Skip to main content
Download PDF

Feasibility of physiologist-led stress echocardiography for the assessment of coronary artery disease

Echo Research & Practice volume 4, pages 29–36 (2017)Cite this article

Abstract

Background Physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There are however no published data on the feasibility of PLSE. We sought to assess the feasibility, safety and robustness of PLSE and cardiologist-led stress echocardiography (CLSE) for coronary artery disease (CAD) assessment.

Methods Retrospective analysis of 898 patients undergoing PLSE or CLSE for CAD assessment using exercise or dobutamine stress over 24 months. PLSE involved 2 cardiac physiologists (exercise) or 1 physiologist plus 1 cardiac nurse (dobutamine). A cardiology registrar was present in the echocardiography department during PLSE in case of medical complications. CLSE involved 1 physiologist and 1 trainee cardiologist who analysed the study and reviewed findings with an imaging cardiologist. Sixteen-segment wall motion scoring (WMS, WMSI) analysis was performed. Feasibility (stressor, image quality, proportion of completed studies, agreement with imaging cardiologist analysis) and safety (complication rate) were compared for PLSE and CLSE.

Results The majority of studies were CLSE (56.2%) and used dobutamine (68.7%). PLSE more commonly used exercise (69.2%). Overall, 96% of studies were successfully completed (>14 diagnostic segments in 98%, P=0.899 PLSE vs CLSE). Commencement of PLSE was associated with an increase in annual SE’s performed for CAD assessment. Complication rates were comparably very low for PLSE and CLSE (0.8% vs 1.8%, P=0.187). There was excellent agreement between PLSE and CLSE WMS interpretation of 480 myocardial segments at rest (κ=0.87) and stress (κ=0.70) and WMSI (ICCs and Pearson’s r >0.90, zero Bland–Altman mean bias).

Conclusion This to our knowledge is the first study of the feasibility of PLSE. PLSE performed by well-trained physiologists is feasible and safe in contemporary practice. PLSE and CLSE interpretation of stress echocardiography for CAD agree very closely.

References

  1. Indrajith M, Garbi M, Monaghan MJ 2016 Setting up a stress echo service: best practice. Heart 102 1763–1770. (doi:10.1136/heartjnl-2015-308165)

    Article  Google Scholar 

  2. Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P, Varga A, Sicari R, Evangelista A, Nihoyannopoulos P, et al. 2009 European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. European Journal of Echocardiography 10 893–905. (doi:10.1093/ejechocard/jep151)

    Article  Google Scholar 

  3. Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL 2009 Stress echocardiography expert consensus statement – executive summary: European Association of Echocardiography (EAE). European Heart Journal 30 278–289. (doi:10.1093/eurheartj/ehn492)

    Article  Google Scholar 

  4. Becher H, Chambers J, Fox K, Jones R, Leech GJ, Masani N, Monaghan M, More R, Nihoyannopoulos P, Rimington H et al. 2004 BSE procedure guidelines for the clinical application of stress echocardiography, recommendations for performance and interpretation of stress echocardiography: a report of the British Society of Echocardiography Policy Committee. Heart 90 (Supplement 6) vi23–vi30. (doi:10.1136/hrt.2004.047985)

    PubMed  PubMed Central  Google Scholar 

  5. Senior R, Monaghan M, Becher H, Mayet J, Nihoyannopoulos P, British Society of Echocardiography 2005 Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography. Heart 91 427–436. (doi:10.1136/hrt.2004.044396)

    Article  CAS  Google Scholar 

  6. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T & Verani MS 2002 Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation 105 539–542. (doi:10.1161/hbib402.102975)

    Article  Google Scholar 

  7. Popp R, Agatston A, Armstrong W, Nanda N, Pearlman A, Rakowski H, Seward J, Silverman N, Smith M, Stewart W et al. 1998 Recommendations for training in performance and interpretation of stress echocardiography. Committee on Physician Training and Education of the American Society of Echocardiography. Journal of the American Society of Echocardiography 11 95–96. (doi:10.1016/S0894-7317(98)70131-2)

    Article  CAS  Google Scholar 

  8. Castillo E, Osman NF, Rosen BD, El-Shehaby I, Pan L, Jerosch-Herold M, Lai S, Bluemke DA, Lima JAC 2005 Quantitative assessment of regional myocardial function with MR-tagging in a multi-center study: interobserver and intraobserver agreement of fast strain analysis with Harmonic Phase (HARP) MRI. Journal of Clinical Medicine and Research 7 783–791. (doi:10.1080/10976640500295417)

    Google Scholar 

  9. Viera AJ, Garrett JM 2005 Understanding interobserver agreement: the kappa statistic. Family Medicine 37 360–363.

    PubMed  Google Scholar 

  10. Bhattacharyya S, Chehab O, Khattar R, Lloyd G, Senior R British Society of Echocardiography 2014 Stress echocardiography in clinical practice: a United Kingdom National Health Service Survey on behalf of the British Society of Echocardiography. European Heart Journal: Cardiovascular Imaging 15 158–163. (doi:10.1093/ehjci/jebib82)

    PubMed  Google Scholar 

  11. Varga A, Garcia MA, Picano E International Stress Echo Complication Registry 2006 Safety of stress echocardiography (from the International Stress Echo Complication Registry). American Journal of Cardiology 98 541–543. (doi:10.1016/j.amjcard.2006.02.064)

    Article  Google Scholar 

  12. Geleijnse ML, Krenning BJ, Nemes A, van Dalen BM, Soliman OI, Ten Cate FJ, Schinkel AF, Boersma E, Simoons ML 2010 Incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography. Circulation 121 1756–1767. (doi:10.1161/CIRCULATIONAHA.109.859264)

    Article  Google Scholar 

  13. BCS 2015 Strategic Review of Cardiac Physiology Services in England: Final Report. London, UK:, British Cardiovascular Society. (available at: http://www.bcs.com/documents/SRCPS_Final_Report_12052015_2.pdf)

    Google Scholar 

  14. Chambers J, Lloyd G, Rimington HM, Parkin D, Hayes AM, Baldrock-Apps G, Topham A 2011 Multidisciplinary valve clinics with devolved surveillance: a two-year audit. British Journal of Cardiology 18 231–232. (doi:10.5837/bjc.2011.004)

    Article  Google Scholar 

  15. DOH 2010 Modernising Scientic Careers: The England Action Plan. London, UK: Department of Health. (available at: https://www.gov.uk/government/publications/modernising-scientific-careers-the-england-action-plan)

    Google Scholar 

  16. Shah BN, Senior R 2016 Stress echocardiography in patients with morbid obesity. Echo Research and Practice 3 R13–R18. (doi:10.1530/ERP-16-0010)

    Article  Google Scholar 

  17. Allen BD, Chatterjee N, Ayache J, Freed BH, Lee DC, Carroll T, Markl M, Collins JD, Carr JC 2015 Stress perfusion cardiac MRI with regadenoson and gadofoveset trisodium. Journal of Clinical Medicine and Research 17 P113. (doi:10.1186/1532-429x-17-s1-p113)

    Google Scholar 

  18. Duvall WL, Croft LB, Corriel JS, Einstein AJ, Fisher JE, Haynes PS, Rose RK, Henzlova MJ 2006 SPECT myocardial perfusion imaging in morbidly obese patients: image quality, hemodynamic response to pharmacologic stress, and diagnostic and prognostic value. Journal of Nuclear Cardiology 13 202–209. (doi:10.1007/BF02971244)

    Article  Google Scholar 

  19. Picano E, Lattanzi F, Orlandini A, Marini C, L’Abbate A 1991 Stress echocardiography and the human factor: the importance of being expert. Journal of the American College of Cardiology 17 666–669. (doi:10.1016/S0735-1097(10)80182-2)

    Article  CAS  Google Scholar 

  20. Soman P, Lahiri A, Senior R 2004 Vasodilator stress induces infrequent wall thickening abnormalities compared to perfusion defects in mild-to-moderate coronary artery disease: implications for the choice of imaging modality with vasodilator stress. Echocardiography 21 307–312. (doi:10.1111/j.0742-2822.2004.03006.x)

    Article  Google Scholar 

  21. Picano E, Lattanzi F, Masini M, Distante A, L’Abbate A 1987 Comparison of the high-dose dipyridamole-echocardiography test and exercise two-dimensional echocardiography for diagnosis of coronary artery disease. American Journal of Cardiology 59 539–542. (doi:10.1016/0002-9149(87)91165-9)

    Article  CAS  Google Scholar 

  22. Varga A, Picano E, Dodi C, Barbieri A, Pratali L, Gaddi O 1999 Madness and method in stress echo reading. European Heart Journal 20 1271–1275. (doi:10.1053/euhj.1999.1541)

    Article  CAS  Google Scholar 

  23. Mertes H, Sawada SG, Ryan T, Segar DS, Kovacs R, Foltz J, Feigenbaum H 1993 Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography. Experience in 1118 patients. Circulation 88 15–19. (doi:10.1161/01.CIR.88.1.15)

    Article  CAS  Google Scholar 

  24. Pellikka PA, Roger VL, Oh JK, Miller FA, Seward JB, Tajik AJ 1995 Stress echocardiography. Part II. Dobutamine stress echocardiography: techniques, implementation, clinical applications, and correlations. Mayo Clinic Proceedings 70 16–27. (doi:10.1016/S0025-6196(11)64660-0)

    Article  CAS  Google Scholar 

  25. Zahn R, Lotter R, Nohl H, Schiele R, Bergmeier C, Zander M, Seidl K & Senges J 1996 Feasibility and safety of dobutamine stress echocardiography: experiences with 1,000 studies. Zeitschrift füdiologie 85 28–34.

    CAS  Google Scholar 

  26. Elhendy A, van Domburg RT, Poldermans D, Bax JJ, Nierop PR, Geleijnse ML, Roelandt JR 1998 Safety and feasibility of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in diabetic patients unable to perform an exercise stress test. Diabetes Care 21 1797–1802. (doi:10.2337/diacare.21.11.1797)

    Article  CAS  Google Scholar 

  27. Bremer ML, Monahan KH, Stussy VL, Miller FA, Seward JB, Pellikka PA 1998 Safety of dobutamine stress echocardiography supervised by registered nurse sonographers. Journal of the American Society of Echocardiography 11 601–605. (doi:10.1016/S0894-7317(98)70035-5)

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK

    Jamal N. Khan MBChB PhD BMedSci MRCP, Timothy Griffiths BA BSc PGDip Card, Tamseel Fatima MBBS MRCP, Leah Michael MBChB BSc MRCP, Andreea Mihai MBBS MRCP, Zeeshan Mustafa MBBS, Kully Sandhu DM MRCP, Robert Butler MBChB MD FRCP FACC, Simon Duckett MBBS MD BSc MRCP & Grant Heatlie MBBS PhD BSc FRCP

Authors
  1. Jamal N. Khan MBChB PhD BMedSci MRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Timothy Griffiths BA BSc PGDip Card
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tamseel Fatima MBBS MRCP, Leah Michael MBChB BSc MRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andreea Mihai MBBS MRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zeeshan Mustafa MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kully Sandhu DM MRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Robert Butler MBChB MD FRCP FACC
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Simon Duckett MBBS MD BSc MRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Grant Heatlie MBBS PhD BSc FRCP
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Grant Heatlie MBBS PhD BSc FRCP.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://doi.org/creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide 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

Khan, J.N., Griffiths, T., Fatima, T. et al. Feasibility of physiologist-led stress echocardiography for the assessment of coronary artery disease. Echo Res Pract 4, 29–36 (2017). https://doi.org/10.1530/ERP-17-0019

Download citation

  • Received:

  • Revised:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-17-0019

Keywords

Echo Research & Practice

ISSN: 2055-0464

Contact us