Results Of Stress Echocardiography Research Articles

Assessment of blood pressure response to physical activity: influence on the results of five-step stress echocardiography

Abstract Introduction Due to the high prevalence of hypertensive blood pressure response to exercise (HER) during stress echocardiography (SE), the unclear prognostic significance, and the possible impact on SE results, it seems appropriate to analyze the prevalence of HER in outpatients and inpatients. Additionally, it is essential to identify the influence of HER on the results of the modern SE protocol. Aim To evaluate the incidence of HER during SE with physical activity on a treadmill or horizontal bicycle ergometer in patients and the impact of HER on the results of five-step SE. Materials and methods This single-center study included 193 patients who underwent five-step SE according to clinical indications. The steps in the protocol are as follows: Step A: Evaluates local contractility abnormalities; Step B: Assesses B-lines/diastolic function; Step C: Measures the contractile reserve of the left ventricle; Step D: Assesses the reserve coronary blood flow velocity in the anterior interventricular branch; Step E: Evaluates heart rate reserve. The blood pressure (BP) response to exercise was assessed as hypertensive with a systolic blood pressure (SBP) ≥190 mm Hg on the treadmill and 200 mm Hg on a bicycle ergometer in women, and ≥210 mm Hg and 220 mm Hg, respectively, in men. Alternatively, HER was defined as an increase in SBP ≥180 mm Hg from the second stage of the test or when SBP rises relative to the baseline by ≥60 mm Hg in men and ≥50 mm Hg in women. The incidence of HER during the SE study and the relationship of HER with positive outcomes of the study protocol steps were examined. Results The prevalence of HER in patients undergoing SE was 36.3% (70 patients). Patients with HER were significantly more likely to have low exercise tolerance (p=0.013). Blood flow velocity in the coronary artery, both at rest and under load, and the amount of contractile reserve were significantly higher in patients with HER (p=0.009, p=0.008, and p=0.002, respectively). There was a trend towards a greater value of relative LV wall thickness in patients with HER (p=0.070). Among patients with HER, a decrease in contractile reserve was less common than among patients with an adequate blood pressure response: 45 (64.3%) versus 99 (80.5%) (p=0.013). Conclusion An excessive increase in blood pressure may be a limiting factor, leading to premature termination of testing. Patients with HER are significantly more likely to have poorer exercise tolerance and require more careful monitoring and control of risk factors. There is a relationship between the response of blood pressure to exercise and the results of SE, particularly the effect of peak blood pressure on contractile reserve. The relationship between BP response to exercise and SE steps, as well as its prognostic significance, requires further study.

Long-term outcomes after stress echocardiography in real-world practice: five year follow-up of the EVAREST study

Abstract Background/Introduction Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a national healthcare system has not been previously reported. Purpose We report patient outcome up to five years after stress echocardiogram for patients undergoing a clinically-indicated stress echocardiogram for ischaemic heart disease in a real-world, multi-centre national healthcare system and determine the event-free ‘warranty’ period following a normal stress echocardiogram. Methods Patients participating in the EVAREST/BSE-NSTEP (Echocardiography: Value and Accuracy at Rest and Stress/ British Society of Echocardiography National Review of Stress Echo Practice) prospective cohort study were recruited from 32 UK NHS hospitals between 2018 and 2022. Medical outcome data up to 2023 was available from NHS England. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions and relevant cardiovascular diagnoses, using Kaplan-Meier analysis and Cox proportional hazard ratios. Warranty period following a negative stress echocardiogram was defined as time the cumulative event rate of myocardial infarction or cardiac-related death remained below 5%. Results 5503 patients were included in the analysis with a median follow-up of 829 days (IQR 224 – 1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction (HR 2.71, 95% CI 1.73 – 4.24, P<0.001), revascularisation (HR 10.52, 95% CI 8.26 – 13.42, P<0.001) and reaching a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.04, 95% CI 1.41 – 2.93, P<0.001). Hazard ratios for all events increased with ischaemic burden identified at stress echocardiography (Figure 1). A negative stress echocardiogram identified an event-free ‘warranty period’ of at least five years in patients with no prior history of coronary artery disease, and four years for those with disease (Figure 2). Conclusions In real-world practice, the degree of ischaemia recorded by clinicians at stress echocardiography correctly categorises risk of future events over the next five years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period. Figure 1 Figure 2

Long-term prognostic value of contemporary stress echocardiography in patients with suspected or known coronary artery disease: systematic review and meta-analysis

BackgroundLong-term outcome of contemporary stress echocardiography has not been systematically assessed.ObjectiveTo evaluate the association between results of stress echocardiography and patients’ outcomes with suspected coronary artery disease using randomised controlled...

Long-term outcomes after stress echocardiography in real-world practice: a 5-year follow-up of the UK EVAREST study.

Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported. Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73-4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease. In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Accuracy of machine learning techniques to predict stress echocardiography results using clinical variables

Abstract Background Stress echocardiography (SE) is a diagnostic prognostic imaging modality for suspected coronary artery disease (CAD). Cardiovascular risk factors (CVRF) are used in the assessment of the probability of CAD. The link between the outcome of SE and patients’ variables including CVRF, current medication, and anthropometric variables has not been widely investigated.Objective: The aim of this study is to understand whether a machine learned algorithm can be used to predict significant CAD defined by inducible ischemia on SE in patients with suspected CAD based on anthropometrics, CVRF, and medication as variables. Methods A machine learning (ML) framework was generated to automate the prediction of inducible ischemia on stress echocardiography results. A mutual information-based feature selection methods (support vector machine (SVM) and random forest (RF) classifiers) were used to investigate the amount of information that each feature carried to define the positive outcome of SE.Data from 2201 patients were used to train and validate the framework. Patients mean age was 62 (SD 11) years. The data consists of anthropological data and classical CVRF, atrial fibrillation, prior diagnosis of CAD, stroke, obstructive airways disease, chronic inflammatory disease, chronic kidney disease (CKD&amp;gt;3) and prescribed medications at the time of the test. There were 394 positive and 1807 negative SE cases. Five-fold cross-validation was used to validate the performance of the framework. Results The feature selection methods showed that prescribed medications such as Weight, Diabetes, Antiplatelet drugs and ACE- inhibitor/ARB, were the features that shared the most information about the outcome of SE (sensitivity and specificity of 81% and 51% and 81% and 61% for SVM and RF, respectively) with the accuracy of 82%. Conclusion This study shows that ML can predict the outcome of SE based on only 4 clinical features. Further research correlating the clinical variable and SE result to cardiovascular outcome will improve the model’s clinical utility and facilitate patient selection for early treatment avoiding unnecessary downstream testing.

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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.&#x0D; 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.

Is It Possible to Predict False-Positive Exercise Stress Echocardiography Results by Measuring the Left Atrial Antero-Posterior Diameter?

Left atrial (LA) size is a well-known prognostic determinant in the setting of coronary artery disease (CAD). No previous study has evaluated LA antero-posterior (A-P) diameter as a potential screening method for identifying individuals with a low probability of CAD. We aimed to assess the influence of LA A-P diameter adjusted for chest wall conformation (A-P thoracic diameter) on the occurrence of false-positive (FP) results on exercise stress echocardiography (ESE) in patients with suspected CAD. All consecutive patients who had undergone coronary angiography at MultiMedica IRCCS (via San vittore 12, 20123, Milan, Italy) within two months from a positive ESE over a seven-year periodwere retrospectively analyzed. All patients underwent LA A-P diameter/A-P thoracic diameter ratio assessment, resting transthoracic echocardiography, and subsequent ESE. The primary endpoint was FP-ESE, defined as a positive ESE with no evidence of obstructive CAD (≥70% stenosis in any epicardial coronary artery) on subsequent coronary angiography. A total of 160 patients (64.4±13.0 years, 56.9% females) with a positive ESE were retrospectively analyzed. In light of coronary angiography results, 129 patients (80.6%) had an obstructive CAD, while 31 (19.4%) did not (FP). On the multivariate logistic regression analysis, the LA A-P diameter/A-P thoracic diameter ratio (odds ratio (OR) 0.42, 95% confidence interval (CI) 0.31-0.57) showed a strong inverse correlation with the primary endpoint. An LA A-P diameter/A-P thoracic diameter ratio ≤0.25 had 100% sensitivity and 85% specificity for predicting FP-ESE results (area under the curve (AUC) = 0.94). A strong linear correlation was demonstrated between the LA A-P diameter and A-P thoracic diameter (r = 0.85), whereas the correlation between the LA volume index and A-P thoracic diameter was moderate (r = 0.47). Echocardiographic assessment of the LA A-P diameter adjusted for the A-P thoracic diameter may allow clinicians to identify, among individuals with suspected CAD, those at lower risk of obstructive CAD.

Left ventricular mass index versus results of diastolic stress echocardiography in patients with heart failure with preserved ejection fraction

Background: Left ventricular mass and left ventricular mass index (LVMI) is an index reflecting the thickness of the cardiac muscle, and the E/e’ ratio is a specific indicator for identifying increased left ventricular filling pressure. Limited data exist regarding the prognostic value of incorporating left ventricular mass index in heart failure with preserved ejection fraction (HFpEF). Aim: This study aimed to assess diagnostic value of LVMI at rest versus diastolic stress echo results in patients with HFpEF. Patients and methods: This study is a cross sectional descriptive study. In our study, we investigated 80 patients with unexplained exertional dyspnea with normal resting LV filling pressure at rest. Some of these patients may show elevated LV filling pressure with exercise. The current guidelines recommend to do diastolic stress echocardiography for those patients. All patients underwent complete resting echocardiography including assessment of diastolic dysfunction using the recommended 2016 guidelines and left ventricular mass index. Then we did diastolic stress echocardiography for all participants and the result of diastolic stress echocardiography was compared with the resting LVMI results.

Diagnostic value of exercise stress echocardiography on a horizontal cycle ergometer in patients with low-risk non-ST elevation acute coronary syndrome

Aim. To evaluate the diagnostic accuracy of exercise stress echocardiography on a horizontal cycle ergometer for the detection of obstructive coronary artery disease (CAD) in patients with low-risk non-ST-elevation acute coronary syndrome (NSTE-ACS).Material and methods. The study included 95 patients aged 53 (46;63) years (men, 58%), hospitalized in the regional vascular center with low-risk NSTE-ACS. Patients with known CAD, impaired resting left ventricular contractility were not included. During hospitalization, standard stress echocardiography on a horizontal cycle ergometer and invasive or non-invasive coronary angiography (CAG) were performed. All values of coronary obstruction ≥70% were verified by invasive CAG. The assessment of myocardial revascularization was observational.Results. All patients had normal structural and functional cardiac parameters at rest. No adverse events were recorded during the tests. The result of stress echocardiography according to impaired local contractility (ILC) criterion was positive in 9 (16%), negative in 28 (49%), incomplete symptom-limited in 20 (35%) patients. Coronary artery stenosis ≥50%/≥70% was detected in 78/78% of cases in the subgroup with a positive result, in 29/11% — with a negative result, 30/10% — with a non-diagnostic result. The association of ILC with stenosis ≥70% was higher, with an odds ratio of 30,1 (4,9; 186,5) vs 8,5 (1,6; 46,1) for stenosis ≥50%. There were following diagnostic accuracy for stenosis ≥70%: sensitivity — 70%, specificity — 93%, positive predictive value — 78%, negative predictive value — 89%, overall accuracy — 86%.Conclusion. Exercise stress echocardiography on a horizontal cycle ergometer in patients with low-risk NSTE-ACS patients is safe and feasible. The method has moderate sensitivity and positive predictive value and high specificity, negative predictive value and overall accuracy for the detection of anatomically significant coronary artery stenosis. In the structure of results, there is a significant proportion (35%) of symptom-limited tests incomplete due to heart rate, characterized by the lowest incidence of obstructive atherosclerosis.

Long-term prognostic value of stress echocardiography in patients with suspected coronary artery disease - Systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Objective To evaluate the association between results of stress echocardiography and outcomes for patients with suspected coronary artery disease. Design Systematic review and meta-analysis. Data Sources Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, and Clinicaltrials. Eligibility criteria for selecting studies Randomised controlled trials (RCT) evaluating long term outcome of SE in patients suspected of coronary artery disease. Data Synthesis A meta-analysis utilising the fixed effects model to evaluate evidence from recent RCT trials on SE or comparing SE to other non-invasive diagnostic modalities. The primary outcome was the composite of all-cause mortality, or cardiovascular death and non-fatal myocardial infarction. Positive SE result was defined as inducible ischaemia in at least 1 of the 16 left ventricular segments. Results Six trials fulfilled the search criteria. A total of 19477 subjects who underwent either pharmacological (Dobutamine or Dipyridamole) or treadmill SE were recruited in the meta-analysis with a median follow-up of 31 months (range 21–101). The mean age was 59 years, and 55% were male. Fifty six percent had hypertension, 48% dyslipidaemia, 33% history of smoking, 21% diabetes mellitus and 26% history of myocardial infarction. The overall annual event rate was 1.79% for the composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction and for death 1.82%. Positive SE result was associated with an increased risk of the composite outcome and death with an annual event rate of 1.98% vs 1.26%, Odds Ratio 1.99 (CI 1.75–2.26) and 3.59% vs. 0.93, Odds Ratio 2.06 (CI 1.80–2.35) for the composite outcome and death, respectively Figure A,B. Heterogeneity and inconsistency (Chi2 1.7 P= 0.89) were low. Imprecision was low in the composite outcomes, and the optimal information size was achieved across the studies. Conclusions In this meta -analysis positive SE results were associated with poorer long-term composite outcome of all-cause or cardiovascular mortality and non-fatal myocardial infarction as well as for death only. Figure. Composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction. (Abstract picture 1) All-cause or cardiovascular death. (Abstract picture 2)

415 DOES MYOCARDIAL BRIDGING TRIGGER MYOCARDIAL ISCHEMIA?

Abstract Background Myocardial bridging (MB) is a congenital epicardial coronary abnormality, in which a segment of the artery runs through the myocardium, determining dynamic stenosis during systole. Whether MB can be responsible by itself for myocardial ischemia remains unclear. Thus, we aimed to evaluate whether the dynamic stenosis related to MB can cause signs and symptoms of myocardial ischemia. Methods We enrolled 41 consecutive patients who underwent coronary angiography because of chest pain suspected for ischemic heart disease and were found to have MB in the absence of any significant flow-limiting coronary stenosis and any other cardiac disease. A group of 14 patients who also underwent coronary angiography because of chest pain suspected for ischemic heart disease, but found to be free of any coronary or cardiac abnormality (including MB) and also showed negative results at exercise stress test (EST) served as controls. All enrolled patients underwent a maximal treadmill EST according to standard Bruce protocol. A complete echocardiographic examination was performed at rest and at peak exercise. Results Baseline EST parameters were comparable between groups, whereas peak diastolic blood pressure (pDBP) was slightly higher in the MB group (p=0.044). No clinically significant differences were found in baseline echocardiographic parameters, although the E wave deceleration time (DcT) was longer (p=0.038) and global longitudinal strain (GLS) was higher (p=0.05) in the MB group. During exercise, left ventricular ejection fraction (LVEF) improved significantly in both groups (p&amp;lt;0.001), without any difference between the 2 groups. GLS did not show any significant changes with exercise in both groups. Moreover, among MB patients, no differences were found in stress echocardiographic results between those with positive vs. those with negative EST. Conclusions We failed to demonstrate any significant ischemic impairment of LV systolic and diastolic function at maximal EST in patients with MB. Moreover, we also failed to demonstrate any LV dysfunction in MB patients that developed ECG signs of myocardial ischemia during EST, as compared to those without evidence of myocardial ischemia. Thus, our data question about the ability of MB itself to trigger significant myocardial ischemia in clinical practice.

Modified Haller index is inversely correlated with true positive exercise stress echocardiographic results.

The influence of chest wall shape on exercise stress echocardiography (ESE) results has been poorly investigated. We aimed at evaluating the main predictors of true positive (TP)-ESE in a population of subjects with suspected coronary artery disease (CAD), categorized according to chest wall conformation, assessed by modified Haller index (MHI, chest transverse diameter over the distance between sternum and spine). All consecutive patients with suspected CAD referred to our EchoLab for performing ESE between September 2011 and October 2021 were retrospectively enrolled. Preliminary assessment of both pretest probability (PTP) and MHI was performed. All patients with positive ESE underwent coronary angiography. Obstructive CAD was diagnosed by ≥70% stenosis in any epicardial coronary artery. Outcome was TP ESE result. One thousand two hundred and seventy-five consecutive patients (64.9 ± 13.0 years) entered the study. Subjects with concave-shaped chest wall (MHI > 2.5) (10.7%) and those with normal chest shape (MHI ≤ 2.5) (89.3%) were separately analyzed. PTP was similar in both groups (21.8 ± 13.2 vs. 23.5 ± 13.3%, P = 0.15). One hundred and seventy patients were diagnosed with positive ESE: 129 (75.9%) had obstructive CAD (TP), whereas the remaining 41 (24.1%) had no CAD. Only 2.3% of TP ESE was detected in subjects with MHI >2.5. PTP [odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.04], dyslipidemia (OR 4.37, 95% CI 2.81-6.80), dyssynergy in the left anterior descending territory (OR 8.21, 95% CI 5.07-13.3) were linearly correlated with TP ESE, whereas MHI >2.5 (OR 0.25, 95% CI 0.14-0.67) was inversely associated with outcome. Subjects with MHI >2.5 have low prevalence of TP ESE, regardless of PTP. Preliminary MHI assessment may reduce overestimation of PTP of CAD.

Stress echocardiography in patients with ischemic mitral regurgitation and left ventricular dysfunction qualified to cardiosurgery treatment

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Ischemic mitral regurgitation (IMR) is predominantly related to left ventricle (LV) remodeling and mitral valve deformation. Although coronary artery bypass grafting alone (CABGa) or with mitral annuloplasty (CABGmp) is considered the best therapeutic strategies for patients with IMR, some recurrences are still reported. Purpose The aim of this study was to evaluate use of the mitral deformation indices (MDI) as a predictor of recurrence of IMR in 1-year follow-up after surgery. Methods A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Patients were referred for CABGa (gr.1; n = 90) or CABGmp (gr.2; n = 55), based on clinical assessment and the results of rest and stress echocardiography. One year after surgery each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify factors of recurrence of IMR in 1 year follow-up. Results Logistic regression analysis revealed that in CABGa group preoperative changes of TA and CH during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx &amp;gt; 1 cm2 provided sensitivity of 90% and specificity of 29%, (AUC 0.6436); The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%; AUC 0.6432). In both groups no significant differences were observed in 12-month mortality (1.2% vs 0%; p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs 8.5%; p = 0.72) and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs 8.5%; p = 0.742). Conclusion Preoperative assessment of MDI changes during dbx can be used to identify patients with IMR at increased risk of recurrence of significant IMR in 1 year follow-up. Abstract Figure 1 Abstract Figure 2

Stress Echocardiography Protocol for Deciding Type of Surgery in Ischemic Mitral Regurgitation: Predictors of Mitral Regurgitation Recurrence following CABG Alone.

Purpose: Although coronary artery bypass grafting alone (CABGa), or, with mitral annuloplasty (CABGmp), is considered the best therapeutic strategy for patients with ischemic mitral regurgitation (IMR), some recurrences are still reported. The aim of this study was to evaluate the use of the mitral deformation indices (MDI) as a predictor of recurrence of mitral regurgitation in a 12-month follow-up after CABG alone. Methods: A total of 145 patients after myocardial infarction with significant IMR, eligible for CABG, were prospectively enrolled in the study. Mitral valve morphology, left ventricle function, IMR degree as assessed by effective regurgitation orifice area (ERO), myocardial viability, and MDI were assessed prior to surgery. Patients were referred for CABGa (gr.1; n = 90) or CABGmp (gr.2; n = 55) based on clinical assessment, and the results of rest and stress echocardiography (exercise echocardiography and low dose dobutamine echocardiography-DBX). One year after surgery, each patient underwent the evaluation of cardiovascular events. Univariable logistic regression analysis was used to identify the factors of recurrence of IMR in 1 year follow-up. Serial echo examinations were performed in all patients at discharge, and at 1 and 12 months after surgery. Results: Logistic regression analysis revealed that in CABGa, group preoperative changes of tenting area (TA) and coaptation high (CH) during DBX remained the predictors of the recurrence of IMR in 12 months follow-up. TAdbx > 1 cm2 provided a sensitivity of 90% and specificity of 29%, (AUC 0.6436). The best cut-off value for CHdbx was 0.4 cm (sensitivity 90%, specificity 34%; AUC 0.6432). In both groups (CABGa vs. CABGmp) no significant differences were observed in 12-month mortality (1.2% vs. 0%; p = 1.0), hospitalizations due to the heart failure (HF) exacerbation (5.9% vs. 8.5%; p = 0.72), and in the incidence of the composite endpoint (deaths/CV hosp/stroke) (7% vs. 8.5%; p = 0.742). Conclusions: The preoperative assessment of MDI changes during dbx can be used to identify patients with IMR qualified to CABG alone at increased risk of recurrence of IMR in 1 year follow-up. Mitral deformation analysis should be used for a better qualification of patients with IMR to the exact surgical approach.

Does chest shape influence exercise stress echocardiographic results in patients with suspected coronary artery disease?

Despite the good specificity of exercise stress echocardiography (ESE) for the detection of coronary artery disease (CAD), false positive (FP) results may occur. We have previously reported that chest abnormalities may affect parameters of cardiac contractility. The influence of chest shape on ESE results has never been previously investigated. We retrospectively analyzed 160 consecutive patients (64.4 ± 13.0-year old, 91 women) who had undergone coronary angiography at our Institution because of positive ESE, between June 2014 and May 2020. Modified Haller index (MHI; chest transverse diameter over the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥ 70% stenosis in any epicardial coronary artery. Outcome was false-positivity at ESE. 80.6% of patients were diagnosed with obstructive CAD, while 19.4% had no CAD (FP). We separately analyzed patients with normal chest shape (MHI ≤ 2.5) and those with concave-shaped chest wall (MHI > 2.5). These latter were mostly women with small cardiac chambers, mitral valve prolapse (MVP) and exercise-induced ST-segment changes. Likelihood of false-positivity was significantly higher in subjects with MHI > 2.5 than those with MHI ≤ 2.5 (30.7% vs 9.4%, p = 0.001). By multivariate logistic regression analysis, MHI > 2.5 (OR 4.04, 95%CI 1.45-11.2, p = 0.007), MVP (OR 3.47, 95%CI 1.32-9-12, p = 0.01) and dyssynergy in the left circumflex territory (OR = 3.35, 95%CI 1.26-8.93, p = 0.01) were independently associated with false-positivity. Concave-shaped chest wall (MHI > 2.5) may be associated with false-positive stress echocardiographic result. Mechanisms underpinning this finding need to be further explored.

Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease.

The hypothesis that modified Haller index (MHI) integration with the existing appropriate use criteria (AUC) categories may predict exercise stress echocardiography (ESE) results and outcome of patients with suspected coronary artery disease (CAD) has never been previously investigated. We retrospectively analyzed 1230 consecutive patients (64.8 ± 13.1 years, 58.9% men) who underwent ESE for suspected CAD between February 2011 and September 2019 at our institution. MHI (chest transverse diameter over the distance between sternum and spine) was assessed in all patients. A true positive (TP) ESE was a positive ESE with obstructive CAD according to subsequent coronary angiography. During follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations; (2) Cardiac death or sudden death. Overall, 734 (59.7%), 357 (29.0%) and 139 (11.3%) indications for ESE were classified as appropriate (Group 1), rarely appropriate (Group 2) and which may be appropriate (Group 3), respectively. A funnel chest (defined by an MHI > 2.5) was detected in 30.3%, 82.1% and 49.6% of Groups 1, 2 and 3 subjects, respectively (p < 0.0001). On multivariate logistic regression analysis, male sex (OR 1.41, 95%CI 1.02-2.03, p = 0.01) and type-2 diabetes (OR 3.63, 95%CI 2.49-5.55, p = 0.001) were directly correlated to a TP ESE, while "rarely appropriate" indication for ESE with MHI > 2.5 (OR 0.16, 95%CI 0.11-0.22, p < 0.0001) showed a significant inverse correlation with the outcome. During a mean follow-up of 2.5 ± 1.9 years, 299 CV events occurred: 76.4%, 3.5% and 20.1% in Groups 1, 2 and 3, respectively. On multivariate Cox regression analysis, smoking (HR 1.33, 95%CI 1.19-1.48), type 2 diabetes (HR 2.28, 95%CI 1.74-2.97), dyslipidemia (HR 3.51, 95%CI 2.33-5.15), beta-blockers (HR 0.55, 95%CI 0.41-0.75), statins (HR 0.60, 95%CI 0.45-0.80), peak exercise average E/e' ratio (HR 1.08, 95%CI 1.06-1.09), positive ESE (HR 3.12, 95%CI 2.43-4.01) and finally "rarely appropriate" indication for ESE with MHI > 2.5 (HR 0.15, 95%CI 0.08-0.23) were independently associated with CV events. The implementation of AUC categories with MHI assessment may select a group of patients with extremely low probability of both TP ESE and adverse CV events over a medium-term follow-up. A simple noninvasive chest shape assessment could reduce unnecessary exams.

The effects of lockdown-induced air quality changes on the results of cardiac functional stress testing in coronary artery disease and heart failure patients.

In vulnerable subjects, the increase in air pollution worsens the signs of myocardial ischemia. Lockdown during COVID-19 pandemics substantially cleaned the air. The objective of this is to assess the effects of air cleaning due to lockdown on stress echocardiography (SE) results. We enrolled 19 patients with chronic coronary artery disease and/or heart failure referred to SE (semi-supine bicycle exercise, n = 8, or dipyridamole, n = 11). Before and soon after lockdown, we assessed regional wall motion abnormalities (abnormal value: worsening of ≥ 2 segments), B-lines (a sign of pulmonary congestion, 4-site simplified scan, abnormal value ≥ 2), and coronary flow velocity reserve in left anterior descending artery (CFVR, abnormal value < 2.0). Local air quality indicators (same day of SE) of fine particulate matter (PM2.5) and nitrogen dioxide (NO2) were obtained from publicly available data sets of the regional authority of environmental protection. After lockdown, NO2 concentration decreased from 19 ± 10 to 10 ± 4 μg/m3 (p = 0.006). After lockdown, abnormal responses remained unchanged for ischemia (21% vs 16%, p = ns) and decreased for B-lines (42% vs 5%, p = 0.008) and CFVR (84 vs 42%, p = 0.007). Changes in coronary flow velocity reserve (CFVR) were correlated to same-day variations in NO2 (r = −0.578, p = 0.010) and preceding 30-day changes in PM2.5 (r = −0.518, p = 0.023). After lockdown, air cleaning was associated with a beneficial effect on coronary small vessel dysfunction and alveolar-capillary barrier distress mirrored by improvement of CFVR and B-lines during SE in vulnerable patients. ClinicalTrials.gov Identifier: NCT 030.49995

The Effect of Echocardiography Based on Lipid Nano Contrast Agent on Cardiology Patients with Heart Failure and Atrial Fibrillation.

This paper discusses the effect and evaluation of echocardiography based on lipid nano contrast agent on patients with heart failure and atrial fibrillation in cardiology department, providing reference for clinical diagnosis and treatment. Fifty two patients with diastolic heart failure diagnosed by echocardiography were selected for routine echocardiographic examination after optimizing the drug treatment scheme, and then the patients underwent treadmill exercise test and stress echocardiography evaluation. The results of conventional echocardiography and stress echocardiography after treatment were compared with those before treatment, and the clinical parameters and biochemical indexes before and after treatment were compared. Results after treatment, the clinical symptoms of the patients improved, the level of NT proBNP in the N-terminal forebrain decreased significantly, and the exercise tolerance increased significantly. Compared with the conventional echocardiography before and after treatment, the left ratio and e' value of stress echocardiography after treatment increased significantly, while E/e' decreased significantly. There was no significant difference in the indexes of general echocardiography before and after treatment. After treatment, positively correlated with the ratio of peak a to peak E. The results show that the sensitivity of stress echocardiography to evaluate ischemic diastolic heart failure has been improved, and some indexes have clinical significance. Compared with conventional echocardiography, it can effectively evaluate the therapeutic effect of drugs.

Hypertensive response to exercise: prevalence and impact on stress echocardiography results

Background. Hypertensive response of blood pressure (BP) to exercise has substantial prognostic impact. Hypertensive response to exercise is shown to be a predictor for development of hypertension and stroke. The data concerning hypertensive response to exercise influence on stress echocardiography results are controversial. Objective. The aim of the study was to assess the frequency of hypertensive response of BP to exercise and its impact on the result of the stress echocardiography on treadmill in patients with known or suspected ischemic heart disease. Design and methods. We analyzed 3434 tests performed in out-patient department during 1 month period (21.01–21.02) of every year since 2007 to 2020. We studied the occurrence of hypertensive response to exercise during exercise stress echocardiography on treadmill and its relation to positive results of the test. Results. The prevalence of hypertensive response to exercise varied from 8,6 % to 41,5 % (average in 14-year period — 23,24%), however, the proportion of tests with hypertensive response to exercise significantly declined in the period from 2015 to 2020 years. Patients with hypertensive response to exercise showed significantly more frequent positive tests in comparison to patients with normotensive BP response: 40,6 % vs 31,0% (r = 12,2, р = 0,0005), though yearly analysis showed no correlation between the number of tests with hypertensive response to exercise and number of positive tests (r = 0,21; р = 0,47). Conclusions. Significant correlation between BP response and stress echocardiography results means that hypertensive response to exercise has an impact on the test results, therefore antihypertensive treatment optimization is essential before test.

The prognostic value of coronary flow reserve of left anterior descending artery in non-diagnostic or inconclusive stress echocardiography tests

Abstract Background Relevant number of all stress echocardiography results are non-diagnostic or inconclusive. Such importance cannot be ignored as previous studies have shown that these patients have higher risk for adverse events. Non-invasive transthoracic Doppler derived coronary flow reserve (CFR) of left anterior descending (LAD) artery, as additional test, is an effective tool to predict adverse cardiac events in various clinical settings. Purpose The aim of this study was to investigate the value of CFR of LAD in predicting outcome. Methods 122 patients, (35,8% with previous MI) with nondiagnostic stress echocardiography results (target heart rate not reached, chest pain without ECG and echo changes) and with inconclusive stress echocardiography results (target heart rate reached, chest pain with ECG changes and without echo changes) were referred for transthoracic Doppler echocardiographic CFR assessment of LAD. CFR was calculated as the ratio between maximal hyperemic and baseline coronary flow velocity. CFR ≤2 was considered abnormal. All patients were followed for major adverse cardiac events (MACE): nonfatal myocardial infarction, hospitalization, revascularization (CABG or PCI) and death. Results Measured values of CFR LAD were in the range 1,52- 4,00 (mean: 2,4±0.44). CFR LAD was abnormal in 22 (18%), and preserved in 100 patients (82%). During median follow-up of 23 months (interquartile range 9–35), 14 patients underwent revascularization (2 had CABG, 12 had PCI). There were no myocardial infarctions, hospitalizations or cardiovascular deaths in the follow-up period. Patients with lower CFR values (CFR≤2) had a higher event rate and shorter event free survival time compared to those with CFR&amp;gt;2, event rate (9/22, 40,9% vs 5/98 5,1%; p&amp;lt;0.0001) and event free time (22±3 vs 33±1 months; p&amp;lt;0.0001) by Kaplan Maier analyses, (Log Rank 24.42; p&amp;lt;0.001). Conclusions Preserved CFR of LAD (&amp;gt;2.0) predicts excellent survival in patients with non-diagnostic and inconclusive stress echocardiography. Funding Acknowledgement Type of funding source: None