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Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation

Echo Research & Practice volume 5, pages E1–E6 (2018)Cite this article

Abstract

Stress echocardiography is a widely utilised test in patients with known or suspected coronary artery disease (CAD), valvular heart disease and cardiomyopathies. Its advantages include the ubiquitous availability of echocardiography, lack of ionising radiation, choice of physiological or pharmacological stressors, good diagnostic accuracy and robust supporting evidence base. SE has evolved significantly as a technique over the past three decades and has benefitted considerably from improvements in overall image quality (superior resolution), machine technology (e.g. digital cine-loop acquisition and side-by-side image display) and development of second-generation ultrasound contrast agents that have improved reader confidence and diagnostic accuracy. The purpose of this article is to review the breadth of SE in contemporary clinical cardiology and discuss the recently launched British Society of Echocardiography (BSE) Stress Echocardiography accreditation scheme.

References

  1. Wann LS, Faris JV, Childress RH, Dillon JC, Weyman AE & Feigenbaum H. Exercise cross-sectional echocardiography in ischemic heart disease. Circulation 197960 1300–1308. https://doi.org/10.1161/01.CIR.60.6.1300)

    Article  CAS  Google Scholar 

  2. Fleischmann KE, Hunink MG, Kuntz KM & Douglas PS. Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance. JAMA 1998280 913–920. https://doi.org/10.1001/jama.280.10.913

    Article  CAS  Google Scholar 

  3. Geleijnse ML, Fioretti PM & Roelandt JR. Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography. Journal of the American College of Cardiology 199730 595–606. https://doi.org/10.1016/S0735-1097(97)00206-4)

    Article  CAS  Google Scholar 

  4. Severi S, Picano E, Michelassi C, Lattanzi F, Landi P, Distante A & L’Abbate A. Diagnostic and prognostic value of dipyridamole echocardiography in patients with suspected coronary artery disease. Comparison with exercise electrocardiography. Circulation 199489 1160–1173. https://doi.org/10.1161/01.CIR.89.3.1160)

    Article  CAS  Google Scholar 

  5. Plana JC, Mikati IA, Dokainish H, Lakkis N, Abukhalil J, Davis R, Hetzell BC & Zoghbi WA. A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease. The OPTIMIZE Trial. Journal of the American College of Cardiology: Cardiovascular Imaging 20081 145–152. https://doi.org/10.1016/j.jcmg.2007.10.014)

    Article  Google Scholar 

  6. Shah BN, Zacharias K, Pabla JS, Karogiannis N, Calicchio F, Balaji G, Alhajiri A, Ramzy IS, Elghamaz A, Gurunathan S, et al. The clinical impact of contemporary stress echocardiography in morbid obesity for the assessment of coronary artery disease. Heart 2016102 370–375. https://doi.org/10.1136/heartjnl-2015-308796)

    Article  CAS  Google Scholar 

  7. Wei K, Jayaweera AR, Firoozan S, Linka A, Skyba DM & Kaul S. Basis for detection of stenosis using venous administration of microbubbles during myocardial contrast echocardiography: bolus or continuous infusion? Journal of the American College of Cardiology 199832 252–260. https://doi.org/10.1016/S0735-1097(98)00212-5)

    Article  CAS  Google Scholar 

  8. Shah BN, Chahal NS, Bhattacharyya S, Li W, Roussin I, Khattar RS & Senior R. The feasibility and clinical utility of myocardial contrast echocardiography in clinical practice: results from the Incorporation of Myocardial Perfusion Assessment into Clinical Testing with Stress Echocardiography (IMPACT-SE) study. Journal of the American Society of Echocardiography 201427 520–530. https://doi.org/10.1016/j.echo.2014.01.028)

    Article  Google Scholar 

  9. Shah BN, Gonzalez-Gonzalez AM, Drakopoulou M, Chahal NS, Bhattacharyya S, Li W, Khattar RS & Senior R. The incremental prognostic value of the Incorporation of Myocardial Perfusion Assessment into Clinical Testing with Stress Echocardiography (IMPACT-SE) study. Journal of the American Society of Echocardiography 201528 1358–1365. https://doi.org/10.1016/j.echo.2015.07.001)

    Article  Google Scholar 

  10. Smart SC, Sawada S, Ryan T, Segar D, Atherton L, Berkovitz K, Bourdillon PD & Feigenbaum H. Low-dose dobutamine echocardiography detects reversible dysfunction after thrombolytic therapy of acute myocardial infarction. Circulation 199388 405–415. https://doi.org/10.1161/01.CIR.88.2.405)

    Article  CAS  Google Scholar 

  11. Shah BN, Balaji G, Alhajiri A, Ramzy IS, Ahmadvazir S & Senior R. Incremental diagnostic and prognostic value of contemporary stress echocardiography in a chest pain unit: mortality and morbidity outcomes from a real-world setting. Circulation: Cardiovascular Imaging 20136 202–209 https://doi.org/10.1161/CIRCIMAGING.112.980797)

    Google Scholar 

  12. Lancellotti P, Lebois F, Simon M, Tombeux C, Chauvel C & Pierard LA. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation 2005112(Supplement) I377–I382. https://doi.org/10.1161/CIRCULATIONAHA.104.523274)

    Article  Google Scholar 

  13. Marechaux S, Hachicha Z, Bellouin A, Dumesnil JG, Meimoun P, Pasquet A, Bergeron S, Arsenault M, Le Tourneau T, Ennezat PV, et al. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. European Heart Journal 201031 1390–1397. https://doi.org/10.1093/eurheartj/ehq076)

    Article  Google Scholar 

  14. Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B, Lancellotti P, Lansac E, Munoz DR, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 2017 38 2739–2791. https://doi.org/10.1093/eurheartj/ehx391)

    Article  Google Scholar 

  15. deFilippi CR, Willett DL, Brickner ME, Appleton CP, Yancy CW, Eichhorn EJ & Grayburn PA. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. American Journal of Cardiology 199575 191–194. https://doi.org/10.1016/S0002-9149(00)80078-8)

    Article  CAS  Google Scholar 

  16. Schwammenthal E, Vered Z, Agranat O, Kaplinsky E, Rabinowitz B & Feinberg MS. Impact of atrioventricular compliance on pulmonary artery pressure in mitral stenosis: an exercise echocardiographic study. Circulation 2000102 2378–2384. https://doi.org/10.1161/01.CIR.102.19.2378)

    Article  CAS  Google Scholar 

  17. Pierard LA & Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. New England Journal of Medicine 2004351 1627–1634. https://doi.org/10.1056/NEJMoa040532)

    Article  CAS  Google Scholar 

  18. Magne J, Mahjoub H, Dulgheru R, Pibarot P, Pierard LA & Lancellotti P. Left ventricular contractile reserve in asymptomatic primary mitral regurgitation. European Heart Journal 201435 1608–1616. https://doi.org/10.1093/eurheartj/eht345)

    Article  CAS  Google Scholar 

  19. Magne J, Donal E, Mahjoub H, Miltner B, Dulgheru R, Thebault C, Pierard LA, Pibarot P & Lancellotti P. Impact of exercise pulmonary hypertension on postoperative outcome in primary mitral regurgitation. Heart 2015101 391–396. https://doi.org/10.1136/heartjnl-2014-306296)

    Article  Google Scholar 

  20. Magne J, Lancellotti P & Pierard LA. Exercise-induced changes in degenerative mitral regurgitation. Journal of the American College of Cardiology 201056 300–309. https://doi.org/10.1016/j.jacc.2009.12.073)

    Article  Google Scholar 

  21. Bhattacharyya S, Kamperidis V, Shah BN, Roussin I, Chahal N, Li W, Khattar RS & Senior R. Clinical utility and prognostic value of appropriateness criteria in stress echocardiography for the evaluation of valvular heart disease. Journal of the American College of Cardiology: Cardiovascular Imaging 20136 987–992. https://doi.org/10.1016/j.jcmg.2013.04.011)

    Article  Google Scholar 

  22. Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, et al. 2011 ACCF/AHA Guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 201158 e212–e260. https://doi.org/10.1016/j.jacc.2011.06.011)

    Article  CAS  Google Scholar 

  23. Ramahi TM, Longo MD, Cadariu AR, Rohlfs K, Slade M, Carolan S, Vallejo E & Wackers FJ. Dobutamine-induced augmentation of left ventricular ejection fraction predicts survival of heart failure patients with severe non-ischaemic cardiomyopathy. European Heart Journal 200122 849–856. https://doi.org/10.1053/euhj.2001.2654)

    Article  CAS  Google Scholar 

  24. Iacopino S, Gasparini M, Zanon F, Dicandia C, Distefano G, Curnis A, Donati R, Neja CP, Calvi V, Davinelli M, et al. Low-dose dobutamine stress echocardiography to assess left ventricular contractile reserve for cardiac resynchronization therapy: data from the Low-Dose Dobutamine Stress Echocardiography to Predict Cardiac Resynchronization Therapy Response (LODO-CRT) trial. Congestive Heart Failure 201016 104–110. https://doi.org/10.1111/j.1751-7133.2010.00141.x)

    Article  CAS  Google Scholar 

  25. Picano E, Lattanzi F, Orlandini A, Marini C & L’Abbate A. Stress echocardiography and the human factor: the importance of being expert. Journal of the American College of Cardiology 199117 666–669 https://doi.org/10.1016/S0735-1097(10)80182-2)

    Article  CAS  Google Scholar 

  26. Bairey CN, Rozanski A & Berman DS. Exercise echocardiography: ready or not? Journal of the American College of Cardiology 198811 1355–1358. https://doi.org/10.1016/0735-1097(88)90304-X)

    Article  CAS  Google Scholar 

  27. Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU & Zamorano JL. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE). European Journal of Echocardiography 20089 415–437. https://doi.org/10.1093/ejechocard/jen175)

    Article  Google Scholar 

  28. Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA & Sawada SG. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. Journal of the American Society of Echocardiography 200720 1021–1041. https://doi.org/10.1016/j.echo.2007.07.003)

    Article  Google Scholar 

  29. Ryan T, Armstrong WF & Khandheria BK. Task force 4: training in echocardiography endorsed by the American Society of Echocardiography. Journal of the American College of Cardiology 200851 361–367. https://doi.org/10.1016/j.jacc.2007.11.012)

    Article  Google Scholar 

  30. Joint Royal Colleges of Physicians Training Board. Specialty Training Curriculum for Cardiology, pp 1–173. London, UK: Royal College of Physicians, 2010.

    Google Scholar 

  31. Shah BN, Lindsay AC & Nicol ED. What is the role of accreditation in the era of competency-based specialist training–a perspective from the United Kingdom. International Journal of Cardiology 2012160 79–81. https://doi.org/10.1016/j.ijcard.2012.01.085)

    Article  Google Scholar 

  32. Wheeler R, Bhattacharyya S, Bradlow W, Collins K, Harkness A, Knight D, O’Gallagher K, Oxborough D, Mathew T, Preston N, et al. A practical guide for performing stress echocardiography in coronary artery disease. ECHO 201694 9–15.

    Google Scholar 

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Authors and Affiliations

  1. Wessex Cardiac Centre, University Hospital Southampton, Southampton, UK

    Benoy N. Shah MD MRCP FESC

  2. University Hospital of South Manchester, Manchester, UK

    Anita MacNab MBChB FRCP, Jane Lynch MSc & Reinette Hampson BSc

  3. Northwick Park Hospital, Harrow, UK

    Roxy Senior FRCP FESC FACC & Richard P. Steeds MD FRCP FESC

  4. National Heart and Lung Institute, Imperial College, London, UK

    Richard P. Steeds MD FRCP FESC

  5. University Hospital Birmingham, Birmingham, UK

    Roxy Senior FRCP FESC FACC

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  1. Benoy N. Shah MD MRCP FESC
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The British Society of Echocardiography Stress Accreditation Committee

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Correspondence to Benoy N. Shah MD MRCP FESC.

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Shah, B.N., MacNab, A., Lynch, J. et al. Stress echocardiography in contemporary clinical cardiology: practical considerations and accreditation. Echo Res Pract 5, E1–E6 (2018). https://doi.org/10.1530/ERP-17-0032

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Echo Research & Practice

ISSN: 2055-0464

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