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Stress Echocardiography: Comparison With Other Techniques

Cardiovascular disease, in particular coronary artery disease (CAD), remains the leading cause of death worldwide. There is also enormous burden on health care systems. Annually, 10 million stress tests and 1 million invasive cardiac angiograms (ICAs) are performed in the United States. Management of CAD requires an accurate diagnosis. For decades, ICA has served as the gold standard for the diagnosis of CAD. However, there is…

Stress Echocardiography for Valve Disease: Aortic Regurgitation and Mitral Stenosis

Stress echocardiography (SE) has been less well validated in the context of aortic regurgitation (AR) and mitral stenosis (MS) than for coronary disease and mitral regurgitation (MR). In both these conditions, exercise stress echocardiography (ESE) represents the imaging approach of choice, being especially useful in apparently asymptomatic patients, mainly caused by sedentary lifestyle, and in nonsevere valve disease with symptoms. Stress Echocardiography Protocol Either immediate after…

Ultrasound-Enhanced Stress Echocardiography

Ultrasound-Enhancing Agents for Stress Echocardiography In the updated 2018 guidelines for ultrasound-enhancing agents (UEAs), it was recommended that UEAs be used whenever a coronary artery territory cannot be completely visualized on unenhanced echocardiography. This becomes especially relevant during stress echocardiography (SE), when all segments must be visualized to adequately assess regional wall motion (WM) at rest and during any form of stress. Very low mechanical index…

Echocardiography for the Assessment of Myocardial Viability in Ischemic Cardiomyopathy

Introduction and General Concepts There has been a dramatic change in the acute presentation, chronic consequences, and mode of death related to coronary artery disease (CAD) in the past few decades. The rapid recognition of acute coronary syndromes and increased availability and utilization of percutaneous coronary interventions have led to a reduction in sudden cardiac death and early in-hospital mortality rates, with a resulting increase in…

Stress Echocardiography: Prognosis

Stress echocardiography (SE), first introduced in 1979, was initially introduced for the detection of obstructive coronary artery disease (CAD). The underlying principle is that ischemic myocardium is unable to augment in function during stress. The severity and distribution of myocardial ischemia in turn determine the extent and severity of wall motion abnormalities (WMAs) detected during SE. Although initially introduced primarily for the detection of CAD, over…

Stress Echocardiography: Methodology

General Test Protocol During stress echocardiography (SE), electrocardiographic leads are placed at standard limb and precordial sites, slightly displacing (upward and downward) any leads that may interfere with the chosen acoustic windows. A 12-lead electrocardiogram (ECG) is recorded in resting condition and each minute throughout the examination. An ECG lead is also continuously displayed on the echo monitor to provide the operator with a reference for…

Diagnostic Criteria and Accuracy

The main sign of ischemia during stress echocardiography (SE) is the transient regional wall motion abnormality (RWMA) caused by a flow-limiting coronary artery disease (CAD). RWMA can be provoked by exercise or pharmacologic stressors, either by increased myocardial oxygen demand or decreased subendocardial myocardial oxygen supply with vasodilators determining underperfusion through horizontal and vertical steal phenomena. , All main SE modalities (exercise, dobutamine, vasodilators) have comparable…

Effects of Exercise, Pharmacologic Stress, and Pacing on the Cardiovascular System

The responses of the cardiovascular system to different stressors are not homogenous and vary depending on the nature of the effect sought. Although laboratories typically have expertise with one or two approaches, it is desirable to have experience with multiple stressors because not a single one suits all clinical scenarios. Hemodynamic Effects The hemodynamic effects of treadmill or bicycle exercise include an increase in heart rate…

Coronary Artery Imaging

Noninvasive coronary artery imaging has become popular since it was first used to measure coronary flow velocity (CFV) of the proximal left anterior descending coronary artery (LAD) using transesophageal echocardiography in the early 1990s followed by CFV measurements in the distal portion of the LAD using a transthoracic high-frequency transducer in the late 1990s. This was followed by the recording of flow velocity of all three…

Coronary Artery Anomalies

Congenital coronary artery (CA) anomalies (CAAs) encompass a diverse spectrum of pathology. They include both benign variations in CA anatomy as well as patterns that predispose to sudden cardiac death (SCD). Broadly speaking, congenital CA anomalies include abnormalities in ( ) CA origin, ( ) CA course or distribution, and ( ) CA termination (fistulae). This chapter focuses on the echocardiographic evaluation of anomalous CA origin…

End-Stage Cardiomyopathy Due to Coronary Artery Disease

End-stage coronary artery disease (CAD) typically manifests as a dilated cardiomyopathy, commonly termed ischemic cardiomyopathy (ICM). The patient has known CAD combined with significant left ventricular (LV) systolic dysfunction with an ejection fraction of 35% or less. The most common clinical presentation is that of a patient with a prior history of one or more myocardial infarctions (MIs) who now on echocardiographic evaluation has evidence of…

Old Myocardial Infarction

Myocardial infarction (MI) is characterized by acute ischemia caused by occlusion of an epicardial coronary artery causing irreversible cardiomyocyte death and subsequent cell necrosis, which results in a localized inflammatory response with recruitment and migration of macrophages, monocytes, neutrophils, and fibroblasts into the infarcted zone and eventual discrete collagen scar formation. , Within hours of the initial insult, acute dilatation and thinning of the area of…

Echocardiography in Stable Coronary Artery Disease

Diagnosis Echocardiography can show a regional wall motion abnormality (WMA) that may indicate the presence of coronary artery disease (CAD). Even in patients without established CAD, a WMA is associated with a 2.4- to 3.4-fold increase in risk of cardiac events. Wall motion analysis should be done using the method recommended by the American Society of Echocardiography (ASE) in 1989, with particular attention to endocardial thickening.…

Echocardiography in Acute Myocardial Infarction

Patients who have had an acute myocardial infarction (MI) are subject to a broad range of potential complications, some of which are life threatening. These complications range from cardiogenic shock caused by the loss of a critical mass of myocardium to various mechanical complications, such as the development of a left ventricular (LV) thrombus, ventricular septal rupture, free-wall rupture, papillary muscle rupture, dynamic LV outflow tract…

Acute Chest Pain Syndromes: Differential Diagnosis

When patients present with chest pain, the clinician needs to be alert and thorough in trying to determine its cause. The patient’s demographic characteristics together with a careful history should provide the initial information for understanding the likely etiologies. The addition of bedside evaluation by means of physical examination, chest radiography, and electrocardiography (ECG) should further narrow the differential diagnosis. However, more advanced diagnostic tools are…

Ischemic Heart Disease: Basic Principles

Acknowledgment The authors acknowledge the contributions of Dr. Shmuel S. Schwartzenberg, MD, who was a coauthor of this chapter in the previous edition. Acute Effects Of Myocardial Ischemia Significant coronary artery stenosis results in impaired blood flow and reduced myocardial oxygen supply. When myocardial oxygen demand exceeds supply, myocardial ischemia develops. In addition, in the setting of a complete coronary artery occlusion, myocardial necrosis can occur.…

Ischemic Heart Disease: Which Test to Use?

New-onset, stable chest pain among patients without known coronary artery disease (CAD) is a common clinical problem that results in approximately 4 million stress tests annually in the United States. Significant variations in diagnostic strategies are well documented and may be related to differences in health care systems, access to testing technologies, and risk tolerance. , Furthermore, there are limited information on health-related outcomes in this…

Assessment of Left Atrial Function

The recent interest in left atrial (LA) function has enhanced our understanding of the atrial contributions to cardiovascular performance in both health and disease. The development of sophisticated, noninvasive indices of LA function has been critical to this resurgence. Although echocardiography is most often used because of its availability, safety, versatility, and ability to image in real time with high temporal and spatial resolution, cardiac computed…

Assessment of Left Atrial Size

Acknowledgment The author thanks Dr. Theresa S.M. Tsang for her contribution to the previous edition of this chapter. A wealth of imaging and hemodynamic data have documented that the left atrium (LA) is not only a simple conduit for left ventricular filling; it also represents a critical structure for overall cardiac performance. It not only acts as a contractile pump that delivers 15% to 30% of…