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Update in Stress Echocardiography

Session 133

This high quality session was dedicated to updates in stress echocardiography in different clinical situations.

The first speaker, Roxy Senior from the UK, presented data related to stress echo in ischemic heart disease. He showed that the rate of use of stress echocardiography is still lower than that of nuclear imaging, probably due to the slightly lower sensitivity this imaging modality. However, he pointed out that the use of contrast significantly increases the confidence of interpretation and the accuracy of the results. He showed recently published data on the incremental diagnostic and prognostic value of contemporary stress echocardiography in the chest pain unit, revealing very high feasibility (>95%) of the test and the fact that patients with a negative test can safely be discharged from the hospital as early as day 1. He also showed that stress echo has been reported to have a higher positive predictive value (72%) compared to exercise-ECG (46%) in patients with recent onset chest pain. There is an incremental benefit of perfusion analysis over wall motion analysis during myocardial contrast stress echocardiography, which was confirmed in a recent study indicating its higher sensitivity in comparison with SPECT. Adding myocardial deformation analysis (strain rate), and especially the simultaneous assessment of contrast perfusion, wall motion and deformation during stress echo is feasible and may have potential value. Finally3D stress echo appears to be a valuable and promising technique but, due to its lower frame rate and the need for good image quality, further refinement is warranted. Dr. Senior is convinced that using contrast during stress echocardiography is a must, and reflects contemporary state-of-the art practice in this field.

The second speaker, Victoria Delgado from the Netherlands, presented the role of imaging for the detection of myocardial viability. She showed different patterns (normal, stunned, hibernated and scarred myocardium) according to the results of the assessment of coronary flow reserve (CFR), contractile reserve, perfusion, metabolism and scarring by different imaging modalities. She pointed out that viability assessment has a significant impact on prognosis and that dobutamine stress echocardiography (DSE) predicts global and regional recovery after revascularization. A combination of DES with strain imaging may offer better sensitivity and more quantification, and may be helpful in differentiating between stunned myocardium, non transmural and transmural myocardial infarction.  

The third speaker, Marie-Annick Clavel from Canada, gave the audience an overview about stress echo in valvular heart disease (VHD). She underlined that the dynamic component of VHD is important for patient management and prognosis, and that stress echocardiography can be used to unmask symptoms in “asymptomatic” patients and to assess the dynamics of valve and left ventricular function. She specifically talked about asymptomatic aortic stenosis (AS), low flow-low gradient AS, mitral stenosis and mitral regurgitation, and showed data indicating the prognostic impact of parameters derived during stress echocardiography (mean gradients across the valves, severity of regurgitation, pulmonary artery pressure). She concluded that careful evaluation of symptomatic status and stenosis severity at rest is important. According to the clinical situation (age, level of activity of the patient) stress testing can have a role in the evaluation of VHD patient, and some stress-derived parameters like the worsening of hemodynamics during stress, exercise-induced pulmonary hypertension and impaired LV contractile/flow reserve may have an incremental predictive value over rest echocardiography derived data.

The final speaker, Christine Selton-Suty from France, dealt with the physiology and the properties of pulmonary circulation during stress. She pointed out that pulmonary artery pressure (PAP) alone, is not sufficient to fully characterize pulmonary vascular function during exercise because of its variability and interpretation issues. She therefore proposed a few other parameters, such as the pressure-flow relationship during exercise, mean PAP/CO slope, pulmonary vascular resistance (PVR) and RV function reserve, which can provide a more accurate assessment of pulmonary vascular reaction during stress. Echocardiography and cardiac magnetic resonance imaging may be equally useful for the estimation of these parameters. She concluded that an abnormal pulmonary vascular response during exercise cannot be characterized by the evolution of PAP during exercise alone, but requires the analysis of pressure-flow relationships, together with the estimation of LV filling pressures and PVR. This is feasible by stress echocardiography (exercise or dobutamine) and validated against CMR and invasive measurements. RV function reserve can be also analysed by echocardiography, but normative data need to be further defined.

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.