scholarly journals Prognostic value of ABCDE stress echocardiography

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
Q Ciampi ◽  
A Zagatina ◽  
L Cortigiani ◽  
K Wierzbowska-Drabik ◽  
M Haberka ◽  
...  
Keyword(s):  
Prognostic Value ◽  
Stress Echocardiography ◽  
Large Scale ◽  
Multivariable Analysis ◽  
Regional Wall Motion ◽  
Left Ventricular ◽  
Contractile Reserve ◽  
Pharmacological Stress ◽  
Funding Sources ◽  
Regional Wall Motion Abnormalities

Abstract Background Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B-lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, EKG-based heart rate reserve. Aim: to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicenter, international, effectiveness study. Methods From July 2016 to November 2020, we enrolled 3,574 all-comers (age 65±11 years, 2,070 males, 58%; ejection fraction 60±10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent ABCDE-SE. The employed stress modality was exercise (n=952, with semi-supine bike, n=887, or treadmill, n=65 with adenosine for step D) or pharmacological stress (n=2,622, with vasodilator, n=2,151; or dobutamine, n=471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only end-point. Results Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D and 37% for E step. During a median follow-up of 21 months, 73 deaths occurred. At univariable analysis, predictors of all-cause mortality were step B (hazard ratio, HR: 2.621, 95% Confidence Intervals, CI: 1.654–4.152, p<0.001), step D (HR: 2.578, 95% CI: 1.624–4.093, p<0.001), and step E (HR: 2.955, 95% CI: 1.848–4.725, p<0.001), but not step A (HR: 1.333, 95% CI: 0.731–2.430, p=0.349) and step C (HR1.581, 95% CI: 0.997–2.506, p=0.051). At multivariable analysis, ABCDE-SE was an independent predictor of mortality with score 3 (HR: 3.472, 95% CI: 1.483–8.135, p=0.004), 4 (HR: 4.045, 95% CI: 1.595–10.259, p=0.003) and 5 (HR: 5.678, 95% CI: 2.106–15.313, p=0.001) (Figure). Annual mortality rate ranged from 0.4% person/year for score 0 up to 2.4% person/year for score 5. Conclusion ABCDE-SE allows an effective risk stratification of patient global vulnerability. FUNDunding Acknowledgement Type of funding sources: None. Survival curves based on ABCDE score

scholarly journals P329 Outcome prediction with force-based left ventricular contractile reserve during stress echocardiography

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
D Morrone ◽  
A Zagatina ◽  
Q Ciampi ◽  
L Cortigiani ◽  
N Gaibazzi ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Hospital Admissions ◽  
Multivariable Analysis ◽  
Peak Stress ◽  
Regional Wall Motion ◽  
Left Ventricular ◽  
Contractile Reserve ◽  
Single Plane ◽  
Systolic Volume ◽  
Stress Echo

Abstract OnBehalf Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging Background Stress echo (SE) risk stratification is based on regional wall motion abnormalities (RWMA). The assessment of global left ventricular contractile reserve (LVCR) based on load-independent Force may refine prognosis. Aim To assess the value of LVCR during SE in predicting outcome Methods From September 2016 to December 2018, we prospectively enrolled 1848 patients (age 63 ± 11 years; 1121 males, 60%) with known or suspected coronary artery disease and/or heart failure evaluated with SE (exercise in 543, dipyridamole in 1184, adenosine in 10, dobutamine in 43) in 9 quality-controlled centers of 6 countries. Force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/end-systolic volume by 2D and biplane Simpson method of disks. When Simpson method was not feasible, apical single plane or linear parasternal methods were used to calculate volumes. Abnormal values of LVCR (peak/ rest) based on force were ≤1.10 for dipyridamole and adenosine; ≤1.61 for exercise or dobutamine. All patients were followed-up for a median of 16 months. Results RWMA and Force-based LVCR were obtained in all pts. Force was 4.24 ± 1.88 mmHg/ml at rest and increased during stress (7.07 ± 4.60 mmHg/ml, p<.001). At individual patient analysis, LVCR was abnormal in 495 (26%) and normal in 1373 (74%) patients. At follow-up, there were 218 events: 22 deaths, 22 non-fatal myocardial infarctions, 62 hospital admissions for acute heart failures, and 112 late (> 3 months from SE) myocardial revascularizations. At multivariable analysis, stress-induced RWMA (Hazard Ratio, HR, 2.899, 95% Confidence Intervals, CI: 2.032-4.137, p<.0.001), force-based LVCR (HR 1.747, 95% CI: 1.245-2.470, p=.002) were independent predictors. Kaplan-Meier curves showed worse event-free survival for pts with abnormal LVCR: see figure. Conclusion LVCR based on Force is a useful adjunct to RWMA for risk stratification with SE. Abstract P329 Figure. Survival curves and LVCR

scholarly journals Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

2020 ◽  
Vol 9 (10) ◽  
pp. 3184
Author(s):  
Eugenio Picano ◽  
Angela Zagatina ◽  
Karina Wierzbowska-Drabik ◽  
Clarissa Borguezan Daros ◽  
Antonello D’Andrea ◽  
...  
Keyword(s):  
Stress Echocardiography ◽  
Large Scale ◽  
Regional Wall Motion ◽  
Coronary Plaque ◽  
Suspected Coronary Artery Disease ◽  
Qualitative Assessment ◽  
Contractile Reserve ◽  
Two Dimensional ◽  
Conventional View ◽  
Cardiac Strain

For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study.

Additional prognostic value of heart rate reserve over left ventricular contractile reserve and coronary flow velocity reserve in diabetic patients with negative vasodilator stress echocardiography by regional wall motion criteria

2020 ◽  
Author(s):  
Lauro Cortigiani ◽  
Quirino Ciampi ◽  
Clara Carpeggiani ◽  
Cristiano Lisi ◽  
Francesco Bovenzi ◽  
...  
Keyword(s):  
Coronary Flow ◽  
Prognostic Value ◽  
Stress Echocardiography ◽  
Wall Motion ◽  
Left Ventricular ◽  
Contractile Reserve ◽  
Diabetic Patients ◽  
Normal Value ◽  
Coronary Flow Velocity ◽  
Cardiac Autonomic Dysfunction

Abstract Aims  In diabetic patients, a blunted left ventricular contractile reserve (LVCR) and/or a reduced coronary flow velocity reserve (CFVR) identify patients at higher risk in spite of stress echocardiography (SE) negative for ischaemia. Cardiac autonomic dysfunction contributes to risk profile independently of inducible ischaemia and can be assessed with heart rate reserve (HRR). We sought to assess the added prognostic value of HRR to LVCR and CFVR in diabetic patients with non-ischaemic SE. Methods and results  Six-hundred and thirty-six diabetic patients (age 68 ± 9 years, 396 men, ejection fraction 58 ± 10%) with sinus rhythm on resting electrocardiogram underwent dipyridamole SE in a two-centre prospective study with assessment of wall motion, force-based LVCR (stress/rest ratio, normal value > 1.1), CFVR of the left anterior descending coronary artery (stress/rest ratio, normal value >2.0), and HRR (stress/rest ratio, normal value >1.22). All-cause death was the only considered endpoint. During a median follow-up of 39 months, 94 (15%) patients died. Independent predictors of death were abnormal CFVR [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.0–2.52, P = 0.05], reduced LVCR (HR 1.76, 95% CI 1.15–2.69, P = 0.009), and blunted HRR (HR 1.92, 95% CI 1.24–2.96, P = 0.003). Eight-year death rate was 9% for patients with triple negativity (n = 252; 40%), 18% for those with single positivity (n = 216; 34%), 36% with double positivity (n = 124; 19%), and 64% for triple positivity (n = 44; 7%) (P < 0.0001). Conclusion  Diabetic patients with dipyridamole SE negative for ischaemia still may have a significant risk in presence of an abnormal LVCR and/or CFVR and/or HRR, which assess the underlying myocardial, microvascular, and cardiac autonomic dysfunction. Clinical trials Gov Identifier NCT 030.49995.

Contrast echocardiography

ESC CardioMed ◽  
2018 ◽  
pp. 435-438
Author(s):  
Anastasia Vamvakidou ◽  
Roxy Senior
Keyword(s):  
Image Quality ◽  
Stress Echocardiography ◽  
Wall Motion ◽  
Contrast Echocardiography ◽  
Regional Wall Motion ◽  
Left Ventricular ◽  
Regional Wall ◽  
Regional Wall Motion Abnormalities ◽  
Wall Motion Abnormalities ◽  
Artery Disease

The major requirement for optimal echocardiographic image interpretation, reproducibility, and diagnostic accuracy is image quality. Despite the use of harmonics, a significant proportion of patients have challenging images, which has an impact on diagnosis and management. The ultrasound contrast agents (UCAs), which are administered intravenously, have been a significant development in image quality optimization and have proved to be an important aid in the assessment of structural abnormalities, detection of regional wall motion abnormalities, and calculation of left ventricular ejection fraction. The use of UCAs is also of critical importance for the detection of ischaemia and the assessment of significant coronary artery disease through detection of inducible regional wall motion abnormalities during stress echocardiography. UCAs can also assess myocardial perfusion, which improves assessment of myocardial ischaemia during stress echocardiography. Similarly the simultaneous assessment of wall motion and perfusion improves assessment of viable myocardium in patients with left ventricular dysfunction. As the use of UCAs results in increased feasibility, reproducibility, and diagnostic and prognostic accuracy of echocardiography including cost-efficiency, both European and American guidelines endorse its use in clinical cardiology.

scholarly journals Coronary Flow, Left Ventricular Contractile and Heart Rate Reserve in Non-Ischemic Heart Failure

2021 ◽  
Vol 10 (15) ◽  
pp. 3405
Author(s):  
Clarissa Borguezan Daros ◽  
Quirino Ciampi ◽  
Lauro Cortigiani ◽  
Nicola Gaibazzi ◽  
Fausto Rigo ◽  
...  
Keyword(s):  
Heart Failure ◽  
Heart Rate ◽  
Ejection Fraction ◽  
Coronary Flow ◽  
Regional Wall Motion ◽  
Left Ventricular ◽  
Contractile Reserve ◽  
Heart Rate Reserve ◽  
Reduced Ejection Fraction ◽  
Regional Wall Motion Abnormalities

Background: Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) affect outcome in heart failure (HF). They can be simultaneously measured during dipyridamole stress echocardiography (DSE). Aim: To assess the value of comprehensive DSE in patients with non-ischemic HF. Methods: We evaluated 610 patients with HF, no history of coronary artery disease, and no inducible regional wall motion abnormalities: 270 patients with preserved ejection fraction (≥50%), 146 patients with mid-range ejection fraction (40–49%), and 194 patients with reduced ejection fraction (<40%). All underwent DSE (0.84 mg/kg in 6’) in 7 accredited laboratories. We measured LVCR (abnormal value ≤ 1.1), CFVR in left anterior descending artery (abnormal value: ≤2.0), and HRR (peak/rest heart rate; abnormal value: ≤1.22). All patients were followed up. Results: Abnormal CFVR, LVCR, and HRR occurred in 29%, 45%, and 47% of patients, respectively (p < 0.001). After a median follow-up time of 20 months (interquartile range: 12–32 months), 113 hard events occurred in 105 patients with 41 deaths, 8 myocardial infarctions, 61 admissions for acute HF, and 3 strokes. The annual mortality rates were 0.8% in 200 patients with none abnormal criteria, 1.8% in 184 patients with 1 abnormal criterion, 7.1% in 130 patients with 2 abnormal criteria, 7.5% in 96 patients with 3 abnormal criteria. Conclusion: Abnormal LVCR, CFVR, and HRR were frequent during DSE in non-ischemic HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation, and cardiac autonomic balance) and are useful for outcome prediction.

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