Skip to main content
Download PDF

Exercise stress echocardiography in patients with valvular heart disease

Echo Research & Practice volume 2, pages 89–98 (2015)Cite this article

Abstract

Stress echocardiography is recommended for the assessment of asymptomatic patients with severe valvular heart disease (VHD) when there is discrepancy between symptoms and resting markers of severity. The aim of this study is to determine the prognostic value of exercise stress echocardiography in patients with common valve lesions. One hundred and fifteen patients with VHD (aortic stenosis (n=28); aortic regurgitation (n=35); mitral regurgitation, (n=26); mitral stenosis (n=26)), and age- and sex-matched controls (n=39) with normal ejection fraction underwent exercise stress echocardiography. The primary endpoint was a composite of death or hospitalization for heart failure. Asymptomatic VHD patients had lower exercise capacity than controls and 37% of patients achieved <85% of their predicted metabolic equivalents (METS). There were three deaths and four hospital admissions, and 24 patients underwent surgery during follow-up. An abnormal stress echocardiogram (METS <5, blood pressure rise <20 mmHg, or pulmonary artery pressure post exercise >60 mmHg) was associated with an increased risk of death or hospital admission (14% vs 1%, P<0.0001). The assessment of contractile reserve did not offer additional predictive value. In conclusion, an abnormal stress echocardiogram is associated with death and hospitalization with heart failure at 2 years. Stress echocardiography should be considered as part of the routine follow-up of all asymptomatic patients with VHD.

References

  1. Ross J Jr Braunwald E 1968 Aortic stenosis. Circulation 38 61–67. (doi:10.1161/01.CIR.38.1S5.V-61)

    Article  Google Scholar 

  2. Horstkotte D, Loogen F 1988 The natural history of aortic valve stenosis. European Heart Journal 9 (Suppl E) 57–64. (doi:10.1093/eurheartj/9.suppl_E.57)

    Article  Google Scholar 

  3. Wood P 1954 An appreciation of mitral stenosis. I. Clinical features. British Medical Journal 1 1051–1063; contd. (doi:10.1136/bmj.1.4870.1051)

    Article  CAS  Google Scholar 

  4. Delahaye JP, Gare JP, Viguier E, Delahaye F, De Gevigney G, Milon H 1991 Natural history of severe mitral regurgitation. European Heart Journal 12 (Suppl B) 5–9. (doi:10.1093/eurheartj/12.suppl_B.5)

    Article  Google Scholar 

  5. Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB 1997 Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms. Journal of the American College of Cardiology 30 746–752. (doi:10.1016/S0735-1097(97)00205-2)

    Article  CAS  Google Scholar 

  6. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 63 e57–e185. (doi:10.1016/j.jacc.2014.02.536)

    Article  Google Scholar 

  7. Joint Task Force on the Management of Valvular Heart Disease of the European Society of C, European Association for Cardio-Thoracic S, Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, Borger MA, Carrel TP et al. 2012 Guidelines on the management of valvular heart disease (version 2012). European Heart Journal 33 2451–2496. (doi:10.1093/eurheartj/ehs109)

    Article  Google Scholar 

  8. Bonow RO, Carabello BA, Kanu C, de Leon AC Jr Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O’Gara PT et al. 2006 ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 114 e84–e231. (doi:10.1161/CIRCULATIONAHA.106.176857)

    Article  Google Scholar 

  9. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M et al. 2009 Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. European Journal of Echocardiography 10 1–25. (doi:10.1093/ejechocard/jen303)

    Article  Google Scholar 

  10. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H et al. 2003 Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. Journal of the American Society of Echocardiography 16 777–802. (doi:10.1016/S0894-7317(03)00335-3)

    Article  Google Scholar 

  11. Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O’Gara PT, O’Rourke RA, Shah PM, Bonow RO, Carabello BA et al. 2008 ACC/AHA guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 118 887–896. (doi:10.1161/CIRCULATIONAHA.108.190377)

    Article  Google Scholar 

  12. Leung DY, Griffin BP, Stewart WJ, Cosgrove DM III Thomas JD, Marwick TH 1996 Left ventricular function after valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. Journal of the American College of Cardiology 28 1198–1205. (doi:10.1016/S0735-1097(96)00281-1)

    Article  CAS  Google Scholar 

  13. Lester SJ, Ryan EW, Schiller NB, Foster E 1999 Best method in clinical practice and in research studies to determine left atrial size. American Journal of Cardiology 84 829–832. (doi:10.1016/S0002-9149(99)00446-4)

    Article  CAS  Google Scholar 

  14. Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ, Krohn MJ, Mays JM 1993 Quantitative Doppler assessment of valvular regurgitation. Circulation 87 841–848. (doi:10.1161/01.CIR.87.3.841)

    Article  CAS  Google Scholar 

  15. Enriquez-Sarano M, Miller FA Jr Hayes SN, Bailey KR, Tajik AJ, Seward JB 1995 Effective mitral regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method. Journal of the American College of Cardiology 25 703–709. (doi:10.1016/0735-1097(94)00434-R)

    Article  CAS  Google Scholar 

  16. Detaint D, Messika-Zeitoun D, Avierinos JF, Scott C, Chen H, Burnett JC Jr Enriquez-Sarano M 2005 B-type natriuretic peptide in organic mitral regurgitation: determinants and impact on outcome. Circulation 111 2391–2397. (doi:10.1161/01.CIR.0000164269.80908.9D)

    Article  CAS  Google Scholar 

  17. Nakatani S, Masuyama T, Kodama K, Kitabatake A, Fujii K, Kamada T 1988 Value and limitations of Doppler echocardiography in the quantification of stenotic mitral valve area: comparison of the pressure half-time and the continuity equation methods. Circulation 77 78–85. (doi:10.1161/01.CIR.77.1.78)

    Article  CAS  Google Scholar 

  18. Martin RP, Rakowski H, Kleiman JH, Beaver W, London E, Popp RL 1979 Reliability and reproducibility of two dimensional echocardiograph measurement of the stenotic mitral valve orifice area. American Journal of Cardiology 43 560–568. (doi:10.1016/0002-9149(79)90014-6)

    Article  CAS  Google Scholar 

  19. Hatle L, Brubakk A, Tromsdal A, Angelsen B 1978 Noninvasive assessment of pressure drop in mitral stenosis by Doppler ultrasound. British Heart Journal 40 131–140. (doi:10.1136/hrt.40.2.131)

    Article  CAS  Google Scholar 

  20. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA 2002 American Society of Echocardiography, Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. Journal of the American Society of Echocardiography 15 167–184. (doi:10.1067/mje.2002.120202)

    Article  Google Scholar 

  21. Himelman RB, Stulbarg M, Kircher B, Lee E, Kee L, Dean NC, Golden J, Wolfe CL, Schiller NB 1989 Noninvasive evaluation of pulmonary artery pressure during exercise by saline-enhanced Doppler echocardiography in chronic pulmonary disease. Circulation 79 863–871. (doi:10.1161/01.CIR.79.4.863)

    Article  CAS  Google Scholar 

  22. Otto CM 2000 Textbook of Clinical Echocardiography, Philadelphia: WB. Saunders.

    Google Scholar 

  23. DuBois D, DuBois EF 1916 Clinical Calorimetry: tenth paper. A formula to estimate the approximate surface area if height and weight be known. Archives of Internal Medicine 17 863 (doi:10.1001/archinte.1916.00080130010002)

    Article  CAS  Google Scholar 

  24. Lee R, Haluska B, Leung DY, Case C, Mundy J, Marwick TH 2005 Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation. Heart 91 1407–1412. (doi:10.1136/hrt.2004.047613)

    Article  CAS  Google Scholar 

  25. Marechaux S, Bellouin A, Polge AS, Richardson-Lobbedez M, Lubret R, Asseman P, Berrebi A, Chauvel C, Vanoverschelde JL, Nevière R et al. 2008 Clinical value of exercise Doppler echocardiography in patients with cardiac-valvular disease. Archives of Cardiovascular Diseases 101 351–360. (doi:10.1016/j.acvd.2008.04.003)

    Article  Google Scholar 

  26. Amato MC, Moffa PJ, Werner KE, Ramires J 2001 Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart 86 381–386. (doi:10.1136/heart.86.4.381)

    Article  CAS  Google Scholar 

  27. Alborino D, Hoffmann JL, Fournet PC, Bloch A 2002 Value of exercise testing to evaluate the indication for surgery in asymptomatic patients with valvular aortic stenosis. Journal of Heart Valve Disease 11 204–209.

    Google Scholar 

  28. Das P, Rimington H, Chambers J 2005 Exercise testing to stratify risk in aortic stenosis. European Heart Journal 26 1309–1313. (doi:10.1093/eurheartj/ehi250)

    Article  Google Scholar 

  29. Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C, Pierard LA 2005 Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation 112 I377–I382. (doi:10.1161/CIRCULATIONAHA.104.523274)

    Article  Google Scholar 

  30. Marechaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, Bergeron S, Arsenault M, Le Tourneau T, Ennezat PV et al. 2010 Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. European Heart Journal 31 1390–1397. (doi:10.1093/eurheartj/ehq076)

    Article  Google Scholar 

  31. Wahi S, Haluska B, Pasquet A, Case C, Rimmerman CM, Marwick TH 2000 Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation. Heart 84 606–614. (doi:10.1136/heart.84.6.606)

    Article  CAS  Google Scholar 

  32. Gabriel RS, Kerr AJ, Sharma V, Zeng IS, Stewart RA 2008 B-type natriuretic peptide and left ventricular dysfunction on exercise echocardiography in patients with chronic aortic regurgitation. Heart 94 897–902. (doi:10.1136/hrt.2007.126508)

    Article  CAS  Google Scholar 

  33. Magne J, Lancellotti P, Pierard LA 2010 Exercise-induced changes in degenerative mitral regurgitation. Journal of the American College of Cardiology 56 300–309. (doi:10.1016/j.jacc.2009.12.073)

    Article  Google Scholar 

  34. Magne J, Mahjoub H, Dulgheru R, Pibarot P, Pierard LA, Lancellotti P 2014 Left ventricular contractile reserve in asymptomatic primary mitral regurgitation. European Heart Journal 35 1608–1616. (doi:10.1093/eurheartj/eht345)

    Article  CAS  Google Scholar 

Download references

Funding

This project was supported by grants from the New Zealand Heart Foundation, Middlemore Hospital Cardiac Trust (V Sharma) and Green Lane Research and Education Fund (R A Stewart).

Author information

Authors and Affiliations

  1. Department of Cardiology, Royal Liverpool University Hospital, Liverpool, L7 8XP, UK

    Vishal Sharma MD FESC FRCP

  2. Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK

    Vishal Sharma MD FESC FRCP & David E. Newby MD PhD

  3. Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand

    Ralph A. H. Stewart MD FCSANZ

  4. Department of Cardiology, Middlemore Hospital, Auckland, New Zealand

    Mildred Lee BTech (Hons) MSc, Ruvin Gabriel MD, Niels Van Pelt MD & Andrew J. Kerr MB ChB

Authors
  1. Vishal Sharma MD FESC FRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David E. Newby MD PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ralph A. H. Stewart MD FCSANZ
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mildred Lee BTech (Hons) MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ruvin Gabriel MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Niels Van Pelt MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Andrew J. Kerr MB ChB
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vishal Sharma MD FESC FRCP.

Rights and permissions

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provided a link to the Creative Commons license, and indicate if changes were made.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sharma, V., Newby, D.E., Stewart, R.A.H. et al. Exercise stress echocardiography in patients with valvular heart disease. Echo Res Pract 2, 89–98 (2015). https://doi.org/10.1530/ERP-15-0015

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-15-0015

Key Words

Echo Research & Practice

ISSN: 2055-0464

Contact us