scholarly journals Upright exercise stress echocardiography may unmask dynamic left ventricular obstruction also beyond hypertrophic cardiomyopathy

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
C Cotrim ◽  
H Cafe ◽  
I Goncalves ◽  
J Guardado ◽  
N Cotrim ◽  
...  
Keyword(s):  
Chest Pain ◽  
Hypertrophic Cardiomyopathy ◽  
Sudden Death ◽  
Stress Echocardiography ◽  
Continuous Wave ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Exercise Stress Echocardiography ◽  
Left Ventricular Outflow ◽  
Orthostatic Position

Abstract Background Dynamic left ventricular outflow obstruction (LVOTO) during exercise stress echocardiography (ESE) is recommended in hypertrophic cardiomyopathy (HCM) to identify the obstructive phenotype. Aim To assess left ventricular outflow gradient (LVOTG) during ESE in different conditions. Methods In a single-group, prospective, observational study, we performed peak and/or post-treadmill ESE with systematic assessment of LVOTG in the orthostatic position by continuous-wave Doppler in 1333 subjects (837 males, mean age 38,2±20 ranging from 6 to 87 years) recruited over a period of twenty years, from 2001 to 2021. Peak LVOTG ≥30 mm Hg was considered abnormal for LVOTO during ESE. We enrolled 7 different populations: asymptomatic healthy controls (n=35); HCM (n=81); genotype-positive, phenotype negative asymptomatic HCM (n=6); patients with chest pain symptoms, suspected myocardial ischemia and either normal coronary arteries (INOCA, n=131,or with very low pre-test probability of coronary artery disease (probable INOCA, n=416) and; fatigue and suspected heart failure with preserved ejection fraction (HFpEF, n=206); amateur athletes with ischemia-like ECG changes during exercise-test or symptoms such as near syncope or chest pain or dizziness (n=457); aborted sudden death and with negative screening (n=1). Results Technical success rate of LVOTG assessment was 1333/1333 at rest and at peak stress (feasibility 100%). Imaging and analysis time were <1 minute. LVOTG at rest was present in 25 pts (2.8%) of the overall population: 23 HCM, 1 INOCA, and 1 HFpEF. Overall prevalence during ESE was 432/1333 (32%). During ESE, LVOTO (see Figure 1 and 2) was 0% (0/35) in normals, 58% (47/81) in HCM (23 with obstruction at rest), 33% (2/6) in genotype-positive, phenotype negative HCM, 37% (33/131) in INOCA, 40% (135/416) in athletes and 1/1 in the patient with aborted sudden death on strenuous exercise. Conclusion LVOTO in orthostatic position is detectable during treadmill ESE in several cardiovascular conditions associated with symptoms such as dyspnea, chest pain or near syncope, and even in asymptomatic patients with genotype-positive, phenotype-negative HCM. The identification of the obstructive phenotype is easy to capture during ESE without any significant additional imaging and analysis burden and can be important also outside HCM. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

scholarly journals P794 Treadmill exercise stress echocardiography in children; our experience.

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
C Cotrim ◽  
I Joao ◽  
J Guardado ◽  
P Cordeiro ◽  
M ANA Sampaio ◽  
...  
Keyword(s):  
Chest Pain ◽  
Stress Echocardiography ◽  
Continuous Wave ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Exercise Stress Echocardiography ◽  
Group I ◽  
Ecg Alterations ◽  
Group Ii ◽  
Exercise Induced

Abstract Background Exercise stress echocardiography (ESE) is routinely used in adults but its role in children (C) is less established Purpose To assess the feasibility and clinical value of ESE in outpatient children Methods We enrolled 309 consecutive C (mean age = 14,1 ± 2,6 years, range 6-17 yrs) who underwent treadmill ESE between 2002 and 2019: One group (Group I) of 258 C including: 237 with exercise related symptoms (chest pain and/or dyspnea and/ or lypotimia-syncope), 15 with resting ECG alterations, 6 with positive ECG stress test and other group of C (Group II) including: 10 asymptomatic for screening requested by parents, 11 with symptoms unrelated to exercise, 12 with antecedents of sudden death in the family, and 17 with known pathology - 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, 1 each with Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, aortic switch operation. Regional wall motion abnormalities (RWMA) by 2-D and continuous wave Doppler (transvalvular or transaortic or intraventricular (IVG) gradients were assessed in all. Results The success rate was 309/309 (100%). Only one complication (allowing asthma diagnosis by serendipity) occurred: a severe asthmatic crisis in one girl studied because of chest pain with exercise (with ESE negativity), Stress-induced RWMA occurred in 2 pts (one with HCM, the other with normal coronary arteries). A significant orthostatic exercise induced IVG (> 30 mmHg) was present in 101 of the 258 C (39%) studied due to symptoms, ECG alterations or positive stress ECG. In group II the C with induced IVG attained greater heart rate (HR) 184 ± 12 vs 174 ± 16 (p < 0,001); greater blood pressure (BP) 150 ± 19 mmHg vs 136 ± 23 mmHg (p < 0,001). The OR to the reproduced symptoms that motivated the exam during the SE comparing the 101 C with IVG with the 158 without IVG was 8,22 (4,83-13,99) p < 0,001 (95% CI). Conclusions Treadmill ESE is feasible and safe in young people. RWMA are of limited usefulness in our outpatient C group. Doppler often documents significant exercise induced IVG, occult at rest that associate with symptoms. Abstract P794 Figure. ESE Induced IVG in a C with chest pain

scholarly journals Prognostic value of reduced heart rate reserve during exercise stress-echocardiography in hypertrophic cardiomyopathy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Q Ciampi ◽  
I Olivotto ◽  
M.A D'Alfonso ◽  
L Tassetti ◽  
A Milazzo ◽  
...  
Keyword(s):  
Heart Rate ◽  
Hypertrophic Cardiomyopathy ◽  
Autonomic Dysfunction ◽  
Prognostic Value ◽  
Stress Echocardiography ◽  
Beta Blockers ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Heart Rate Reserve ◽  
Exercise Stress Echocardiography

Abstract Background Heart rate reserve (HRR) during exercise evaluates chronotropic incompetence and is a prognostically important marker of cardiac autonomic dysfunction, additive to regional wall motion abnormalities (RWMA) in patients with coronary artery disease. Objectives To assess determinants and prognostic value of HRR in patients with hypertrophic cardiomyopathy (HCM). Methods From 1998 to 2019, we enrolled 774 HCM patients (age = 48.8±15.9 years, 410 men) with exercise stress echocardiography (ESE) in 10 certified centres of the international stress echo network. During ESE we assessed: left ventricular outflow tract obstruction (LVOTO, significant when >50 mmHg); RWMA; HRR (peak/ rest heart rate), 344 in beta-blockers therapy (44.4%). Patients were followed for a median 49 months (IQ range, 25–78 months). The study end-point was all-cause mortality. Results During ESE, we observed stress-induced RWMA in 42 (5.4%) and LVOTO in 248 (33%); HRR was 1.92.±0.41. There were no difference in patients with normal and abnormal HRR with and without beta-blockers therapy (147, 41.1% vs 211, 58.9%, p=0.079). During follow-up, 43 deaths occurred. Beta blockers therapy in univariate analysis did not have prognostic role (HR 1.105, 95% CI 0.602–2.028, p=0.768). The lowest HRR quartile (≤1.62) had a 10-fold higher 6-year death rate (10.9%) than the highest quartile (>2.16, 1.04%): see figure. At multivariable analysis, lowest HRR quartile (HR 2.074, 95% CI 1.082–6.773, p=0.034), age (HR 1.045, 95% CI 1.014–1.077, p=0.004), maximal wall thickness (HR 1.137, 95% CI 1.054–1.226, p=0.001), stress-induced RWMA s(HR 4.289, 95% CI 1.733–10.615, p=0.002) and ≥ moderate mitral regurgitation at rest (HR 3.127, 95% CI 1.507–6.488, p=0.002) predicted death. Conclusions A blunted HRR during ESE predicts adverse outcome independent of inducible RWMA in HCM patients. Autonomic dysfunction deserves consideration as a potential therapeutic target in this disease. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals What Is Really a Nonobstructive Hypertrophic Cardiomyopathy? The Importance of Orthostatic Factor in Exercise Echocardiography

2011 ◽  
Vol 2011 ◽  
pp. 1-4 ◽  
Author(s):  
Carlos Cotrim ◽  
Ana Rita Almeida ◽  
Luís Lopes ◽  
Paula Fazendas ◽  
Isabel João ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Left Ventricular Outflow Tract ◽  
Treadmill Exercise ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Stress Echo ◽  
Left Ventricular Outflow ◽  
Orthostatic Position

The authors report the case of a 23-year-old girl with nonobstructive hypertrophic cardiomyopathy evaluated by resting echocardiography. The patient complained of syncope after playing basketball. The patient was submitted to treadmill exercise echocardiogram, and she exercised for 9 minutes in standard Bruce protocol. The left ventricular outflow gradient did not occur at peak workload; however she developed intraventricular gradient greater than 100 mmHg after exercise in orthostatic position. There was fall in arterial pressure, and the patient was then put in supine position. The authors suggest the possible role of exercise stress echo in symptomatic patients with no significant gradient at baseline, as well as maintenance in orthostatic position after exercise, as an important stress factor. This can disclose the occurrence of left ventricular outflow tract obstruction that should not be detected in other way and has potential relevance in the patient's symptoms understanding.

Prognostic value of peak stress cardiac power in patients with normal ejection fraction undergoing exercise stress echocardiography

2020 ◽  
Author(s):  
Vidhu Anand ◽  
Garvan C Kane ◽  
Christopher G Scott ◽  
Sorin V Pislaru ◽  
Rosalyn O Adigun ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Stress Echocardiography ◽  
Stress Test ◽  
Peak Stress ◽  
Left Ventricular ◽  
Exercise Stress ◽  
Cardiac Power ◽  
Exercise Stress Echocardiography ◽  
Lv Mass

Abstract Aims  Cardiac power is a measure of cardiac performance that incorporates both pressure and flow components. Prior studies have shown that cardiac power predicts outcomes in patients with reduced left ventricular (LV) ejection fraction (EF). We sought to evaluate the prognostic significance of peak exercise cardiac power and power reserve in patients with normal EF. Methods and results  We performed a retrospective analysis in 24 885 patients (age 59 ± 13 years, 45% females) with EF ≥50% and no significant valve disease or right ventricular dysfunction, undergoing exercise stress echocardiography between 2004 and 2018. Cardiac power and power reserve (developed power with stress) were normalized to LV mass and expressed in W/100 g of LV myocardium. Endpoints at follow-up were all-cause mortality and diagnosis of heart failure (HF). Patients in the higher quartiles of power/mass (rest, peak stress, and power reserve) were younger and had higher peak blood pressure and heart rate, lower LV mass, and lower prevalence of comorbidities. During follow-up [median 3.9 (0.6–8.3) years], 929 patients died. After adjusting for age, sex, metabolic equivalents (METs) achieved, ischaemia/infarction on stress test results, medication, and comorbidities, peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.5, 95% confidence interval (CI) 0.4–0.6, P < 0.001] and HF at follow-up [adjusted HR, highest vs. lowest quartile, 0.4, 95% CI (0.3, 0.5), P < 0.001]. Power reserve showed similar results. Conclusion  The assessment of cardiac power during exercise stress echocardiography in patients with normal EF provides valuable prognostic information, in addition to stress test findings on inducible myocardial ischaemia and exercise capacity.

Value of Exercise Stress Echocardiography in Children with Hypertrophic Cardiomyopathy

2020 ◽  
Vol 33 (7) ◽  
pp. 888-894.e2 ◽  
Author(s):  
Iqbal El Assaad ◽  
Kimberlee Gauvreau ◽  
Raheel Rizwan ◽  
Renee Margossian ◽  
Steven Colan ◽  
...  
Keyword(s):  
Hypertrophic Cardiomyopathy ◽  
Stress Echocardiography ◽  
Exercise Stress ◽  
Exercise Stress Echocardiography

The feasibility and clinical implication of tricuspid regurgitant velocity and pulmonary flow acceleration time evaluation for pulmonary pressure assessment during exercise stress echocardiography

2019 ◽  
Vol 20 (9) ◽  
pp. 1027-1034 ◽  
Author(s):  
Karina Wierzbowska-Drabik ◽  
Eugenio Picano ◽  
Eduardo Bossone ◽  
Quirino Ciampi ◽  
Piotr Lipiec ◽  
...  
Keyword(s):  
Stress Echocardiography ◽  
Continuous Wave ◽  
Close Correlation ◽  
Exercise Stress ◽  
Peak Exercise ◽  
Acceleration Time ◽  
Flow Acceleration ◽  
Exercise Stress Echocardiography ◽  
Pulmonary Flow ◽  
Pulmonary Arterial

Abstract Aims Echocardiography can estimate pulmonary arterial pressure (PAP) from tricuspid regurgitation velocity (TRV) or acceleration time (ACT) of pulmonary flow. We assessed the feasibility of TRV and ACT measurements during exercise stress echocardiography (ESE) and their correlation in all stages of ESE. Methods and results We performed ESE in 102 subjects [mean age 49 ± 17 years, 50 females, 39 healthy, 30 with cardiovascular risk factors, and 33 with pulmonary hypertension (PH)] referred for the assessment of exercise tolerance and ischaemia exclusion. ESE was performed on cycloergometer with the load increasing by 25 W for each 2 min. Assessment of TRV with continuous wave and ACT with pulsed Doppler were attempted in 306 time points: at rest, peak exercise, and recovery. In 20 PH patients we evaluated the correlations of TRV and ACT with invasively measured PAP. The success rate was 183/306 for TRV and 304/306 for ACT (feasibility: 60 vs. 99%, P < 0.0001). There was a close correlation between TRV and ACT: r = 0.787, P < 0.001 and ACT at peak ≤67 ms showed 94% specificity for elevated systolic PAP detection. Moreover, TRV and ACT at peak exercise reflected better that resting data the invasive systolic PAP and mean PAP with r = 0.76, P = 0.0004 and r = −0.67, P = 0.0018, respectively. Conclusion ACT is closely correlated with and substantially more feasible than TRV during ESE and inclusion of both parameters (TRACT approach) expands the possibility of PAP assessment, especially at exercise when TRV feasibility is the lowest but correlation with invasive PAP seems to increase.

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