Stress

Echocardiography

Dr. Surinder Singh Hansra

 Evolution of Stress Echo
• 1970 – Kraunz and Kennedy studied normal LV wall motion with rest and exercise

• 1973 – Jacobs et al noted LV RWMAs with M-mode Echo

• 1979 – Stress echo introduced with supine exercise

• Other methods - hand grips & treadmill (1981), pacing (1983), upright bicycle & cold
pressor test (1984)

• 1984 - Digital recording : simultaneous display of rest and exercise images

• Pharmacological agents – dipyradimole(1986), adenosine & dobutamine (1991)

• 1990 – Tranesophageal atrial pacing stress echo

• 1992 - Validation of accuracy by Quinones and Verani

• 1998 – Tissue harmonic and tissue doppler imaging

 Stress Echo Methods
• Exercise
Immediate post-treadmill exercise
Supine bicycle
Upright bicycle
Isometric stress (occ. with pharmacologic)

• Pharmacologic
Dobutamine infusion (+/- atropine)
Dipyradimole (+/- atropine)
Adenosine (+/- atropine)
Combined Dobu – Dipyradimole
Arbutamine

• Other
Transesophageal atrial pacing
Transvenous pacing (temp/permanent)
Ergonovine
Hyperventilation
Cold pressor
Mental Stress
Indication for using stress echo

• Unable to exercise

• Complete LBBB

• Paced ventricular rhythm

• Resting ST depression more than 1mm

 Exercise Echo
• Post treadmill imaging
Need to modify few precordial lead positions
No cool-down
Left lateral position
Diagnostic accuracy falls within 60-90 sec

• Supine bicycle ergometry

2 min stages of 25-50W increments
Imaging every stage

• Upright bicycle ergometry

Parasternal views frequently unavailable
 Accuracy of Exercise Echo for
detecting CAD
• Treadmill
Sensitivity 71 - 97% PPV 59 – 100%
Specificity 37 - 100% NPV 34 – 91%
Accuracy 62 - 91%

• Bicycle
Sensitivity 76 - 100% PPV 71 – 97%
Specificity 67 - 96% NPV 44 – 100%
Accuracy 81 - 94%

• Single Vessel 59 – 94% Multivessel 85 – 100%

• Meta-analysis of 44 articles (1998)

Exercise Echo Sens 85% Spec 77%

SPECT Thallium Sens 87% Spec 64%
 Dobutamine Stress Echo
• Markers of ischemia –
RWMA, reduced systolic thickening, LV cavity dilatation,
altered transmitral flow, decrease transaortic flow, new
or worsening MR, sinus node decceleration, ischemic ECG
changes and hypotension.

• Protocol –

• Starting dose – 2.5 (viability), 5 (standard), 10 (low risk)

• Echo images, ECG & BP – 1 min after & just before each dose increase
• Each stage 3 min
• Dose doubled for 2nd stage, and after 10 – 20, 40 and 50
• IV atropine (total 2mg) / handgrip
• Discontinuation of infusion if
− HR 85% of max age-predicted
− New or worsening RWMA
− Severe cardiac / noncardiac symptoms
− SBP > 240/120 or hypotension
− Ischemic ECG changes
− Significant ventricular/ supraventricular dysarhythmias
− Completion of protocol
Clinical implications of
response
 DSE
• Safety
• Chestpain, dysrhythmias, hypotension, nausea, vomiting,
headache, anxiety, tremors , chills and shivering
• Serious complications 0.3%
• Nonserious 8%
• No mortality

• Contraindications
• Ongoing ACS
• Uncontrolled HF
• Uncontrolled dysrhythmias
• Severe HTN
• HOCM
• Severe AS
Accuracy of DSE for detecting CAD
Meta-analysis 0f 28 studies (1997)

• Sensitivity 80% (SVD 74%, DVD 86% & TVD 92%)

• Specificity 84%
• Accuracy 92%
• PPV 69 – 95%
• NPV 61 – 86% (MACE 1.5%/yr)

• Comparison with other tests

• Better than TMT
• Similar to exercise echo
• More sensitive than dypridamole stress
• Similar to arbutamine
• Similar to adenosine
• Similar to TC99m-MIBI SPECT
 Dipyridamole Stress Echo
• Mild increase in BP & HR – Supply ischemia

• Flow maldistribution –
• coronary steal (vertical & horizontal) / Reverse Robinhood
efect

• Diagnostic Accuracy –
• Sensitivity 73%
− lower than dobu for SVD & similar for MVD

• Specificity 92% (higher than Dobu)

• Accuracy 79% (lower than Dobu)

• Prognostic value similar to Dobu

 Dip SE
• Safety –
• Hypotension, bradycardia, headache, nausea
• Minor effects in 2/3rd with high doses (t/ted with
aminophylline)
• MI, CHB, asystole, VT and PE - 1 in 1500

• Contrindications-
• SSS / high grade AV block
• Asthma
• No adenosine testing for 24 hrs

• Compared to DSE -
• Easier, cheaper, short imaging time (10mins) and safe.
 Number of institutions with agreement on
positivity or negativity of dobutamine stress
European Heart Journal (2002) 23, 821–829
 Limitations of Stess echo
• Subjective nature of visual interpretation.

• Correct visual interpretation requires long

training and continuing experience

• The assessment of all motion score largely

depends on image quality

• Side effects
Quantification of wall motion
• Two techniques:

• endocardial border motion from 2-D images

• measurement of myocardial velocity by tissue Doppler

• Doppler myocardial imaging

• MYDISE study (289 subjects)

Peak systolic velocity (cm/s) - most reproducible parameter
Sensitivity and specificity for the detection of LAD, LCX, and
RCA disease were 80% and 80%, 91% and 80%, 93% and 82%

• Advantages: high signal-to-noise ratio and assessment of longitudinal

contraction, which contributes to half of LVEF
• Disadvantages –
The velocity is influenced by the motion of adjacent segments and by
translation &rotation of the heart

• The mean duration of DMI acquisition was 30.6 min

• Post systolic motion by PW DMI –

• Recently shown be the most sensitive and specific marker of

ischaemia

• High sensitivity (73–100%) and specificity (82–97%)

• Accuracy superior to accuracy of the visual evaluation of WMA.

• Seen easily and quickly on-line during stress echo

 Stress / strain imaging
• During acute induced there is progressive reduction in systolic S/SR with
development or increase in post-systolic strain (PSS)

• Possible to differentiate a transmural myocardial infarction from non-transmural.

• Flow-reserve can also be evaluated during DSE by assessing changes in peak

systolic strain.

• Voigt et al., compared the sensitivity and specificity S/SR imaging in 44 patients

• 2D Echo - 97% segments assessed, sensitivity and specificity of 81% and 82%
• TDI - 92% of segments assessed . Sensitivity of 74% and specificity of 63%.
• S/SR - only 85% of segments assessed.
A post-systolic/ max systolic strain ratio >35% showed the highest sensitivity
and specificity (82% and 85%,resp).

• When visual inspection suggests a regional RWMA, the regional long-axis velocity
responses during DSE should be used . If this is abnormal then S/SR imaging

• In hearts with conduction or rhythm disturbances or complex WMA at rest,

deformation imaging should now be used as the firstline approach
 Parameters associated with false negative
stress test results

• Incorrect assessment of the angiographic severity of the lesion

• Insufficient stress level to induce myocardial ischaemia

• low image quality

• Patients with a false-negative stress test

• More frequently received atropine

• More frequent completed protocol

• Less frequently had angina or ECG changes during dobutamine stress

• More frequently WMA in basal posterior circulation

 DSE in women
• Exercise Echo

• Sensitivity 79 -88%
• Specificity 37 – 86%
• NPV 54 – 89%
• PPV 66 – 86%
• Accuracy 63 – 86%

• DSE
• Sensitivity 68 – 93%
• Spec city 55 – 100%
• NPV 68 – 90%
• PPV 64 – 100%
• Accuracy 58 – 95%

• DSE reliably detects multivessel disease in women

• DSE is usually negative in women with SVD

 Arbutamine Stress Test
• Closed loop delivery system

• Efficacy for detecting CAD

• Senstivity 71 - 89%
− SVD 55%
− DVD 75%
− TVD 83%

• Specificity 67%
• Accuracy 80%

• Shorter infusion time but longer recovery time compared to

DSE

• Side effects – flushing, headche, tremors, arhythmias,

dizziness,hypotension
 Pacemaker stress
echocardiography (PASE)
• Protocol –

• Pacing catheter introduced orally (10F transesophageal bipolar pacing catheters)

• Catheter position optimized by maximizing the size of the esophageal P wave

(advanced to 40-cm mark and then withdrawn until a 1:1 capture achieved)

• Pacing initiated at 10 beats/min above the patient’s baseline heart rate and at 3
to 5 mA above the threshold for atrial capture

• 2-min stages with 20 beats/min increments at every stage until THR or another
end point

• If Wenckebach 2nd degree heart block occurred, IV atropine

• End points –
THR, new or worsening WMA, VT/SVT, ECG of severe ischemia,
severe angina, intolerable symptoms, SBP 240 mmHg, DBP 120
mmHg and SBP <90 mmHg
 Diagnostic accuracy of PASE for CAD
JACC 2000;36:1935– 41

• sensitivity 88 -95% specificity 87 -91%

• NPV 67 - 87% PPV 95 - 97%

• Accuracy 89 – 92% concordance with CAG 83%

 Advantages Limitations

• Intolerant to pharmacologic stress • Only increases HR, SBP

echo
remains unchanged
• Chronotropic incompetence
(betablockers)
• Suboptimal sensitivity in
SVD
• Noninvasive test in pt. with
permanent PM
• Ventricularly paced
• Ability to instantly lower heart rate patients, the interpreter
and to terminate stress (high safety) must focus on nonseptal
regions of the LAD territory
• Possibility to perform test at bedside

• Requires intact AV
• No adverse drug effects and the
prolonged recovery period conduction

• Shorter preparation time & • Requires absence of

imaging time
significant esophageal
disease
 Transesophageal Stress Echo
• Atrial Pacing

• Senstivity 90%
• Specificty 93%

• Dipyridamole

• Sensitvity 92%
• Specificity 100%

• Dobtamine

• Sensitivity 89%
• Specificity 100%
• Accuracy 91% (higher than thallium)
 Clinical Uses
• Chest pain evlauation

• Known CAD
• Myocardial viability
• Post MI residual ischemia
• Post revascularization residual ischemia

• Risk Stratification
• Chest pain
• Known CAD
• Known LV dysfunction
• Preop for noncardiac surgery

• Valvular heart disease

Cardiac & Total mortality in patients with presence
and absence of ischemia on pharmacologic SE
JACC 2003;41:589 –95
 Dobu Stress Echo Predicts Cardiac
Mortality
Large-Scale Multicenter Prospective International Study 4,037 pts .

JACC Vol. 41, 2003:589–95

DSE risk stratification in patients
with LV dysfunction
 Prediction of events Preop Risk
Post-MI Stratification
DSE
• Exercise Echo (TMT)
• PPV 26 – 42%
• PPV 67 – 82%
• NPV 99 – 100%
• NPV 84 – 100%
Dip SE
• Similar PV as DSE
• Dob SE
• PPV 14 – 72%
• NPV 67 – 90%
Valvular Heart Disease
• Dip SE
• PPV 33 – 40% • MR – latent LV dysf preMVR
• NPV 89 – 97% stress induced MR in
MVP (Dobu)

• TAP
• AS – low grad with LV dysf
• PPV 62 – 65%
cause of angina (Dip)
• NPV 76 – 92%
 Real-Time 3D DSE vs. 2D DSE
JACC 2001;37;1303-1309

• Advantages -
• rapid acquisition, simultaneous visualization of the same
segments in different planes, superior interobserver
agreement, Short learning curve

• Larger clinical trials for comparisons with 2D and CAG needed

 Exercise vs. Non exercise test
Parameter Treadmill Bicycle Pharmacologic

Integrity of ECG response Yes Yes No

Functional Status Yes Yes No
Diagnostic utility of BP Yes Yes Uncertain
Relation of symptoms to finding Yes Yes No
Physiological significance of Limited Yes Yes
lesion
Stage of onset of ischemia No Yes Yes
Physically limited / deconditioned No No Yes
patients
Patient Ease High Moderate High
Sonographer Ease Moderate Moderate High
Nurse No No Yes
Need for Physician Low Low Moderate
 Clinical Utility of Stress Echo
Methods
Clinical Role Treadmill Bicycle DSE
Chest pain evaluation + + +/-
Fatigue & dyspnea evaluation + + -
Screen high-risk pts. + + +/-
Preop risk assessment +/- +/- +
Post MI stratification + + +
Functional significance of +/- + +
CAD
Myocardial viability - - +
Valvular disease + + -
Pulmonary HTN + + -
 From technical viewpoint, dipyridamole represents the primary school,
dobutamine the secondary school, and exercise the university in stress echo.
 FUTURE DIRECTIONS

• Aimed to further improve accuracy, decrease

subjectivity, and increase reproducibility of
interpretation.

• Tissue Doppler
• Stress & strain rate imaging
• contrast echo
• 3D imaging.
• Color kinesis