Resposta Exagerada da Pressão Arterial Sistólica ao Exercício e Isquemia Miocárdica à Ecocardiografia sob Estresse Físico / Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Resumo Fundamento A associação entre resposta exagerada da pressão arterial sistólica ao exercício (REPASE) e isquemia miocárdica é controversa e pouco estudada em indivíduos com síndrome coronariana crônica estabelecida ou suspeita. Objetivo Verificar a relação entre isquemia miocárdica e REPASE em indivíduos submetidos à ecocardiografia sob estresse físico (EEF). Métodos Trata-se de estudo transversal com 14.367 indivíduos submetidos à EEF, de janeiro de 2000 a janeiro de 2022, divididos em dois grupos: G1 - composto por pacientes cuja pressão sistólica de pico apresentou incremento ≥ 90 mmHg (valor correspondente ao percentil 95 da população estudada) -, e G2 - formado por indivíduos que não apresentaram resposta hipertensiva exagerada. Os grupos foram comparados mediante os testes t de Student e qui-quadrado. Foram considerados significativos os valores de p < 0,05. Realizou-se, também, regressão logística para identificação de fatores de risco independentes para isquemia miocárdica, REPASE, queixa de precordialgia típica prévia ao exame e angina durante o teste. Resultados Dos 14.367 pacientes, 1.500 (10,4%) desenvolveram REPASE e 7.471 (52,0%) eram do sexo feminino. Os percentuais de queixa prévia de precordialgia típica, angina durante o teste e isquemia miocárdica dos pacientes com REPASE foram de 5,8%, 2,4% e 18,1% contra 7,4%, 3,9% e 24,2%, em indivíduos sem REPASE, respectivamente (p = 0,021, p = 0,004, p < 0,001). Na análise multivariada, a REPASE foi associada, independentemente, a uma menor probabilidade de isquemia miocárdica (odds ratio: 0,73; intervalo de confiança de 95%: 0,58 a 0,93; p = 0,009). Conclusão O incremento exagerado da pressão arterial sistólica durante a EEF pode ser um marcador de exclusão de isquemia miocárdica.

Abstract Background The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. Objective To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). Methods This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. Results Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). Conclusion Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

Early Use of Handgrip Exercise Associated with Dobutamine Stress Echocardiography in Women

Abstract Background Coronary artery disease (CAD) is an important cause of morbidity and mortality in women and requires early diagnosis for defining the appropriate treatment. Objective To identify the positive predictive value (PPV) and safety of the early use of handgrip exercise in pharmacological stress echocardiography using dobutamine (early-ECHO) in women. Methods Positive ischemic early-ECHO records from 111 women were evaluated from January 2012 to March 2018. Subsequently, the hospital medical records were verified to locate patients who underwent conventional coronary angiography (CCA), and we analyzed the medical conduct adopted for these patients. Statistical analyses were performed using SPSS employing one-way analysis of variance (ANOVA), Fisher's exact test, or Pearson's chi-square test. The level of statistical significance was set at p < 0.05 for all analyses. Results Four patients (4.4%) presented serious complications during the examination. Out of 90 patients who underwent CCA, 71 (78.9%) had CAD. Among these 71 patients, 58 (81.7%) had severe lesions and 13 (18.3%) presented moderate CAD. Moreover, CCA did not demonstrate relevant coronary lesions in 19 of the 90 patients (21.1%). Among patients with severe CAD, 16 (27.6%) underwent myocardial revascularization surgery; 34 (58.6%) underwent percutaneous coronary angioplasty; and 08 (13.7%) had their clinical treatments intensified. The PPV for early-ECHO was 78.9%. Conclusions Early-ECHO showed a high PPV for diagnosing myocardial ischemia in women. It presented a low complication rate and provided rapid disease identification, allowing the early treatment of injuries and potentially preventing CAD complications.

Study on the application of exercise stress echocardiography combined with layer-sepcific strain in patients with essential hypertension / 中华超声影像学杂志

Objective:To evaluate the diagnostic value of exercise stress echocardiography combined with left ventricular two-dimensional speckle tracking layer-specific strain technique in evaluating subclinical myocardial damage and reserve function in patients with hypertension.Methods:A total of 51 healthy subjects(control group) and 55 hypertensive patients (hypertension group) were enrolled in the treadmill exercise stress test in Sichuan Provincial People′s Hospital from October 2018 to January 2020. According to the European Guidelines for the Prevention and Treatment of Hypertension, the inclusion criteria for patients with hypertension were: blood pressure≥140/90 mmHg or who explicitly took antihypertensive drugs, and related cardiovascular diseases were excluded. The conventional parameters of resting and peak exercise, including left ventricular mass index, left ventricular end-diastolic volume index and left ventricular ejection fraction et al, were analyzed by speckle tracking software in two groups. According to the standard images in the resting and peak exercise, the endocardium /mid-myocardium /epicardium of left ventricular (three-, two-, four-chamber and global) longitudinal strain and circumferential strain (papillary muscle level) were compared respectively in two groups. The characteristics of strain differences and the systolic function reserve between the resting and peak exercise were evaluated.Results:There were significant differences in conventional ultrasound parameters between resting and peak exercise period in hypertension group, except E/A and e/a ratio (all P<0.05), and E/e value increased significantly(12.1±0.38) during peak exercise, indicating impaired diastolic reserve function. The longitudinal and circumferential layer-specific strain values from endocardial to epicardial were gradually decreased in both two groups. Compared with the control group, the resting longitudinal and circumferential endocardial strain values in hypertensive group were decreased, and the differences were more obvious at peak status, for instance global longitudinal endocardium strain at rest[control group (24.4±1.5)%, hypertension group (20.4±2.3)%], peak status[control group (30.8±2.8)%, hypertension group (22.8±2.9)%]( P<0.05). There were no significant differences of the partial layer-specific strain values between the peak exercise and resting status in hypertension group, while peak layer-specific strain of the control group were all significantly increased, suggesting that the left ventricular systolic reserve function of hypertension patients was lower than that of the control group. Conclusions:Left ventricular layer-specific strain can effectively evaluate the myocardial function in patients with hypertension, especially the endocardial strain can be used as an indicator parameter, and the peak exercise stress state is more sensitive. The systolic and diastolic reserve function of the left ventricle in patients with hypertension at the peak period are reduced to different degrees. Exercise stress echocardiography combined with left ventricular layer-specific strain technique can be used as a new method for detection of myocardial function impairment in patients with hypertension.

Objective Evidence of Inducible Ischemia in Patients with Ischaemic Heart Disease by Global Longitudinal Strain During Dobutamine Stress Echocardiography

Background: Operator dependent two-dimensional (2D) echocardiography is a noninvasive test to assess myocardial hypokinesia. Inter observer variability is more as it is subjective. Objective evidence of 2D global longitudinal strain (2D GLS) and strain rate imaging are getting popularity. Methods: This cross sectional study was done on 20 patients who came for dobutamine stress echo (DSE) in the department of cardiology of BSMMU, Dhaka from 1st February 2019 to 31st July 2019. 2D GLS was done before and just after DSE. Results: DSE findings revealed 6 patients had viable LAD, 9 had viable LCX and 6 had viable RCA, 9 had nonviable LAD, 2 had nonviable LCX and 3 had nonviable RCA territories. Difference in Post-systolic strain rate (SRps) in myocardial segments supplied by LAD at baseline peak stress in patients who had normal and nonviable LAD (-21% to. -23%, p=0.98) and (-6%to – 7%, p= 2.87) which were not significant. At peak exercise there was a trend towards greater SRps in viable territory of LAD in compared with baseline and peak stress (-1% to -16%, P = 0.05) which was significant. SRps in myocardial segments supplied by LCX at baseline and peak stress in patients who have normal and nonviable LCX (-20% to. -21%, p=0.82) and (-5%to – 5%, p=1.18) which had similar result as LAD territory. At peak exercise there was a trend towards greater SRps in viable territory of LCX compared with baseline and peak stress (-12% to -15%, P = 0.06). There was no significant difference in SRps in myocardial segments supplied by RCA at baseline and peak stress in patients who had normal and nonviable RCA (-23% to. -24%, p=1.72) and (-4%to – 5%, p=2.10). At peak exercise there was a trend towards greater SRps in viable territory of RCA compared with baseline and peak stress (-10% to -15%, P = 0.04). Conclusion: Results of subjective interpretation of DES has compared with objective evidence 2D GLS on peak stress which has similarity. It was a small study. Future large study is needed to establish these findings.

Quantification of left ventricular performance in different phenotypes of hypertrophic cardiomyopathy / 中华超声影像学杂志

Objective@#To evaluate the characteristics of left ventricular structure, function, myocardial mechanics, hemodynamics and synchrony in different phenotypes of hypertrophic cardiomyopathy (HCM) using state-of-the-art echocardiography.@*Methods@#A consecutive series of 85 adult HCM patients who were admitted to the Xi Jing HCM center from January 2016 to November 2017 were collected. According to the peak left ventricular outflow tract pressure gradient in exercise stress echocardiography, the patients were divided into three groups: patients with non-obstructive HCM (n=28), those with labile-obstructive HCM (n=27), and those with obstructive HCM (n=30). In addition, 16 normal family members of HCM patients were included as control group. Two-dimensional speckle tracking imaging, tissue Doppler imaging and exercise stress echocardiography were used to evaluate the left ventricular function in resting and exercise states.@*Results@#①As compared with the control group, left ventricular end-diastolic diameter decreased and left ventricular ejection fraction increased in all three HCM groups(all P<0.05). Left ventricular maximum wall thickness and left ventricular mass index were the highest in obstructive HCM, followed by labile-obstructive and non-obstructive HCM, and the lowest in the control group (all P<0.05). ②At rest, the left ventricular global longitudinal, circumferential and radial strain (GLS, GCS and GRS), as well as the twist of obstructive HCM were significantly lower than the other three groups (all P<0.05). As compared with the control group, the GLS and twist decreased in the labile-obstructive and non-obstructive HCM(all P<0.05), but there were no significant changes of GCS and GRS (all P>0.05). The obstructive HCM had the lowest mitral annular plane systolic excursion (MAPSE) and s′, and the longest systolic peaking time standard deviation(Ts-SD) and early diastolic peaking time standard deviation(Te-SD) (all P<0.05). The left ventricular diastolic function of obstructive HCM (e′, the E/e′ ratio and the left atrial volume index) was the worst, labile-obstruction and non-obstructive HCM were better, and the control group was the best (all P<0.001). ③During exercise, the GLS, GCS, GRS, twist of the left ventricle and the MAPSE were the lowest in the obstructive HCM, which increased in the labile-obstructive and non-obstructive HCM, and were best in the control group. The Ts-SD and Te-SD were the shortest in the control group, were prolonged in non-obstructive and labile-obstruction HCM, and were longest in obstructive HCM (all P<0.05). Additionally, the exercise time of the control group was the longest, followed by non-obstructive and labile-obstruction HCM, and the shortest in the obstructive HCM (all P<0.05). The METs of obstructive HCM were significantly lower than the other three groups (all P<0.05).@*Conclusions@#In obstructive HCM, the left ventricular systolic strain and synchronization, as well as the MAPSE, are significantly impaired in patients both at rest and during exercise. The patients with labile-obstructive and non-obstructive HCM have reduced left ventricular GLS, twist, and e′, but normal left ventricular GCS, GRS, synchrony, and MAPSE at rest, which are all impaired during exercise.

Quantification of left ventricular performance in different phenotypes of hypertrophic cardiomyopathy / 中华超声影像学杂志

Objective To evaluate the characteristics of left ventricular structure ,function ,myocardial mechanics ,hemodynamics and synchrony in different phenotypes of hypertrophic cardiomyopathy ( HCM ) using state‐of‐the‐art echocardiography . Methods A consecutive series of 85 adult HCM patients w ho were admitted to the Xi Jing HCM center from January 2016 to November 2017 were collected . According to the peak left ventricular outflow tract pressure gradient in exercise stress echocardiography ,the patients were divided into three groups :patients with non‐obstructive HCM ( n ＝28) ,those with labile‐obstructive HCM ( n ＝27) ,and those with obstructive HCM ( n ＝ 30 ) . In addition ,16 normal family members of HCM patients were included as control group . T wo‐dimensional speckle tracking imaging ,tissue Doppler imaging and exercise stress echocardiography were used to evaluate the left ventricular function in resting and exercise states . Results ① As compared with the control group ,left ventricular end‐diastolic diameter decreased and left ventricular ejection fraction increased in all three HCM groups ( all P ＜ 0 .05 ) . Left ventricular maximum wall thickness and left ventricular mass index were the highest in obstructive HCM , followed by labile‐obstructive and non‐obstructive HCM ,and the lowest in the control group ( all P ＜0 .05) . ②A t rest ,the left ventricular global longitudinal ,circumferential and radial strain ( GLS ,GCS and GRS) ,as well as the twist of obstructive HCM were significantly lower than the other three groups ( all P ＜0 .05) . As compared with the control group ,the GLS and twist decreased in the labile‐obstructive and non‐obstructive HCM ( all P ＜0 .05 ) ,but there were no significant changes of GCS and GRS ( all P ＞ 0 .05 ) . T he obstructive HCM had the lowest mitral annular plane systolic excursion ( M APSE ) and s′,and the longest systolic peaking time standard deviation( T s‐SD) and early diastolic peaking time standard deviation ( Te‐SD) ( all P ＜0 .05) . T he left ventricular diastolic function of obstructive HCM ( e′,the E/e′ratio and the left atrial volume index ) was the worst ,labile‐obstruction and non‐obstructive HCM were better ,and the control group was the best ( all P ＜ 0 .001 ) . ③ During exercise ,the GLS ,GCS ,GRS ,twist of the left ventricle and the M APSE were the lowest in the obstructive HCM ,which increased in the labile‐obstructive and non‐obstructive HCM ,and were best in the control group . T he T s‐SD and Te‐SD were the shortest in the control group ,were prolonged in non‐obstructive and labile‐obstruction HCM ,and were longest in obstructive HCM ( all P ＜ 0 .05 ) . Additionally ,the exercise time of the control group was the longest , followed by non‐obstructive and labile‐obstruction HCM ,and the shortest in the obstructive HCM ( all P ＜0 .05) . T he M ET s of obstructive HCM were significantly lower than the other three groups ( all P ＜0 .05) . Conclusions In obstructive HCM ,the left ventricular systolic strain and synchronization ,as well as the M APSE ,are significantly impaired in patients both at rest and during exercise . T he patients with labile‐obstructive and non‐obstructive HCM have reduced left ventricular GLS , twist ,and e′,but normal left ventricular GCS ,GRS ,synchrony ,and M APSE at rest ,which are all impaired during exercise .

The change of left ventricular function and mechanical dispersion in patients with hypertrophic cardiomyopathy :a study with exercise stress echocardiography / 中华超声影像学杂志

To investigate the association between the change of left ventricular ( LV ) function and mechanical dispersion ( MD ) and exercise capacity in patients with hypertrophic cardiomyopathy ( HCM ) by exercise stress echocardiography . Methods Sixty‐five HCM patients [ 40 cases of hypertrophic non‐obstructive cardiomyopathy ( HNCM ) , 25 cases of hypertrophic obstructive cardiomyopathy ( HOCM ) ] and 25 control subjects were recruited .LV function ,MD and exercise capacity were evaluated by two‐dimensional speckle‐tracking imaging and echocardiography at rest and during exercise ,and the following parameters of LV function were recorded : LV global longitudinal strain ( LVGLS) ,MD ,early diastolic strain rate ( Sre) ,the ratio of peak early diastolic mitral inflow and annulus velocity ( E/e′) ,LV outflow tract gradient ( LVO TG) ; LV functional reserve was assessed by ΔLVGLS and ΔSRe ; exercise capacity was evaluated by metabolic equivalents ( M ET s ) . T he association between the change of LV function and MD and exercise capacity was investigated . Results ①Compared with normal controls ,LVO TG ,E/e′ and MD increased ,and LVGLS ,Sre , ΔLVGLS , ΔSRe and M ET s decreased in HNCM patients at rest and during exercise ( all P ＜ 0 .05 ) . ② LVO TG , E/e′ and MD were further increased ,LVLGS ,Sre ,ΔSRe and M Ets were further reduced in HOCM patients compared with HNCM patients ( all P ＜ 0 .05 ) . ③LVGLS and MD measured at peak exercise were associated with M ET s ( r ＝－0 .68 , P ＜ 0 .001 ; r ＝ －0 .43 , P ＜ 0 .001 ) . ④ ROC curve analysis showed LVGLS had a better predictive value for exercise intolerance in HCM patients ,followed by E/e′ and MD . Conclusions LV function and mechanic reserve are reduced but MD is increased in HCM patients ,especially in HOCM patients . Exercise capacity is associated with LV function and MD ,w hich can predict the reduced exercise capacity in HCM patients .

Entrenamiento por etapas basado en la web: el camino hacia el Eco Estrés 2020 / Multi-step Web-based Training: the Road to Stress Echo 2020

RESUMEN Introducción: Una plataforma de entrenamiento estandarizada ayuda a armonizar la lectura de la ecocardiografía de estrés (EE) más allá de las anormalidades en la motilidad parietal regional (AMPR) Objetivo: Armonizar los criterios de lectura del EE a través de diferentes laboratorios. Métodos: El laboratorio central preparó para los lectores de ecocardiografía un módulo obligatorio de 5 parámetros basado en la web de 2 horas de duración: AMPR; líneas B, reserva de la velocidad de flujo coronario (RVFC) evaluada mediante la velocidad pico del flujo diastólico en la arteria coronaria descendente anterior; reserva contráctil ventricular izquierda (RCVI, evaluada a partir de mediciones crudas del volumen de fin de sístole, VFS); y presión sistólica de la arteria pulmonar (basada en mediciones crudas de la velocidad del jet de regurgitación tricuspídea, VRT). La prueba de control de calidad consistió en 20 casos seleccionados por el centro coordinador. El umbral de aprobación determinado a priori fue de 18/20 (> 90%) con un coeficiente de correlación intraclase entre el laboratorio coordinador y el lector periférico > 0.90. Resultados: Ochenta y cuatro lectores completaron la certificación para las AMPR, 65 para las líneas B, 30 para la RVFC, 24 para el VFS y 20 para la VRT. El tiempo de lectura medio por intento fue más corto para la VRT (9 ± 4 min), la RVFC (13 ± 6 min) y las líneas B (17 ± 3 min), intermedio para el VFS (24 ± 7 min), y más prolongado para las AMPR (29 ± 12 min, p < 0.01). La tasa de acierto del primer intento fue más alta para la RVFC (85%), intermedia para la VRT (75%) y las líneas B (43%), menor para el VFS (35%) y más baja para las AMPR (28%, p < 0.01). Conclusiones: La plataforma de aprendizaje basada en la web mejora las habilidades de interpretación de imágenes sin necesidad de un equipamiento de imágenes costoso o de estudiar un paciente. El camino hacia la certificación es más largo para las AMPR, intermedio para el VFS y más corto para la VRT, la RVFC y las líneas B.

ABSTRACT Background: A standardized training platform helps to achieve reading harmonization in stress echocardiography (SE) beyond regional wall motion abnormalities (RWMA). Objective: To harmonize SE reading criteria across different laboratories. Methods: The core lab prepared for readers an obligatory 2-hour web-based learning module for 5 parameters: RWMA; B-lines; coronary flow velocity reserve (CFVR) based on peak diastolic flow velocity on the left anterior descending coronary artery; left ventricular contractile reserve (LVCR, from raw measurementis of end-systolic volume, ESV); systolic arterial pulmonary pressure (from raw measurementis of peak tricuspid regurgitant jet velocity, TRV). The quality control test consisted of 20 cases selected by the coordinating center. The a priori determined pass threshold was 18/20 (>90%) with intra-class correla-tion coefficient between the coordinating lab and the peripheral reader >0.90. Resultis: The certification was completed by 84 readers for RWMA, 65 for B-lines, 30 for CFVR, 24 for ESV and 20 for TRV The mean reading time per attempt was shorter for TRV (9±4 min), CFVR (13±6 min) and B-lines (17±3 min), intermedi-ate for ESV (24±7 min), and longer for RWMA (29±12 min, p <0.01). The success rate of the first attempt was higher for CFVR (85%), intermediate for TRV (75%) and B-lines (43 %), lower for ESV (35%) and lowest for RWMA (28 %, p <0.01). Conclusions: A web-based learning platform improves image interpretation skills without need for expensive imaging equip-ment or a patient to scan. The road to certification is longer for RWMA, intermediate for ESV, and shorter for TRV, CFVR and B-lines.

Eff ect of interventional therapy on chronic total occlusion by doubutamine stress echocardiography evaluation / 中国介入心脏病学杂志

Objective To evaluate the effect of percutaneous coronary intervention (PCI) on chronic total occlusion (OCT) by doubutamine stress echocardiography. Methods Forth-six CTO patients were categorized into the reopening group and failed-reopening group based on the results of PCI. All patients had undergoing low dose doubutamine stress echocardiography before PCI and at 6-month follow-up, measuring rest and stress wall motion score index (WMSI) with semi-quantitative method. Cardiac volumes and ejection fraction were measured with 3D full volume echocardiographic. Results The two groups showed no differences in general clinical data and all baseline echocardiography data before PCI. During follow-up, the reopening group was observed to have improvement in ejection fraction[(60.00±3.22)% vs.(62.65±3.58)%,P=0.017)],and WMSI in stress status[(1.42±0.37)vs.(1.32±0.36),P<0.001], compared with pre-PCI results. The reopening group showed improvement in ejection fraction[(62.65±3.58)% vs.(57.7±5.61)%,P=0.001)]and WMSI in stress status[(1.32±0.36)vs.(1.62±0.47),P<0.001)],when compared with the failed-reopening group. Conclusions Low dose doubutamine stress echocardiography can be nsed for evaluation of the eff ect of revascularization of CTO. The cardiac volumes and contractile function representing by wall motion in stress status were improved after recanalization of CTO.

Real World Utility of Dobutamine Stress Echocardiography in Predicting Perioperative Cardiovascular Morbidity and Mortality after Orthotopic Liver Transplantation

BACKGROUND AND OBJECTIVES: Stress echocardiography is the current standard for cardiac risk stratification of patients undergoing orthotopic liver transplantation (OLT). We aim to evaluate the role of dobutamine stress echocardiography (DSE) in predicting perioperative major adverse cardiac event (MACE) in patients undergoing OLT. METHODS: This was a single-center retrospective study including 144 OLT patients. Of 144 patients, 118 had DSE. MACE included myocardial infarction (MI), heart failure (HF), cardiovascular and all-cause death 1 year after OLT. RESULTS: Our study cohort included 118 patients. The mean age was 57.3±8.2 years (range, 25–72 years). There were 85 men and 33 women, male to female ratio being 2.6:1. Of 118, 15 (13%) had positive DSE and 103 (87%) had negative DSE. Perioperative MACE incidence was 5.9% (95% confidence interval [CI], 2.6–12.3%). In predicting MACE, DSE had sensitivity of 5.6% (95% CI, 0.2–29.4%), specificity 86% (95% CI, 77.3–91.9%), positive predictive value 6.7% (95% CI, 0.3–33.4%), and negative predictive value (NPV) 83.5% (95% CI, 74.6–89.8%). Eighteen patients had MACE in first year post OLT (15%, 95% CI, 9.5–23.3%). Adverse events included cardiogenic shock (2/18), systolic HF (2/18), non-ST-elevated MI (7/18), cardiac mortality (3/18), and all-cause mortality (7/18). The overall complication rate of DSE was 17% (20/118). CONCLUSIONS: In our cohort, DSE had a low sensitivity but high NPV in predicting perioperative MACE post OLT. A similar trend was noted for DSE in predicting 1-year MACE post OLT. We reiterate the need of a better screening and risk stratification tool for OLT.

Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women

BACKGROUND: Exercise-stress electrocardiography (ECG) is initially recommended for the diagnosis of coronary artery disease. But its value has been questioned in women because of suboptimal diagnostic accuracy. Stress echocardiography had been reported to have comparable test accuracy in women. But the data comparing the diagnostic accuracy of exercise-stress ECG and stress echocardiography directly are few. The aim of the study was to compare the diagnostic accuracy of exercise-stress ECG and dobutamine stress echocardiography (DSE) in Korean women. METHODS: 202 consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The diagnostic accuracy TET and DSE were calculated by the definition of > 50% or > 75% coronary artery stenosis (CAS). RESULTS: The sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CAS. The higher accuracy of DSE was maintained after exclusion of the patients who could not achieve over 85% age predicted heart rate before ischemia induction. DSE also showed greater diagnostic accuracy than TET by > 75% CAS criteria, and in subsets of patient with intermediate pretest probability. CONCLUSION: In the diagnosis of CAS, DSE showed higher accuracy than TET in female patients who presented with chest pain. As well as the test accuracy, adequate stress was more feasible with DSE than TET. These finding suggests DSE may be used as the first-line diagnostic tool in the detection of CAS in women with chest pain.

Estudo comparativo do fluxo da artéria torácica interna utilizada "in situ" na revascularização miocárdica, com e sem a ligadura dos ramos proximais, utilizando a ecocardiografia Doppler / Comparative study of the internal thoracic artery flow used "in situ" for myocardial revascularization, with and without ligation of its proximal branches using Doppler echocardiography

Fundamento: A artéria torácica interna (ATI) "in situ" apresenta predomínio de fluxo sistólico, mas após sua anastomose no sistema coronariano esquerdo torna-se um sistema híbrido com predomínio de fluxo diastólico, sendo a relevância da patência ou não dos grandes ramos proximais da ATI anastomosada controversa quanto à possibilidade de roubo de fluxo. Porém, constata-se que durante o ecocardiograma sob estresse com dobutamina (EED), o estado funcional da ATI anastomosada pode ser avaliado através da reserva coronariana, além da verificação dos distintos efeitos no fluxo sistólico (FS), diastólico (FD) e total (FT = sistólico + diastólico). Objetivo: Verificar por meio da ecocardiografia e Doppler o efeito dos ramos proximais importantes da ATI no fluxo, na reserva de velocidade (RVFC) e de fluxo (RFC) coronariano, em pacientes com fração de ejeção do ventrículo esquerdo (FEVE) preservada (>50%). Métodos: Em ensaio clínico prospectivo controlado e randomizado, foram avaliados pacientes com (Grupo I) e sem (Grupo II), a ligadura dos ramos proximais importantes da ATI anastomosada na coronária descendente anterior. As avaliações das ATIs em nível supraclavicular e os ecocardiogramas transtorácicos foram realizados no pré-operatório, no pós-operatório precoce, seis meses após a cirurgia em condição basal e durante o EED. Neste, foi alcançada a frequência cardíaca submáxima [(220 - idade) x (0,85)] sem a ocorrência de isquemia no território subjacente à ATI anastomosada em todos os pacientes. Foram medidos o FS, o FD, o FT e o percentual de FD, nos quatro momentos do estudo. O percentual de FD resultou da divisão da integral da velocidade diastólica do fluxo pela integral da velocidade total (sistólica + diastólica) do fluxo. A reserva coronariana foi obtida através do Doppler da ATI anastomosada seis meses após a cirurgia, sendo calculada através da razão entre o valor da variável registrado no EED e em condição basal, utilizando-se para as RVFCs o pico e a...

Background: The internal thoracic artery (ITA) "in situ" has systolic flow predominance, but when grafted to the left coronary artery system, the ITA becomes a hybrid system with diastolic flow predominance. The relevance of the patency or not-patency of the large proximal branches of the ITA graft is controversial in regards to the possibility of flow steal. During dobutamine stress echocardiography (DSE), the functional status of the ITA graft can be assessed by the coronary reserve in addition to assessment of the distinct effects of DSE on systolic (SF), diastolic (DF), and total flow (TF = systolic + diastolic). Objective: To assess, by Doppler echocardiography, the effects of the significant proximal branches of ITA graft in the flow, coronary flow velocity reserve (CFVR) and coronary flow reserve (CFR), in patients with preserved (> 50%) left ventricular ejection fraction (LVEF). Methods: In a prospective randomized controlled clinical trial we evaluate patients with (Group I) and without (Group II) ligation of important proximal branches of the ITA grafted to the anterior descending coronary artery. Supraclavicular assessment of the ITAs and transthoracic echocardiograms were performed, at rest and during DSE, on pre-operative, early and six months post-operative. In all patients, the submaximal heart rate [(220 - age) x (0.85)] was achieved during DSE with no ischemia to the area matching the ITA graft. The SF, DF, TF and percentage of DF were measured in the four moments of this study. The percentage of DF was calculated by the ratio of the integral of the diastolic flow velocity by the integral of the total flow velocity (systolic + diastolic). The coronary reserve was assessed at six months post-operative, and it was calculated by the ratio of the variable during DSE and at rest, using the maximum and the mean of the diastolic flow velocity to calculate the CFVR; and the TF to calculate the CFR. Student's t-tests or Wilcoxon's rank sum test (Mann...

The Predictive Value of Coronary Flow Reserve in Diagnosing Coronary Stenosis by Transthoracic Doppler Echocardiography in Patients of Hypertension / 中国循环杂志

Objective: To assess the predictive value of coronary lfow reserve (CFR) for diagnosing coronary stenosis by transthoracic Doppler echocardiography (TTDE) in patients with hypertension. Methods: A total of 132 patients scheduled for elective coronary angiography (CAG) due to chest pain were enrolled. The patients were divided into 2 groups: Hypertension group,n=95 and Non-hypertension group,n=37. The CRF of left anterior descending coronary artery (LAD) was measured by ATP stress TTDE at 2 days before CAG in all patients and the results were compared between 2 groups. ROC curve was conducted to assess CFR value in diagnosing LAD stenosis which was deifned by LAD luminal diameter stenosis ≥ 70% in relevant patients. Results: The condition of LAD stenosis was similar between 2 groups (42.1% vs. 35.1%),P>0.05. The CFR value in Hypertension group was lower than that in Non-hypertension group (2.39 ± 0.86) vs. (2.87 ± 1.12),P Conclusion: The patients of hypertension combining chest pain had decreased CFR which implied the dysfunction of their microcirculation. CFR had the better diagnostic value for predicting the signiifcant LAD stenosis in such patients.

Role of Hs-CRP and Exercise Stress Echocardiography in Cardiovascular Risk Stratification of Asymptomatic Type 2 Diabetic Patients.

Background: Silent ischaemia is a well known cause of mortality and morbidity in type-2 diabetic patients; however the role of high-sensitive C-Reactive Protein (hs-CRP) and exercise stress echocardiography in early detection of silent ischaemia is still less understood. Methods: Seventy three asymptomatic diabetic patients were enrolled from Dr Ram Manohar Lohia Hospital, Delhi in year 2013-15 and the baseline characteristics of the patients were studied. All the patients underwent exercise stress echocardiography for screening of coronary artery disease (CAD). All the patients with positive exercise stress echocardiography underwent angiography for confirmation of coronary artery disease. The patients were divided into two groups on basis of exercise stress echocardiography result as positive and negative and the baseline characteristics and risk factors including high-sensitivity C-reactive protein (hs-CRP) concentrations were compared between two groups in cross sectional study. Results: Silent ischaemia was found in 17.81% in asymptomatic diabetic patients. The positive predictive value of exercise stress echocardiography taking angiography as gold standard was found to be 84.6%. Sensitivity of hs-CRP >3 mg/L in predicting a positive exercise stress echocardiography is 53.8% and specificity is 90%. Negative predictive value of hs-CRP ≤3 mg/L in ruling out CAD is 90.0% and positive predictive value in detecting positive exercise stress echocardiography was 53.8%. Positive exercise stress echocardiography was found to be significantly associated with hypertension (HTN) (P=0.048), smoking (P=0.018), family history of CAD (P=0.002), total cholesterol (P=0.031), serum low-density lipoprotein (LDL) concentrations (P=0.041), serum hs-CRP (P=0.001), strict glycaemic control (glycated haemoglobin <7%) (P=0.028) and final ejection fraction after exercise stress (P=0.01). Conclusion: hs-CRP and exercise stress echocardiography can be used as simple screening tool for coronary artery disease in asymptomatic diabetic patients.

Factibilidad y aportes del análisis de la deformación longitudinal 2D global y regional durante el eco estrés con ejercicio / Feasibility and Contribution of Global and Regional 2D Strain during Exercise Stress Echocardiography

Introducción La factibilidad del análisis de la deformación longitudinal 2D en ejercicio y la contribución de su información para detectar isquemia a frecuencia cardíaca alta no están bien establecidas; si bien se han realizado estudios de eco estrés farmacológico para la evaluación de isquemia y viabilidad, no se conocen trabajos que hayan evaluado el uso de la deformación longitudinal 2D para el diagnóstico de isquemia miocárdica durante el eco estrés con ejercicio. Objetivos Se consideró de interés determinar la factibilidad del análisis de la deformación longitudinal 2D y evaluar su comportamiento durante el eco estrés con ejercicio. Material y métodos Entre febrero y marzo de 2012 se les realizó un eco estrés en camilla supina, en etapas de 150 kgm, a 93 pacientes consecutivos (59 hombres, 54,9%), edad promedio de 58,8 ± 11,8 años. Se determinó la motilidad semicuantitativa visual en condiciones basales, en el pico del ejercicio y en el posesfuerzo inmediato y se analizó la deformación longitudinal 2D de 16 segmentos en reposo y en el posejercicio inmediato mediante un algoritmo de seguimiento de marcadores acústicos (AFI: automatic functional images de GE). Simultáneamente se evaluaron los síntomas, el electrocardiograma de 12 derivaciones y la tensión arterial en cada etapa. Resultados La frecuencia cardíaca basal fue de 76 ± 18 lat/min, alcanzó 133 ± 25 lat/min en el pico del ejercicio y 117 ± 15 lat/min en el posesfuerzo inmediato. Las pruebas fueron suficientes en 64 (68,8%) de los 93 pacientes evaluados; de los 29 pacientes con pruebas insuficientes, 9 fueron positivas y 20 negativas. Desarrollaron isquemia durante la prueba 21 pacientes (22,5%), diagnosticada como asinergias regionales transitorias (7 casos en territorio anterior, septal y/o apical, en otros 7 afectó las caras inferior, posterior y/o lateral, mientras que 7 pacientes tuvieron trastornos en segmentos de ambos territorios), los cuales eran más añosos (63,5 ± 8,7 vs. 57,4 ± 12,2 años; p = 0,03), con mayor antecedente de infarto de miocardio (14,3% vs. 7%; p = 0,01) y de cirugía de revascularización miocárdica (14,3% vs. 2,77%; p = 0,04) respecto de los pacientes que no desarrollaron isquemia. No se encontraron diferencias significativas en los antecedentes de hipertensión arterial, diabetes, dislipidemia y tabaquismo. El valor de la deformación longitudinal 2D apical se incrementó en 79 (85%) de los 93 pacientes evaluados, en los que solo 3 (3,8%) presentaron trastornos contráctiles en la misma región, mientras que de los 14 pacientes en los que la deformación longitudinal 2D apical no aumentó o disminuyó, 11 (78,6%) presentaron isquemia apical visualmente confirmada (sensibilidad 79%, especificidad 96%; p = 0,0001). De los 53 pacientes en los que se incrementó el valor de la deformación longitudinal 2D inferior, posterior y/o lateral, 6 (11,3%) presentaron trastornos contráctiles homozonales, mientras que de los 40 pacientes en los que no aumentó la deformación longitudinal 2D, en 8 (20%) se constataron visualmente asinergias transitorias en la misma región (sensibilidad 43%, especificidad 41%). La deformación longitudinal 2D se pudo evaluar en 1.472 de 1.488 segmentos en el reposo (factibilidad 99%), en 1.452 en el posesfuerzo (factibilidad 97,5%) y en 1.147 de 1.488 (77%) en el pico del esfuerzo (esta etapa no se consideró para el análisis). Conclusiones El análisis de la deformación longitudinal 2D resultó factible en el posesfuerzo inmediato. La falta de aumento o la disminución en la deformación longitudinal 2D de los segmentos apicales fueron concordantes con presencia de isquemia detectada visualmente. Las frecuencias cardíacas altas fueron responsables de la obtención de resultados poco específicos en los segmentos inferoposterolaterales basales y mediales, por lo que el strain 2D longitudinal solo sería de ayuda para analizar territorio irrigado por la arteria descendente anterior.

Feasibility and Contribution of Global and Regional 2D Strain during Exercise Stress Echocardiography Introduction The feasibility of longitudinal 2D strain analysis during exercise and the contribution of the information provided to detect ischemia at elevated heart rate are not well established. Although pharmacologic stress echocardiography has been used to evaluate ischemia and viability in several studies, the use of longitudinal 2D strain for the diagnosis of myocardial ischemia during exercise stress echocardiography has not been analyzed. Objectives The goal of this study was to determine the feasibility of analyzing longitudinal 2D strain and to evaluate its performance during exercise stress echocardiography. Methods Between February and March 2012, 93 consecutive patients (59 men, 54.9%), with mean age 58.8 ±11.8 years), underwent supine exercise stress echocardiography, in 150 kgm stages. Wall motion was visually evaluated using a semiquantitative analysis at baseline, peak exercise and immediately after exercise. Longitudinal 2D deformation was analyzed in 16 segments at rest and immediately after exercise using a tracking algorithm of acoustic markers (AFI: automatic functional images, GE). Symptoms, 12-lead electrocardiogram and blood pressure were simultaneously evaluated in each stage. Results Baseline heart rate was 76 ± 18 bpm, increased to 133 ± 25 bpm during peak exercise and was 117 ± 15 bpm immediately after exercise. The target heart rate was achieved in 64 (68.8%) of the 93 patients evaluated; in the 29 patients who did not achieve target heart rate, 9 tests were positive and 20 were negative for coronary artery disease. Twenty-one patients (22.5%) developed ischemia diagnosed as transient regional assynergies during exercise stress echocardiography: 7 patients in the anterior, septal and/or apical territories, 7 in the inferior, posterior and/or lateral territories and 7 in segments corresponding to both territories. These patients were older (63.5 ± 8.7 vs. 57.4 ± 12.2 years; p = 0.03) and the prevalence of previous myocardial infarction (14.3% vs. 7%; p = 0.01) and myocardial revascularization surgery (14.3% vs. 2.77%; p = 0.04) was higher compared to those without ischemia. There were no significant differences in the history of hypertension, diabetes, dyslipidemia or smoking habits. The value of longitudinal 2D strain in the apical segments increased in 79 (85%) of the 93 patients evaluated: only 3 of these patients (3.8%) developed new wall motion abnormalities in the same region. In the 14 patients in whom longitudinal 2D strain did not increase or decreased, 11 (78.6%) presented apical ischemia in the visual analysis (sensitivity 79%, specificity 96%; p = 0.0001). Among the 53 patients presenting increased longitudinal 2D strain in the inferior, posterior and/or lateral segments, 6 (11.3%) presented wall motion abnormalities in the same sites, whereas in the 40 patients in whom longitudinal 2D strain did not increase, 8 (20%) presented transient dyssynergias which were visually detected in the same region (sensitivity 43%, specificity 41%). Longitudinal 2D strain could be evaluated in 1472 of 1488 segments at rest (feasibility 99%), in 1452 after exercise (feasibility 97.5%) and in 1147 of 1488 (77%) during peak exercise (this stage was not considered for the analysis). Conclusions The analysis of longitudinal 2D strain is feasible immediately after exercise. The lack of increase or decrease in longitudinal 2D strain in the apical segments was consistent with the presence of visually detected ischemia. Elevated heart rates were responsible of the lack of specificity in the inferior, posterior and lateral basal and mid segments. Thus, longitudinal 2D strain would only help to analyze the territory irrigated by the left anterior descending coronary artery.

The Value of Assessing Myocardial Deformation at Recovery after Dobutamine Stress Echocardiography

BACKGROUND: The purpose of this study was to evaluate whether performing an assessment of myocardial deformation using speckle tracking imaging during the recovery period after dobutamine stress echocardiography (DSE) allows detection of significant coronary artery disease (CAD) in patients with chest discomfort. METHODS: DSE and coronary angiography were performed in 44 patients with chest discomfort. The mean global longitudinal peak systolic strain (GLS) was measured at rest, at low stress (dobutamine infusion rate of 10 microg/kg/min) and at recovery (5 min after cessation of dobutamine infusion) of DSE using automated function imaging with apical views. Fractional flow reserve (FFR) was also performed in patients with intermediate coronary stenosis. CAD was defined as having a > or = 70% diameter stenosis on coronary angiography or as having a FFR < 0.8. Patients were divided two groups based on the absence or presence of CAD [CAD (-) group vs. CAD (+) group]. RESULTS: There were no significant differences in the clinical characteristics and results of conventional echocardiography between the two groups. GLS at recovery was lower in the CAD (+) group than in the CAD (-) group (-18.0 +/- 3.4% vs. -21.0 +/- 1.9%, p = 0.003). The optimal cutoff of GLS at recovery for detection of CAD was -19% (sensitivity of 70.6%, specificity of 83.3%). CONCLUSION: Assessment of GLS at recovery of DSE is a reliable and objective method for detection of CAD. This finding may suggest that systolic myocardial stunning remains even after recovery of wall motion abnormalities in patients with CAD.

Experiencia con Ecocardiograma de estrés dipiridamol y Reserva coronaria no invasiva: Comunicación preliminar / Dipyridamol Stress Echocardiography and Non-invasive Coronary Reserve: Preliminary report

Antecedentes: El Ecocardiograma de Estrés (EE) es una técnica ampliamente utilizada en el estudio de pacientes con Enfermedad Coronaria conocida o sospechada Recientemente se ha preconizado efectuar el test vasodilatador, método recomendado para evaluar no invasivamente la reserva de flujo coronario (RFC). Objetivos: Mostrar la experiencia preliminar con el EE Dipiridamol, con un seguimiento inicial, así como el estudio de la RFC en la porción distal de la arteria Descendente Anterior (ADA). Métodos: Se analizaron 164 pacientes (101 hombres, edad promedio 65 años) a los que se les efectuó un EE Dipiridamol entre Julio 2011 y Septiembre 2012, con una dosis de 0.84mg/kg en 6 minutos, que incluyó el estudio de RFC. Todos los pacientes completaron la prueba sin efectos secundarios significativos, y en un tiempo menor a 25 minutos. El seguimiento se hizo con miras a la aparición de eventos cardiovasculares mayores (revascularización, infarto al miocardio y muerte cardíaca). Resultados: EE resultó positivo para isquemia en 19 (21 por ciento) pacientes. En 19 (12 por ciento) el EE resultó alterado por motilidad parietal; 29 (15 por ciento) presentaron respuesta anormal en la RFC, con una coincidencia de 12 pacientes (7 por ciento) con ambos tipo de alteración; En 142 (88 por ciento) pacientes se logró medir la RFC en ADA. En 151 pacientes se obtuvo datos confiables del seguimiento, que fue en promedio 10 meses (6 a 18); entre estos, 10 pacientes tuvieron alguna revascularización. No hubo infartos ni fallecidos por causa cardio-vascular. Dado el corto período de seguimiento y baja incidencia de eventos, no se pudo establecer el valor predictivo del resultado de la prueba en esta muestra. Conclusiones: Esta experiencia permitió familiarizarse con la técnica del EE con Dipiridamol y estudiar en un alto porcentaje la RFC en la ADA. La técnica es segura y consume muy poco tiempo. Queda pendiente la determinación del valor predictivo de estos resultados en nuestras manos.

Background: Stress Echocardiography is a common technique in the study of patients with known or suspected Coronary artery disease (CAD). Recently the vasodilation test has been recommended for the non invasive study of Coronary Flow Reserve (CFR). Aim: to report our preliminary experience with Di-pyridamol Stress Echocardiography (DSE), an initial follow-up, and the study of CFR in the distal portion of the left anterior descending coronary artery (LAD). Methods: 164 consecutive patients (101 men, mean age 65) with suspected or known CAD underwent a high-dose DSE (0.84 mg/kg over 6 min) between July 2011 and September 2012. The test included a study of CFR. All patients completed the test within 25 min. Prospective follow-up regarding major adverse cardiovascular events(revascularization, cardiac mortality and infarction) was conducted for a mean of 10 months (range 6-18) Results: DSE was positive for ischemia in 34 (21 percent) patients, showed abnormal wall motion in 19 (12 percent), abnormal CFR in 29 (15 percent) , and both abnormalities in12 (7 percent). 142 patients (88 percent) had a normal CFR in the LAD. 151 patients were followed for a mean of 10 months (6 to 18). Ten of these patients required some type of revascularization. There were no myocardial infarctions or cardiac deaths. Due to the short follow up period and the low incidence of events, it was not possible to estimate the predictive value of abnormal CFR. Conclusion: The dipyridamol echo stress test with a study of coronary flow reserve is safe and brief. The predictive value for cardiac events remains to be determined.

Recurrent Syncope Episodes and Exercise Intolerance in Hypertrophic Cardiomyopathy Combined with Atrioventricular Conduction Disturbance

A 30-year-old female patient with known hypertrophic cardiomyopathy (HCMP) was admitted for recurrent syncope episodes. Electrocardiogram (ECG) showed 2 : 1 atrioventricular (AV) block. Stress echocardiography with bicycle showed high grade AV block at high stage of the exercise associated with exercise intolerance and dyspnea. Twenty-four hour ECG monitoring also revealed high grade AV block and 1 episode of non-sustained ventricular tachycardia. Implantable cardioverter/defibrillator-pacemaker (ICD-P) was inserted. After implantation of ICD-P, conduction disturbance and exercise intolerance were improved. AV block is a rare complication HCMP. There are just a few case reports that present symptoms caused by conduction disturbance in HCMP. This case describes repeated syncope episodes and exercise intolerance caused by conduction disturbance during exercise in HCMP patient. For evaluating the cause of syncope in HCMP, stress echocardiography can be helpful to understand the probable mechanism of syncope.

Assesment of Myocardial Ischemia by Combination of Tissue Synchronisation Imaging and Dobutamine Stress Echocardiography

BACKGROUND AND OBJECTIVES: Dobutamine stress echocardiography (DSE) is an important non-invasive imaging method for evaluating ischemia. However, wall motion interpretation can be impaired by the experience level of the interpreter and the subjectivity of the visual assessment. In our study we aimed to combine DSE and tissue syncronisation imaging to increase sensitivity for detecting ischemia. SUBJECTS AND METHODS: 50 patients with indications for DSE were included in the study. In 25 patients we found DSE positive for ischemia and in the other 25 patients we found it to be negative. The negative group was accepted as the control group. There was no significant difference in terms of risk factors and echocardiographic parameters between the two groups, except for wall motion scores. In both groups, left ventricular dyssychrony was accepted as the difference between time to peak systolic velocity (Ts) in the reciprocal four couple of non-apical segments at rest and during peak stress. Timings were corrected for heart rate. We compared the differences of the dyssynchronisation value at rest and during peak stress to determine the distinctions within the groups and between the groups of DSE positive and negative patients. RESULTS: We found that stress and ischemia did not create any significant difference over the left intraventricular dyssynchrony with DSE, although at the segmenter level it prolonged the time to peak systolic velocity (p<0.05). These alterations did not show any significant difference between positive and negative DSE groups. CONCLUSION: As a result, this segmenter dyssynchrony and the time to peak systolic velocity, which is corrected for heart rate, did not enhance any new value over DSE for detecting ischemia.