Chronic stable angina exercise echocardiography

Editors-In-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Associate Editor(s)-In-Chief: ; 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, pharmacological stress echocardiography can be a useful alternative. Common pharmacological stressors include: adenosine, dipyridamole, and dobutamine.

As a testing modality, exercise echocardiography is noted as 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.
 * In patients with chronic ischemic LV dysfunction, stress echocardiography can assist in prediction of full functional recovery of the myocardium after revascularisation.
 * The capability of stress echocardiography to detect ischemia earlier in the ischemic cascade has been greatly improved with the advent of tissue Doppler imaging and strain rate imaging.
 * Tissue Doppler imaging is useful in the quantification of myocardial wall motion and strain.
 * Strain rate imaging is useful to determine regional deformation where 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%..
 * 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) == {{cquote|

Class I
1. 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:
 * a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
 * b. More than 1 mm of rest ST depression. (Level of Evidence: B)

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 IIb
1. 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:
 * a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
 * b. More than 1 mm of ST depression. (Level of Evidence: B)

2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have 1 of the following:
 * a. Digoxin use with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)
 * b. LV hypertrophy with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)

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) == {{cquote|

Class I
1. 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 IIa
1. 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)}}

Related Chapters

 * Exercise/Pharmacologic Stress Echocardiography


 * Comparison of exercise SPECT imaging and Exercise Echocardiography

Vote on and Suggest Revisions to the Current Guidelines

 * The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina


 * Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology


 * TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina


 * The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina