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(/* ACC / AHA Guidelines- Exercise Echocardiography in patients Who Are Able to Exercise (DO NOT EDIT)Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chron)
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===Class I===
===Class I===
'''1.''' Exercise myocardial perfusion imaging or exercise [[echocardiography]] in patients with an intermediate pretest probability of [[CAD]] who have 1 of the following baseline [[ECG]] abnormalities:
'''1.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] or exercise echocardiography in patients with an intermediate pretest probability of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:b. More than 1 mm of rest ST depression. ''(Level of Evidence: B)''
:b. More than 1 mm of rest [[ST depression]]. ''(Level of Evidence: B)''


'''2.''' Exercise myocardial perfusion imaging or exercise [[echocardiography]] in patients with prior [[revascularization]] (either [[percutaneous transluminal coronary angioplasty]] ([[PTCA]]) or [[coronary artery bypass graft]] ([[CABG]]). ''(Level of Evidence: B)''
'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] or exercise echocardiography in patients with prior [[revascularization]] (either [[percutaneous transluminal coronary angioplasty]] ([[PTCA]]) or [[coronary artery bypass graft]] ([[CABG]]). ''(Level of Evidence: B)''


===Class IIb===
===Class IIb===
'''1.''' Exercise myocardial perfusion imaging and exercise [[echocardiography]] in patients with a low or high probability of [[CAD]] who have 1 of the following baseline [[ECG]] abnormalities:
'''1.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] and exercise echocardiography in patients with a low or high probability of [[CAD]] who have 1 of the following baseline [[Chronic stable angina electrocardiography|ECG]] abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:a. Preexcitation ([[Wolff-Parkinson-White|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:b. More than 1 mm of ST depression. ''(Level of Evidence: B)''
:b. More than 1 mm of ST depression. ''(Level of Evidence: B)''


'''2.''' Exercise myocardial perfusion imaging or exercise [[echocardiography]] in patients with an intermediate probability of [[CAD]] who have 1 of the following:
'''2.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]] or exercise echocardiography in patients with an [[Chronic stable angina assessing the pretest probability of coronary artery disease|intermediate probability of CAD]] who have 1 of the following:
:a. [[Digoxin]] use with <1 mm ST depression on their baseline [[ECG]]. ''(Level of Evidence: B)''
:a. [[Digoxin]] use with less than 1 mm [[ST depression]] on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''(Level of Evidence: B)''
:b. [[LV hypertrophy]] with <1 mm ST depression on their baseline [[ECG]]. ''(Level of Evidence: B)''
:b. [[LV hypertrophy]] with less than 1 mm ST depression on their baseline [[Chronic stable angina electrocardiography|ECG]]. ''(Level of Evidence: B)''


'''3.''' Exercise myocardial perfusion imaging, exercise [[echocardiography]], [[adenosine]] or [[dipyridamole]] myocardial perfusion imaging, or [[dobutamine]] [[echocardiography]] as the initial stress test in a patient with a normal rest [[ECG]] who is not taking [[digoxin]]. ''(Level of Evidence: B)''
'''3.''' [[Chronic stable angina myocardial perfusion scintigraphy|Exercise myocardial perfusion imaging]], exercise echocardiography, [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|adenosine or dipyridamole myocardial perfusion imaging]], or [[dobutamine]] echocardiography as the initial stress test in a patient with a normal [[Chronic stable angina electrocardiography|rest ECG]] who is not taking [[digoxin]]. ''(Level of Evidence: B)''


'''4.''' Exercise or [[dobutamine]] [[echocardiography]] in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''}}
'''4.''' Exercise or [[dobutamine]] echocardiography in patients with [[left bundle-branch block]]. ''(Level of Evidence: C)''}}


==ESC Guidelines for the use of exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
==ESC Guidelines for the use of exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==

Revision as of 17:25, 17 August 2011

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [3] Phone:617-632-7753; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [4]; Smita Kohli, M.D.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Stress echocardiography is echocardiography with different stressors such as exercise or pharmacological with adenosine or dipyridamole or dobutamine. In patients who are unable to exercise pharmacological stress echocardiography is a useful alternative.

Exercise echocardiography appears to be more sensitive, more specific and have a higher predictive value in comparison to exercise ECG. Exercise echocardiography is helpful in the evaluation of regional wall motion response, location and extent of ischemia during stress in patients with MI. During exercise, the normal myocardium is hyperdynamic while in patients with MI, the ischemic myocardium is either akinetic or hypokinetic.

Advantages of stress echocardiography

  • Detection of CAD and in patients with known or suspected CAD, assessing the prognosis of CAD.
  • Stress echocardiography is a more specific test for the assessment of myocardial viability after acute MI [1].
  • In patients with chronic ischemic LV dysfunction, prediction of full functional recovery of the myocardium after revascularisation [2].
  • The capability of stress echocardiography to detect ischemia earlier in the ischemic cascade [3] [4] has been greatly improved with the advent of tissue Doppler imaging [5] and strain rate imaging [6] [7].
  • Tissue Doppler imaging is useful in the quantification of myocardial wall motion and strain.
  • Strain rate imaging is useful to determine regional deformation and strain being the difference per unit length.

Sensitivity and Specificity

  • Exercise echocardiography has been reported to have a sensitivity of 74% to 100% and a specificity of 64% to 93% for detecting CAD.
  • The sensitivity and specificity of exercise echocardiography based on a meta-analysis is 80-85% and 84-86% respectively [8].
  • With the use of high dose of dobutamine (up to 50 gm / kg / min), a method of dobutamine stress echocardiography can be performed with 86% to 96% of sensitivity and 66% to 95% of specificity.
  • Lower doses of dobutamine can also be used to detect hibernating myocardium. Areas of hibernating myocardium exhibit poor or absent contraction at rest but normal contraction during dobutamine infusion. By comparison, areas damaged by myocardial infarction or fibrosis exhibit no improvement with dobutamine.

Diagnostic criteria

  • The signs suggestive of severe CAD on exercise echocardiography include:
  • reduction on global systolic function,
  • LV dilation,
  • new or progressively worsening MR

ACC / AHA Guidelines- Exercise Echocardiography in patients Who Are Able to Exercise (DO NOT EDIT)[9]

“

Class I

1. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate pretest probability of CAD who have 1 of the following baseline ECG abnormalities:

a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
b. More than 1 mm of rest ST depression. (Level of Evidence: B)

2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with prior revascularization (either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG). (Level of Evidence: B)

Class IIb

1. Exercise myocardial perfusion imaging and exercise echocardiography in patients with a low or high probability of CAD who have 1 of the following baseline ECG abnormalities:

a. Preexcitation (Wolff-Parkinson-White) syndrome. (Level of Evidence: B)
b. More than 1 mm of ST depression. (Level of Evidence: B)

2. Exercise myocardial perfusion imaging or exercise echocardiography in patients with an intermediate probability of CAD who have 1 of the following:

a. Digoxin use with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)
b. LV hypertrophy with less than 1 mm ST depression on their baseline ECG. (Level of Evidence: B)

3. Exercise myocardial perfusion imaging, exercise echocardiography, adenosine or dipyridamole myocardial perfusion imaging, or dobutamine echocardiography as the initial stress test in a patient with a normal rest ECG who is not taking digoxin. (Level of Evidence: B)

4. Exercise or dobutamine echocardiography in patients with left bundle-branch block. (Level of Evidence: C)

”

ESC Guidelines for the use of exercise stress with imaging techniques (either echocardiography or perfusion) in the initial diagnostic assessment of angina (DO NOT EDIT)[10]

“

Class I

1. Patients with resting ECG abnormalities, LBBB, more than 1 mm ST-depression, paced rhythm, or WPW which prevent 12 ESC Guidelines accurate interpretation of ECG changes during stress. (Level of Evidence: B)

2. Patients with a non-conclusive exercise ECG but reasonable exercise tolerance, who do not have a high probability of significant coronary artery disease and in whom the diagnosis is still in doubt. (Level of Evidence: B)

Class IIa

1. Patients with prior revascularization (PCI or CABG) in whom localization of ischaemia is important. (Level of Evidence: B)

2. As an alternative to exercise ECG in patients where facilities, cost, and personnel resources allow. (Level of Evidence: B)

3. As an alternative to exercise ECG in patients with a low pre-test probability of disease such as women with atypical chest pain. (Level of Evidence: B)

4. To assess functional severity of intermediate lesions on coronary arteriography. (Level of Evidence: C)

5. To localize ischaemia when planning revascularization options in patients who have already had arteriography. (Level of Evidence: B)

”

Vote on and Suggest Revisions to the Current Guidelines

Sources

  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [10]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [9]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [11]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [12]

References

  1. ↑ Anselmi M, Golia G, Maines M, Marino P, Goj C, Turri M et al. (2000) Comparison between low-dose dobutamine echocardiography and thallium-201 scintigraphy in the detection of myocardial viability in patients with recent myocardial infarction. Int J Cardiol 73 (3):213-23. PMID: 10841962
  2. ↑ Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E et al. (2001) Time course of functional recovery of stunned and hibernating segments after surgical revascularization. Circulation 104 (12 Suppl 1):I314-8. PMID: 11568075
  3. ↑ Mädler CF, Payne N, Wilkenshoff U, Cohen A, Derumeaux GA, Piérard LA et al. (2003) Non-invasive diagnosis of coronary artery disease by quantitative stress echocardiography: optimal diagnostic models using off-line tissue Doppler in the MYDISE study. Eur Heart J 24 (17):1584-94. PMID: 12927194
  4. ↑ Yip G, Khandheria B, Belohlavek M, Pislaru C, Seward J, Bailey K et al. (2004) Strain echocardiography tracks dobutamine-induced decrease in regional myocardial perfusion in nonocclusive coronary stenosis. J Am Coll Cardiol 44 (8):1664-71. DOI:10.1016/j.jacc.2004.02.065 PMID: 15489101
  5. ↑ Cain P, Baglin T, Case C, Spicer D, Short L, Marwick TH (2001) Application of tissue Doppler to interpretation of dobutamine echocardiography and comparison with quantitative coronary angiography. Am J Cardiol 87 (5):525-31. PMID: 11230833
  6. ↑ Voigt JU, Exner B, Schmiedehausen K, Huchzermeyer C, Reulbach U, Nixdorff U et al. (2003) Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia. Circulation 107 (16):2120-6. DOI:10.1161/01.CIR.0000065249.69988.AA PMID: 12682001
  7. ↑ Yip G, Abraham T, Belohlavek M, Khandheria BK (2003) Clinical applications of strain rate imaging. J Am Soc Echocardiogr 16 (12):1334-42. DOI:10.1067/j.echo.2003.09.004 PMID: 14652617
  8. ↑ Schinkel AF, Bax JJ, Geleijnse ML, Boersma E, Elhendy A, Roelandt JR et al. (2003) Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography? Eur Heart J 24 (9):789-800. PMID: 12727146
  9. ↑ 9.0 9.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
  10. ↑ 10.0 10.1 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  11. ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58.[1] PMID: 12515758
  12. ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007)2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72.[2] PMID: 17998462


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