Transcript Document

TRANSTHORACIC
ECHOCARDIOGRAPHY &
STRESS ECHO IHD
MORTEZA ABDAR ESFAHANI MD.
ADVANCED ECHOCARDIOLOGIST ( 3 D )
ASSOCIATE PROFESSOR OF ISFAHAN UNIVERSITY
MEMBERSHIP OF EHA , & EES
Different type Echo mehode :
RESTING CONVENTIONALTRANSTHORACIC
ECHOCARDIOGRAPHY
EXERCISE
SERESS
ECHOCARDIOGRAPHY
DOBUTAMIN
STRESS
ECHOCARDIOGRAPHY
RESTING CONVENTIONALTRANSTHORACIC
ECHOCARDIOGRAPHY
EXERCISE
SERESS
ECHOCARDIOGRAPHY
DOBUTAMIN
STRESS
ECHOCARDIOGRAPHY
T -- ACC/AHA
Guidelines for Echocardiography for Diagnosis of Cause of Chest Pain in Patients with Suspected Chronic Stable Angina Pectoris
CLASS
INDICATION
LEVEL OF EVIDENCE*
Chronic stable angina
Echocardiography in
I (indicated)
1. Patients with systolic murmur suggestive
of aortic stenosis or hypertrophic
C
cardiomyopathy
2. Evaluation of extent (severity) of
ischemia (e.g., LV segmental wall motion
abnormality) when the echocardiogram can C
be obtained during pain or within 30 min
after its abatement
IIa (good supportive evidence)
IIb (weak supportive evidence)
Patients with a click or murmur to diagnose
C
mitral valve prolapse
III (not indicated)
Patients with a normal ECG, no history of
myocardial infarction, and no signs or
symptoms suggestive of heart failure,
valvular heart disease, or hypertrophic
cardiomyopathy
C

Echocardiography can also be used, with and without stress, to detect wall
motion abnormalities consistent with myocardial ischemia.
 The
presence of induced or baseline regional wall
motion abnormalities correlates with a worse
prognosis.

The sensitivity of stress echocardiography appears to be comparable to
myocardial perfusion imaging (∼85%), and the specificity is somewhat better
(95% versus 90%).[49]
Echocardiography
stable Angina – lV FUNCTION

Echocardiographic assessment of LV function is one of the most valuable aspects of
noninvasive imaging.

Such testing is not necessary for all patients with angina pectoris and, in patients with a
normal ECG and no previous history of MI, the likelihood of preserved LV systolic function
is high.

In contrast, in patients with a history of MI, ST-T wave changes, or conduction defects or
Q waves on the ECG, LV function should be measured with echocardiography or an
equivalent technique.

The presence or absence of inducible regional wall motion abnormalities and the
response of the ejection fraction to exercise or pharmacologic stress appear to provide
incremental prognostic information to the data provided by the resting echocardiogram.
TABLE 57-2 --
Sensitivity and Specificity of Stress Testing*
Data from Gibbons RJ, Abrams J, Chatterjee K, et al: ACC/AHA 2002 guideline update for the management
:A
of patients with chronic stable angina
report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee to update the 1999 guidelines for the management of patients with chronic stable angina) (http://www.acc.org/clinical/guidelines/stable/stable.pdf ).
MODALITY
Exercise ECG
TOTAL NO. OF PATIENTS ssensivity
24,047
0.68
especi[fi†]
0.77
Exercise SPECT
5,272
0.88
0.72
Adenosine SPECT
2,137
0.90
0.82
Exercise
echocardiography
2,788
0.85
0.81
Dobutamine
echocardiography
2,582
0.81
0.79
*
Without correction for referral bias.
†
Weighted average pooled across individual trials.
Exercise STRESS ECHO IN Stable angina
 Numerous
studies have shown that exercise
echocardiography can detect the presence of
CAD with an accuracy similar to that of stress
myocardial perfusion imaging
 and
superior to exercise electrocardiography
alone .
 Stress
echocardiography is also valuable in
localizing and quantifying ischemic myocardium .
STRESS ECHO

Stress echocardiography and radionuclide scans are the preferred
noninvasive testing modalities for patients who cannot undergo
treadmill electrocardiographic testing because of physical disability
or who have resting ECGs that confound interpretation.

Imaging studies are less readily available and more expensive than
exercise electrocardiography, but have increased sensitivity for the
detection of coronary disease and the ability to quantify the extent
of, and localize, jeopardized myocardium.

Stress Echocardiography

Stress echocardiography is an excellent method for :


comparing wall motion (regional contractility), myocardial perfusion,
pressure gradient,

pulmonary pressure,

valvular regurgitation,

or filling pressures before and after a stress to identify pathologic conditions
that are not apparent at rest.
EXERCISE STRESS ECHO
 Because
exercise-induced regional wall
motion abnormalities due to ischemia usually
last for a few minutes after the termination of
exercise, images taken immediately after
exercise can be compared with the baseline
pre-exercise images to detect exerciseinduced regional wall motion abnormalities.
EXERCISE ECHO

The typical exercise echocardiography protocol , ( SEE IN NEXT SLIDE )

.

Some centers favor a supine bicycle exercise protocol, as images can be obtained
at peak exercise.
Diagnostic Criteria for Stress Echocardiography

Normally with exercise, dobutamine, or pacing, LV wall motion becomes
Hyperdynamihc . The lack of hyperdynamic motion may indicate ischemia,
but it is less specific.

When the stress level is inadequate or the patient is taking a beta blocker,
however, the entire LV segment may contract normally without
hyperdynamic motion

Worsening of wall motion abnormalities or the development of new
abnormalities is the hallmark of stress-induced myocardial ischemia .

.

Not infrequently, an akinetic myocardial segment becomes dyskinetic
during stress echocardiography, but this change was not found to have any
diagnostic or prognostic implication.
LV SIZE & SYSTOLIC FUNCTION

Other adjunctive diagnostic criteria for an abnormal
stress echocardiogram include LV cavity dilation and a
decrease in global systolic function. These adjunctive
diagnostic criteria are more specific for detection of
severe coronary artery disease.

Also, the response to dobutamine is different from that
due to exercise. Even in patients with severe coronary
artery disease, including left main coronary artery
disease, the LV cavity may not dilate and global systolic
function may improve with dobutamine infusion despite
new wall motion abnormalities due to severe ischemia.
Exercise Echocardiography = Thallium scan

The sensitivity of exercise echocardiography and
exercise thallium imaging for coronary artery disease in
patients with single-, double-, or triple-vessel
involvement was also similar :
(58%, 86%,and 94%
respectively).

versus
61%, 86%, and 94%,
When a diagnostic test is used routinely, the diagnostic
accuracy depends on the population of patients, the
expertise of the interpreter, and the quality of the image.
Stress Echocardiography as a Prognostic Indicator
 The
likelihood of a cardiac event (cardiac
death, nonfatal infarct, or coronary
revascularization) after normal stress
echocardiography is extremely low.

Moreover, a negative stress test portends a
low risk for future events (less than
1%/person-year).
DSE

in myocardial viability
Several human studies have demonstrated that
a low dose of dobutamine (5 to 20 µg/kg per
minute) induces contractility in viable
myocardium, whether stunned or hibernating.
 Dobutamine-responsive
wall motion
improvement predicts subsequent improvement
in regional LV wall thickening after coronary
revascularization
DSE (dose of dobutamin )

Most of the initial improvement in wall
motion takes place with a low dose of
dobutamine, between 10 and 20 µg/kg
per minute, and worsening occurs at a
higher dose, 30 to 40 µg/kg per minute,
or with atropine.
Preoperative non cardiovascular
evaluation by stress echo

Stress echocardiography has also been widely used as a preoperative test

. One advantage of this test is that it assesses myocardial ischemia
dynamically in response to increased inotropy and HR, such as may occur
during the perioperative period.

The presence of new wall motion abnormalities that occur at low HR is the
best predictor of increased perioperative risk, with large areas of defect
being of secondary importance
Multi slices CT
CT Angio
Using multidetector computed tomography (MDCT), coronary CTA has a
sensitivity of approximately 90% and a
specificity of 65% to 90% for coronary
stenosis greater than 50%.
* renal function and very high X ray EXPOSE
Definite indication

CABG

Congenital coronary abnormality

Don’t recommended for screening test