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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 the years, applications of SE has expanded. Beyond its role in the identification of obstructive CAD, SE can also provide prognostic information in valvular heart disease, , diastolic heart failure, and after myocardial infarction (MI) and can also provide cardiovascular risk evaluation before noncardiac surgery.
Evaluation for Obstructive Coronary Artery Disease
In the evaluation of CAD, exercise and pharmacologic SE add incremental prognostic information to predict the occurrence of adverse cardiovascular events compared with clinical, rest echocardiographic, and exercise electrocardiographic (ECG) characteristics alone.
Exercise Echocardiography
In a cohort of 5798 individuals who underwent exercise echocardiography for evaluation of known or suspected CAD, workload and exercise wall motion score index had the strongest association with outcomes that included cardiac death or nonfatal MI. Although other studies have shown stress testing to be less sensitive and specific in women, this study demonstrated similar prognostic value of exercise echocardiography in men and women. Notably, the incremental value of SE in predicting adverse outcomes (death or nonfatal MI) has also been subsequently demonstrated across various subset of patients, including older adults (65 years of age or older), after coronary bypass surgery, and in those with diabetes. In a study of 5375 individuals, the prognostic value of SE appeared most useful in patients with intermediate-risk Duke treadmill scores with exercise echocardiography further substratifying patients into groups with a yearly mortality rate between 2% to 7%. An example of an abnormal stress echocardiogram is shown in 
.
Video 53.1. A 51-year-old woman referred for treadmill stress echocardiography for evaluation of angina. Left, A two-chamber view of the left ventricle demonstrating basal inferior wall motion abnormality at rest. Right, A two-chamber view of the left ventricle after exercise that demonstrates exercise-induced wall motion abnormality involving the apex.
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