Chronic stable angina exercise echocardiography: Difference between revisions
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==Overview== | ==Overview== | ||
[[Stress echocardiography]] is echocardiography with different stressors such as exercise or pharmacological | [[Stress echocardiography]] is echocardiography that is paired with different forms of stressors, such as exercise or pharmacological. Exercise stress echocardiography is the preferred stress echocardiography modality. However, it is not suitable for all patients and may not be feasible in populations that do not meet a minimum level of fitness. In patients who are ineligible for exercise stress echocardiography, pharmacolgoical stress echocardiography can be a useful alternative. Common pharmacological stressors include: [[adenosine]], [[dipyridamole]], and [[dobutamine]]. | ||
As a testing modality, exercise echocardiography is notedas more sensitive, more specific and has a ''higher predictive value'' than [[Chronic stable angina exercise electrocardiogrpahy|exercise ECG]]. Exercise echocardiography can be helpful in the evaluation of regional wall motion response, location and extent of [[ischemia]] during stress in patients with [[MI]]. During exercise, the normal myocardium is hyperdynamic while in patients with [[MI]], the ischemic myocardium is either akinetic or hypokinetic. | |||
==Advantages of stress echocardiography== | ==Advantages of stress echocardiography== | ||
* | *Aids in detection of [[coronary artery disease|coronary artery disease (CAD)]]. | ||
*Stress echocardiography is a | *In patients with known or suspected [[CAD]], stress echocardiography can assess the prognosis of [[CAD]]. | ||
*In patients with [[ischemic cardiomyopathy|chronic ischemic LV dysfunction]], prediction of full '''functional recovery of the myocardium after revascularisation''' <ref name="pmid11568075">Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11568075 Time course of functional recovery of stunned and hibernating segments after surgical revascularization.] ''Circulation'' 104 (12 Suppl 1):I314-8. PMID: [http://pubmed.gov/11568075 11568075]</ref> | *Stress echocardiography is noted as a specific testing modality for the assessment of '''myocardial viability after acute [[MI]]'''.<ref name="pmid10841962">Anselmi M, Golia G, Maines M, Marino P, Goj C, Turri M et al. (2000) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10841962 Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction.] ''Int J Cardiol'' 73 (3):213-23. PMID: [http://pubmed.gov/10841962 10841962]</ref> | ||
*The capability of stress echocardiography to detect ischemia earlier in the ischemic cascade <ref name="pmid12927194">Mädler CF, Payne N, Wilkenshoff U, Cohen A, Derumeaux GA, Piérard LA et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12927194 Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study.] ''Eur Heart J'' 24 (17):1584-94. PMID: [http://pubmed.gov/12927194 12927194]</ref> <ref name="pmid15489101">Yip G, Khandheria B, Belohlavek M, Pislaru C, Seward J, Bailey K et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15489101 Strain echocardiography tracks dobutamine-induced decrease in regional myocardial perfusion in nonocclusive coronary stenosis.] ''J Am Coll Cardiol'' 44 (8):1664-71. [http://dx.doi.org/10.1016/j.jacc.2004.02.065 DOI:10.1016/j.jacc.2004.02.065] PMID: [http://pubmed.gov/15489101 15489101]</ref> has been greatly improved with the advent of '''tissue Doppler imaging''' <ref name="pmid11230833">Cain P, Baglin T, Case C, Spicer D, Short L, Marwick TH (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11230833 Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography.] ''Am J Cardiol'' 87 (5):525-31. PMID: [http://pubmed.gov/11230833 11230833]</ref> and '''strain rate imaging''' <ref name="pmid12682001">Voigt JU, Exner B, Schmiedehausen K, Huchzermeyer C, Reulbach U, Nixdorff U et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12682001 Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia.] ''Circulation'' 107 (16):2120-6. [http://dx.doi.org/10.1161/01.CIR.0000065249.69988.AA DOI:10.1161/01.CIR.0000065249.69988.AA] PMID: [http://pubmed.gov/12682001 12682001]</ref> <ref name="pmid14652617">Yip G, Abraham T, Belohlavek M, Khandheria BK (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14652617 Clinical applications of strain rate imaging.] ''J Am Soc Echocardiogr'' 16 (12):1334-42. [http://dx.doi.org/10.1067/j.echo.2003.09.004 DOI:10.1067/j.echo.2003.09.004] PMID: [http://pubmed.gov/14652617 14652617]</ref> | *In patients with [[ischemic cardiomyopathy|chronic ischemic LV dysfunction]], stress echocardiography can assist in prediction of full '''functional recovery of the myocardium after revascularisation'''.<ref name="pmid11568075">Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E et al. (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11568075 Time course of functional recovery of stunned and hibernating segments after surgical revascularization.] ''Circulation'' 104 (12 Suppl 1):I314-8. PMID: [http://pubmed.gov/11568075 11568075]</ref> | ||
*The capability of stress echocardiography to detect ischemia earlier in the ischemic cascade <ref name="pmid12927194">Mädler CF, Payne N, Wilkenshoff U, Cohen A, Derumeaux GA, Piérard LA et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12927194 Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study.] ''Eur Heart J'' 24 (17):1584-94. PMID: [http://pubmed.gov/12927194 12927194]</ref> <ref name="pmid15489101">Yip G, Khandheria B, Belohlavek M, Pislaru C, Seward J, Bailey K et al. (2004) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15489101 Strain echocardiography tracks dobutamine-induced decrease in regional myocardial perfusion in nonocclusive coronary stenosis.] ''J Am Coll Cardiol'' 44 (8):1664-71. [http://dx.doi.org/10.1016/j.jacc.2004.02.065 DOI:10.1016/j.jacc.2004.02.065] PMID: [http://pubmed.gov/15489101 15489101]</ref> has been greatly improved with the advent of '''tissue Doppler imaging''' <ref name="pmid11230833">Cain P, Baglin T, Case C, Spicer D, Short L, Marwick TH (2001) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11230833 Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography.] ''Am J Cardiol'' 87 (5):525-31. PMID: [http://pubmed.gov/11230833 11230833]</ref> and '''strain rate imaging'''.<ref name="pmid12682001">Voigt JU, Exner B, Schmiedehausen K, Huchzermeyer C, Reulbach U, Nixdorff U et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12682001 Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia.] ''Circulation'' 107 (16):2120-6. [http://dx.doi.org/10.1161/01.CIR.0000065249.69988.AA DOI:10.1161/01.CIR.0000065249.69988.AA] PMID: [http://pubmed.gov/12682001 12682001]</ref> <ref name="pmid14652617">Yip G, Abraham T, Belohlavek M, Khandheria BK (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=14652617 Clinical applications of strain rate imaging.] ''J Am Soc Echocardiogr'' 16 (12):1334-42. [http://dx.doi.org/10.1067/j.echo.2003.09.004 DOI:10.1067/j.echo.2003.09.004] PMID: [http://pubmed.gov/14652617 14652617]</ref> | |||
:*Tissue Doppler imaging is useful in the quantification of myocardial wall motion and strain. | :*Tissue Doppler imaging is useful in the quantification of myocardial wall motion and strain. | ||
:*Strain rate imaging is useful to determine regional deformation | :*Strain rate imaging is useful to determine regional deformation whee strain can be defined as the difference per unit length. | ||
==Diagnostic criteria== | ==Diagnostic criteria== | ||
* | *'''Signs suggestive of severe [[CAD]]''' on exercise echocardiography include: | ||
:* | :*Reduction on global systolic function | ||
:*LV dilation, | :*LV dilation, | ||
:* | :*New or progressively worsening [[mitral regurgitation|mitral regurgitation (MR)]] | ||
==Sensitivity and Specificity== | ==Sensitivity and Specificity== | ||
*Exercise echocardiography has been reported to have a sensitivity | *Exercise echocardiography has been reported to have a sensitivity between 74% to 100%. | ||
*The specificity has been reported to be between 64% to 93% for detecting [[CAD]]. | |||
* | *In one meta-analysis, the sensitivity of exercise echocardiography was between 80-85%. Specificity was reported between 84-86%.<ref name="pmid12727146">Schinkel AF, Bax JJ, Geleijnse ML, Boersma E, Elhendy A, Roelandt JR et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12727146 Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography?] ''Eur Heart J'' 24 (9):789-800. PMID: [http://pubmed.gov/12727146 12727146]</ref>. | ||
*A good level of agreement has also been reported between [[stress echocardiography]] and [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|stress scintigraphy]]. | |||
* | |||
:*With the use of '''high dose''' of [[dobutamine]] (up to 50 gm / kg / min), a method of dobutamine stress echocardiography can be performed with 86% to 96% of sensitivity and 66% to 95% of specificity. | :*With the use of '''high dose''' of [[dobutamine]] (up to 50 gm / kg / min), a method of dobutamine stress echocardiography can be performed with 86% to 96% of sensitivity and 66% to 95% of specificity. | ||
:*'''Lower doses''' of [[dobutamine]] can also be used to detect [[hibernating myocardium]]. Areas of hibernating myocardium exhibit poor or absent contraction at rest but normal contraction during dobutamine infusion. By comparison, areas damaged by myocardial infarction or fibrosis exhibit no improvement with dobutamine. | :*'''Lower doses''' of [[dobutamine]] can also be used to detect [[hibernating myocardium]]. Areas of hibernating myocardium exhibit poor or absent contraction at rest but normal contraction during dobutamine infusion. By comparison, areas damaged by myocardial infarction or fibrosis exhibit no improvement with dobutamine. | ||
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==References== | ==References== | ||
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Revision as of 12:59, 12 October 2011
Chronic stable angina Microchapters | ||
Classification | ||
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
Diagnosis | ||
Alternative Therapies for Refractory Angina | ||
Discharge Care | ||
Guidelines for Asymptomatic Patients | ||
Case Studies | ||
Chronic stable angina exercise echocardiography On the Web | ||
to Hospitals Treating Chronic stable angina exercise echocardiography | ||
Risk calculators and risk factors for Chronic stable angina exercise echocardiography | ||
Editors-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [4]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Stress echocardiography is echocardiography that is paired with different forms of stressors, such as exercise or pharmacological. Exercise stress echocardiography is the preferred stress echocardiography modality. However, it is not suitable for all patients and may not be feasible in populations that do not meet a minimum level of fitness. In patients who are ineligible for exercise stress echocardiography, pharmacolgoical stress echocardiography can be a useful alternative. Common pharmacological stressors include: adenosine, dipyridamole, and dobutamine.
As a testing modality, exercise echocardiography is notedas more sensitive, more specific and has a higher predictive value than exercise ECG. Exercise echocardiography can be helpful in the evaluation of regional wall motion response, location and extent of ischemia during stress in patients with MI. During exercise, the normal myocardium is hyperdynamic while in patients with MI, the ischemic myocardium is either akinetic or hypokinetic.
Advantages of stress echocardiography
- Aids in detection of coronary artery disease (CAD).
- In patients with known or suspected CAD, stress echocardiography can assess the prognosis of CAD.
- Stress echocardiography is noted as a specific testing modality for the assessment of myocardial viability after acute MI.[1]
- In patients with chronic ischemic LV dysfunction, stress echocardiography can assist in prediction of full functional recovery of the myocardium after revascularisation.[2]
- The capability of stress echocardiography to detect ischemia earlier in the ischemic cascade [3] [4] has been greatly improved with the advent of tissue Doppler imaging [5] and strain rate imaging.[6] [7]
- Tissue Doppler imaging is useful in the quantification of myocardial wall motion and strain.
- Strain rate imaging is useful to determine regional deformation whee strain can be defined as the difference per unit length.
Diagnostic criteria
- Signs suggestive of severe CAD on exercise echocardiography include:
- Reduction on global systolic function
- LV dilation,
- New or progressively worsening mitral regurgitation (MR)
Sensitivity and Specificity
- Exercise echocardiography has been reported to have a sensitivity between 74% to 100%.
- The specificity has been reported to be between 64% to 93% for detecting CAD.
- In one meta-analysis, the sensitivity of exercise echocardiography was between 80-85%. Specificity was reported between 84-86%.[8].
- A good level of agreement has also been reported between stress echocardiography and stress scintigraphy.
- With the use of high dose of dobutamine (up to 50 gm / kg / min), a method of dobutamine stress echocardiography can be performed with 86% to 96% of sensitivity and 66% to 95% of specificity.
- Lower doses of dobutamine can also be used to detect hibernating myocardium. Areas of hibernating myocardium exhibit poor or absent contraction at rest but normal contraction during dobutamine infusion. By comparison, areas damaged by myocardial infarction or fibrosis exhibit no improvement with dobutamine.
ACC / AHA Guidelines- Exercise Echocardiography in patients Who Are Able to Exercise (DO NOT EDIT) [9]
“ |
Class I1. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate pretest probability of CAD who have 1 of the following baseline ECG abnormalities:
2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with prior revascularization (either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). (Level of Evidence: B) Class IIb1. Exercise myocardial perfusion imaging and exercise echocardiography in patients with a low or high probability of CAD who have 1 of the following baseline ECG abnormalities:
2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have 1 of the following:
3. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography as the initial stress test in a patient with a normal rest ECG who is not taking digoxin. (Level of Evidence: B) 4. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C) |
” |
ESC Guidelines- Exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT) [10]
“ |
Class I1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST depression, paced rhythm, or WPW which prevent accurate interpretation of ECG changes during stress. (Level of Evidence: B) 2. Patients with a non-conclusive exercise ECG but reasonable exercise tolerance, who do not have a high probability of significant coronary artery disease and in whom the diagnosis is still in doubt. (Level of Evidence: B) Class IIa1. Patients with prior revascularization (PCI or CABG) in whom localization of ischaemia is important. (Level of Evidence: B) 2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B) 3. As an alternative to exercise ECG in patients with a low pre-test probability of disease such as women with atypical chest pain. (Level of Evidence: B) 4. To assess functional severity of intermediate lesions on coronary arteriography. (Level of Evidence: C) 5. To localize ischaemia when planning revascularization options in patients who have already had arteriography. (Level of Evidence: B) |
” |
Vote on and Suggest Revisions to the Current Guidelines
Sources
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [9]
- Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [10]
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [11]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [12]
References
- ↑ Anselmi M, Golia G, Maines M, Marino P, Goj C, Turri M et al. (2000) Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction. Int J Cardiol 73 (3):213-23. PMID: 10841962
- ↑ Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E et al. (2001) Time course of functional recovery of stunned and hibernating segments after surgical revascularization. Circulation 104 (12 Suppl 1):I314-8. PMID: 11568075
- ↑ Mädler CF, Payne N, Wilkenshoff U, Cohen A, Derumeaux GA, Piérard LA et al. (2003) Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study. Eur Heart J 24 (17):1584-94. PMID: 12927194
- ↑ Yip G, Khandheria B, Belohlavek M, Pislaru C, Seward J, Bailey K et al. (2004) Strain echocardiography tracks dobutamine-induced decrease in regional myocardial perfusion in nonocclusive coronary stenosis. J Am Coll Cardiol 44 (8):1664-71. DOI:10.1016/j.jacc.2004.02.065 PMID: 15489101
- ↑ Cain P, Baglin T, Case C, Spicer D, Short L, Marwick TH (2001) Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography. Am J Cardiol 87 (5):525-31. PMID: 11230833
- ↑ Voigt JU, Exner B, Schmiedehausen K, Huchzermeyer C, Reulbach U, Nixdorff U et al. (2003) Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia. Circulation 107 (16):2120-6. DOI:10.1161/01.CIR.0000065249.69988.AA PMID: 12682001
- ↑ Yip G, Abraham T, Belohlavek M, Khandheria BK (2003) Clinical applications of strain rate imaging. J Am Soc Echocardiogr 16 (12):1334-42. DOI:10.1067/j.echo.2003.09.004 PMID: 14652617
- ↑ Schinkel AF, Bax JJ, Geleijnse ML, Boersma E, Elhendy A, Roelandt JR et al. (2003) Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? Eur Heart J 24 (9):789-800. PMID: 12727146
- ↑ 9.0 9.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
- ↑ 10.0 10.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
- ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[1] PMID: 12515758
- ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462