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Contrast in Stress Echocardiography

The evidence for use of contrast in clinical echocardiography: Left Ventricular Opacification – LVO


Given the above, it should come as little surprise that contrast use has been shown to improve the diagnostic accuracy of stress echocardiography, during both exercise [10] and pharmacological [11-12] stress. Although contrast use itself has some associated cost, an accurate test result can prevent further unnecessary investigations [13] and the cost savings of using contrast stress echocardiography for risk stratification (including early discharge) in patients admitted to hospital with chest pain has been demonstrated [14]. Inter-observer variability of image interpretation is also reduced by contrast administration. A retrospective analysis of over 18000 patients who received contrast during stress echocardiography found that the diagnostic accuracy in those with sub-optimal image quality receiving contrast was equivalent to those with optimal image quality, demonstrating the efficacy and safety of using contrast during stress imaging [15].

Consequently, the EAE guidelines for contrast echocardiography [16] recommend contrast use when two or more endocardial borders of contiguous segments are not well visualized in order to:

  • Obtain diagnostic assessment of systolic wall thickening at rest and at stress
  • Increase the proportion of diagnostic studies
  • Increase reader confidence in image interpretation

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10. Shimoni S, Zoghbi WA, Xie F, Kricsfeld D, Iskander S, Gobar L, et al. Real-time assessment of myocardial perfusion and wall motion during bicycle and treadmill exercise echocardiography: comparison with single photon emission computed tomography. J Am Coll Cardiol 2001;37(3):741-7
11. Plana JC, Mikati IA, Dokainish H, Lakkis N, Abukhalil J, Davis R, et al.A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease The OPTIMIZE Trial. JACC Cardiovasc Imaging 2008;1(2):145-52
12. Rainbird AJ, Mulvagh SL, Oh JK, McCully RB, Klarich KW, Shub C, et al. Contrast dobutamine stress echocardiography: clinical practice assessment in 300 consecutive patients. J Am Soc Echocardiogr 2001;14(5):378-85
13. Thanigaraj S, Nease RF, Jr., Schechtman KB, Wade RL, Loslo S, Perez JE. Use of contrast for image enhancement during stress echocardiography is cost-effective and reduces additional diagnostic testing. Am J Cardiol 2001;87(12):1430-2
14. Jeetley P, Burden L, Stoykova B, Senior R. Clinical and economic impact of stress echocardiography compared with exercise electrocardiography in patients with suspected acute coronary syndrome but negative troponin: a prospective randomized controlled study. Eur Heart J 2007;28(2):204-11
15. Dolan MS, Gala SS, Dodla S, Abdelmoneim SS, Xie F, Cloutier D, et al. Safety and efficacy of commercially available ultrasound contrast agents for rest and stress echocardiography a multicenter experience. J Am Coll Cardiol 2009;53(1):32-8
16. Senior R, Becher H, Monaghan M, Agati L, Zamorano J, Vanoverschelde JL, et al. Contrast echocardiography: evidence-based recommendations by European Association of Echocardiography. Eur J Echocardiogr 2009;10(2):194-212