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Usefulness of stress echocardiography for risk stratification: a whiter shade of pale?

Joint session with the American Society of Echocardiography


Stress echocardiography in Coronary Artery Disease (Patricia Pellikka, Rochester, USA)

There is abundant and robust evidence documenting the prognostic value of stress echocardiography in coronary artery disease (CAD). The accuracy of stress echocardiography for detection of significant coronary stenoses ranges from 80–90%, exceeding that of the resting echocardiography or exercise electrocardiogram (ECG) and comparable to that of stress myocardial perfusion nuclear imaging. Patients with normal stress echocardiography have an excellent outcome. In the case of positive stress echo study, the risk is largely related to the extent and severity of myocardial ischemia. Stress echo does not directly measure the coronary artery stenosis, but rather the functional consequences of this stenosis. There is a need for randomized trials comparing management strategies based primarily on non-invasive anatomic imaging strategies (i.e. Computed Tomography angiography) versus functional imaging strategies (i.e. stress echo) with respect to impact on outcomes.
Stress echocardiography in Heart Failure (John Chambers, London, UK)
The role of stress echo for risk stratification in heart failure is well established. As regards the impact on management, data from large registries suggest that revascularization should be performed in patients with CAD and evidence of myocardial viability on dobutamine stress echo. This approach was, however, challenged by the data from the randomized STICH trial, which reported that the impact of revascularization on outcomes is similar in patients with- versus without- viability (Bonow et al, N Engl J Med. 2011;364:1617-25). However, the STICH trial had several limitations, including the small number of patients with no viability, the potential for selection bias, and the fact that no distinction was made between myocardial segments with sustained improvement versus those with biphasic response on dobutamine stress echo. In patients with non-ischemic dilated cardiomyopathy, assessment of myocardial contractile reserve may be useful to identify patients who should be considered for earlier cardiac transplantation.
Stress echocardiography in Hypertrophic Cardiomyopathy (Erwan Donal, Rennes, France)
Left ventricular (LV) outflow tract obstruction is associated with symptoms, reduced functional capacity, and worse prognosis in patients with hypertrophic cardiomyopathy (HOCM). About 40% of patients with HOCM have dynamic obstruction of LV outflow tract during exercise. Exercise stress echocardiography is useful to identify dynamic LV outflow obstruction and document the presence of symptoms. Assessment of myocardial strain during exercise may also be helpful to identify subclinical LV dysfunction. These stress echo findings may be used to enhance risk stratification. There is, however, a weak level of evidence to support exercise stress echo in HOCM and more studies in larger series of patients are needed.

Stress echocardiography in Valvular Heart Disease (Patrizio Lancellotti, Liège, Belgium)
Most valvular heart diseases have a dynamic component. Exercise stress echocardiography is helpful to enhance risk stratification and determine optimal timing for valve procedure in asymptomatic patients with valvular heart disease. In particular, a large increase in transvalvular gradient is associated with an increased risk of cardiovascular events in patients with aortic stenosis (AS). Worsening of the severity of regurgitation during exercise provides incremental prognostic value in both organic and functional mitral regurgitation. A large, exercise-induced increase in pulmonary arterial pressure is also associated with worse outcomes in patients with mitral regurgitation, as well as in those with AS. In patients with low-flow, low-gradient AS, dobutamine stress echocardiography is useful to differentiate true- versus pseudo- severe stenosis and to assess the presence of myocardial contractile reserve. Patients with pseudo-severe AS should be treated medically, whereas those with true-severe aortic stenosis and contractile reserve should be referred to surgery. Patients with no contractile reserve have a high operative risk and could be considered for transcatheter valve replacement after evaluation by the Heart Team.


Stress echocardiography is a versatile, inexpensive tool that provides incremental diagnostic and prognostic information in a variety of diseases. However, the quantification of disease severity and of its repercussions on cardiac chambers during exercise is often challenging and requires better training and technical developments to further improve reliability, adoption, and standardization of this tool in routine practice.


Suggested reading

(1)  Sicari R, Nihoyannopoulos P, Evangelista A et al. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2008 July;9(4):415-37.
(2)  Picano E, Pibarot P, Lancellotti P, Monin JL, Bonow RO. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol 2009 August 12;54(24):2251-60.




Usefulness of stress echocardiography for risk stratification: a whiter shade of pale?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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