Detection of Ischaemia

Clinical cases

Normal Example

Rest: A 66year old lady with progressively increasing breathlessness. Resting study normal. Unable to perform exercise then referred for pharmacological stress echocardiography. Normal perfusion at rest in all territories (as expected given normal wall motion)
Stress: Repeat imaging performed after dobutamine intravenous infusion. Heart rate 130-140bpm, so full replenishment expected in 3-4beats (see Chapter 2). Note rapid replenishment indicating normal perfusion in all walls.

Abnormal Example

Stress: 55yr old male smoker with hypertension referred for investigation of chest pain. Unable to perform exercise stress due to arthritis. Rest wall motion and perfusion normal. Pharmacological stress echocardiogram performed using dipyridamole.

Clinical Case 1

Patient with an episode of chest pain, no significant Troponin increase at 12hours and no significant ECG abnormalities. Stress echocardiogram is requested.

Clinical Case 2

Patient with recurrent episodes of atypical chest pain and no baseline ECG abnormalities. Treadmill ECG requested.

Clinical Case 3

Patient with recurrent episodes of chest pain, no baseline ECG abnormalities, normal exercise-SPECT (few months before) but symptoms persist... Contrast stress echocardiogram requested.

Clinical Case 4

Patient with recurrent episodes of chest pain, no baseline ECG abnormalities. Significant diffuse downsloping ST depression but no chest pain on treadmill.

Clinical Case 5

80yr old patient with effort dyspnea, no chest pain. Hypertensive, type II diabetes. Normal resting ECG. Normal resting echocardiogram. Referred for stress echocardiography.

Conclusions

• Echocardiographic assessment of myocardial perfusion is feasible and reproducible by MCE
• MCE can be performed using exercise (treadmill or bicycle), inotropic (dobutamine) or vasodilator (dipyridamole / adenosine / regadenoson) stress
• MCE detects ischaemia (perfusion defect) in many instances before wall motion abnormalities have developed
• Real-time and triggered (end-systolic) imaging protocols can be combined for optimal perfusion assessment
• MCE is a safe technique which does not involve ionising radiation or radiopharmaceutical compounds.