Κ. ΑΓΓΕΛΗ

Echocardiography is….

Echocardiography is well recognized for its noninvasive application.

� It does not require isotopes-there is no risk of radiation

� It does not require magnetic resonance� It’s patient-friendly� It’s portable� It provides both anatomy and function� It’s the sine qua not to detect and elucidate or to

exclude structural cardiac disease.� It’s the tool to follow up…

Protocols of Stress Echocardiography

Protocols of Stress Echocardiography

Ποτε διακοπτετε η δοκιμασια κοπωσης ή

φορτισης?

� Α. ΣΕ ΕΜΦΑΝΙΣΗ ΠΑΡΑΤΕΤΑΜΕΝΟΥΠΡΟΚΑΡΔΙΟΥ ΑΛΓΟΥΣ

� Β. ΣΕ ΕΜΦΑΝΙΣΗ ΕΠΕΙΣΟΔΙΟΥ ΚΟΙΛΙΑΚΗΣΤΑΧΥΚΑΡΔΙΑΣ

� Γ. ΣΕ ΕΜΦΑΝΙΣΗ ΣΥΜΠΤΩΜΑΤΙΚΟΥΒΑΓΟΤΟΝΙΚΟΥ ΕΠΕΙΣΟΔΙΟΥ

� Δ. ΣΕ ΕΜΦΑΝΙΣΗ ΕΚΤΑΚΤΩΝ ΚΟΙΛΙΑΚΩΝΣΥΣΤΟΛΩΝ

� The EAE acreditation exam is highly

recommended.

� The basic skills required for imaging the heart

under resting conditions

� The diagnostic accuracy of an experienced

echocardiographer who is an absolute beginner is

stress echocardiography is more or less

equivalent to that achieved by tossing a coin

� Start with low-dose tests for viability and later

progress to tests for ischemia

� Start with safer and easier vasodilator tests and

later progress to adrenergic stresses

� Start with pharmacological and then progress to

physical exercise stress echocardiography

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria

for Echocardiography

Appropriate echocardiograms are those that are likely to contribute to improving patients’ clinical outcomes, and importantly, inappropriate use of echocardiography may be potentially harmful to patients and generate unwarranted costs to the healthcare system.

� Appropriate test for specific indication (Median score 7-9)

� Uncertain for specific indication (Median score 4-6)

� Inappropriate test for specific indication (Median score 1-3)

STRESS ECHOCARDIOGRAPHY-CAD APPROPRIATE TEST FOR SPECIFIC INDICATION

�Intermediate pretest probability of CAD A(9)

�ECG uninterpretable or unable to exercise A(9)

�Coronary stenosis of unclear significance A(8)

�Assessment of viability in patients eligible for revascularization A(8)

�Equivocal or borderline stress testingA(8)

�Post revascularization risk assessment for symptomaticpatientsA(8)

STRESS ECHOCARDIOGRAPHY-CAD INAPPROPRIATE TEST FOR SPECIFIC

INDICATION

�Low global CAD risk in asymptomatic patientsI(1)

� Asymptomatic patients < 2 years after PCI I(1)

�Asymptomatic patients < 5 years after CABGI(1)

�Perioperative risk assessment for low risk

non-cardiac surgeryin patients without active cardiac conditions I(1)

STRESS ECHOCARDIOGRAPHY FOR CHRONIC VALVULAR DISEASE

�Low cardiac output or LV ejection fraction (“low gradient aortic stenosis”) A(8)

�Asymptomatic severe mitral stenosis, severe mitral

regurgitation, severe aortic regurgitationA(7)

�Symptomatic moderate mitral stenosis or MR A(7)

�Asymptomatic moderate mitral stenosis or

regurgitation U(5)

�Asymptomatic moderate aortic stenosis or

regurgitation U(5)

�Symptomatic severe mitral stenosis or regurgitation I(3)

�Acute moderate/severe mitral or aortic regurgitation I(3)

�Severe aortic stenosis I(1)

ΣΕ LBBB ΠΟΙΑ ΜΟΡΦΗ ΦΟΡΤΙΣΗΣ Ή

ΑΣΚΗΣΗΣ ΠΡΟΤΙΜΑΤΑΙ?

� Α. ΔΟΚΙΜΑΣΙΑ ΦΟΡΤΙΣΗΣ ΜΕ ΔΟΒΟΥΤΑΜΙΝΗ, ΑΠΟΚΛΕΙΣΤΙΚΑ

� Β. ΑΣΚΗΣΗ ΜΕ ΤΑΠΗΤΑ, ΑΠΟΚΛΕΙΣΤΙΚΑ

� Γ. ΑΣΚΗΣΗ ΜΕ ΠΟΔΗΛΑΤΟ, ΑΠΟΚΛΕΙΣΤΙΚΑ

� Δ. ΟΠΟΙΑΔΗΠΟΤΕ ΜΟΡΦΗ ΑΡΚΕΙ ΝΑΜΕΛΕΤΑΤΑΙ ΤΑΥΤΟΧΡΟΝΑ ΚΑΙ Η ΑΙΜΑΤΩΣΗΜΥΟΚΑΡΔΙΟΥ

Αντενδειξεις του stress echo

� ΕΠΕΙΣΟΔΙΟ ΠΡΟΚΑΡΔΙΟΥ ΑΛΓΟΥΣ ΜΕ ΑΥΞΗΣΗΤΡΟΠΟΝΙΝΗΣ ΤΟ ΤΕΛΕΥΤΑΙΟ 24ΩΡΟ

� ΜΕΤΑ ΑΠΟ 24 ΩΡΕΣ ΕΠΕΙΣΟΔΙΟΥ ΠΡΟΚΑΡΔΙΟΥΑΛΓΟΥΣ ΧΩΡΙΣ ΑΥΞΗΣΗ ΤΡΟΠΟΝΙΝΗΣ.

� ΑΝΕΥΡΥΣΜΑ ΚΟΙΛΙΑΚΗΣ ΑΟΡΤΗΣ

� ΑΝΕΥΡΥΣΜΑ ΘΩΡΑΚΙΚΗΣ ΑΟΡΤΗΣ

Αποτελουν αντενδειξεις οι

κατωθι?

� ΟΙ ΕΚΤΑΚΤΕΣ ΚΟΙΛΙΑΚΕΣ ΣΥΣΤΟΛΕΣ

� Η ΠΑΡΟΥΣΙΑ ΣΤΟ HOLTER ΕΠΕΙΣΟΔΙΩN NSVT

� Η ΠΑΡΟΥΣΙΑ ΕΠΕΙΣΟΔΙΩΝ ΔΙΑΤΑΡΑΧΩΝΚΟΛΟΚΟΙΛΙΑΚΗΣ ΑΓΩΓΙΜΟΤΗΤΑΣ

� Η ΝΟΣΟΣ ΦΛΕΒΟΚΟΜΒΟΥ

The Ischaemic CascadeThe Ischaemic Cascade

•Perfusion abnormality

•Metabolic disorder

•Diastolic dysfunction

•Systolic dysfunction

•ECG alterations

•Anginal pain

Stress

Rest

ECG stress test

Stress echo

MCE, SPECT

PET

Clinical syndrome

The assessment of two of the main features of myocardial viability, i.e. maintained resting perfusion and residual inotropic reserve.

Echocardiography in the Emergency Room

•Acute chest pain is one of the most common reasons for presentation to the Emergency Department (ED) accounting for approximately 7 million ED visits per year in the United States.

•The challenge for the clinician is to identify those patientswith a serious cause of chest pain requiring intervention, particularly when acute coronary syndromes (ACSs) present with atypical symtoms, or diagnostic changes in the electrocardiogram(ECG) or cardiac enzyme markers are lacking.

Adenosine Stress Myocardial Contrast Echocardiography for the Detection of a Coronary Artery Disease

A Comparison With Coronary Angiography and Cardiac Magnetic Resonance

Arnold JR, et al., JACC, 2010

Characteristics and Outcomes of Patients WithAbnormal Stress Echocardiograms and

Angiographically Mild Coronary Artery Disease (<50%Stenoses) or Normal Coronary Arteries

�1477 consecutive patients with abnormal stress echocardiography underwent coronary angiography

�997 (67.5%) had “true positive” results (stenoses >50%)

�480 (32.5%) had “false positive” (<50% stenoses or normal coronary arteries)

Conclusions: A sizable proportion of patients with abnormal stress echocardiographic results who are referred for coronary angiography have false-positive findings. The outcomes of patients with false-positive results were similar to those of patients with true-positive results. This finding suggests that patients with false-positive results on stress echocardiography should still receive intensive risk factor management and careful clinical follow-up.

From AM,…, McCully RB., J Am Soc Echocardiogr. 2010

MYOCARDIAL CONTRAST ECHO

Safety of myocardial flash-contrast echocardiography in combination with dobutamine stress testing for detection of ischemia in 5250 studies.

C. Aggeli, Giannopoulos G, Roussakis G., et al. Heart 2008

Adverse bioeffects of ultrasound contrast agents used in echocardiography: true safety issue or ‘’much ado about nothing’’C. Aggeli, G. Giannopoulos, K. Lampropoulos, C. Pitsavos, C. Stefanadis. Curr Vasc Pharmacol 2009

Contrast echo: Really safe after all?C. Aggeli, J. Felekos, C. Pitsavos, C. Stefanadis. Minnerva Cardiologica 2011

contractile reserve

Radioisotope uptakeResidual

metabolic activity

ECHOSPECTMRIPET

Multimodality echo approach of myocardial viability

� Assessment of myocardial viability is another area in which echocardiography plays an important diagnostic role.

� It indeed allows for the assessment of two of the main features of myocardial viability, i.e. maintained resting perfusion and residual inotropic reserve.

Resting myocardial perfusion� MCE

� PET

Resting flow measurements obtained in viable myocardium have been markedly variable, about half of the segments showing reduced perfusion, the other half displaying only minor or no reduction in MBF.

Myocardial perfusion-

contraction patterns

� Perfusion-contraction mismatch (stunning)

� Moderate parallel reductions in perfusion and contraction (hibernation)

Myocardial flow reserve

� Perfusion reserve is always reduced in viable myocardium, albeit more severely in segments with low rest perfusion.

� The severity of flow reserve reduction directly impacts on contractile reserve, as this requires increases in MBF and oxygen consumption.

Microcirculation (several

structural alterations)

� The microvasculature is usually better preserved in viable than in non-viable segments.

� The major determinant of capillary density is the severity of interstitial fibrosis.

�We learn more about the pathophysiologic mechanisms behind myocardial viability, research is being directed into understanding the clinical manifestations of the data, interpretations, and clinical recommendations that these modalities provide.

The patterns of chronic ischemic dysfunction

Representative CE-3D-Echo and DE-CMr

ΠΟΙΑ ΕΚ ΤΩΝ ΚΑΤΩΘΙ ΕΙΝΑΙ ΣΩΣΤΑ ΓΙΑ ΤΗΝ

ΒΙΩΣΙΜΟΤΗΤΑ ΜΥΟΚΑΡΔΙΟΥ?

� Α. Η ΔΙΦΑΣΙΚΗ ΑΠΑΝΤΗΣΗ ΑΠΟΤΕΛΕΙ ΤΟΝ ΚΑΛΥΤΕΡΟΠΡΟΓΝΩΣΤΙΚΟ ΔΕΙΚΤΗ ΓΙΑ ΤΗΝ ΑΝΑΔΕΙΞΗ ΒΙΩΣΙΜΟΤΗΤΑΣΜΥΟΚΑΡΔΙΟΥ ΤΟ ΟΠΟΙΟ ΘΑ ΑΝΑΛΑΒΕΙ ΤΗΝ ΣΥΣΤΟΛΙΚΗ ΤΟΥΑΠΟΔΟΣΗ ΜΕΤΑ ΤΗΝ ΕΠΑΝΑΙΜΑΤΩΣΗ.

� Β. Η ΣΥΝΕΧΗΣ ΒΕΛΤΙΩΣΗ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣ ΤΩΝΔΥΣΛΕΙΤΟΥΡΓΟΥΝΤΩΝ ΤΜΗΜΑΤΩΝ ΧΑΡΑΚΤΗΡΙΖΕΙ ΤΟ STUNNED MYOCARDIUM.

� Γ. Η ΣΥΝΕΧΗΣ ΕΠΙΔΕΙΝΩΣΗ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣ ΤΩΝΜΥΟΚΑΡΔΙΑΚΩΝ ΤΜΗΜΑΤΩΝ ΑΠΟΤΕΛΕΙ ΤΟΝ ΚΑΛΥΤΕΡΟΠΡΟΒΛΕΠΤΙΚΟ ΔΕΙΚΤΗ ΒΕΛΤΙΩΣΗΣ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣΜΕΤΑ ΤΗΝ ΕΠΑΝΑΙΜΑΤΩΣΗ.

� Δ. ΤΟ ΠΑΧΟΣ ΤΩΝ ΔΥΣΛΕΙΤΟΥΡΓΟΥΝΤΩΝ ΜΥΟΚΑΡΔΙΑΚΩΝΤΜΗΜΑΤΩΝ ΣΥΝΕΚΤΙΜΑΤΑΙ ΣΤΗΝ ΜΕΛΕΤΗ ΒΙΩΣΙΜΟΤΗΤΑΣΜΥΟΚΑΡΔΙΟΥ