PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY
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Transcript of PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY
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Dr. Benny J PanakkalSenior ResidentDept. of CardiologyMedical College, Kozhikode
PHARMACOLOGICAL STRESS ECHOCARDIOGRAPHY
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Understanding Basic Concepts
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Ischemia CascadeThe answer to the Question “Why Echo”
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Wall Motion
More Specific
Requires Ischemia
Perfusion Changes
More Sensitive
May occur without producing Ischemia
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Low cost
Environment friendly
No ionizing radiation
Equally accurate
Why Echo in comparison to SPECT, PET etc.
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Coronary Flow Reserve
Angina with ST-T changes
WITHOUT Wall Motion
Abnormalities
Microvascular Ischemia
• Syndrome X• LV Hypertrophy
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Stressors in Stress Testing
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Exercise Stress Testing
Treadmill
Most potent
Bicycle
Imaging at Peak Stress and during
each stage of stress
Avoids problem of early resolution of
ischemia
Can accurately measure the time of
onset of ischemia
Prognostically important
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Drawbacks
Hyperventilation
Hypercontractility of Normal Walls
Excessive Tachycardia
Excessive chest wall movement
Unable to exercise at all or maximally
Circumvented by Pharmacological
Stressers
Exercise as a StressorPrototype of Demand driven ischemic stress
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Situations where Pharmacological Stress is preferred to Exercise Stress
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Dipyridamol
Less myocardial dysfunction
More blood flow heterogeneity• Sometimes even
without wall motion abnormalities
• Still supply is sufficient for the demand
More myocardial dysfunction
Less blood flow
heterogeneity
Dobutamine
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Adverse Effects and Complications
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Protocols
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Exercise Stress Test Protocol
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Dipyridamol Stress Echo Protocol
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Ergonovine Stress Protocol for Coronary Vasospasm
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Imaging Equipment and Acquisition
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Quad screen FormatNormal response to Exercise, Dobutamine or Pacing Stress Echo
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2D imaging
Qualitiy issues
• Failure to image >1 seg (30%)
• Suboptimal visualization (10-15%)
Harmonic imaging
Contrast Echo
Follow a Road
map
• Avoid excessive gain settings
• Same window, Same view for optimal comparison
• Perfect Apical 2-chamber view
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Contrast Echo in Stress Echo
LV Opacification by micro bubbles
Improved Wall motion detection
Simultaneous perfusion analysis
Targetted approach to assess wall motion
3D Imaging
Decreased Acquisition periods
Technically easier
Contrast Echo and 3D Imaging
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How Contrast Echo improves Endocardial
border defintion
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Excessive Gain setting spoiling the Endocardial border definition
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Comparing Similar looking but totally different views
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TDI or Strain Rate Imaging
QRS to onset of Relaxation = 350 – 400ms
Normally interval decreases by 34% ± 10%
In Ischemia – 12% ± 18%
Speckle Tracking
Diastolic stunning
Lasts longer than wall motion abnormalities
TDI in Stress Echo
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Applying Strain Rate Imaging in Stress Echo
Resting
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Applying Strain Rate Imaging in Stress Echo
Low dose Dobutamine
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Applying Strain Rate Imaging in Stress Echo
High dose Dobutamine
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The Do(s) and Don’t(s)
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CAD• Diagnosis• Prognosticat
ion
Pre Op risk
assessmen
t
Exertional
dyspnoea
to rule out
cardiac
etiology
Localizing ischemia
Evaluation of valve stenosis severity
Indications of Stress Echo
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Special clinical conditions and target endpoints in Stress Echo
• Discordant symptoms and severity of lesion• Rise in contractile
reserve• Exercise induced peak
sytolic pulmonary pressures > 60mm Hg
Regurgitant lesions
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Diagnostic and Prognostic value of CFR during Vasodilator testing
Standalone diagnostic criteria: Structural
limitations
Only LAD imaged
LCx and RCA very difficult to image and impractical
Cannot differentiate between microvascular and
macrovascular CAD
Addition of CFR – ↑ Sensitivity, with modest↓
in Specificity
CFR – Flow (High Neg Pred Value)
2D – Function(High Pos Pred Value)
Used in DCMP too!!
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Interpretation
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Wall motion scoring and attribution to coronary vascular territories
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Interpretation of Pharmacological and Exercise Stress Echo
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Stress induced myocardial ischemia – Hallmarks
• Worsening of wall motion abnormalities• Development of new wall motion abnormalities
Specific
• Lack of hyperdynamic motion• Beta Blockers• THR not attained
Non-Specific
• Akinetic segment becoming dyskinetic
No meaning
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Adjunctive Diagnostic Criteria
LV cavity dilatation
Decreased Global LV systolic function
TVD or Left Main disease
Differential responses to Exercise and Dobutamine Stress Echo
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Diagnostic End Points
• Max dose of pharmacological agent
• Achievement of THR• Akinesis of ≥ 2 LV
segements• Severe Chest pain• Obvious ECG
positivity• ≥ 2mm ST shift
Submaximal Non-diagnostic End Points
• Non tolerable symptoms
• Limiting Asymptomatic side effects• Hypertention (BP
> 220/120)• Hypotension (BP
drop > 40mm Hg)• Supraventricular
Arrythmias• Complex Ventricular
Arrythmias• VT• Frequent
polymorphic VPC
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Dipyridamol Stress Preferred• Hypertension• Atrial and Ventricular Arrhythmias
Dobutamine Stress Preferred• Conduction disturbances • Bronchospastic diseases• On Xanthine medications• Caffeine containing drinks
• Tea• Coffee• Cola
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Contents of Stress Echo Report
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Statistics, StudiesThe Comparison
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Exercise Stress Echo
Dobutamine Stress Echo
VT 1.4% 4%
VF 1 2
SVT and AF are more common than VT/VF
Single Centre Analysis ( >50,000 studies ) – Mayo Clinic
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Sensitivity Specificity
Stress Echo 85% 88%
Stress SPECT 85% 81%
Diagnostic Accuracy - Overall
SVD DVD TVD
Stress Echo 58% 86% 94%
Stress SPECT 61% 86% 94%
Sensitivities in CAD subtypes
Pellikka PA: Stress echocardiography for the diagnosis of coronary artery disease: Progress towards quantification. Curr Opin Cardiol 20:395, 2005.Armstrong WF, Zoghbi WA: Stress echocardiography: Current methodology and clinical applications. J Am Coll Cardiol 45:1739, 2005
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Cardiac Event : Cardiac Death, Non-fatal MI, Coronary Revascularization
Normal Stress Echo – Event Rate < 3% (0.9% per person years of follow up)
Predictors of Cardiac Event (TMT)
Low effort tolerance
LVH
Advancing Age
Stress Echo as a Prognostic Indicator
Mayo Clinic Study comprising 1325 patients
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HR
Diabetes 1.9
Previous MI 2.4
Increase or No change in LV systolic size
1.6
Predictors among patients with Good Effort Tolerance and Abnormal Stress Echo –Event Rate was 2% per person year follow up
Kane GC, Hepinstall MJ, Kidd GM, et al: Safety of stress echocardiography supervised by registered nurses: Results of a 2-year audit of 15,404 patients. J Am Soc Echocardiogr 21:337, 2008
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Among patients with a High Pretest Probability for CAD – cardiac event rate
At 1 yr At 3 yra
Normal Stress Echo 2% 4%
Abnormal Stress Echo
17% 25%
Elhendy A, Mahoney DW, Burger KN, et al: Prognostic value of exercise echocardiography in patients with classic angina pectoris. Am J Cardiol 94:559, 2004
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Ischemic Threshold Event Rate
< 60% THR 43%
≥ 60% THR 9%
No Ischemia 0%
Dobutamine Stress Echo in Preop Evaluation and Prognostication
A Mayo clinic study of 530 patients
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Accuracy of different approaches for diagnosis of CAD with Stress Echo
Hoffmann R, Lethen H, Marwick T, et al. Standardized guidelines for the interpretation of dobutamine echocardiography reduce interinstitutional variance in interpretation. Am J Cardiol. 1998;82:1520–1524.
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Dip
yrid
amol
vs
Dob
utam
ine
Stre
ss E
cho
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Dipyridamol vs Exercise Stress Echo testing
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Dipyridamol vs Exercise Stress Echo testing
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Sensitivity Specificity Accuracy
SVD MVD GLOBAL
Dipyridamol 66 81 72 92 77
Exercise 72 90 79 82 80
Meta analysis of major trials comparing Dipyridamol with Exercise Stess Testing
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3D Echo in Stess Testing
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Prognostication
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Metz LD, Beattie M, Hom R, Redberg RF, Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta- analysis. J Am Coll Cardiol 2007; 49:227–37
Prognostic value of normal stress echoNormal test – Annual risk of Death = 0.4% – 0.9%
Prognostic Value of Inducible Myocardial Ischemia
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Stress Echo Titration of a Negative Test
Prognostic Value of Inducible Myocardial Ischemia
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Biphasic Response is the single most important response in predicting improvement in LV function in patients with LV dysfunction undergoing revascularization
72% vs <15%
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Safety Data
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Safety of Pharmacological Stress Echo
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Physical stress with exercise is probably safer than
pharmacological testing
Lattanzi F, Picano E, Adamo E, Varga A. Dobutamine stress echocardiography: safety in diagnosing coronary artery disease. Drug Saf 2000; 22:251–62.Varga A, Garcia MA, Picano E. International Stress Echo Complication Registry. Safety of stress echocardiography (from the International Stress Echo Complication Registry). Am J Cardiol 2006;98:541–3
Safety of Pharmacological Stress Echo
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Special SubsetsValvular Heart Disease
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Cut Offs for DiagnosisContractile Reserve – 20% of stroke volume
Valve area improvement to differentiate true from Pseudostenosis – 0.2%Asymptomatic Sev AS, mean gradient rise on exercise - > 20 mmHg
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Special SubsetsNon Cardiac Surgery
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Cytokine response
Catecholamine Surge
Hemodynamic stress
Vasospasm
Reduced Fibrinolytic
activity
Platelet activation
Hyper-coagulability
Perioperative Stress Response
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High risk categoryIntermediate risk category with Poor functional capacity
• Age < 70 yrs• β blocker
therapy suffices
• Age > 70 yrs• Revasculariza
tion
Peripheral Vascular Disease
• Stress Echo positivity does not always mean Revascularization
Left main or 2 vessel disease
• Only indication for revascularization
Others
• β blockers and Statins
When to perform Pharmacological Stress Echo in the context of Perioperativerisk stratification
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Special SubsetsEmergency Department
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Randomized muticenter trial - Italy
99% Neg predictive value to
r/o ACS
Still has drawbacks
Patients with negative stress test had early
readmission with ACS
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Special SubsetsMyocardial Viability Assessment
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Viable
Thickness ≥ 6mm
Scarred
Thinned Echodense
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Diagnostic Accuracy comparison for Myocardial Viability AssessmentMetanalysisBax et al. 2001
Bax JJ, Poldermans D, Elhendy A, et al. Sensitivity, specificity, and predictive accuracies of various noninvasive techniques for detecting hibernating myocardium. Curr Probl Cardiol. 2001;26:142–186
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Examples
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Detection of Myocardial Ischemia – Apical wall thickness, improves at low dose but deteriorates and high dose dobutamine stress echo.
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