scholarly journals The dilemma of ischemia testing with different methods

2014 ◽  
Vol 1 (1) ◽  
pp. K1-K4 ◽  
Author(s):  
Maria Pia Donataccio ◽  
Claudio Reverberi ◽  
Nicola Gaibazzi
Keyword(s):  
Coronary Artery ◽  
Myocardial Perfusion ◽  
Stress Echocardiography ◽  
Wall Motion ◽  
Multivessel Disease ◽  
List Type ◽  
Flow Reserve ◽  
Perfusion Defects ◽  
Perfusion Assessment ◽  
Motion Assessment

SummaryA 52-year-old man presented after one episode of effort angina, normal treadmill electrocardiogram (ECG), and clearly positive adenosine cardiac magnetic resonance (aCMR) for reversible perfusion defects in the left anterior descending (LAD) coronary artery territory. Contrast high-dose dipyridamole (0.84 mg/kg per 6 min) stress echocardiography (cSE) demonstrated normal myocardial perfusion (MP) and wall motion at rest, while perfusion defects were shown in the lateral and apical segments after dipyridamole. Wall motion at stress was completely normal and stress/rest Doppler diastolic velocity ratio on the LAD demonstrated reduced flow reserve. In this case, cSE was the provocative test detecting both the LAD and circumflex obstructive lesions, thanks to MP analysis, while wall motion assessment was negative, not different from treadmill ECG, and aCMR highlighted only the LAD disease.Learning pointsIn spite of the low sensitivity of wall motion assessment during stress-echocardiography to detect coronary artery disease (CAD) in patients with multivessel disease and balanced ischemia, the addition of cSE with myocardial perfusion assessment, is not only able to overcome this limitation of false negative rate on a per-patient basis, but may also depict multivessel myocardial perfusion defects more efficiently than aCMR, as in the reported case, thanks to high spatial resolution.Myocardial perfusion assessment during cSE, although not always technically feasible, has a very high spatial and temporal resolution which can easily demonstrate multivessel subendocardial perfusion defects during maximal vasodilation, which is often the only detectable marker of multivessel, balanced CAD.It is known that wall motion analysis during pharmacologic stress may result in falsely negative multivessel disease; in these cases perfusion imaging or Doppler measurement of coronary flow reserve may be helpful to detect multivessel obstructive CAD, which is a significant and dismal prognostic finding. aCMR is assumed as the perfect imaging modality for CAD detection, but in selected cases, such as the one presented, an advanced echocardiographic method in experienced hands can provide even more comprehensive results.

Abstract 4230: Comparison of Dobutamine-atropine Stress Echocardiography and Magnetic Resonance for Detection of Obstructive Coronary Artery Disease by Assessing Wall Motion and Myocardial Perfusion Abnormalities

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Sandra N Falcao ◽  
Jeane Tsutsui ◽  
Carlos E Rochitte ◽  
Luis Silva ◽  
Pedro A Lemos ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Magnetic Resonance ◽  
Coronary Angiography ◽  
Myocardial Perfusion ◽  
Stress Echocardiography ◽  
Wall Motion ◽  
Contrast Echocardiography ◽  
Dobutamine Stress ◽  
Left Ventricular ◽  
Mechanical Index

Background: The analysis of wall motion abnormalities (WMA) with dobutamine stress echocardiography or magnetic resonance is an established method for the detection of myocardial ischemia. Contrast echocardiography has been demonstrated a useful technique for evaluating myocardial perfusion (MP). We test the hypothesis that combination of MP and WMA would improve the diagnosis of coronary artery diseasen (CAD). Objective: To compare the diagnostic accuracy of dobutamine stress real-time myocardial contrast echocardiography (RTMCE) and gadolinium-enhanced magnetic resonance imaging (G-MRI) for detecting CAD by analyzing left ventricular WMA and MP. Methods: We prospectively studied 46 patients (23 males, mean age 58±8 years) referred for coronary angiography, RTMCE and MRI within a maximum interval of two weeks. Protocol used in RTMCE and G-MRI was four-stage dobutamine protocol (10 – 40 mcg/kg/min), with injection of atropine as required to reach 85% of age-adjusted target heart rate. Patients underwent first dobutamine stress RTMCE and then G-MRI using the same doses of dobutamine and atropine. RTMCE was performed using low-mechanical index imaging combined with intravenous commercially available contrast agent (Definity, Bristol-Myers Squibb). Positivity for the stress test was defined as new or worsening WMA or reversible perfusion defects in >2 contiguous segments. Quantitative coronary angiography (QCA) was performed in all patients. CAD was defined as the presence of lesion >50 % in at least one coronary artery territory. Results: All patients tolerated well dobutamine stress. In five patients G-MRI was not performed (2 because of claustrofobia, 1 because patient did not fit in MRI, 2 because of extensive ischemia by dobutamine RTMCE). A total of 41 patients underwent dobutamine RTMCE, G-MRI and QCA. The sensitivity, specificity, and accuracy to detect CAD by dobutamine RTMCE were 74%, 89% and 80% for the analysis of wall motion, 83%, 89% and 85% for the analysis of MP and 65%, 83% and 73% for dobutamine stress G-MRI. C onclusion: RTMCE seems to have better performance for detecting angiographically significant CAD than G-MRI using dobutamine stress. The analysis of MP increases sensitivity to RTMCE without changing specificity.

scholarly journals The influence of afterload on left ventricular contractility: 2D-strain and dyssynchrony in stress echocardiography

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
E Karev ◽  
S Verbilo ◽  
E Malev ◽  
M Prokudina ◽  
A Suvorov
Keyword(s):  
Coronary Artery ◽  
Left Ventricle ◽  
Ejection Fraction ◽  
Stress Echocardiography ◽  
Longitudinal Strain ◽  
Wall Motion ◽  
Wall Motion Score Index ◽  
Wall Motion Abnormalities ◽  
Response To Exercise ◽  
Score Index

Abstract Funding Acknowledgements Type of funding sources: None. Background Hypertensive response to exercise (HRE) has negative prognostic value but its impact on the  left ventricle (LV) contractility and on stress echocardiography (SE) results remains controversial. The global longitudinal strain (GLS) and LV dyssynchrony changes in response to afterload increase were shown even in patients with narrow QRS at rest, but not on exertion. Purpose We aimed to analyze the relation between the blood pressure (BP) during SE and LV GLS and dyssynchrony changes. Methods We performed exercise SE on treadmill in 96 patients without coronary artery stenosis (invasive or CT coronary angiography). Patients divided into two groups: HRE (n = 41) and normal response to exercise (NRE) (n = 55). We analyzed GLS and standard deviation of time between the onset of QRS and segmental longitudinal strain peaks (STE-TIME SD) using speckle tracking and 3d-ejection fraction (EF) at rest and on exertion. Results 2D-EF increase was higher in patients with NRE, but 3D-EF did not differ between groups. Wall motion abnormalities (WMA) on peak stress were detected more often in patients with HRE who had higher wall motion score index (WMSI). GLS on exertion and its increment were lower in HRE group (Fig. 1 - "Bull’s eye" diagrams of GLS at rest and on exertion in patient with NRE (upper panel) and HRE (lower panel)). Among dyssynchrony markers we revealed higher values of STE-TIME SD on exertion in HRE group (Table 1). Moreover the analysis showed positive correlations between BP level on exertion and peak GLS (r = 0.56, p < 0.0001), GLS increase (r = 0.54, p < 0.0001) and STE-TIME SD on exertion (r = 0.27, p < 0.02) Conclusions HRE is associated with less increment in GLS and 2D-EF on exertion. Besides LV dyssynchrony signs can appear in response to exaggerated afterload increase even in patients with narrow QRS complexes. Patients with HRE more often show stress-induced WMA and have greater WMSI on exertion in absence of coronary artery lesions, thus HRE can alter the specificity of the test in transient ischemia detection. Table 1 HRE NRE p Δ-2D ejection fraction 5.0 (4.0; 7.0) 10.0 (8.0; 12.5) <0.0000001 Δ-3D ejection fraction 8.25 (4.0; 8.25) 8.24 (8.15; 11.65) 0.09 Wall motion abnormalities on exertion 46.34% 1.8% <0.00001 Wall motion score index 1.0 (1.0; 1.18) 1.0 (1.0; 1.0) 0.00013 GLS on exertion -21.0 (-22.0; -19.0) -24.0 (-26.5; -23.0) <0.0000001 ΔGLS 0.0 (-1.0; 2.0) 4.0 (2.0; 6.0) <0.0000001 STE-TIME SD-IMPOST 42.0 (35.0; 53.0) 35.0 (27.5; 45.0) 0.012 Left ventricle systolic function and dyssynchrony in two groups. Abstract Figure 1.

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