Treadmill Stress Echocardiography Research Articles

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...

Unmasking Obstruction in Hypertrophic Cardiomyopathy With Postprandial Resting and Treadmill Stress Echocardiography

Latent left ventricular outflow tract obstruction (LVOTO) is an important cause of symptoms in patients with hypertrophic cardiomyopathy (HCM) but can be challenging to provoke. To examine the value of postprandial resting and stress echocardiography and utilization of invasive or enhanced drug therapies (surgical myectomy, alcohol septal ablation, disopyramide, and mavacamten) in patients with postprandial LVOTO. Consecutive HCM patients without LVOTO underwent routine and postprandial echocardiography at rest, with provocation (Valsalva and standing) and after symptom-limited treadmill stress. Among 252 patients (mean age, 58years, 39% women), postprandial LVOT gradients were higher compared with routine echocardiography at rest (median, 9.0 [0-38.0] vs 0 [0-14.0] mm Hg; P<.0001) and with provocation (18.5 [0-70.3] vs 1.5 [0-41.0] mm Hg; P<.0001). Postprandial exercise stress echocardiogram (PPXSE) gradients were higher in a subset of 44 patients who underwent both postprandial and fasting stress echocardiography (47.0 [5.3-81.0] vs 17.5 [0-46.0] mm Hg; P<.0001). In total, 49 (19.5%) patients achieved the ≥50mm Hg threshold under routine conditions (rest/provocation); 90 (35.7%) additional patients achieved postprandial gradients ≥50mm Hg (rest/provocation/exercise), 38 (15.1%) with PPXSE alone. A total of 71 patients were treated with 91 invasive or enhanced drug therapies, 32 (45.1%) of whom had gradients ≥50mm Hg only after eating (rest/provocation) and 8 (11.3%) only with PPXSE, with symptom relief in the majority. Postprandial echocardiography was useful at unmasking LVOTO in more than one-third of patients who did not have high gradients otherwise. Eating before echocardiography is a powerful provocative tool in the evaluation of patients with HCM.

Assessment the Predictive Value of Left Atrial Strain (LAS) on Exercise Tolerance in HCM Patients with E/e' between 8 and 14 by Two-Dimensional Speckle Tracking and Treadmill Stress Echocardiography.

The aim of this study was to evaluate the reservoir, conduit, and contraction function of the left atrium and to evaluate the predictive value of left atrial strain (LAS) on exercise tolerance in hypertrophic cardiomyopathy (HCM) patients with an E/e' between 8 and 14 by two-dimensional speckle tracking using treadmill stress echocardiography. This was a retrospective study in which we analyzed a total of 70 patients with HCM between 2016 and 2017. According to the resting state E/e', patients were either assigned to an HCM-1 group (E/e' 14) or an HCM-2 group (E/e' of 8 to 14). Thirty age-matched healthy controls were included in the normal group. Analysis involved the left atrial reservoir, conduit, contraction strain and reserve function. The normal group had a higher left atrial reservoir and conduit strain than the HCM-2 group; the lowest values were in the HCM-1 group. The LAS reserve capacity of the HCM-1 and HCM-2 groups was lower than those of the normal group. The left atrial contraction strain reserve ( LASct%) and global longitudinal strain reserve ( GLS%) were lower in the HCM-2 and HCM-1 groups than in the normal group. We also found that the LASct% and GLS% in the HCM-2 group were higher than in the HCM-1 group. Furthermore, the metabolic equivalents (METS) in the HCM-2 group was greater than that in the HCM-1 group. Finally, the Rest-LASr indicated the highest differential diagnostic performance for METS 6.0 (area under curve [AUC]: 0.759); the AUC of the composite model Rest-LASr+E/e'-rest was 0.8. Analysis showed that when the E/e' was between 8 and 14, the LAS and reserve capacity of HCM patients were significantly reduced. Our findings suggest that the routine assessment of LAS +E/e' can be a strategy with which to supplement current predictive models and facilitate clinical management strategies.

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

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

A double-blind randomised placebo-controlled trial of percutaneous coronary intervention for the relief of stable angina without antianginal medications: design and rationale of the ORBITA-2 trial.

Percutaneous coronary intervention (PCI) is frequently performed for stable angina. However, the first blinded trial, ORBITA, did not show a placebo-controlled increment in exercise time in patients with single-vessel disease, at 6 weeks, on maximal antianginal therapy. ORBITA-2 will assess the placebo-controlled efficacy of PCI on angina frequency in patients with single- or multivessel disease, at 12 weeks, on no antianginal therapy. ORBITA-2 is a double-blind placebo-controlled trial randomising participants with (i) angina at presentation, (ii) documented angina during the 2-week pre-randomisation symptom assessment phase, (iii) objective evidence of ischaemia, (iv) single- or multivessel disease, and (v) clinical eligibility for PCI. At enrolment, antianginals will be stopped, and angina questionnaires completed. Participants will record their symptoms on a smartphone application daily throughout the trial and will undergo exercise treadmill testing and stress echocardiography at pre-randomisation. They will then undergo coronary angiography with unblinded invasive physiology assessment. Eligible participants will then be sedated to a deep level of conscious sedation and randomised 1:1 between PCI and placebo. After the 12-week blinded follow-up period, they will return for questionnaires, exercise testing and stress echocardiography assessment. If angina becomes intolerable, antianginals will be introduced using a prespecified medication protocol. The primary outcome is an angina symptom score using an ordinal clinical outcome scale for angina. Secondary outcomes include exercise treadmill time, angina frequency, angina severity and quality of life. Trial registration: ClinicalTrials.gov: NCT03742050.

Cardiopulmonary exercise test in patients with refractory angina: functional and ischemic evaluation

ObjectivesRefractory angina (RA) is a chronic condition clinically characterized by low effort tolerance; therefore, physical stress testing is not usually requested for these patients. Cardiopulmonary exercise testing (CPET) is considered a gold standard examination for functional capacity evaluation, even in submaximal tests, and it has gained great prominence in detecting ischemia. The authors aimed to determine cardiorespiratory capacity by using the oxygen consumption efficiency slope (OUES) in patients with refractory angina. The authors also studied the O2 pulse response by CPET and the association of ischemic changes with contractile modifications by exercise stress echocardiography (ESE). MethodsThirty-one patients of both sexes, aged 45 to 75 years, with symptomatic (Canadian Cardiovascular Society class II to IV) angina who underwent CPET on a treadmill and exercise stress echocardiography on a lower limb cycle ergometer were studied. ClinicalTrials.gov: NCT03218891. ResultsThe patients had low cardiorespiratory capacity (OUES of 1.74 ± 0.4 L/min; 63.9±14.7% of predicted), and 77% of patients had a flattening or drop in O2 pulse response. There was a direct association between Heart Rate (HR) at the onset of myocardial ischemia detected by ESE and HR at the onset of flattening or drop in oxygen pulse response detected by CPET (R = 0.48; p = 0.019). ConclusionPatients with refractory angina demonstrate low cardiorespiratory capacity. CPET shows good sensitivity for detecting abnormal cardiovascular response in these patients with a significant relationship between flattening O2 pulse response during CEPT and contractile alterations detected by exercise stress echocardiography.

Does diabetes increase the risk of cardiovascular events in patients with negative treadmill stress echocardiography?

Cardiovascular morbidity and mortality rates are considered to be high in patients with diabetes despite negative stress test results; however, little data are available to support this supposition. We compared the long-term cardiovascular events between patients with diabetes and those without diabetes with negative treadmill stress echocardiography and evaluated the predictors for cardiovascular events in patients with diabetes. A total of 1,243 consecutive patients (mean age, 56 ± 10 years; non-diabetics: diabetics, 975:268; mean follow-up of 5 years) with negative treadmill stress echocardiography were evaluated. Clinical data were examined, and major adverse cardiovascular events (MACEs, a composite of coronary revascularization, acute myocardial infarction, and cardiovascular death) were compared between the non-diabetic and diabetic groups. In the population matched by clinical characteristics, the diabetic and non-diabetic groups had similar occurrence of MACEs (non-diabetics vs. diabetics = 5% versus 7%; p = 0.329) and event-free survival. MACEs in the diabetic group were associated with elevated early diastolic velocity of the mitral inflow/mitral annulus (E/e') ratio, indicative of diastolic dysfunction. The absence of statin and dipeptidyl peptidase-4 inhibitor use and use of sulfonylureas were also predictors of more MACEs. In conclusion, long-term cardiovascular events in patients with diabetes and negative stress echocardiography were comparable to those in patients without diabetes. However, appropriate monitoring of diastolic dysfunction, statin use, and individualized antidiabetic drug selection are required to reduce the cardiovascular risk in patients with diabetes.

OR42. Hypertensive Response to Exercise as Predictor for 1-Year Rehospitalization due to Major Adverse Cardiac Event: A Putative Role of Cardiac Remodeling?

Abstract Background and Aims Recent studies found that hypertensive response to exercise (HRE) was associated with development of target organ damage. The study was to determine the echocardiographic parameters associated with HRE and role of HRE in rehospitalization within 1 year due to major adverse cardiac event (MACE). Method and Results This study was a cohort retrospective study using medical records of patients who underwent treadmill stress test and echocardiography examination at Sanglah General Hospital from May 2018- May 2020 which enrolled 114 patients. Data analysis used SPSS version 21. Pearson chi-square test was used to compare categorical variables based on 1-year rehospitalization after cardiac TST due to MACE that included heart failure, coronary artery disease, stroke, arrhythmia, and cardiovascular death. Mann-Whitney U test was used to compare echocardiographic parameters such as EF, EDV, ES, FS, LVIDd, LVIDs, LV mass index, LAVI, TAPSE, and E/E' ratio. Subjects with HRE had higher LV mass index (82.34±15.05 vs 70.62±9.76), higher E/E’ ratio (16.31±2.95 vs 16.01±13.23), higher LAVI (39.75±15.21 vs 34.27±11.15) with all p-value were &amp;lt;0.05. In this study, HRE also significantly associated with 1-year rehospitalization due to MACE (OR 2.27, 95% CI 1.62–3.16, p = 0.0001). Conclusions HRE may be used to predict 1-year rehospitalization due to MACE. In this study it was also found that HRE was associated with several echocardiographic parameters, such as LV mass index, LAVI, and E/E’ ratio. Further study is needed to determine the putative role of cardiac remodeling in patients with HRE.

OR73. The Relationship Between Echocardiographic Parameters and Chronotropic Incompetence in Patients with Cardiovascular Disease at Sanglah General Hospital, Bali

Abstract Background and Aims Patients with cardiovascular disease commonly have chronotropic incompetence which may be associated with cardiac remodelling and increased LV filling pressure. This study aimed to determine the association between echocardiography findings and chronotropic incompetence (CI) among patients with cardiovascular disease. Method and Results This was a cross-sectional study that included 136 medical records of patients with cardiovascular disease underwent treadmill stress test (TST) and echocardiography examination at outpatient cardiology clinic, Sanglah General Hospital from 2018 until 2020. Chronotropic incompetence was defined as maximum heart rate that can’t reach 85% age-predicted maximum heart rate. Data was analyzed using SPSS version 21. Mann-Whitney U test was used to evaluate the association between echocardiography findings such as ejection fraction (EF), left ventricular internal dimension end-diastolic (LVIDd), LVIDd index (LVIDdi), left ventricular mass, E/E’ ratio, left atrial volume index (LAVI) and CI. Among 136 subjects of this study, the mean age was 54.7 years, 71.3% were male and 37.5% were obese. Patients with CI were found to had lower LVIDd (42.8+0.89 vs 45.2+0.72, p = 0.029), lower LVIDi (24.6+0.37 vs 25.5+ 0.31, p = 0.025), higher left ventricular mass (175.6+3.27 vs 125.1+2.63, p &amp;lt; 0.001), higher E/E’ ratio (17.3+0.29 vs 13+0.35, p &amp;lt; 0.001), and higher LAVI (47+1.98 vs 31.6+1.09, p &amp;lt; 0.001) compared with patients without CI. Conclusion Patients with cardiovascular disease commonly have chronotropic incompetence that could be detected by TST examination, which may be partly predicted by echocardiographic parameters that are associated with cardiac remodelling and increased LV filling pressure.

The feasibility, reliability, and incremental value of two-dimensional speckle-tracking for the detection of significant coronary stenosis after treadmill stress echocardiography

BackgroundTwo-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD.MethodsWe conducted a case–control study of all consecutive patients with abnormal ESE in 2018–2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13–17, segment 17, and segments 15–16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively.ResultsWe excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84, p = 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70, p = 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73, p = 0.11).ConclusionsTwo-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD.

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.

Preconception consultation using treadmill exercise stress echocardiography for pregnant women with the left-sided heart valve stenosis: A preliminary report.

Pregnancy can increase gradients across the heart valves and consequently deteriorates maternal and fetoneonatal conditions. Hence, pregnancy during heart valve diseases can be challenging and we need to risk stratify patients before conception. We tried to assess the role of preconception consultation using treadmill stress echocardiography (TSE) testing for identifying pregnancy outcomes in women with mitral valve stenosis (MS) or aortic valve stenosis (AS). Pregnant patients with a diagnosis of MS or AS were evaluated from January 2015 to December 2018. First group included patients undergoing the TSE testing and they were permitted to get pregnant if they met pre-defined criteria. Second group comprised women who did not undergo TSE testing. Maternal and fetoneonatal outcomes were also recorded. A total of 29 and 18 patients with MS and AS, respectively, were recruited. Among MS patients, individuals without TSE had more functional deterioration (11.1% vs. 35%) and more fetoneonatal events (FNE) (22.2% vs. 55%) compared with those undergoing TSE. The rates of maternal events and mitral valvuloplasty during pregnancy were significantly higher in patients without TSE compared with those undergoing TSE (p=0.015 and p=0.042, respectively). Among AS patients, maternal and FNE were higher in patients without TSE compared with those undergoing TSE, but those were comparable. Pregnant patients with the left-sided valvular stenosis who received preconception TSE testing had better outcomes compared with those who did not undergo preconception consultation. This underscores the utility of stress echocardiography in the risk stratification of pregnancies.

The prognostic value of estimating stroke volume before and after exercise during treadmill stress echocardiography.

Stress echocardiography (SE) is an established technique for assessment of coronary artery disease (CAD) which is difficult to perform and interpret. Left ventricular stroke volume (SV) is readily estimated with Doppler echocardiography. It can be affected by myocardial ischemia, with possible adjunctive value during SE. Patients underwent Bruce protocol SE with SV estimated before and after maximal treadmill exertion post routine regional wall analysis. Incremental change in SV (ΔSV) with exercise was measured. A derivation cohort (n=273) was established to test the hypothesis. An optimal cutoff for detection on inducible ischemia was ΔSV ≤ +10mL. The validation cohort of consecutive patients (n=1093, 376 [34%] female; age 59±12years) were followed clinically after SE for 20460 patient-months. There were 1000 patients with nonischemic SE, and 93 patients with studies suggestive of myocardial ischemia. Secondary analysis yielded 831 patients with a normal exercise response (ΔSV>+10mL) and 192 with an abnormal ΔSV ≤ +10mL. Time to first combined adverse cardiac event (composite of angina, acute coronary syndrome, cardiac revascularization, worsening New York Heart Association (NYHA) class, a reduction in EF, and cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. The hazard ratio for an adverse event with an abnormal ΔSV response (≤10mL) was 10.3 (95% confidence intervals 5.6-19.1, P<.0001). Stroke volume assessment during SE is feasible and readily performed. It is simple, practical, and has incremental diagnostic and prognostic value when added to exercise regional wall-motion analysis.

Impaired global longitudinal strain in elderly patients with preserved ejection fraction is associated with raised post-exercise left ventricular filling pressure.

The purpose of this study was to evaluate whether impaired resting global longitudinal strain (GLS) in elderly patients with preserved left ventricular (LV) ejection fraction (EF) is associated with raised post-exercise LV filling pressure estimated by the ratio of early diastolic transmitral flow velocity to annulus velocity (E/e'). Seventy elderly patients (age = 74 ± 6years, male 40 patients) who underwent treadmill stress echocardiography were studied. All patients had normal sinus rhythm, normal LV wall motion at rest, and had preserved LVEF ≥ 50%. Patients with exercise induced wall motion abnormality were not included. GLS at rest was measured using automated functional imaging. Twenty-four of the 70 patients had raised post-exercise LV filling pressure indicated by septal E/e' ≥ 15.0. Patients with raised post-exercise LV filling pressure had smaller resting GLS than that in patients without it (-16.9 ± 1.8 vs. -19.6 ± 2.5%, respectively, p < 0.0001). Downward stepwise multivariate logistic regression analysis demonstrated that resting GLS was one of independent predictors of raised post-exercise E/e'. Receiver operating characteristic (ROC) curve analysis had demonstrated that optimal cutoff point for resting GLS to predict raised post-exercise E/e' was -17.8% (sensitivity 83.3%, specificity 80.4%, respectively), and the area under the ROC curve was 0.820. In elderly patients with preserved LVEF and without obvious myocardial ischemia, impaired resting GLS at rest is associated with raised post-exercise LV filling pressure estimated by E/e' ≥ 15.0.

1680 Left ventricular filling pressure assessment with exercise stress echocardiography in patients with non-valvular atrial fibrillation

Abstract Background Noninvasive parameters of LV filling pressure (E/e’) and pulmonary pressures (RVSP) by Doppler echocardiography correlate with functional capacity and outcome in sinus rhythm (SR). Their role in AF is less clear. Elevated left ventricular filling pressures (E/e’) and pulmonary artery systolic pressures (PASP) by Doppler stress echocardiography correlate with impaired functional capacity in patients in sinus rhythm (SR). However, there is limited data in atrial fibrillation (AF). Purpose The aim of this study was to delineate the characteristics of patients with AF referred for exercise stress echocardiography and determine the prevalence and significance of E/e’ and PASP elevations in AF. Methods Subjects were patients referred for exercise treadmill stress echocardiography (n= 14,937) and underwent regional wall motion assessment, Doppler assessment of mitral inflow (E) and early tissue relaxation (e’) velocities and PASP at rest and immediately following maximum symptom limited exercise. Exclusion criteria included significant valvular heart disease (moderate or greater stenosis and/or regurgitation of any cardiac valve or previous valve repair or replacement) (1%), congenital heart disease (&amp;lt;1%) or refusal to participate in research (&amp;lt;1%). Results Patients with AF (n = 310, 2%) were older (71 ± 10 vs 59 ± 13 years, p &amp;lt; 0.001). While resting blood pressure was similar, resting heart rates were higher in AF (80 ± 17 bpm vs 73 ± 13 bpm, p &amp;lt; 0.0001). AF patients achieved lower workloads (6.4 ± 2.4 METS vs 9 ± 2.4 METS, p &amp;lt; 0.001) with lower peak double products (22336 ± 6677 vs 25148 ± 5438, p &amp;lt; 0.001). Rates of resting (27% vs 10%, p &amp;lt; 0.0001) and exercise-induced (37% vs 20%, p &amp;lt; 0.0001) regional wall motion abnormalities were higher in AF. Mean E/e’ was higher in AF at rest (12 ± 5 vs 9 ± 3, p &amp;lt; 0.001) and with exercise (12 ± 5 vs 10 ± 4, p &amp;lt; 0.001), with a higher percentage of patients in AF having E/e’ ≥15 at rest (20% vs 6% in SR, p= &amp;lt;0.001) and with exercise in (23% vs 8%, p &amp;lt; 0.001). PASP was higher in AF at rest (33 ± 8 mm Hg vs 28 ± 6 mm Hg, p &amp;lt; 0.001) and with exercise (48 ± 12 vs 42 ± 11, p &amp;lt; 0.001) compared to SR. E/e’ correlated with exercise capacity in AF and in SR, with an E/e’ cutoff of 11.7 that was best predictive of impaired functional capacity (&amp;lt; 5 METS in women and &amp;lt; 7 METS in men). Conclusions Abnormalities of E/e’ and PASP are more prevalent in patients with AF and correlate with impaired functional capacity. In patients with AF, a medial E/e’ ratio of ≥ 12 immediately following exercise is best associated with impaired functional capacity.

Prospective multicenter Polish Stress Echocardiography Registry (PolStress-Echopro) - the role in clinical practice.

Stress echocardiography (SE) is becoming an increasingly frequently performed diagnostic examination in Poland. After the published retrospective PolSTRESS Registry, this prospective study is the first one available so far. The aim of the study was to analyze SE tests, taking into account the clinical characteristics of the patients, indications, applied protocols, and diagnostic and therapeutic decisions. Reference cardiological centers in Poland were asked for a 1-month prospective analysis of the data obtained. The study included 189 SE examinations. To evaluate coronary artery disease (CAD) (178 tests), all 17 centers performed dobutamine SE (DSE) (100%), 3 centers (17%) performed pacing, while cycle ergometer and treadmill SE were performed by 1 (5%) and 2 (11%) centers, respectively. In patients with valvular heart disease (VHD) (11 tests), 3 centers (16%) performed SE to evaluate low-flow/low-gradient aortic stenosis (AS), 4 (22%) in asymptomatic AS and 1 (5%) to evaluate mitral regurgitation. For CAD assessment, a positive result was found in 37 (20%) patients, negative in 109 (61%) and nondiagnostic in 32 (19%). In the CAD group, coronarography was performed in 41 (23%) people. The analysis of the significance of the SE results for decision-making on interventional measures revealed that 30 patients (from the total study population of 189) were referred for the intervention. The most commonly used SE is the DSE. Negative test results allowed in almost half of the patients to resign from invasive coronarography. Stress echocardiography should be more frequently used in patients with VHD in the qualification for invasive treatment.

The Diagnostic Accuracy of Exercise Treadmill Testing and Stress Echocardiography for the Detection of Obstructive Coronary Artery Disease in Patients Aged ≥ 70 Years

to compare diagnostic accuracy of exercise treadmill testing and stress echocardiography in the diagnosis of stable coronary artery disease (CAD) in patients aged &gt;70 years. The study included 390 patients aged &gt;70 years with suspected stable ischemic heart disease, who underwent elective coronary artery angiography (CAG). Exercise treadmill testing (ETT) according to the modified Bruce protocol was carried out in 189 patients (48 %), bicycle stress echocardiography - in 179 patients (46 %). Initially we determined the prevalence of angiographically significant CAD according to the gender and chest pain character, and identified persons in whom stress testing was appropriate. After that diagnostic accuracy of both tests was evaluated in patients with atypical angina and non-anginal chest pain. Among 72 patients with atypical angina and non-anginal pain who underwent ETT and had unequivocal results, 38 (53 %) had obstructive CAD. ETT for detection of obstructive CAD had sensitivity 79 %, specificity 82 %, positive likelihood ratio (LR+) 4.4, and negative likelihood ratio (LR-) 0.3. Positive result increased probability of obstructive CAD from 53 % to 83 %, negative result reduced probability of obstructive CAD to 25 %. Among 111 patients with atypical angina and non-anginal pain who underwent stress echocardiography and had unequivocal results, 69 (62 %) had obstructive CAD. Sensitivity, specificity, LR+, and LR- of stress echocardiography were equal to 89 %, 95 %, 17.8, and 0.1, respectively. Positive result increased probability of obstructive CAD from 62 % to 95 %, negative result reduced probability of obstructive CAD to 16 %. bicycle stress echocardiography was found to be more accurate than ETT to rule in or rule out obstructive CAD in patients aged ≥ 70 years with atypical angina and non-anginal pain.

P2644Coronary atherosclerotic burden and risk of major adverse cardiac events in hypertensive patients with erectile dysfunction

Abstract Purpose Aim of the study is to assess the prevalence of angiographically coronary artery disease (CAD) and the incidence of future cardiovascular (CV) events among hypertensive males with erectile dysfunction (ED) on the basis of calculated total CV risk at first presentation. Methods A total of 392 hypertensive ED patients without diabetes or known cardiovascular disease underwent a comprehensive evaluation for presence of target organ damage (TOD) and stratified into three total CV risk categories based on blood pressure (BP) category, CV risk factors, TOD and presence of chronic kidney disease. Total testosterone (TT) and peak systolic velocity (PSV) at penile arteries were measured as markers of ED severity and predictors of CV risk. All patients underwent exercise treadmill test and stress echocardiography to reveal myocardial ischemia. Men with positive one or both of the two tests were referred for coronary angiography in order to document CAD. Our primary outcome was a composite measure which included acute myocardial infarction (AMI), stroke, congestive heart failure, revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. All patients were followed from cohort entry until major CV event, or end of study period (December 2018), whichever occurred first. Results The whole population was divided into high (n=176), intermediate (n=120) and low (n=96) total CV risk groups. The three groups had similar mean age (57 yrs). The prevalence of angiographically documented CAD was significantly higher among patients in the high risk group (n=32, 18%), compared to intermediate (n=15, 12.5%) and low risk (n=4, 4.1%) (overall P&lt;0.05). Furthermore, there was a progressive decrease in penile PSV and TT levels from low to moderate and high total CV risk (35 vs 31 vs 28 cm/s and 5.1 vs 4.3 vs 3.8 ng/ml, respectively, overall P&lt;0.001), indicating significant microvascular damage and androgen deficiency in men with a higher CV risk category. Interestingly, Kaplan-Meier analysis revealed a comparable incidence of major CV events in patients who were at high and intermediate total CV risk at entry (12.5% vs. 11%, respectively, log-rank =0.57) and a greater incidence of major CV events compared to that of low CV risk patients (3.2%), (log-rank P=0.004, for all comparisons) during a 9-year follow-up period (figure). CV events during a 9-year follow-up Conclusion The incidence of future CV events is considerably high among hypertensive ED patients with a intermediate total CV risk at first evaluation. Such patients may require a comprehensive evaluation to reveal occult CAD and they need an aggressive management of BP and concomitant risk factors to reduce their CV risk and improve their sexual life.

The Prognostic Value of the Diastolic Stress Test in Patients Undergoing Treadmill Stress Echocardiography

Exercise stress echocardiography (SE) is well validated for the evaluation of myocardial ischemia. Diastolic stress testing (DST) is recommended in the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging Guidelines for unexplained dyspnea. This study's aim was to prognostically evaluate the DST prospectively in a large stress testing population. Patients underwent SE with mitral E/e' measured before and after maximal treadmill exertion to estimate diastolic function. Patients were divided into four groups: group 1 (n=201)-ischemic; group 2 (n=1,563)-negative DST (E/e'pre<12, E/e'post<12); group 3 (n=68)-positive DST (E/e'pre<12, E/e'post≥12); group 4 (n=314)-high baseline E/e' (E/e'pre≥12). Consecutive patients (n=2,201, 770 [35%] female; 58±12years) were followed after SE for 27,964 patient-months. Time to first heart failure event (composite of heart failure admission, worsening New York Heart Association class, worsening ejection fraction, or cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. Ischemic patients hazard ratio (HR) was 28, 95% CI, 17-44, P<.0005, for subsequent heart failure compared with negative DST patients. Nonischemic, positive DSTs were highly predictive (HR=4.2; 95% CI, 1.6-11.0; P=.001); while high E/e'pre was not predictive (HR=1.3; 95% CI, 0.7-2.4; P=.49) of future heart failure events. DST differentiates heart failure prognosis in patients with induced diastolic dysfunction. Ischemia predictably portends the worst heart failure outcomes, and nonischemic, positive diastolic stress tests predicted more events compared with negative tests. These prognostic data support and add to the recommendations of the 2016 guidelines.

Characteristics and Outcomes in a Contemporary Group of Patients With Suspected Significant Mitral Stenosis Undergoing Treadmill Stress Echocardiography

In contemporary patients with suspected significant mitral stenosis (MS) undergoing rest and treadmill stress echocardiography, we assessed characteristics and factors associated with longer-term survival. We studied 515 consecutive patients (asymptomatic/atypical symptoms, mean left ventricular ejection fraction 58±2%; 43% male) with suspected at least moderate MS ([1] native mitral valve [MV]: resting mean MV gradient ≥5 mm Hg or area ≤1.5 cm2 and [2] prosthetic valve: resting mean MV gradient ≥5 mm Hg or effective orifice area ≤2 cm) who underwent rest and treadmill stress echocardiography between 1/2003 and 12/2013. MS was categorized as rheumatic (n=170, 33%), postsurgical (prior mitral repair/replacement, n=245, 48%), and primary nonrheumatic (n=100, 19%). Primary outcome was all-cause mortality. Mean resting MV gradient and right ventricular systolic pressure were 8.5±3 and 39±13 mm Hg. Patients achieved 95±29% age-sex predicted metabolic equivalents; peak-stress MV gradient and right ventricular systolic pressure were 17±7 and 61±14 mm Hg, respectively. At 54 days (median), 224 (44%) underwent invasive mitral procedure. At 6±4 years, 76 (15%) died. On survival analysis, primary nonrheumatic MS (hazard ratio [HR], 4.92), higher Society of Thoracic Surgeons score (HR, 1.92), lower % age-sex predicted metabolic equivalents (HR, 1.22), and higher peak-stress right ventricular systolic pressure (HR, 1.35), was associated with higher mortality, while invasive mitral procedures were associated with improved survival (HR, 0.67; all P<0.01). In asymptomatic patients (or with atypical symptoms) with significant MS undergoing treadmill stress echocardiography, higher mortality was associated with primary nonrheumatic MS, lower % age-sex predicted metabolic equivalents, and higher peak-stress right ventricular systolic pressure, while invasive MV procedures were associated with survival.