Use Of Exercise Stress Echocardiography Research Articles

Usefulness of exercise stress echocardiography for predicting cardiovascular events and atrial fibrillation in hypertrophic cardiomyopathy

BackgroundIn hypertrophic cardiomyopathy (HCM), the determinants of exercise tolerance and the usefulness of exercise stress echocardiography (ESE) for predicting hard endpoints have not been fully investigated. We aimed to assess the key parameters of ESE for exercise tolerance and the factors predictive of cardiovascular events and new-onset atrial fibrillation (AF) in patients with HCM. MethodsSeventy-four consecutive patients with HCM who underwent ESE and with an ejection fraction ≥50 % were enrolled. The primary endpoint was a composite of cardiovascular death, heart failure hospitalization, ventricular fibrillation or tachycardia, and ventricular assist device implantation. The secondary endpoint was new-onset AF. ResultsThe primary endpoint occurred in 13 patients. The left and right ventricular functions during exercise were responsible for decreased exercise tolerance. Peak exercise e′ and tricuspid annular plane systolic excursion (TAPSE) significantly predicted increased primary outcome risk (hazard ratio 1.35, 95 % confidence interval 1.10–1.76, p = 0.003; hazard ratio 1.19, 95 % confidence interval 1.07–1.32, p = 0.002, respectively), and the results were consistent even after adjustment by maximum workload. These ESE parameters improved the prognostic model containing estimated glomerular filtration rate (eGFR) and left atrial (LA) volume index. In AF-naive patients (n = 58), LA volume, peak exercise LA reservoir strain, and left ventricular outflow tract (LVOT) pressure gradient predicted new-onset AF. ConclusionsIn patients with HCM, ESE parameters related to left and right ventricular function were responsible for low exercise tolerance. Furthermore, e′ and TAPSE at peak workload could be useful for predicting cardiovascular events in addition to eGFR and LA volume index. LVOT pressure gradient and LA function during exercise predicted new-onset AF.

Exercise Stress Echocardiography in Athletes: Applications, Methodology, and Challenges.

This comprehensive review explores the role of exercise stress echocardiography (ESE) in assessing cardiovascular health in athletes. Athletes often exhibit cardiovascular adaptations because of rigorous physical training, making the differentiation between physiological changes and potential pathological conditions challenging. ESE is a crucial diagnostic tool, offering detailed insights into an athlete's cardiac function, reserve, and possible arrhythmias. This review highlights the methodology of ESE, emphasizing its significance in detecting exercise-induced anomalies and its application in distinguishing between athlete's heart and other cardiovascular diseases. Recent advancements, such as LV global longitudinal strain (GLS) and myocardial work (MW), are introduced as innovative tools for the early detection of latent cardiac dysfunctions. However, the use of ESE also subsumes limitations and possible pitfalls, particularly in interpretation and potential false results, as explained in this article.

Abstract 12932: Should We Screen For Radiotherapy-Induced Heart Disease With Exercise Stress Echocardiography? Emphasis on Major Adverse Cardiac Events

Introduction: Exercise Stress Echocardiography (ESE) is recommended as a screening tool for the evaluation of Coronary Artery Disease (CAD) in patients with suspected Radiation-Induced Heart Disease (RIHD). Up to now, studies have only evaluated its association with the extent of CAD. Hypothesis Cancer survivors treated with chest Radiotherapy (RT) that undergo an ESE and have a +ESE develop more MACE than those who have -ESE. Methods: A retrospective, descriptive, cohort study was conducted. Patients who had chest RT and underwent ESE with Treadmill Bruce Stress Protocol, from 2000 to 2012, at Mayo Clinic Rochester and Mayo Clinic Health System were included. A univariate analysis was performed to characterize the population. An analysis including Kruskal Wallis and Pearson Chi-Squared tests was completed to identify variables associated with + SE (Table 1). Multivariable Cox Model for MACE was conducted and is shown in Table 2. A time-to-event curve using Kaplan-Meier estimates is shown in Figure 1. Results: We identified 113 patients, with a mean age of 67 years and a median follow-up of 15.1 years. Of those, 99% were female, 98% were breast cancer survivors, 59% had HTN, 14% DM, 11% AFib, 2% COPD, and 12% had a history of MI. All the patients received >3000cGy of Photon RT, and 57% were treated with systemic cancer therapies. A +ESE was seen in 20.3% of the patients with no significant difference in METS achieved compared with patients who had a -ESE. COPD, RT dose, and systemic therapies, specifically doxorubicin, were associated with a +ESE. The cumulative incidence of MACE was higher in the group of +ESE (p=0.029). After adjustment for HTN, DM, smoking history, hyperlipidemia, and prior MI, the HR for MACE associated with a +ESE was 1.97 (1.09-3.59). Conclusion: MACE was more frequent in patients with a +ESE who received chest RT and doxorubicin versus -ESE. These results support the usefulness of ESE in cancer survivors after RT as a cardiovascular screening tool.

Prognostic Value of Exercise Stress Echocardiography in Pediatric Cardiac Transplant Recipients

Cardiac allograft vasculopathy (CAV) is a leading cause of long-term morbidity and mortality in pediatric heart transplant (HTx) recipients. Exercise stress echocardiography (ESE) has been shown to be useful in the detection of angiographically confirmed coronary artery disease in children. However, the prognostic utility of ESE for prediction of cardiac events in HTx survivors is unknown. We aim to assess whether an abnormal (positive) ESE is be associated with a higher risk of future cardiovascular (CV) outcomes in pediatric HTx recipients. We conducted a retrospective review of CV outcomes in a cohort of 95 pediatric HTx recipients who underwent 188 ESEs over a 10-year period. A composite endpoint for CV events including myocardial infarction, hospitalization for nonrejection heart failure, coronary revascularization, need for repeat transplantation, and death was used. Based on the interpretation of the ESE results, each ESE study was classified for this study as either positive (abnormal) or negative (normal) for ischemia. Results of the coronary angiograms performed near the time of ESE were also assessed and classified for this study as positive (abnormal) or negative (normal) for CAV according to standard HTx criteria for CAV. Fifty-one (27%) ESEs were positive for ischemia. There was a total of 35 CV events in 23 patients. A positive ESE was associated with increased risk of any CV event (hazard ratio=3.55; 95% CI, 1.52, 8.28), as well as an increased risk of CV death (hazard ratio=3.19; 95% CI, 1.23, 8.28). Freedom from composite CV outcome at 1, 2, and 3years following a positive ESE was 89.9% (95% CI=77.3%, 95.7%), 81.5% (95% CI=65.9%, 90.5%), and 63.2% (95% CI=41.9%, 78.5%), respectively. Freedom from composite CV outcome at 1, 2, and 3years following a negative ESE was 99.3% (94.8, 99.9), 98.4% (93.6, 99.6), and 97.0% (90.6, 99.1), respectively. No patient died within 1year of a negative ESE. In this largest study of ESE in pediatric HTx recipients, a positive or abnormal ESE is associated with increased future CV morbidity and mortality. Conversely, a negative ESE can help predict CV event-free survival. Even in the setting of a normal coronary angiogram, our pilot data show that an abnormal ESE may still be clinically important. Use of ESE in follow-up may improve risk stratification and management of pediatric HTx recipients.

Exercise stress echocardiography with ABCDE protocol in unexplained dyspnoea.

Current guidelines recommend the use of exercise stress echocardiography (ESE) in patients with unexplained dyspnoea. SE was recently reshaped with the ABCDE protocol: A for asynergy, B for B-lines (4-site simplified scan), C for contractile reserve based on force, D for Doppler-based coronary flow velocity reserve (CFVR) in left anterior descending coronary artery; and E for EKG-based heart rate reserve (HRR, defined as peak/rest HR < 1.62). Aim of the study was to define the ESE response in patients with dyspnoea as the main symptom. From the initial population of patients referred in 2018 in a single center for semi-supine ESE, we selected two groups (without history of previous myocardial infarction or coronary revascularization) on the basis of the main presenting symptom: dyspnoea (Group 1, n = 100, 62 men, 63 ± 10years) or chest pain (Group 2, n = 100, 58 men, age 61 ± 8years). All underwent ESE with ABCDE protocol. Success rate was 100% for steps A, B, C, E, and 88% for step D. Positivity for A criterion occurred in 56 patients of Group 1 and 24 of Group 2 (p < 0.0001). B-lines positivity (stress > rest for ≥ 2 points) occurred in 40 patients of Group 1 and 28 of Group 2 (p = 0.07). LVCR positivity (< 2.0) occurred in 60 patients of Group 1 and 42 of Group 2 (p < 0.05). A reduced CFVR occurred in 56 of Group 1 and 22 of Group 2 (p < 0.0001). A blunted HRR was present in 44 patients of Group 1 and 22 of Group 2 (p < 0.001). In conclusion, in patients with unexplained dyspnoea, SE with ABCDE protocol is useful to document the cardiac origin of dyspnoea with a comprehensive assessment focused not only on ischemia (A) but also pulmonary congestion (B), myocardial scar or necrosis (C), coronary microvascular dysfunction (D) or chronotropic incompetence (E).

P1504Impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block

Abstract Background/Introduction ECG has always provided very useful information that can be used to diagnosis, treatment and prevention of cardiovascular events, but ECG changes is not useful to the detection of myocardial ischemia in patients with left bundle branch block (LBBB). QT dispersion (QTd) is a measure of inhomogeneous repolarization of myocardium. Abnormally high QTd has been correlated with risk of cardiac death in coronary patients. Purpose The aim of this study was to establish the impact of myocardial ischemia induced by exercise stress echocardiography on the QT dispersion in patients with the left bundle branch block. Methods The study involved 123 patients with LBBB, average age 52.7 years. In all subjects clinical examination, standard ECG and exercise stress echocardiography, were performed. The criterion for myocardial ischemia was the appearance of transient segmental wall motion abnormality. The first ECG was done before the exercise stress echocardiography and the second one was done immediately after exercise, with calculation of corrected QT dispersion (QTdc). Results During exercise stress echocardiography, in 45 (36.6%) subjects wall motion abnormality occurred (group with myocardial ischemia: MI), and 78 (63.4%) subjects were without ischemia (group without myocardial ischemia: NMI). Before starting the exercise stress echocardiography, MI group patients had significantly higher values of QTdc (61.2±17.6 vs 43.6±15.4 ms; p&lt;0.001) in comparison to NMI group patients. During the exercise stress echocardiography, the QTdc significantly increased in MI group from 61.2±17.6 to 87.4±20.3 ms (p&lt;0.001). In the NMI group there were no significant changes in the values QTdc during exercise stress echocardiography (from 43.6±15.4 to 46.5±19.8 ms (p - NS). Conclusions Significant increase of QT dispersion is associated with the occurrence of myocardial ischemia during exercise stress echocardiography in patients with LBBB. This new diagnostic approach, of using QT dispersion, significantly improves the clinical usefulness of exercise stress echocardiography in detecting myocardial ischemia in patients with LBBB.

P4986Quadruple imaging exercise stress echocardiography in unexplained dyspnoea

Abstract Background Current guidelines recommend the use of exercise stress echocardiography (ESE) in patients with unexplained dyspnoea. The methodological standard of ESE was recently reshaped with the quadruple imaging protocol, mainly tested in patients with chest pain. Aim of this study was to define the ESE pattern of response in patients with dyspnoea as the main symptom Methods From the initial population on a 1-year cohort of 604 patients referred in a single center for clinically-driven semi-supine ESE, we selected a subset of 93 consecutive patients (age 63±9 years, 52 females, resting Ejection fraction = 64±7%) with exertional dyspnea (shortness of breath, exertional fatigue or poor exercise capacity). All underwent quadruple imaging ESE: 1- Regional wall motion abnormalities (RWMA, step A) assessment (with wall motion score index, WMSI); 2- B-lines (step B) with simplified 4-site scan, each space scored from 0 = black, to 10= white (positivity criterion: stress score &gt; rest for at least 2 points); 3- Left ventricle contractile reserve (LVCR, step C) assessment with stress/rest ratio of LV force measured as systolic blood pressure/end-systolic volume (positivity criterion:&lt;2.0); 4- Pulsed-wave Doppler coronary flow velocity reserve (CFVR, step D) assessment in mid-distal LAD (positivity criterion: stress/rest diastolic peak flow velocity &lt;2.0). Readers were accredited for each parameter upstream to recruitment via a web-based system. Results Feasibility was 100% for steps A, B and C, and 82% for step D. RWMA were present in 56 patients (60%). Of them, 27 underwent coronary angiography verification, showing significant coronary artery disease in 81%. B-lines positivity occurred in 35 patients (38%), an abnormal LVCR in 63 patients (68%), and a reduced CFVR in 44 pts (55%). At least one positivity criterion was observed in 80 patients (86%). Conclusions Patients with unexplained dyspnea are a reason of referral to ESE, accounting for 15% of contemporary testing. Quadruple imaging is useful to document the origin of dyspnoea as an ischemic equivalent (A positivity) and/or its cardiogenic origin for acute backward failure with pulmonary congestion (B positivity), myocardial function abnormalities (C positivity), and reduction of CFVR of microvascular-epicardial-myocardial origin (D positivity). Dyspnoea of unexplained origin is a multifactorial problem, and a more comprehensive assessment of these patients during ESE expands the clinical potential of the method.

Exercise stress echocardiography in hypertrophic cardiomyopathy.

In this review, we make a comprehensive summary of exercise stress echocardiography in hypertrophic cardiomyopathy (HCM) and practical tips used in our hospital. The main objective of performing exercise stress echocardiography in patients with HCM is to evaluate left ventricular outflow tract obstruction, mitral regurgitation, left ventricular asynergy, and diastolic function during exercise. There are limitations to the explanations that can be provided for exertional symptoms when resting echocardiography is performed in patients with HCM. In contrast, exercise stress echocardiography causes the manifestation of findings that are latent at rest, which possibly provides the elucidation of symptom etiology. In this article, we focus on the usefulness of exercise stress echocardiography in HCM.

When exploring patients during exercise makes sense?

This editorial refers to ‘Clinical characteristics and determinants of exercise-induced pulmonary hypertension in patients with preserved left ventricular ejection fraction’, by A. Young Lim et al. doi: 10.1093/ehjci/jew199. Dealing with exertional dyspnoea or unexplained shortness of breath is a common problem in clinical practice. However, the exploration of such symptoms is difficult and does not always lead to definite positive diagnosis and thus appropriate treatment. Moreover, the perception of dyspnoea is subjective and relies on determinants that are often unclear. In these patients, exploring pulmonary pressures and diastolic function during exercise appears to be an interesting way to assess the potential causes triggering their symptoms. In this issue of European Heart Journal - Cardiovascular Imaging , Lim et al. 1 present a remarkable study exploring the value of exercise-induced pulmonary hypertension (EIPH) in patients with preserved left ventricular ejection fraction and complaining about unexplained dyspnoea. This exhaustive work included a large number of patients (1383 were analysed) and enabled a comprehensive description of the clinical aspects and features of EIPH in this population. To date, this population has not been well characterized, so the data published in this issue allow interesting insights in this not-so-well-known clinical entity. EIPH has been explored and demonstrated as clinically interesting in the field of heart valve diseases and in the prognostic assessment of patients diagnosed for a heart failure with preserved ejection fraction.2–4 Notably, larger studies confirming those first results are mandatory to justify a more generalized use of exercise stress echocardiography in our routine clinical practice. The first surprising fact in the study by Lim et al . appears to be the population with …

0032: Additional value of exercise-stress echocardiography in asymptomatic patients with aortic valve stenosis

Usefulness of exercise-stress echocardiography for risk-stratification of asymptomatic patients with aortic stenosis (AS) is still debated (Class IIb recommendation). The exercise-induced increase in transvalvular gradient has been proposed as a prognostic factor but data are scarce. We sought to evaluate the additional prognostic value of echocardiographic parameters during exercise-stress echocardiography. In this observational prospective study, we enrolled all consecutive asymptomatic patients with moderate/severe AS and normal ejection fraction who underwent an exercise-stress echocardiography at our institution. Clinical and echocardiographic data at rest and at peak exercise were collected. The composite primary outcome variable was the occurrence of AS related events (symptoms or heart failure related to the AS or cardiovascular death during follow-up). Among the 121 patients enrolled, 35 (29%) had an abnormal exercise test (occurrence of symptoms or abnormal blood pressure profile during exercise) and were operated on within the following weeks. Eighty-six patients (mean [quartiles]; age 67 [57-75] years, 68 male, mean gradient 46 [35-52]mmHg, aortic valve area 0,97 [0,82-1,11]) had a normal exercise test and 39 (48%) reached the clinical endpoint during follow-up (17.5 [10.9-36.4] months). The proposed threshold of 18mmHg mean gradient increase had no prognostic value. In multivariate analysis, rest mean gradient (p<0.001; HR 1.07 [1.03-1.11]) but not exercise-induced increase mean gradient (p=0.4; HR 0.69 [0.29-1.65]) were predictive of outcome. Exercise-induced increase in mean gradient was not predictive of outcome in patients with normal exercise-test. Our results raise question regarding the additional value and therefore the use of exercise-stress echocardiography for risk-stratification of asymptomatic patients with AS.

0112: Determinants and prognostic impact of left ventricular contractile reserve in asymptomatic aortic stenosis

The management of asymptomatic patients with severe aortic stenosis (AS) is extremely controversial. There are very few data regarding the assessment, determinants and prognostic value of left ventricular contractile reserve (LVCR) in these patients. We aimed to quantify LVCR and to evaluate its determinants and usefulness for risk stratification in asymptomatic patients with severe AS. Asymptomatic patients with severe AS (n=150, aortic valve area<1cm², 70±9 years, 64% of male) and preserved left ventricular (LV) systolic function (LV ejection fraction ≥55%) were prospectively referred to exercise stress echocardiography. Using 2D speckle tracking analysis, LVCR was defined as an exercise-induced changes in LV global longitudinal strain >2%. LVCR was present in 62 patients (41%) and there was no significant difference between LVCR and no LVCR groups regarding demographic, clinical and exercise data, as well as risk factors. Using multiple linear regression, after adjustment for age, sex and E/Ea ratio, the independent determinant of exercise-induced changes in LV global longitudinal strain were aortic mean pressure gradient (p=0.005), LV ejection fraction (p=0.035) and exercise indexed LA area (p=0.002). During a mean follow-up of 19±12 months, 76 events (51%) occurred. The absence of LVCR was associated with reduced 4-year cardiac event-free survival (26±6 vs. 53±11%, p<0.0001). By opposition, exercise-induced changes in LV ejection fraction did not predict the outcome (p=0.96). In multivariate analysis, the independent predictors of events were resting brain natriuretic peptide level (p<0.0001), aortic mean pressure gradient (p=0.037), exercise cardiac output (p=0.004) and absence of LVCR (HR=1.8, 95%CI: 1.05-3.08, p=0.033). In asymptomatic patients with severe AS, the main determinants of LVCR, as assessed using exercise-induced changes in LV global longitudinal strain, were related to AS severity and exercise LA size. The absence of LVCR is a powerful predictor of reduced cardiac event-free survival. These results strongly support the use of exercise stress echocardiography in asymptomatic AS.

0110: Exercise stress echocardiography in secondary mitral regurgitation: impact of pulmonary hypertension

Secondary mitral regurgitation (MR) is a serious and frequent complication of dilated cardiomyopathy and/or coronary artery disease. The impact of exerxise pulmonary hypertension (ExPHT) on outcome in patients with secondary MR is unknown. All patients with secondary MR, sinus rhythms, narrow QRS (<120ms) and referred for exercise stress echocardiography with quantifiable exercise systolic pulmonary arterial pressure (SPAP), were included in this study (n=159, 65±11 years, 66% of male). Resting and ExPHT were defined as a systolic pulmonary arterial pressure (SPAP) >50mmHg and >60mmHg, respectively. ExPHT was more frequent than resting PHT (40% vs. 13%, p<0.0001). There was no significant difference between patients with or without ExPHT regarding demographic and clinical data, as well as medication. Using multiple linear regression, exercise SPAP was determined by resting SPAP (β=0.94±0.1, p<0.0001), exercise MR severity (β=0.58±0.1, p<0.0001), and resting e’-wave velocity (β=–1.3±0.4, p=0.004). During a mean follow-up of 35±11 months, 60 major adverse cardiovascular events occured. The incidence of combined cardiac event was significantly higher in patients with ExPHT as compared to those without ExPHT (2-year: 11±3 vs. 28±6%; 4-year: 20±5 vs. 40±7%, p<0.0001). Similarly, patients with ExPHT demonstrated significantly reduced survival (2-year: 88±4 vs. 99±1%; 4-year: 62±8% vs. 94±2%, p<0.0001). In multivariate Cox proportional Hazard model, after adjustment for age, sex, left ventricular volumes, both resting and exercise diastolic function and resting MR severity, ExPHT remains significantly associated with high risk of combined cardiac event (Hazard ratio=3.7, 95% of CI: 1.9-7.2, p<0.0001). In patients with secondary MR, ExPHT may be frequent and mainly determined by resting SPAP, LV diastolic burden markers and exercise MR severity. ExPHT is a powerful predictor of poor outcome and is associated with a 3.7-fold increase in risk of cardiac event. These results further highlight the usefulness of exercise stress echocardiography for the management and the risk stratification of these patients.

Roelandt's Young Investigator Award session: Thursday 4 December 2014, 15:30-16:30 * Location: Agora

Roelandt's Young Investigator Award session: Thursday 4 December 2014, 15:30-16:30 * Location: Agora

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

Oral Abstract session: Stress echo in clinical practice: Friday 5 December 2014, 08:30-10:00 * Location: Agora

Circulation: Heart Failure Editors’ Picks

Summary : Lifelong exercise training maintains a youthful compliance of the left ventricle (LV), whereas a year of exercise training started later in life fails to reverse LV stiffening, possibly because of accumulation of irreversible advanced glycation end products. Alagebrium is a novel drug that breaks advanced glycation end product crosslinks and improves LV stiffness in aged animals. In this study, the authors prescribed alagebrium (200 mg daily) or placebo combined with aerobic exercise training or contact control in healthy, sedentary older individuals for 1 year. The authors evaluated overall cardiac function by the use of several modalities, including invasive pressure–volume measurements, exercise testing, and cardiac MRI before and after the training. To the authors’ knowledge, this is the first study to evaluate the effects of alagebrium and exercise training in healthy aged humans. After intervention, exercise training significantly increased exercise capacity, LV mass, and LV end-diastolic volume. Conversely, alagebrium had little effect on exercise capacity or LV geometry. However, alagebrium showed a modest improvement in LV stiffness compared with placebo. This favorable effect of alagebrium on LV stiffness was most prominent in individuals with combined alagebrium and exercise training. Conclusions : Alagebrium had no effect on hemodynamics, LV geometry, or exercise capacity in healthy, previously sedentary seniors. However, it did show a modestly favorable effect on age-associated LV stiffening.1 Summary : Maximum oxygen consumption (peak VO2) and efficiency of ventilation (VE) during exercise (VE/VCO2 slope) are known to stratify adults in heart failure for 1-year survival. On the basis of adult data, a recent American Heart Association scientific statement suggested that peak VO2<50% predicted for age and sex should be considered substantial impairment in exercise performance in children with heart disease and therefore a class I indication for heart transplant listing. This single-center study examined the association of …

Young Investigator Award session - Clinical: 11/12/2013, 12:45-13:45 * Location: Bursa

Young Investigator Award session - Clinical: 11/12/2013, 12:45-13:45 * Location: Bursa

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks

Stress echocardiography in clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography

Stress echocardiography (SE) is one of the leading modalities for the assessment of coronary artery disease and dynamic valvular heart disease. A wide range of different techniques have been established. There are no data which identify how current techniques have been integrated into clinical practice. An electronic questionnaire was devised to identify SE practice in five core areas: service demographics, indications, methods, reporting, and adverse events. The questionnaire was sent to 198 National Health Service hospitals. Eighty-five (71%) out of the 120 departments who perform SE responded. Each unit performed a median of 400 SE (inter-quartile range 175-600). Thirty-two (37.6%) operators performed <100 SE per year. Exercise, dobutamine, dipyridamole, adenosine, and pacing SE were available in 57 (67.1%), 85 (100%), 6 (7.1%), 11 (12.9%), and 34 (40%) units, respectively. Eighty-one (95.3%) units performed SE for the evaluation of low-flow, low-gradient aortic stenosis. Thirty-four (40%) and 32 (37.6%) performed SE for the evaluation of asymptomatic severe aortic stenosis and symptomatic moderate mitral regurgitation, respectively. Eighty-three (97.6%) administered contrast agents during SE. Additional analysis of perfusion and strain was performed in 9 (10.5%) and 13 (15.3%) units, respectively. SE has been incorporated into the majority of UK hospitals. A substantial proportion of operators perform less than the recommended number of procedures per year. The use of exercise SE, vasodilator SE, and SE for the evaluation of VHD are under-utilized. Penetration of new techniques is variable, contrast for left ventricular opacification has been almost universally adopted, while myocardial perfusion and mechanics are used much less.

Dynamic Assessment of Stenotic Valvular Heart Disease by Stress Echocardiography

During the past 2 decades, the dynamic nature of valvular heart disease has become a recognized phenomenon. Changes in loading conditions, heart rate, and ventricular contractility that occur with exercise can alter the physiological effects of valvular disease.1,2 Disparity between resting evaluation of valve dysfunction and patient symptoms is not uncommon. Stress echocardiography (SE) has emerged as a modality able to provide new diagnostic information by identifying dynamic changes in the severity of valve stenosis on exertion responsible for symptoms and evaluate the severity of valve disease in altered flow states.3 This review seeks to review critically the existing evidence base, identify new emerging prognostic markers, evaluate their role in clinical practice, and identify future directions for research. The clinical scenarios where SE aids diagnosis and has prognostic value include the evaluation of asymptomatic severe aortic stenosis (AS), low-flow (LF), low-gradient (LG) AS, and moderate AS with symptoms (Table). View this table: Table. Clinical Use of Stress Echocardiography in Stenotic Valvular Heart Disease The prognosis of patients with symptomatic, severe AS is dismal.4 The prognosis for those who are asymptomatic is more favorable with a <1% per year mortality.5 However, one third of patients who claim to be asymptomatic actually develop symptoms on exertion. Therefore, physiological testing may be used to uncover symptoms in an apparently asymptomatic individual.6,7 The use of exercise SE in asymptomatic severe AS is slowly emerging.3 An increase in mean aortic pressure gradient by ≥18 mm Hg during exercise has been reported to be an independent predictor of cardiac events (development of symptoms, death, aortic valve replacement [AVR], or hospital admission).8 This has been validated more recently in a larger cohort of patients showing that a resting mean gradient of 35 mm Hg and an increase in mean …

Circulation Editors’ Picks

<i>Circulation</i> Editors’ Picks