extracted from sulphur hexafluoride contrast and non-contrast images using the same software. Results A full set of 31 novel imaging features were successfully extracted from 79 studies acquired using the perfluoropropane contrast agent with a dropout rate of 14% (n=92, 8 incomplete image sets). Repeated analysis in a subset of 10 perfluoropropane cases demonstrated excellent reproducibility of the extracted feature values (R2=1). Automated values of GLS and EF, at both rest (GLS = −16.4±4.8%, EF = 63±13%) and stress stages (GLS = −17.7±5.8%, EF = 68±11%), were extracted from 83 perfluoropropane studies, with a dropout rate of 16% (n=99, fewer incomplete sets as short axis view not required). The ranges of GLS and EF measures extracted from the perfluoropropane images were comparable to the other contrast studies (n=222) (Rest GLS = −16.8±5.8%, Rest EF = 63±10%; Stress GLS = −19.1±6.7%, Stress EF = 71±9%) and non-contrast studies (n=86) (Rest GLS = −15.7±5.3%, Rest EF = 57±10%; Stress GLS = −17.3±6.4%, Stress EF = 61±14%). Conclusions Novel features and clinically relevant measures were extracted from images acquired using perfluoropropane contrast for the first time in a fully automated and reproducible way using a deep learning algorithm. The analysis failure rate and generated measures are comparable to those extracted from images using other commonly used sulphur hexafluoride contrast agents and non-contrast stress echocardiography studies. These findings demonstrate that deep learning algorithms can be used for automated quantitative analysis of stress echocardiograms acquired using various contrast agents and in non-contrast studies to improve stress echocardiography practice. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Lantheus Medical Imaging, Inc.

Myocardial energetic efficiency is depressed in ischemia with non-obstructive coronary arteries

Abstract Background Ischemia with non-obstructive coronary arteries (INOCA) is incompletely understood. Depressed myocardial energetic efficiency index (MEEi), the ratio between external work and myocardial oxygen consumption, has been shown in heart failure. However, MEEi in INOCA has not been explored. Purpose To test whether MEEi is associated with INOCA. Methods We included 125 patients (56% women, age 62±9 years) with exercise-induced chest pain and non-obstructive coronary arteries (stenosis &amp;lt;50%) by coronary computed tomography angiography (CCTA). Stroke volume (SV) and left ventricular (LV) mass were assessed by echocardiography. MEEi was calculated as (systolic blood pressure (SBP) x SV) / (SBP x heart rate) and normalized for LV mass. LV hypertrophy was defined as LV mass index &amp;gt;46.7 g/m2.7 in women and &amp;gt;49.2 g/m2.7 in men. Myocardial ischemia was detected by myocardial contrast stress echocardiography. Coronary artery plaque burden was measured as plaque volume by CCTA. Results In univariable regression analysis, stress-induced ischemia, male sex, diabetes, hypertension, LV hypertrophy, lower LV ejection fraction and higher SBP were associated with MEEi (all p&amp;lt;0.05). There were no associations with age, obesity or coronary artery plaque burden. MEEi was lower in patients with stress-induced ischemia (n=66) compared to patients without ischemia (0.47±0.16 vs. 0.54±0.21 ml/sec x g–1, p=0.026). In multivariable linear regression analysis, MEEi remained associated with stress-induced myocardial ischemia after adjustment for cardiovascular risk factors, SBP, LV hypertrophy, LV ejection fraction and coronary artery plaque burden (R2 0.26, p&amp;lt;0.001, Table). Conclusion MEEi is depressed in patients with INOCA. Our results suggest that myocardial ischemia negatively influences MEEi in patients with non-obstructive coronary arteries. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority, University of Bergen

Comparison of myocardial contrast stress-echocardiography and standard stress-echocardiography in detecting myocardial ischemia in patients with different severity of coronary artery stenoses

To compare diagnostic value between standard stress-echocardiography and myocardial contrast stress echocardiography in detection of myocardial ischemia in patients with different severity of coronary artery stenoses. Myocardial contrast stress-echocardiography and standard stress-echocardiography were performed in 38 patients with coronary artery stenoses over 50% by angiography. Of all lesions 39 were intermediate (5075%) and 33 over 75% stenoses. Fractional flow reserve (FFR) was measured in 12 coronary arteries. During myocardial contrast stress-echocardiography wall motion and myocardial perfusion was assessed. Adequate visualisation increased from 81.6% in unenhanced segments to 96.1% in contrast-enhanced segments. The sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography in intermediate (5075%) coronary stenoses were 44%, 83%, 56% and 56%, 94% и 64% respectively compare to angiography. Taking into account the 12 arteries with evaluated FFR, these parameters increased to 52%, 93% и 65% in standard stress-echocardiography and to 68%, 100% and 75% in myocardial contrast stress-echocardiography. In coronary stenoses over 75% the sensitivity, specificity, and diagnostic accuracy of standard stress-echocardiography and myocardial contrast stress-echocardiography were 78%, 88%, 80% and 86%, 100%, 92% respectively Conclusion. Use of contrast-enhanced stress-echorardiography significantly increased the diagnostic value of this method by improving endocardial border visualization and possibilities of myocardial perfusion assessment.

Long-term prognostic value of stress myocardial perfusion echocardiography in patients with coronary artery disease: a meta-analysis.

To evaluate the prognostic value of myocardial perfusion (MP) imaging during contrast stress echocardiography (cSE) in patients with known or suspected coronary artery disease (CAD). A search in PubMed, Embase databases, and the Cochrane library was conducted through May 2019. The Cochran Q statistic and the I2 statistic were used to assess heterogeneity, and the results were analysed by RevMan V5.3 and Stata V15.1 software. Twelve studies (seven dipyridamole and five exercise/dobutamine) without evidence of patient overlap (same institution publishing results over a similar time period) enrolling 5953 subjects (47% female, 8-80 months of follow-up) were included in the analysis. In all studies, total adverse cardiovascular events were defined as either cardiac death, non-fatal myocardial infarction (NFMI), or need for urgent revascularization. Hazard ratios (HRs) revealed that a MP abnormality [pooled HR 4.75; 95% confidence interval (CI) 2.47-9.14] was a higher independent predictor of total events than abnormal wall motion (WM, pooled HR 2.39; 95% CI 1.58-3.61) and resting left ventricular ejection fraction (LVEF, pooled HR 1.92; 95% CI 1.44-2.55) with significant subgroup differences (P = 0.002 compared with abnormal WM and 0.01 compared with abnormal LVEF). Abnormal MP was associated with higher risks for death [Risk ratio (RR) 5.24; 95% CI 2.91-9.43], NFMI (RR 3.09; 95% CI 1.84-5.21), and need for coronary revascularization (RR 16.44; 95% CI 6.14-43.99). MP analysis during stress echocardiography is an effective prognostic tool in patients with known or suspected CAD and provides incremental value over LVEF and WM in predicting clinical outcomes.

Coronary Microvascular Dysfunction: An Update

Structural and functional abnormalities of the microcirculation can impair myocardial perfusion which is called coronary microvascular dysfunction and the resulting ischemia is known as microvascular ischaemia. Most of the researches have focused on the epicardial coronary arteries while addressing angina pectoris. Although the importance of the coronary microcirculation in maintaining appropriate myocardial perfusion has been recognized for several decades, the substantial morbidity of coronary microvascular dysfunction (CMD) has not been appreciated until recently. It is not possible to diagnose of microvascular angina clinically with the current knowledge. Resting or exercise electrocardiogram is nondiagnostic. Imaging with speckle tracking in echocardiography may reveal focal diastolic and/or systolic dysfunction. Other noninvasive investigations includes, Contrast stress echocardiography, 99Tc-sestamibi imaging, cardiovascular magnetic resonance (CMR),Nuclear magnetic resonance spectroscopy may show some degree of abnormality. Invasive methods like intracoronary adenosine and acetylecholine test may guide us to diagnose CMD. No guideline directed medical therapy is still available for the CMD. Risk factors modification like smoking cessation and weight-loss may improve endothelial dysfunction and CMD. Beta blockers, calcium channel blockers, Angiotensin converting enzyme inhibitors and statin are now used in different clinical condition related to microvascular angina. After these medical treatment patient with microvascular angina have higher risk of MACE compared with people without angina. So, physicians must be aware of this potentially fatal but under recognized clinical entity.&#x0D; University Heart Journal Vol. 16, No. 1, Jan 2020; 43-49

P4983Safety of dobutamine stress contrast echocardiography; a single-center experience of 15 years

Abstract Introduction Dobutamine stress contrast echo (DSCE) is an accurate method for the diagnosis of coronary artery disease (CAD). Scarcity of serious adverse events has led to its establishment as a popular method for the diagnosis of CAD and to its increased use beyond CAD. However, data regarding the safety of single-line dobutamine and contrast infusion are limited. The aim of our study was to assess the safety of a DSCE protocol using a single line of intravenous access. Methods Over a 15-year period (2004–2018), 34,675 patients underwent DSCE in our department, which was performed using 10–20–30–40–50 μg/kg/h of dobutamine with dosage increase every three minutes, while atropine up to 1mg could also be administered. Two commercially available contrast agents were used at rest and at peak in all patients and a single intravenous line was used for infusion of dobutamine, atropine and contrast agents. Demographic data, risk factors and information concerning the most common cardiovascular or allergic adverse events were available for all patients. Finally, the adverse events of DSCE were compared with respective events reported by relevant studies in order to determine the safety of our method. Results Mean age of patient population was 63.9 (SD: 11.4 years), while 67.9% of patients (n=23,544) were males. There were 22,731 hypertensive patients (65.6%), 9,256 diabetics (26.7%), 21,683 patients (62.5%) had dyslipidemia, 11,760 (33.9%) were smokers and 10,437 (30.1%) had a positive family history of CAD. Adverse events were reported in 876 patients (2.5%). Allergic reaction was reported in 69 patients (0.2%). We recorded 643 patients (1.85%) with non-sustained VT or frequent premature ventricular ectopic beats and 154 patients (0.44%) with AF or SVT episodes leading to protocol termination. In 24 patients (0.07%) with sustained VT, antiarrhythmic drugs were given intravascularly, while in 10 patients (0.03%) with VT or VF, resuscitation was needed. No death was reported. Frequency of life threatening adverse events reported by relevant studies did not differ significantly when compared to the present results. Conclusion DSCE protocols involving single line infusion of dobutamine, atropine and ultrasound enhancing agents are safe, since adverse event rates are low and do not differ significantly to rates reported for unenhanced DSE by other relevant studies. Implementation of such protocols in clinical practice may increase patient comfort and cost-effectiveness and should therefore be encouraged.

Left ventricular hypertrophy contributes to Myocardial Ischemia in Non-obstructive Coronary Artery Disease (the MicroCAD study)

BackgroundThe underlying mechanisms causing myocardial ischemia in non-obstructive coronary artery disease (CAD) are still unclear. We explored whether left ventricular hypertrophy (LVH) was associated with myocardial ischemia in patients with stable angina and non-obstructive CAD. Methods132 patients (mean age 63 ± 8 years, 56% women) with stable angina and non-obstructive CAD diagnosed as <50% stenosis by coronary computed tomography angiography (CCTA) underwent myocardial contrast stress echocardiography. Left ventricular (LV) hypertrophy (LVH) was identified by LV mass index >46.7 g/m2.7 in women and >49.2 g/m2.7 in men. Patients were grouped according to presence or absence of myocardial ischemia by myocardial contrast stress echocardiography. The number of LV segments with ischemia at peak stress was taken as a measure of the extent of myocardial ischemia. ResultsMyocardial ischemia was found in 52% of patients, with on average 5 ± 3 ischemic LV segments per patient. The group with myocardial ischemia had higher prevalence of LVH (23 vs. 10%, p = 0.035), while age, sex and prevalence of hypertension did not differ between groups (all p > 0.05). In multivariable regression analyses, LVH was associated with presence of myocardial ischemia (odds ratio 3.27, 95% confidence interval [1.11–9.60], p = 0.031), and larger extent of myocardial ischemia (β = 0.22, p = 0.012), independent of confounders including age, hypertension, obesity, hypercholesterolemia, calcium score and segment involvement score by CCTA. ConclusionsLVH was independently associated with both presence and extent of myocardial ischemia in patients with stable angina and non-obstructive CAD by CCTA. These results suggest LVH as an independent contributor to myocardial ischemia in non-obstructive CAD.Clinical trial registration number: ClinicalTrials.gov, identifier NCT018535271.

Contrast stress-echocardiography compared with single photon emission computed tomography to detect multivessel coronary artery disease

We describe the case of a 55-year-old man admitted to our echo-laboratory for follow-up visit. In her history-taking: dyslipidemia, obesity and smoker. A basal electrocardiogram was considered norm...

PO616 Clinical Profile and Risk Factors of In-Hospital Mortality Among Filipino Patients With Infective Endocarditis

The underlying mechanisms causing myocardial ischemia in non-obstructive coronary artery disease (CAD) are still unclear. We explored whether left ventricular hypertrophy (LVH) was associated with myocardial ischemia in patients with stable angina and non-obstructive CAD.132 patients (mean age 63 ± 8 years, 56% women) with stable angina and non-obstructive CAD diagnosed as <50% stenosis by coronary computed tomography angiography (CCTA) underwent myocardial contrast stress echocardiography. Left ventricular (LV) hypertrophy (LVH) was identified by LV mass index >46.7 g/m2.7 in women and >49.2 g/m2.7 in men. Patients were grouped according to presence or absence of myocardial ischemia by myocardial contrast stress echocardiography. The number of LV segments with ischemia at peak stress was taken as a measure of the extent of myocardial ischemia.Myocardial ischemia was found in 52% of patients, with on average 5 ± 3 ischemic LV segments per patient. The group with myocardial ischemia had higher prevalence of LVH (23 vs. 10%, p = 0.035), while age, sex and prevalence of hypertension did not differ between groups (all p > 0.05). In multivariable regression analyses, LVH was associated with presence of myocardial ischemia (odds ratio 3.27, 95% confidence interval [1.11–9.60], p = 0.031), and larger extent of myocardial ischemia (β = 0.22, p = 0.012), independent of confounders including age, hypertension, obesity, hypercholesterolemia, calcium score and segment involvement score by CCTA.LVH was independently associated with both presence and extent of myocardial ischemia in patients with stable angina and non-obstructive CAD by CCTA. These results suggest LVH as an independent contributor to myocardial ischemia in non-obstructive CAD.Clinical trial registration number: ClinicalTrials.gov, identifier NCT018535271.

Prognostic Utility of Stress Testing and Cardiac Biomarkers in Menopausal Women at Low to Intermediate Risk for Coronary ARTery Disease (SMART Study): 5-Year Outcome

In women with low to intermediate risk of coronary artery disease (CAD), prognostic detection strategies have been controversial. We present the follow-up data of the SMART trial in peri/postmenopausal women at low to intermediate risk of CAD. To determine the value of contrast stress echocardiography (CSE), stress electrocardiogram (sECG), and serum biomarkers for prediction of cardiovascular events (CE) in peri/postmenopausal women at low to intermediate risk of CAD. From January 2004 to August 2007, 400 peri/postmenopausal women were prospectively enrolled. All women had detailed risk factor assessment, and underwent simultaneous CSE (Definity®, Lantheus Medical Imaging) and sECG. Laboratories included brain natriuretic peptide (BNP), atrial natriuretic peptide, endothelin, and high sensitivity C-reactive protein. Wall motion score index was based on a 16-segment model. Abnormal CSE was defined as new or worsening wall motion abnormality at stress, while abnormal sECG was ≥1 mm horizontal/downsloping ST segment depression/elevation (80 mseconds duration). Self-reported outcome data were collected from a mailed Women's Heart Clinic Questionnaire. CE outcomes included all-cause mortality, nonfatal myocardial infarction (MI), heart failure, chest pain hospitalization or development of typical angina (CP), and revascularization (REVASC). Adjusted Cox proportional hazard ratios (HR; 95% confidence intervals) were reported. A total of 366 women (54.4 ± 5.5 years, Framingham risk 6.5% ± 4.4%) completed simultaneous CSE and sECG. Forty-two (11.5%) had abnormal CSE, while sECG was abnormal in 22 (6%) women. Follow-up (4.4 ± 1.2 years) was available in 315/366 (86%) women (78% exercise-CSE, 22% dobutamine-CSE). In those who completed follow-up, CSE was abnormal in 33 women (10.5%) and sECG was abnormal in 21 (6.7%). In 33 women with abnormal CSE, sECG was abnormal in 7 (21.2%) and normal in 26 (79%), p = 0.0004. CE occurred in 27 (8.6%) women: 8 all-cause mortality, 2 nonfatal MI, 13 CP, and 4 REVASC. CE occurred in 21% versus 7% of women with abnormal versus normal CSE, p = 0.014 and 38% versus 6% of women with abnormal versus normal sECG, p < 0.0001. Rest BNP was higher in women with CE versus those without (p = 0.018). Abnormal sECG and abnormal CSE were associated with CE, while only abnormal sECG was an independent predictor of CE (adjusted HR 10.3 [1.9-61.4], p = 0.007). Of the laboratory results, only BNP was associated with CE (adjusted HR 2.9 [1.1-7.3], p = 0.028). sECG and rest BNP were independent predictors of subsequent CE within 5 years in peri/postmenopausal women at low to intermediate risk of CAD.

Vasodilator Stress Single-Photon Emission Computed Tomography or Contrast Stress Echocardiography Association with Hard Cardiac Events in Suspected Coronary Artery Disease

We compared the long-term outcome of subjects without prior cardiac disease who underwent either vasodilator single-photon emission computed tomography (SPECT) or contrast stress-echocardiography (cSE) for suspected coronary artery disease (CAD). Subjects who underwent vasodilator SPECT or cSE between 2008 and 2012 for suspected CAD but no history of cardiac disease were included. We retrospectively compared the association of each method with combined all-cause death and nonfatal myocardial infarction and their positive predictive value (PPV) for angiographically obstructive CAD. A total of 1,387 subjects were selected: 497 who underwent SPECT and 890 who underwent cSE. During 4years of mean follow-up there were 78 hard events in the cSE group and 51 in the SPECT group. Event-free survival in subjects testing positive for ischemia, either with SPECT or cSE, was significantly worse both in the overall population and after propensity matching patients. In multivariable analyses, vasodilator SPECT or cSE demonstrated significant stratification capability with an ischemic test doubling (SPECT) or more than doubling (cSE) the risk of future hard events independently from other variables. PPV of vasodilator SPECT for the diagnosis of obstructive CAD was inferior to vasodilator cSE (PPV=63% vs 89%, respectively; P<.001). Our study suggests that the associations of vasodilator SPECT or cSE with outcome are comparable, with cSE demonstrating better diagnostic PPV for CAD. The absence of ionizing radiation and anticipated lower costs from higher PPV suggest that vasodilator cSE is a valid alternative to vasodilator SPECT as a gatekeeper in subjects without a prior history of CAD.

PROGNOSTIC IMPLICATION OF PERFUSION DEFECT ON CONTRAST STRESS ECHOCARDIOGRAPHY AFTER PERCUTANEOUS CORONARY INTERVENTION

The aim of this study was to investigate the prognostic implication of perfusion defect on contrast stress echocardiography (CSE) in patients who underwent percutaneous coronary intervention (PCI). Between January 2012 and April 2017, patients who underwent CSE after PCI were enrolled in the

Equivocal tests after contrast stress-echocardiography compared with invasive coronary angiography or with CT angiography: CT calcium score in mildly positive tests may spare unnecessary coronary angiograms

BackgroundImaging stress tests are not ideally accurate to predict anatomically obstructive CAD, leading to a non-trivial rate of unnecessary iCA. This may depend on the threshold used to indicate iCA, and maybe CTA or, one step earlier, CT calcium score could spare most unnecessary iCA in only mildly positive cSE. We assessed the diagnostic accuracy of contrast stress-echocardiography (cSE) in comparison with invasive coronary angiography (iCA), and CT angiography (CTA) only in case of equivocal tests, to find hints helping reduce falsely positive cSE in the suspicion of coronary artery disease (CAD).MethodsPatients who were indicated cSE for suspected CAD between 2012 and 2016, who also underwent iCA were selected and diagnostic results compared. A second group, specifically with equivocal cSE who underwent CTA was also analyzed.Results137 subjects with equivocal cSE and CTA and 314 with cSE (any result) and iCA were selected. In the CTA-equivocal cSE group, an Agatston score < 105 and a coronary flow reserve (CFR-LAD) <1.7 had very high negative predictive value (99%, 92% respectively) to exclude obstructive CAD. The Agatston score was the most significant incremental predictor of CAD beyond clinical variables (chi square 31 to 47, p < 0.001). In the iCA group a more-than-mild reversible wall motion abnormality (WMA) demonstrated high positive predictive value for CAD (89%), while CFR-LAD appeared less useful. More-than-mild reversible WMA was the most significant predictor of CAD beyond clinical variables (chi square 37.5 to 56, p < 0.001).ConclusionsOur data suggest iCA should be indicated only for more-than-mild reversible WMA at cSE, due to the very high positive predictive value for CAD of this finding, while mildly positive tests should be shifted to non-invasive CT, with CTA performed only for coronary calcium Agatston score > 100, since lower scores demonstrated very high negative predictive value for CAD, not justifying proceeding to CTA and even less to iCA.

The Cardiac Advanced Practice Nurse: An Initial Experience of a Novel Role

Background: The Cardiac Investigations Unit (CIU) is a busy component of every cardiology department. The current department has grown exponentially since 2016 with cardiac computed tomography (CT), outpatient clinics, daily treadmill, and dobutamine stress echo and contrast echocardiography. Staffing these individual services can be challenging and requires multiple skill sets and people.