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Stress Echocardiography

Non-Invasive Imaging

Last update: July 2012

Methodology of Stress Echocardiography

Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL

In the last 10 years, stress echocardiography has reached its established rank in the diagnosis and prognosis of coronary artery disease. These guidelines conclude that nuclear cardiology and stress echocardiography provide comparable information on diagnosis accuracy for noninvasive detection of coronary disease, identification of myocardial viability and prognostic stratification.
Reference: Eur Heart J 2009; 30:278-89

ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emerg

Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Peterson ED, Hendel RC, Stainback RF, Blaivas M, Des Prez RD, Gillam LD, Golash T, Hiratzka LF, Kussmaul WG, Labovitz AJ, Lindenfeld J, Masoudi FA, Mayo PH, Porembka D, Spertus JA, Wann LS, Wiegers SE, Brindis RG, Douglas PS, Patel MR, Wolk MJ, Allen JM
Reference: Circulation 2008; 117:1478-97

The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stress echo

Rigo F, Sicari R, Gherardi S, Djordjevic-Dikic A, Cortigiani L, Picano E
In the last 5 years, a major innovation changed the face and the diagnostic content of stress echocardiography: dual imaging of wall motion and coronary flow reserve with pulsed-Doppler imaging of the middistal left anterior descending coronary artery. Imaging coronary flow reserve expands the prognostic potential of stress echocardiography, since in the absence of wall motion negativity, the patient subset with reduced coronary flow reserve also have a more malignant prognosis.
Reference: Eur Heart J 2008; 29:79-88

Transthoracic echocardiographic imaging of coronary arteries: tips, traps, and pitfalls 

Rigo F, Murer B, Ossena G, Favaretto E
In the same setting, with the same stress, it is now possible to image function and flow simultaneously and therefore catch both flow and function, with vasodilatator stone. Although coronary flow reserve in a technology-in-progress and has yet to reach its full maturity, it is now considered a new standard in the clinical application of stress echocardiography.
Reference: Cardiovasc Ultrasound 2008; 6:7


Stress echocardiography from 1979 to present

Armstrong WF, Ryan T
In USA, exercise echocardiography is based on the posttreadmill approach with imaging at rest and as soon as possible during the recovery period.

Reference: J Am Soc Echocardiogr 2008; 21:22-8
Head to head comparison between perfusion and function during accelerated high-dose dipyridamole magnetic resonance stress for the detection of coronary artery disease
Pingitore A, Lombardi M, Scattini B, De Marchi D, Aquaro GD, Positano V, Picano E
Ischemic effect is the requiqite for functional imaging, usually with2D echocardiography but also performed with cardiovascular magnetic resonance.
Reference: Am J Cardiol 2008;101:8-14
Picano E, Molinaro S, Pasanisi E
The sensitivity, specificity and accuracy of fast (or atropine-potentiated) high-dose dipyridamole is identical to dobutamine stress echocardiography, as shown by this meta-analysis including five studies with 435 patients.
Reference: Cardiovasc Ultrasound 2008; 6:30
Sicari R, Rigo F, Gherardi S, Galderisi M, Cortigiani L, Picano E
The combination of conventional wall motion analysis with 2D echocardiography and coronary flow reserve with pulsed Doppler flowmetry of the mid-distal left anterior descending artery has been shown to provide an added and complementary power of prognostication in patients with known or suspected coronary artery disease.
Reference:Am Heart J 2008; 156:573-9
Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG
In comparison to the 1998 publication of the Recommendations for Performance and Interpretation of Stress Echocardiography, the present release include improvements in imaging equipment, refinements in stress testing protocols and standards for image interpretation,and important progress toward quantitative analysis.
Reference: J Am Soc Echocardiogr 2007; 20: 1021-1041.

Valve disease

Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation

Magne J, Lancellotti P, Pierard LA

In this study, it has been shown that exercise pulmonary hypertension is more accurate than resting pulmonary artery pressure in predicting the occurrence of symptoms during follow-up.
Reference: Circulation 2011; 122:33-41
Rosenhek R, Zilberszac R, Schemper M, Czerny M, Mundigler G, Graf S, Bergler-Klein J, Grimm M, Gabriel H, Maurer G
Prognosis depends on the presence or absence of clinical symptoms and not on hemodynamic severity per se although the rate of events is much higher in patients with very severe AS (jet velocity > 5m/s). There is a significant overlap in all measures of hemodynamic severity between symptomatic and asymptomatic patients with a jet velocity > 4 m/s. Moreover, the rate of hemodynamic progression is variable between patients. On average, jet velocity increases by about 0.3 m/s per year, mean pressure gradient increases by about 7 mmHg per year, and valve area decreases by about 0.1 cm² per year. While hemodynamic progression may present as an increase in aortic jet velocity (and transaortic pressure gradient), disease progression can occur with no change in jet velocity if there is a concurrent decrease in transaortic stroke volume.
Reference: Circulation 2010; 121:151-6
Marechaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, Bergeron S, Arsenault M, Le Tourneau T, Ennezat PV, Pibarot P
Exercise-induced changes in LV function or AS indices have been related to an increased rate of cardiac death, development of symptoms and need for aortic valve replacement. A large increase in mean gradient during exercise of 20 mmHg was associated with marked increase in event risk even in the group of patients with a normal exercise ECG test.
Reference: Eur Heart J 2010; 31:1390-7
Clavel MA, Burwash IG, Mundigler G, Dumesnil JG, Baumgartner H, Bergler-Klein J, Senechal M, Mathieu P, Couture C, Beanlands R, Pibarot P
In the absence of contractile reserve, it is difficult to differentiate between true aortic stenosis and a pseudo-severe stenosis. A new echocardiographic parameter has beeen proposed to better distinguish between these 2 conditions: the projected effective orifice area at normam transvalvular flow rate (projAVA1 cm² is a marker of true severe aortic stenosis).
Reference:J Am Soc Echocardiogr 2010; 23:380-6
Magne J, Lancellotti P, Pierard LA
Degenerative MR might be dynamic and markedly increases during exercise in one-third of patients. Important changes in MR severity (increase 15ml in regurgitatnt volume, or increase in 10 mm² or more in effective regurgitant orifice area) are associated with exercise induced-changes in systolic pulmonary artery pressure and reduced symptoms-free survival.
Reference: J Am Coll Cardiol 2010; 56:300-9
Rafique AM, Biner S, Ray I, Forrester JS, Tolstrup K, Siegel RJ
Aortic stenosis (AS)is a gradually progressive disease. When severe and symptomatic, it leads to aortic valve replacement. Exercise testing is contraindicated in symptomatic AS patients. However, symptomatic status can be difficult to establish in elderly patients, who may ignore their symptoms or may reduce their level of physical activity to avoid or minimize symptoms. Exercise testing could be useful to unmask symptoms in patients with severe AS who claim to be asymptomatic. This meta-analysis confirmed that symptom-limited stress testing is safe and has an important prognostic value.
Reference: Am J Cardiol 2009; 104:972-7
Laskey WK, Kussmaul WG, 3rd, Noordergraaf A
A decrease of LVEF during exercise reveals subclinical dysfunction of the LV and is associated with a lower event-free survival, even in the absence of transvalvular gradient increase. Exercise-induced changes in aortic compliance may also influence the LV function and symptomatic status. It has also been shown that abnormal vascular response to exercise is an important contributor to the diminished stroke output and possibly the development of exercise-related symptoms.
Reference: Circulation 2009; 119:996-1004
Picano E, Pibarot P, Lancellotti P, Monin JL, Bonow RO
Abnormal vascular response to exercise is an important contributor to the diminished stroke output and possibly to the development of effort-related symptoms in AS patients.
Reference: J Am Coll Cardiol 2009; 54:2251-60
Tribouilloy C, Levy F, Rusinaru D, Gueret P, Petit-Eisenmann H, Baleynaud S, Jobic Y, Adams C, Lelong B, Pasquet A, Chauvel C, Metz D, Quere JP, Monin JL
Five-year survival was higher in operated patients compared to those medically treated, despite a high operative mortality.
Reference: J Am Coll Cardiol 2009;53:1865-73
Ennezat PV, Marechaux S, Iung B, Chauvel C, LeJemtel TH, Pibarot P
The ability of exercise testing to identify asymptomatic patients with severe AS who are likely to develop adverse events was assessed in a meta-analysis of data from seven studies with a total of 491 patients (mean age 50-66 years). Reduced exercise tolerance (inability to reach 80% of the predicted normal level of exercise), dizziness, dyspnea at low workload, angina or syncope predicts the rapid development of symptoms in daily life, cardiac death (including sudden cardiac death) and need for aortic valve replacement. Dizziness during a treadmill test has a higher positive predictive value for development of symptoms during the next year. The occurrence of rapidly reversible dyspnea at high workloads is considered to be normal.
Reference: Heart 2009; 95:877-84
Lafitte S, Perlant M, Reant P, Serri K, Douard H, DeMaria A, Roudaut R
The ability of exercise testing to identify asymptomatic patients with severe AS who are likely to develop adverse events was assessed in a meta-analysis of data from seven studies with a total of 491 patients (mean age 50-66 years). Reduced exercise tolerance (inability to reach 80% of the predicted normal level of exercise), dizziness, dyspnea at low workload, angina or syncope predicts the rapid development of symptoms in daily life, cardiac death (including sudden cardiac death) and need for aortic valve replacement. Dizziness during a treadmill test has a higher positive predictive value for development of symptoms during the next year. The occurrence of rapidly reversible dyspnea at high workloads is considered to be normal.
Reference: Eur J Echocardiogr 2009; 10:414-9
Lancellotti P, Karsera D, Tumminello G, Lebois F, Pierard LA
Patients with decrease or smaller increase in LV ejection fraction during exercise were more likely to develop a clinical abnormal exercise response and cardiac events.
Reference: Eur J Echocardiogr 2008;9:338-43
Bonow RO, Masoudi FA, Rumsfeld JS, Delong E, Estes NA, 3rd, Goff DC, Jr., Grady K, Green LA, Loth AR, Peterson ED, Pina IL, Radford MJ, Shahian DM
The ACC/AHA guidelines concluded that exercise testing may be considered in asymptomatic AS patients to elicit exercise-induced symptoms or abnormal blood pressure response.
Reference: Circulation 2008; 118:2662-6
In addition to its role in distinguishing between true stenosis and pseudostenosis, low-dose dobutamine echocardiography is helpful in risk strafying patients with severe true AS and in determining the appropriate therapy. Contractile reserve is defined as 20% increase in forward stroke volume. Absence of contractile reserve, baseline pressure gradient of 20 mmHg or less and associated coronary artery disease are predictors of high operative mortality.
Reference: J Am Coll Cardiol 2008; 51:1466-72
Magne J, Senechal M, Mathieu P, Dumesnil JG, Dagenais F, Pibarot P
In patients undergoing surgical correction of ischemic mitral regurgitation (MR), a restrictive annuloplasty combined with coronary artery bypass grafting is the most common approach. However, this procedure is associated with a relatively high rate of recurrence of MR, and restrictive annuloplasty may result in functional MS in some patients. In patients with postoperative symptoms or evidence of either residual MR or functional MS, exercise testing may be useful to assess symptoms and exercise capacity, and the assessment of exercise hemodynamics with stress echocardiography can provide additional important information regarding the significance of MS and/or dynamic MR.
Reference: J Am Coll Cardiol 2008;51:1692-701
Lancellotti P, Cosyns B, Zacharakis D, Attena E, Van Camp G, Gach O, Radermecker M, Pierard LA
The results of this study suggest that 2D strain obtained during exercise could be useful to better identify contractile reserve in these patients. An increase of less than 1.9% in global longitudinal strain during exercise predicts postoperative LV dysfunction as well as impairment in LV function in medically treated patients with a better sensitivity and specificity than an inadequate increase in LV ejection fraction.
Reference: J Am Soc Echocardiogr 2008; 21:1331-6
Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C, Pierard LA.
Quantitative Doppler exercise echocardiography could be useful to identify a high-risk subset of patients with asymptomatic valvular aortic stenosis and help for clinical decision making. Independent predictors of cardiac events were as follows: an increase in mean transaortic pressure gradient by > or =18 mm Hg during exercise, an abnormal exercise test, and an aortic valve area <0.75 cm2.
Reference: Circulation. 2005 Aug 30;112(9 Suppl):I377-82.
Piérard L, and Lancellotti P.
Reference: Heart 2007; 93: 766-772

Deformation Stress Echocardiography

Experimental validation of circumferential, longitudinal, and radial 2-dimensional strain during dobutamine stress echocardiography in ischemic conditions
Reant P, Labrousse L, Lafitte S, Bordachar P, Pillois X, Tariosse L, Bonoron-Adele S, Padois P, Deville C, Roudaut R, Dos Santos P
The detection of a regional dysfunction by 2D echocardiography requires a critical ischemic mass of at least 20% of transmural wall thickness and about 5% of the total myocardial mass. Thus relatively milder and more localized forms of myocardial ischemia do not leave echocardiographic fingerprints and represent the physiological scotoma of the echocardiographic eye when compared ischemia, at least when radial strain and regional systolic thickening or (regional or global) ejection fraction are considered. Initial forms of contractile dysfunction can, however, more selectively affect longitudinal and circumferential strain, both at baseline and during stress-induced ischemia of mild degree.
Reference: J Am Coll Cardiol 2008; 51:149-57

Myocardial deformation imaging based on ultrasonic pixel tracking to identify reversible myocardial dysfunction
Becker M, Lenzen A, Ocklenburg C, Stempel K, Kuhl H, Neizel M, Katoh M, Kramann R, Wildberger J, Kelm M, Hoffmann R
In myocardial infarction, transmural extension or scar distribution in the infarct zone is proportionally related to the reduction in systolic function measured by the radial transmural velocity gradient or strain-rate imaging or peak radial strain using the speckle-tracking techniques.
Reference: J Am Coll Cardiol 2008; 51:1473-81 
Ishii K, Miwa K, Sakurai T, Kataoka K, Imai M, Kintaka A, Aoyama T, Kawanami M
Both tissue Doppler imaging and color kinesis provide quantitative information on the magnitude of regional wall motion, color kinesis can also explore apical unction (where tissue Doppler velocities are too low) and adds information regarding the timing of endocardial motion in both systole and diastole and may also have a role in the assessment of regional diastolic function. Regional left ventricular delayed outward wall motion or diastolic stunning after exercise-induced ischemia can last 1h after stress, when normal regional systolic function was completely restored.
Reference: J Am Soc Echocardiogr 2008; 21:309-14

The quantification of dipyridamole induced changes in regional deformation in normal, stunned or infarcted myocardium as measured by strain and strain rate: an experimental study
Marciniak M, Claus P, Streb W, Marciniak A, Boettler P, McLaughlin M, D'Hooge J, Rademakers F, Bijnens B, Sutherland GR
Experimental studies show that parameters derived from strain-rate imaging can be helpful in identifying and quantifying ischemia-induced myocardial abnormalities and in identifying viable myocardium, whose strain rate is normalized in stunned areas following inotropic challenge with dobutamine or dipyridamole.
Reference: Int J Cardiovasc Imaging 2008; 24:365-76

Speckle-derived strain a better tool for quantification of stress echocardiography?
Abraham TP, Pinheiro AC
Some disadvantages of speckle tracking are the lower frame rate in comparison with TDI, influenced by image quality, examination of strain rather than strain rate, and reduced combination with contrast echocardiography for enhancement of border detection.
Reference: J Am Coll Cardiol 2008; 51:158-60

Coronary flow stress echocardiography

Independent association of coronary flow reserve with left ventricular relaxation and filling pressure in arterial hypertension
Galderisi M, de Simone G, D'Errico A, Sidiropulos M, Viceconti R, Chinali M, Mondillo S, de Divitiis O.
Coronary flow reserve in coronary artery disease is feasible, useful, and prognostically validated tool to be considered with standard wall motion analysis; It is currently recommended as the state-of-the art method with vasodilatory stress echocardiography when adequate technology and expertise are available. Its non-invasive, radiation-free nature also make it ideally suited for ethically immaculate, radiation-free research-oriented studies, especially when each subject or patient acts as his/her own control, allowing establishment of acute or chronic changes in coronary flow reserve, induced, for instance, by acute food or beverage intake (such as alcohol or chocolate) or ingestion of medication in chronic therapeutic interventions, for instance, antihypertensive drugs.
Reference: Am J Hypertens 2008;21:1040-6

Prognostic value of left-ventricular and peripheral vascular performance in patients with dilated cardiomyopathy
Bombardini T, Nevola E, Giorgetti A, Landi P, Picano E, Neglia
Coronary blood flow increases three- to fourhold in normal subjects, but the reduction in diastolic time (much greater than shortening in systolic time) limits mostly the perfusion in the subendocardial layer – whose perfusion is mainly diastolic, whereas the perfusion in the subepicardial layer is also systolic.
Reference: J Nucl Cardiol 2008;15:353-62

Diastolic Function

Left ventricular diastolic functional reserve during exercise in patients with impaired myocardial relaxation at rest
Ha JW, Choi D, Park S, Choi EY, Shim CY, Kim JM, Ahn JA, Lee SW, Oh JK, Chung N
Diastolic stress echocardiography has been applied in several clinical settings, including patients with normal systolic function and with myocardial diastolic relaxation at rest.
Reference:Heart 2009; 95:399-404

Usefulness of the evaluation of left ventricular diastolic function changes during stress echocardiography in predicting exercise capacity in patients with ischemic heart failure
Podolec P, Rubis P, Tomkiewicz-Pajak L, Kopec G, Tracz W
Diastolic stress echocardiography has been applied in several clinical settings, including patients with normal systolic function and patients with ischemic heart disease.
Reference:J Am Soc Echocardiogr 2008; 21:834-40