Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease
Publication Date: January 1, 2020
Last Updated: March 14, 2022
Key Points
METHODOLOGY
For treadmill exercise protocols, images obtained at rest and immediately after exercise should be compared side-by-side using quad-screen format.
For pharmacologic stress echocardiography, images from peak stress stages should be compared to rest, low dose, and prepeak or early recovery stages using quad-screen format.
Obtaining data from multiple cardiac cycles at peak stress enhances the accuracy of test interpretation. For continuous recording of rest and stress images, the use of digital recording software is preferable to recording on videotape.
For pharmacologic stress echocardiography, images from peak stress stages should be compared to rest, low dose, and prepeak or early recovery stages using quad-screen format.
Obtaining data from multiple cardiac cycles at peak stress enhances the accuracy of test interpretation. For continuous recording of rest and stress images, the use of digital recording software is preferable to recording on videotape.
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Ultrasound enhancing agents (UEA) s should be utilized during stress echocardiography whenever two or more contiguous segments cannot be visualized or a coronary artery territory cannot be completely visualized. (BI)
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Use of very low dose bolus injections (0.1 ml of Definity, 0.2- 0.4 ml of Optison, and 0.5-1.0 ml of Lumason) followed by slow saline flushes is optimal for reducing cavity shadowing. Alternatively, Definity has been given as a 3-5% dilution in normal saline, and Optison has been infused as a 10% dilution. (CI)
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Very low mechanical index (VLMI) imaging pulse sequence schemes that detect non-linear fundamental frequency responses at <0.2 mechanical index (MI) are recommended for optimal left ventricular opacification (LVO) and reduced basal segment attenuation (Videos 5-8, available online at www.onlinejase.com). Brief high MI (>0.8) impulses (5-15 frames) can be used to clear the myocardium and improve endocardial border resolution. (BIIa)
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STRESS TESTING METHODS
Exercise stress tests are more physiologic than pharmacologic stress tests and include the prognostically important finding of the patient’s exercise capacity. Thus, if a patient can exercise, this is the preferred stress modality. (AI)
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- Bicycle stress echocardiography (upright or supine) is technically more feasible for assessment of both coronary flow reserve and diastology.
- Dobutamine stress echocardiography (DSE) is a preferred alternative test for evaluation of myocardial ischemia when a patient cannot exercise.
- Diagnostic endpoints include achievement of at least 80% of the age- and sex-predicted workload for exercise testing and target heart rate (HR) for DSE.
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IMAGE INTERPRETATION
The RV free wall should be included in apical 4-chamber images for assessment of lateral wall and tricuspid annular motion when right CAD is suspected. Right ventricular lateral wall and tricuspid annular motion should be assessed for detection of RV ischemia. (BI)
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ACCURACY
Multiple studies have demonstrated the excellent accuracy of stress echocardiography using coronary arteriography as the gold standard for comparison.
For detection of coronary artery disease (CAD), stress echocardiography has similar sensitivity to tomographic nuclear perfusion imaging. However, stress echocardiography has higher specificity. For detection of left main or multivessel CAD, stress echocardiography has greater sensitivity.
For detection of coronary artery disease (CAD), stress echocardiography has similar sensitivity to tomographic nuclear perfusion imaging. However, stress echocardiography has higher specificity. For detection of left main or multivessel CAD, stress echocardiography has greater sensitivity.
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Patients who experience hypertensive responses to stress should be evaluated or managed like any patient who has positive stress findings.
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The outcomes of patients with false-positive stress results are similar to those with true-positive results. Patients with falsepositive results on stress echocardiograms should receive intensive risk factor management and careful follow-up.
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When properly performed, perfusion imaging with VLMI imaging, real-time myocardial contrast echocardiography (RTMCE), appears to improve detection of coronary artery stenoses during dobutamine stress echocardiography (DSE) or vasodilator stress imaging. If performing myocardial perfusion imaging, VLMI imaging should be used with real time high MI flash replenishment techniques for simultaneous perfusion and wall motion assessment. (BIIa)
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RISK STRATIFICATION AND PROGNOSIS
Exercise stress echocardiography (ESE) or DSE are appropriate for evaluation of the patient presenting with exertional dyspnea. In addition to detecting ischemia, diastolic dysfunction, pulmonary hypertension and other cardiac causes of this symptom can be readily detected. (BI)
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ESE or DSE may be used for detection of ischemia and risk stratification in patients with LBBB. (BI)
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In LBBB, stress echocardiography allows recognition of nonischemic conditions also associated with LBBB.
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- In patients in whom preoperative stress testing is appropriate before noncardiac surgery, a normal DSE has been shown to be associated with an excellent outcome whereas a positive study is associated with peri-operative events.
- The heart rate at which ischemia develops during DSE can be used for risk stratification.
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When properly performed, perfusion imaging with RTMCE improves the prognostic value of bicycle, dobutamine, and vasodilator stress echocardiography.
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VLMI multi-pulse imaging with UEAs is preferred over low MI imaging to improve the detection of regional wall motion abnormalities. (BI)
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COMPARISON WITH OTHER IMAGING MODALITIES
Stress echocardiography has an accuracy similar to that of other stress imaging techniques for detection of angiographic CAD.
Stress echocardiography has also been demonstrated to provide similar prognostic information compared to other stress imaging techniques and computed tomography angiography.
Comparative studies of the accuracy and prognostic value of stress echocardiography versus other techniques have not considered the incremental value of the additional information available at the time of stress echocardiography regarding the wall thicknesses, chamber sizes, valvular abnormalities, diastolic function, etc., that are assessed at the time of rest imaging.
Contractile reserve by DSE compares favorably with other methods for predicting recovery of systolic function of viable segments; compared to perfusion imaging techniques, DSE has mildly lower sensitivity but better specificity.
Absence of radiation or need for gadolinium as well as cost benefit makes stress echocardiography an attractive technique for many patients.
Stress echocardiography has also been demonstrated to provide similar prognostic information compared to other stress imaging techniques and computed tomography angiography.
Comparative studies of the accuracy and prognostic value of stress echocardiography versus other techniques have not considered the incremental value of the additional information available at the time of stress echocardiography regarding the wall thicknesses, chamber sizes, valvular abnormalities, diastolic function, etc., that are assessed at the time of rest imaging.
Contractile reserve by DSE compares favorably with other methods for predicting recovery of systolic function of viable segments; compared to perfusion imaging techniques, DSE has mildly lower sensitivity but better specificity.
Absence of radiation or need for gadolinium as well as cost benefit makes stress echocardiography an attractive technique for many patients.
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RADIATION-INDUCED CORONARY ARTERY DISEASE
Chest radiation can result in premature multivessel, ostial CAD. Stress echocardiography has advantages over nuclear imaging in the noninvasive assessment of multivessel CAD, secondary to the lower false-negative rate.
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STRESS ECHOCARDIOGRAPHY IN PEDIATRIC PATIENTS AND CONGENITAL HEART DISEASE
Pediatric stress echocardiography using exercise or dobutamine stress has been increasingly utilized for the detection of ischemia and assessment of exercise tolerance.
ESE is extremely well-tolerated in children as it requires no sedation, needle stick, or radiation exposure and can be considered for children age 6 or older.
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Either DSE or ESE, which both have a high negative predictive value, are recommended to help extend the interval between angiograms in the asymptomatic pediatric transplant recipient.
For older children who are able to perform an exercise test, this type of test is preferred over DSE for the same reasons as for adults
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Stress echocardiography is useful for serial screening and prognosis in KD patients with coronary aneurysms; wall motion score index can be used to prognosticate 15-year cumulative event-free survival.
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Stress echocardiography provides helpful information in the pre-operative diagnosis and serial long-term follow-up of patients with AOCA. (BIIa)
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TRAINING REQUIREMENTS AND MAINTENANCE OF COMPETENCY
Dedicated training with a more senior sonographer who oversees the orientation and performance of stress echocardiograms is required for a sonographer to learn to perform stress echocardiography. This should not occur until the individual has performed at least 1,000 transthoracic echocardiograms and has a minimum of 1 year’s clinical experience.
Sonographers should perform at least 100 stress echocardiograms annually for maintenance of competency.
For competence in interpreting stress echocardiography the physician must have mastered TTE and interpreted a minimum of 100 stress echocardiographic studies, supervised by a level III trained echocardiographer.
For maintenance of competency, it is recommended that a physician interpret a minimum of 100 stress echocardiograms per year, in addition to participation in relevant continuing medical education
Sonographers should perform at least 100 stress echocardiograms annually for maintenance of competency.
For competence in interpreting stress echocardiography the physician must have mastered TTE and interpreted a minimum of 100 stress echocardiographic studies, supervised by a level III trained echocardiographer.
For maintenance of competency, it is recommended that a physician interpret a minimum of 100 stress echocardiograms per year, in addition to participation in relevant continuing medical education
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Recommendation Grading
Overview
Title
Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease
Authoring Organization
American Society of Echocardiography
Publication Month/Year
January 1, 2020
Last Updated Month/Year
August 29, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Outpatient, Radiology services
Intended Users
Radiology technologist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Treatment
Diseases/Conditions (MeSH)
D006331 - Heart Diseases, D015150 - Echocardiography, Doppler
Keywords
Ischemic Heart Disease, Doppler echocardiography, stress test