Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC)

Usefulness of dual imaging stress echocardiography for the diagnosis of coronary allograft vasculopathy in heart transplant recipients

BACKGROUND

Coronary allograft vasculopathy (CAV) is the main factor limiting long-term survival after cardiac transplantation. Dual imaging stress echocardiography with wall motion and Doppler-derived coronary flow reserve (CRF) of the left anterior descending artery (LAD) is a state-of-the-art methodology during dipyridamole stress echocardiography (DiSE). This study involving 74 heart transplanted patients has the purpose to assess the diagnostic value of dipyridamole stress echocardiography with evaluation of wall motion (WM) and Doppler-derived coronary flow reserve for the diagnosis of coronary allograft vasculopathy.

METHODS AND RESULTS

All patients underwent DiSE and coronary angiography. Moderate-severe CAV was defined according to International Society of Heart and Lung Transplant (ISHLT) recommended nomenclature for CAV, and CFR < 2 was considered to be impaired. Moderate-severe CAV was present in 11 patients. WM analysis revealed four patients (5%) with rest WM abnormalities. CFR analysis revealed that 40 (54%) individuals had an abnormal result. The combined evaluation of WM analysis and CFR resulted in a sensitivity of 72.7% (95% CI: 39.3 to 92.6%), a specificity of 49.2% (95% CI: 36.5 to 61.9%), a positive predictive value of 20% (95% CI: 9.6 to 36.1%), and negative predictive value of 91.1% (95% CI: 75.1 to 97.6%) for the diagnosis of CAV.

CONCLUSIONS

Our results support the inclusion of DiSE performance in Heart transplant follow up protocol. The addition of CFR evaluation offers valuable information to the angiography findings in the detection of CAV and could be helpful in selected patients to adjust the time and indications of coronary angiography.

Imaging functional stress test for stable chest pain symptoms in patients at low pretest probability of coronary artery disease: Current practice and long-term outcome

BACKGROUND

Stress testing in patients with low pretest probability (PTP) of coronary artery disease (CAD) has become an increasing practice, potentially leading to underestimation of its true clinical value. Our aim was to describe the current use of most employed imaging functional tests and their prognostic value.

METHODS AND RESULTS

We selected patients with low PTP of CAD (CAD consortium clinical score < 15%) who underwent exercise or dipyridamole stress echocardiography or single photon emission computed tomography for suspected angina. Main exclusions were age < 45, known CAD, and abnormal rest wall motion. Of the 2279 subjects undergoing stress test, 883 (39%) had low PTP, and 91 (10.3%) had a positive test for ischemia. After a median follow-up of 5.8 years, 36 patients had events (21 died, 14 had nonfatal myocardial infarction). The percentage of events in the abnormal and normal stress test groups were similar (5 [5.5%] vs 31 [3.9%], P = ns), as the annualized event rate (0.87% vs 0.62%, P = ns). Age was the only variable associated with outcome in the regression analysis (hazard ratio 1.072, 95% CI 1.034-1.113, P < 0.001). An abnormal result was not associated with worse outcome in each of the subgroups of functional tests.

CONCLUSIONS

In our geographical area, a considerable proportion of patients undergoing imaging functional tests for stable chest pain have a low estimated PTP of CAD. Of these, 1 in 10 resulted positive for inducible ischemia. However, none of the most common imaging functional tests, single photon emission computed tomography (SPECT), and stress echocardiography offer prognostic information in these patients.

Comparison of Contrast Enhanced Low-Dose Dobutamine Stress Echocardiography with 99mTc-Sestamibi Single-Photon Emission Computed Tomography in Assessment of Myocardial Viability

INTRODUCTION

Dobutamine stress echocardiography (DSE) and myocardial perfusion scan are the commonly used modalities to detect viable myocardium. DSE is comparatively cheaper and widely available but has a lower sensitivity.

AIM

We aimed to compare contrast-enhanced low-dose dobutamine echocardiography (LDDE) and gated 99mTc-sestamibi myocardial perfusion scan (MPS) for the degree of agreement in the detection of myocardial viability.

METHODS

We studied 850 left ventricular segments from 50 patients (42 men, mean age 55.5 years), with coronary artery disease and left ventricular systolic dysfunction (ejection fraction < 40%), using contrast-enhanced LDDE and 99mTc-Sestamibi gated SPECT. Segments were assessed for the presence of viability by both techniques and head to head comparisons were made.

RESULTS

Adequate visualisation increased from 80% in unenhanced segments to 96% in contrast-enhanced segments. Of the total 850 segments studied, 290 segments (34.1%) had abnormal contraction (dysfunctional). Among these, 138 were hypokinetic (16.2% of total), 144 were severely hypokinetic or akinetic (16.9% of total), and 8 segments were dyskinetic or aneurismal (0.9% of total). Among 151 segments considered viable by technetium, 137 (90.7%) showed contractile improvement with dobutamine; in contrast, only 8 of the 139 segments (5.7%) considered nonviable by technetium had a positive dobutamine response. The per cent of agreement between technetium uptake and a positive response to dobutamine was 78.6% with kappa = 0.63, suggestive of a substantial degree of agreement between the two modalities.

CONCLUSION

Use of contrast-enhanced LDDE significantly increased the adequate endocardial border visualisation. Furthermore, this study showed a strong degree of agreement between the modalities in the detection of viable segments. So, contrast-enhanced LDDE appears to be a safe and comparable alternative to MPS in myocardial viability assessment.

Influence of impaired right ventricular contractile reserve on exercise capacity in patients with precapillary pulmonary hypertension: A study with exercise stress echocardiography

OBJECTIVES

Right ventricular (RV) contractile reserve reflects the ability of RV to accommodate the increased afterload and may play an essential role in the evaluation of precapillary pulmonary hypertension (PH). This study aimed to assess RV contractile reserve based on exercise stress echocardiography (ESE) and to determine the echocardiographic determinants of exercise capacity in patients with precapillary PH.

METHODS

A total of 31 patients with precapillary PH and 15 age- and sex-matched healthy control subjects were prospectively recruited. All subjects underwent ESE to assess RV function at rest and under peak exercise. Changes in these parameters during exercise were calculated to quantify the RV contractile reserve. Patients with precapillary PH also underwent cardiopulmonary exercise test (CPET), and data pertaining to peak oxygen uptake (peak VO₂ ) and minute ventilation/carbon dioxide production (VE/VCO₂ ) were collected.

RESULTS

Right ventricular contractile reserve including change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler-derived tricuspid lateral annular peak systolic velocity (∆S') was significantly depressed in precapillary PH patients compared with control subjects (P < 0.05). Parameters of RV function and RV contractile reserve were markedly associated with maximal exercise capacity (P < 0.05). ∆RVFAC was an independent predictor of peak VO₂ (r²  = 0.601, P < 0.05).

CONCLUSIONS

Assessment of RV contractile reserve facilitates identification of subclinical dysfunction and evaluation of clinical status and severity of precapillary PH. ESE as a noninvasive method may provide a comprehensive clinical assessment and facilitate therapeutic decision-making for these patients.

Evaluation of myocardial viability in patients with acute myocardial infarction: Layer-specific analysis of 2-dimensional speckle tracking echocardiography

BACKGROUND

The value of layer-specific two-dimensional speckle tracking echocardiography (LS2D-STE) for evaluating viable myocardium (VM) in patients with acute myocardial infarction (AMI) was unclear, this study provides new insights into it and to make a comparison with dualisotope simultaneous acquisition single photon emission computed tomography ( DISA-SPECT).

METHODS

Forty hospitalized patients with AMI and left ventricular systolic dysfunction (left ventricular ejection fraction <50%) underwent LS2D-STE and DISA-SPECT before percutaneous coronary intervention (PCI). The longitudinal, circumferential, and radial peak systolic strains and the peak systolic strain rates of 3 myocardiallayers (endocardium, mid-myocardium, and epicardium), as well as the total wall thickness, were determined by LS2D-STE. Routine echocardiography was followedup at 1, 3, 6 months after PCI, with the improvement of the wall motion as the goldenstandard for evaluating VM.

RESULTS

The sensitivity, specificity and accuracy of DISA-SPECT for evaluating VM were 82.1%, 74.3%, and 79.3%, respectively. Among the layer-specific parameters, only endocardial (endo-) longitudinal strain (LS) and endo- longitudinal strain rate (LSr) were used as independent parameters for evaluating VM (P < .05), and the sensitivity, specificity and accuracy of endo-LS and endo-LSr in evaluation of VM were 77.1%, 65.4%, and 72.9% vs 72.9%, 65.4%, and 69.7%. Endo-LS and endo-LSr were superior to total wall thickness LS and LSr (AUC endo-LS 0.767 vs total-LS 0.669; endo-LSr 0.743 vs total-LSr 0.682). The parallel test and the serial test of combination of endo-LS and endo-LSr showed similar sensitivity, specificity and accuracy to DISA-SPECT (P > .05).

CONCLUSION

The endo-LS and endo-LSr analysis of LS2D-STE can evaluate the VM well, and its sensitivity, specificity and accuracy in detection of VM are similar to those of DISA-SPECT, resulting in LS2D-STE being a good option for the assessment of VM.

Validity of tortuosity severity index in chest pain patients with abnormal exercise test and normal coronary angiography

BACKGROUND

Coronary tortuosity (CT) had different definitions and scores in literature with unclear pathophysiological impact.

OBJECTIVES

To study degree of CT and it's relation to ischemic changes in patients with angina but normal coronary angiography (CA).

METHODS

We conducted a prospective study at University hospitals between May 2016 and January 2017. We included 200 consecutive patients who underwent CA due to chest pain assumed to be of cardiac origin, and their CA was normal (no diameter stenosis >30%, nor myocardial bridging). Patients were prospectively divided into 2 groups based on the presence (n = 113) or absence (n = 87) of ischemic changes during stress study and compared for clinical, echocardiographic and CA characteristics. A newly proposed Tortuosity Severity Index (TSI) was developed into significant (mild/moderate CT with more than 4 curvatures in total, or severe/extreme CT with any number of curvatures) or not significant TSI (mild CT with curvatures less than or equal to 4 curvatures in total).

RESULTS

Patients with ischemic changes had the highest rate of CT (76.5 vs 18%, p = 0.004) compared to those without. CT mostly affects the left anterior descending (LAD) coronary artery in mid and distal segments. Females, elderly, and hypertensives with left ventricular hypertrophy were strongly related to CT. Multivariate logistic regression analysis identified CT with significant TSI as the only predictor of ischemic changes in these patients (OR = 6.2, CI = 2.5-15.3, P = <0.001).

CONCLUSIONS

Coronary tortuosity is a strong predictor of anginal pain among patients with normal CA, despite positive stress study. This finding is more pronounced among elderly, hypertensive female patients.

Stress ECHO beyond coronary artery disease. Is it the holy grail of cardiovascular imaging?

Stress echocardiography (SE) is a very useful method in clinical practice, because it offers important information of both the patient's functional status and hemodynamic changes during stress. Therefore, SE provides strong diagnostic and prognostic data in a wide spectrum of cardiovascular diseases. This review summarizes the clinical applications of SE in conditions beyond coronary artery disease (CAD) and highlights practical recommendations and key issues for each condition that need further investigation. SE is an established method for the evaluation of symptomatic and asymptomatic patients with valvular heart disease (VHD) and cardiomyopathies, and provides important information regarding prognosis and management of patients with congenital heart disease, pulmonary hypertension or diastolic dysfunction. Moreover, when one or multiple VHD and cardiomyopathy or CAD coexist in one patient, SE is a very useful clinical tool for the evaluation of etiology and symptomatology.

Layer-specific strain in dipyridamole stress echo: A new tool for the diagnosis of microvascular angina

BACKGROUND

Dipyridamole stress echocardiography (DSE) represents a fundamental test in patients with suspected coronary artery disease (CAD). The diagnosis of microvascular disease is still challenging. We aimed to determine the diagnostic value of left ventricular (LV) layer-specific longitudinal (LS) and circumferential strain (CS) by Speckle Tracking in detecting CAD during DSE and to study if they can help in discriminate between a negative echo and a suspected microvascular angina.

METHODS AND RESULTS

We enrolled 66 patients with known or suspected CAD. All underwent standard DSE. We identified 3 groups according to the result of DSE (36 negative DSE, 19 positive DSE, 11 indicatives for microvascular disease). Wall motion score index, global LV LS and CS (global longitudinal strain [GLS] and global circumferential strain [GCS]), and layer-specific LV LS and CS were measured at rest and peak stress. The Delta between rest and peak stress values was calculated. GLS increased after injection in negative DSE and microvascular disease while reducing in positive DSE. Endocardial GCS and transmural GCS values were stable in microvascular disease while increasing significantly in negative DSE, helping in the diagnosis. The specific analysis of endocardial LS showed the most powerful difference between healthy and macrovascular CAD patients, both for LS and CS.

CONCLUSIONS

Global circumferential strain can be a new valuable added tool in the echocardiographic diagnosis of microvascular disease. Endocardial GLS is the best indicator of an altered wall deformation in the presence of macrovascular ischemia.

The Right Heart International Network (RIGHT-NET): Rationale, Objectives, Methodology, and Clinical Implications

The Right Heart International Network is a multicenter international study aiming to prospectively collect exercise Doppler echocardiography tests of the right heart pulmonary circulation unit (RHPCU) in large cohorts of healthy subjects, elite athletes, and individuals at risk of or with overt pulmonary hypertension. It is going to provide standardization of exercise stress echocardiography of RHPCU and explore the full physiopathologic response.

Stress Echocardiography: Need to Optimize its Appropriate Use in Suspected Angina and a Review of Available Additional Tools for its Clinical Application in 2018: First do no Harm! Second do it at the Highest Possible Accuracy

There is a need to reassess the most appropriate indications for stress echocardiography in the current era, in patients with suspect or known coronary artery disease (CAD), and also the most helpful additional parameters that can be easily calculated in clinical practice to increase the known suboptimal sensitivity for obstructive CAD of this test. The current review tries to clarify what is and what should be the proper role for functional testing in general, but specifically regarding modern stress echocardiography in the current practice, for suspected CAD and/or atypical chest pain. Few candidate additional parameters beyond wall motion assessment are here suggested to improve diagnostic accuracy of stress echocardiography, and pertinent literature is briefly reviewed, together with a more personal view of the author regarding the characteristics of each parameter, as far as ease of acquisition, cost, and true diagnostic or prognostic clinical usefulness are concerned. The reviewed additional parameters, which can be acquired during stress echocardiography, are Doppler coronary flow reserve in the left anterior descending artery, cardiac calcium score, global longitudinal strain, ventricular elastance, and contrast myocardial perfusion. Each of them finds a potential place in the current practice or may find a place in the future practice of stress echocardiography.

Exercise cardiac magnetic resonance imaging: a feasibility study and meta-analysis

Cardiac stress testing improves detection and risk assessment of heart disease. Magnetic resonance imaging (MRI) is the clinical gold-standard for assessing cardiac morphology and function at rest; however, exercise MRI has not been widely adapted for cardiac assessment because of imaging and device limitations. Commercially available magnetic resonance ergometers, together with improved imaging sequences, have overcome many previous limitations, making cardiac stress MRI more feasible. Here, we aimed to demonstrate clinical feasibility and establish the normative, healthy response to supine exercise MRI. Eight young, healthy subjects underwent rest and exercise cinematic imaging to measure left ventricular volumes and ejection fraction. To establish the normative, healthy response to exercise MRI we performed a comprehensive literature review and meta-analysis of existing exercise cardiac MRI studies. Results were pooled using a random effects model to define the left ventricular ejection fraction, end-diastolic, end-systolic, and stroke volume responses. Our proof-of-concept data showed a marked increase in cardiac index with exercise, secondary to an increase in both heart rate and stroke volume. The change in stroke volume was driven by a reduction in end-systolic volume, with no change in end-diastolic volume. These findings were entirely consistent with 17 previous exercise MRI studies (226 individual records), despite differences in imaging approach, ergometer, or exercise type. Taken together, the data herein demonstrate that exercise cardiac MRI is clinically feasible, using commercially available exercise equipment and vendor-provided product sequences and establish the normative, healthy response to exercise MRI.

Safety and efficacy of physiologist-led dobutamine stress echocardiography: experience from a tertiary cardiac centre

Background

Dobutamine stress echocardiography (DSE) services have traditionally been medically led. In some UK institutions, DSE lists are led by physiologists with medical support. In our tertiary cardiac centre at New Cross Hospital (NCH), the DSE service was established by a consultant echocardiographer. Following intensive training and assessment, the Trust approved drug administration by named senior cardiac physiologists. We believe this is the first report of a cardiac physiologist-managed DSE service, including physiologist drug administration. We have assessed the feasibility, safety and validity of this physiologist-led DSE service.

Methods

Retrospective analysis of 333 patients undergoing stress echocardiogram for inducible reversible ischaemia, myocardial viability and valvular heart disease over 6 months. Patients’ case notes review after 18–24 months.

Results

Overall, 92% of all cases (306) were performed by physiologists. In 300 studies, dobutamine was administered. The majority of the referrals were for coronary artery disease (CAD) assessment (281). In 235 cases, the study was uncomplicated. Sixty-seven patients developed dobutamine-related side effects. In 16 cases, complications led to early termination of the study. In two cases, urgent medical review was needed. Of the 281 studies for CAD assessment, 239 were negative for ischaemia, 28 were positive and 14 inconclusive. In 5 out of 28 cases with echocardiogram, evidence of inducible ischaemia, coronary angiography revealed unobstructed coronary arteries.

Conclusion

This study demonstrates the safety and effectiveness of this practice and provides potential for the expansion of the physiologists’ role and physiologist-led DSE services in other hospitals.

β-Blocker therapy for cirrhotic cardiomyopathy: a randomized-controlled trial

BACKGROUND

Cirrhotic cardiomyopathy is characterized by an attenuated contractile response to stress. Long-term exposure of β-adrenergic receptors to persistently high levels of catecholamines has been implicated in its pathogenesis. We hypothesized that β-blockade with metoprolol could reverse the changes in heart function and morphology in cirrhotic cardiomyopathy.

PATIENTS AND METHODS

In this prospective randomized trial, we included 78 patients aged between 18 and 60 years with abnormal cardiac output response under dobutamine stress echocardiography, without primary cardiac disease or a history of alcohol intake. Patients were assigned randomly to receive metoprolol or placebo for 6 months. The primary endpoint was the improvement in cardiac output response to stress, measured by an increase in the left ventricle stroke volume more than 30%.

RESULTS

Three (7.3%) patients in the metoprolol group and nine (24.3%) patients in the placebo group showed improved stroke volume (P=0.057). Diastolic dysfunction was found in two (4.8%) patients before and in five (15.6%) patients after therapy in the metoprolol group, and in 10 (27%) patients before and nine (31%) patients after therapy in the placebo group (P=0.67). After treatment, no echocardiography parameter of morphology was significantly different between metoprolol or placebo groups. No significant differences were observed in noradrenaline, plasma renin activity, and troponin levels between groups. Cirrhosis-related clinical events, including hospitalizations and mortality, were not significantly different between the two groups. Six months of therapy with β-blocker did not ameliorate heart function and morphology in patients with cirrhotic cardiomyopathy.

A randomized, triple-blind trial of cardiac shock-wave therapy on exercise tolerance and symptoms in patients with stable angina pectoris

BACKGROUND

Despite major advances in managing coronary artery disease and continuous research on alternative techniques to enhance myocardial perfusion and reduce symptoms, coronary artery disease is still one of the leading causes of adult disability worldwide. Cardiac shock-wave therapy (CSWT) has shown promising results in the amelioration of myocardial ischemia in experimental studies; however, clinical results are limited to single-center, mostly uncontrolled and underpowered trials. The current study aimed to evaluate whether CSWT can improve exercise tolerance and relieve angina symptoms in addition to optimal medical treatment in patients with stable angina.

PARTICIPANTS AND METHODS

A prospective, randomized, triple blind, sham-procedure-controlled study was carried out. The primary endpoint was total exercise duration in the modified Bruce treadmill test at the 6-month follow-up. The secondary endpoints were changes in ST-segment depression during the treadmill test, angina symptoms during the treadmill test, number of angina attacks per week, number of sublingual nitroglycerin consumption per week, Canadian Cardiovascular Society angina functional class, and the Seattle Angina Questionnaire score at the 6-month follow-up. Patients were randomized at a 1 : 1 ratio to optimal medical plus cardiac shock-wave therapy (OMT+CSWT) and optimal medical therapy with sham procedure (OMT+placebo) groups.

RESULTS

The mean exercise time improved in both study arms - CSWT and placebo treatment - at the 3- and 6-month follow-up, without a significant difference between groups. The magnitude and frequency of peak exercise ST-segment depression reduced significantly in the CSWT+OMT group compared with the OMT+placebo group at the 6-month follow-up (51.4 vs. 90.6%, P=0.001). Percentage of angina-free patients increased progressively in both groups throughout the study. The Seattle Angina Questionnaire scores improved significantly in both arms for four of five domains at the 3- and the 6-month follow-up. Numerically, although insignificant, the decrease in the number of angina episodes was more prominent in the OMT+CSWT group compared with the OMT+placebo group.

CONCLUSION

The total exercise duration in the modified Bruce treadmill test at the 6-month follow-up did not differ significantly in patients treated with CSWT compared with optimal medical therapy alone. In addition, CSWT exerted a neutral effect on the quality of life and level of angina.

Accuracy of cardiac magnetic resonance imaging to rule out significant coronary artery disease in patients with systolic heart failure of unknown aetiology: Single-centre experience and comprehensive meta-analysis

BACKGROUND

Coronary artery disease (CAD) is the leading cause of systolic heart failure (HF). Cardiac magnetic resonance imaging (CMR) is a non-invasive technique that detects a myocardial infarction scar as subendocardial or transmural late gadolinium enhancement (st-LGE).

AIM

We sought to evaluate whether a lack of st-LGE could rule out CAD in new-onset systolic HF of unknown aetiology.

METHODS

We included 232 consecutive patients with new-onset HF and left ventricular ejection fraction ≤35% who underwent both coronary angiography and CMR to assess HF aetiology. CAD was defined as the presence of coronary artery stenosis≥50% on a coronary angiogram. We assessed sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR) of the presence of st-LGE to detect underlying CAD. A complementary meta-analysis of 11 studies (including ours) was also performed.

RESULTS

In our study, 49 (21.1%) patients had CAD. The sensitivity and specificity of the presence of st-LGE to detect CAD were 69 and 92%, respectively. PLR and NLR were 8.47 and 0.33, respectively. In the meta-analysis, 1227 patients were included, and the prevalence of CAD ranged from 19.2 to 68.3%. Sensitivity, specificity, PLR and NLR were 87% (95% confidence interval [CI] 0.80-0.92), 93% (95% CI 0.89-0.96), 12.91 (95% CI 7.70-21.64) and 0.14 (95% CI 0.09-0.22), respectively. Altogether, 55 patients presented CAD with no st-LGE; inversely, 75 patients presented st-LGE with no CAD.

CONCLUSION

With a CMR specificity of 93%, the absence of st-LGE rules out significant underlying CAD in patients with systolic HF of unknown aetiology in most cases.

How I do it: feasibility of a new ultrasound probe fixator to facilitate high quality stress echocardiography

Background

Stress echocardiography (SE) has recently regained momentum as an important diagnostic tool for the assessment of both ischemic and non-ischemic heart disease. Performing SE during physical exercise is challenging due to a suboptimal patient position and vigorous movements of the patient’s chest. This hampers a stable ultrasound position and reduces the diagnostic performance of SE. A stable ultrasound probe position would facilitate producing high quality images during continuous measurements. With Probefix (Usono, Eindhoven, The Netherlands), a newly developed tool to fixate the ultrasound probe to the patient’s chest, stabilization of the probe during physical exercise is possible.

Implementation and results

The technique of SE with the Probefix and its’ feasibility are evaluated in a small pilot study. Probefix fixates the ultrasound probe to the patient’s chest, using two chest straps and a fixation device. The ultrasound probe position and angle may be altered with a relative high degree of freedom. We tested the Probefix for continuous echocardiographic imaging in 12 study subjects during supine and upright ergometer stress tests. One patient was unable to perform exercise and in two study subjects good quality images were not achieved. In the other patients (82%) a stable probe position was obtained, with subsequent good quality echocardiographic images during SE.

Conclusion

We have demonstrated the feasibility of the Probefix support during ergometer tests in supine and upright positions and conclude that this external fixator may facilitate continuous monitoring of cardiac function in a group of patients.

Electronic supplementary material

The online version of this article (10.1186/s12947-018-0124-0) contains supplementary material, which is available to authorized users.

Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association

The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.

High sensitivity cardiac troponins: Can they help in diagnosing myocardial ischaemia?

BACKGROUND

Cardiac troponin is the most sensitive marker of myocardial injury, but controversy still exists about its role in detecting ischaemia.

METHODS

To investigate the role of troponin as a marker of stress-induced ischaemia, circulating high sensitivity cardiac troponin T (hs-cTnT) was measured and compared with the MB fraction of creatine kinase (CK-MB) in 125 patients undergoing a stress test (53 electrocardiogram/echo exercise, 42 echo dipyridamole and 30 echo dobutamine tests).

RESULTS

Plasma concentrations of hs-cTnT increased after the tests in 90/125 patients, while an increase of CK-MB was seen in 31/125 patients ( p<0.0001). Overall, hs-cTnT significantly increased from 17.5±16.9 ng/l to 25.5±27.9 ng/l ( p<0.0001), without significant changes of CK-MB. Significant increments in hs-cTnT were documented after exercise test (from 15.9±11.9 ng/l to 19.5±13.6 ng/l, p<0.0001) and dobutamine test (from 20.6±20.8 ng/l to 37.8±31.1 ng/l, p=0.0006), in absence of changes in CK-MB according to each stressor. Among the 125 tests, 84 were diagnosed as negative and 41 as positive for myocardial ischaemia. Significant increments in hs-cTnT were detected after both negative (from 18.6±19.2 ng/l to 27.1±32.1 ng/l, p=0.0018) and positive test (from 15.2±10.8 ng/l to 22.3±16.2 ng/l, p=0.0005), without significant changes of CK-MB according to the test result. Despite a positive correlation between stress-induced increase of hs-cTnT and obstructive coronary artery disease, the release of troponin was observed also in a significant proportion of patients without coronary stenoses. Left ventricular hypertrophy markedly enhanced myocardial release of troponin.

CONCLUSIONS

Circulating troponin increases in most patients undergoing a stress test, irrespective of the test result and of coronary artery disease. Plasma release of troponin depends on multiple pathogenetic mechanisms, making the biomarker a not reliable tool in detecting transient ischaemia.

[Time course of changes in left ventricular twist in the presence of idiopathic left bundle branch block during exercise testing]

AIM

To investigate left ventricular (LV) deformation properties, rotation, and twist during a bicycle ergometer exercise test among patients with idiopathic left bundle branch block (LBBB).

SUBJECTS AND METHODS

Thirty-four patients with idiopathic LBBB having a mean QRS duration of 153±24 msec were examined. A control group included 18 apparently healthy volunteers. All the patients and apparently healthy individuals underwent echocardiography to determine LV hemodynamic parameters, deformity, rotation and twist at rest and after exercise test.

RESULTS

As compared with the control, the idiopathic LBBB group at rest showed decreases in LV global longitudinal deformity (-15.6±4.7 and -18.4±3.1%, respectively; p=0.037), apical rotation (4.59±4.2° and 8.99±3.68°; p=0.0067) and twist (9.08±4.59° and 13.96±4.61°; p=0.0156), whereas there were no differences in LV ejection fraction and end-systolic and end-diastolic volumes. After exercise testing there were no augmentations in basal and apical rotation and resulting ΔTwist in the idiopathic LBBB group compared with the control (-2.05±8.35 and 4.66±8.49%; p=0.0463). The described changes in LV rotation and twist during exercise testing occurred in the presence of elevated pulmonary artery systolic pressure (PASP) in the LBBB group compared with the control (41.6±3.81 and 32.4±3.81 mm Hg, respectively; p=0.0201).

CONCLUSION

Decreases in LV basal, apical and resulting twist may lead to elevated PASP in patients with idiopathic LBBB during exercise.

Stress Testing in Asymptomatic Aortic Stenosis

Aortic stenosis is 1 of the most common heart valve diseases among adults. When symptoms develop, prognosis is poor, and current guidelines recommend prompt aortic valve replacement. Depending of the severity of the aortic stenosis and the presence of concomitant heart disease and medical comorbidities, stress testing represents a reasonable strategy to help better risk stratify asymptomatic patients. The present report provides a comprehensive review of the current available data on stress testing in aortic stenosis and subsequently summarizes its potential for guiding the optimal timing of aortic valve replacement.

Preoperative cardiac evaluation with transthoracic echocardiography before non-cardiac surgery

Transthoracic echocardiography has become increasingly popular in clinical practice. It is used for the functional evaluation of patients with various cardiovascular diseases. Its use has been extended further in routine screening for cardiovascular health and in preoperative risk assessment before non-cardiac surgery because it is non-invasive, easy to perform, reproducible, and cost-effective. When the results of preoperative echocardiography contain abnormalities, the findings must be interpreted to determine clinical relevance. However, when the results of preoperative echocardiography are apparently normal, many physicians and surgeons readily think that the patient will not have any cardiovascular events in the future, or at least in the perioperative period. In this review, we will cover 1) current guidelines for preoperative echocardiographic assessment, 2) specific cardiac conditions for which the non-cardiac surgery should be delayed, 3) commonly encountered echocardiographic findings before non-cardiac surgeries, 4) application of stress echocardiography, and 5) clinical perspectives of focused transthoracic echocardiography before non-cardiac surgery.

Four-dimensional echocardiography area strain combined with exercise stress echocardiography to evaluate left ventricular regional systolic function in patients with mild single vessel coronary artery stenosis

BACKGROUND

The aim of this prospective study was to assess the diagnosis value of four-dimensional echocardiography area strain (AS) combined with exercise stress echocardiography to evaluate left ventricular regional systolic function in patients with mild single vessel coronary artery stenosis.

METHODS

Based on treadmill exercise load status, two-dimensional conventional echocardiography and four-dimensional echocardiography area strain were performed on patients suspected coronary artery disease before coronary angiogram. Thirty patients (case group) with mild left anterior descending coronary artery stenosis (stenosis <50%) and thirty gender- and age-matched patients (control group) without coronary artery stenosis according to the coronary angiogram results were prospectively enrolled.

RESULTS

All the patients had no left ventricular regional wall motion abnormality in two-dimensional echocardiography at rest and exercise stress. There was no significant difference in the 16 segmental systolic peak AS at rest between two groups. After exercise stress, the peak systolic AS_rest-stress at mid anterior wall (-7.00%±10.90% vs 2.80%±23.69%) and mid anterolateral wall (-4.40%±18.81% vs 8.80%±19.16%) were decreased, while increased at basal inferolateral wall (14.00%±19.27% vs -5.60%±15.94%) in case group compared with control group (P<.05).

CONCLUSIONS

In patients with mild single vessel coronary artery stenosis, the area strain was decreased at involved segments, while compensatory increased at noninvolved segments after exercise stress. Four-dimensional echocardiography area strain combined with exercise stress echocardiography could sensitively find left ventricular regional systolic function abnormality in patients with mild single vessel coronary artery stenosis, and locate stenosis coronary artery accordingly.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016

INTRODUCTION

The modern care of suspected and confirmed acute coronary syndrome (ACS) is informed by an extensive and evolving evidence base. This clinical practice guideline focuses on key components of management associated with improved clinical outcomes for patients with chest pain or ACS. These are presented as recommendations that have been graded on both the strength of evidence and the likely absolute benefit versus harm. Additional considerations influencing the delivery of specific therapies and management strategies are presented as practice points.

MAIN RECOMMENDATIONS

This guideline provides advice on the standardised assessment and management of patients with suspected ACS, including the implementation of clinical assessment pathways and subsequent functional and anatomical testing. It provides guidance on the: diagnosis and risk stratification of ACS; provision of acute reperfusion therapy and immediate post-fibrinolysis care for patients with ST segment elevation myocardial infarction; risk stratification informing the use of routine versus selective invasive management for patients with non-ST segment elevation ACS; administration of antithrombotic therapies in the acute setting and considerations affecting their long term use; and implementation of an individualised secondary prevention plan that includes both pharmacotherapies and cardiac rehabilitation. Changes in management as a result of the guideline: This guideline has been designed to facilitate the systematic integration of the recommendations into a standardised approach to ACS care, while also allowing for contextual adaptation of the recommendations in response to the individual's needs and preferences. The provision of ACS care should be subject to continuous monitoring, feedback and improvement of quality and patient outcomes.

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

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.

Addition of Exercise to Dipyridamole Stress Echocardiography in Order to Carry on the Ischemic Cascade: Role in the Diagnosis of Coronary Artery Disease and Prognostic Value

Background:

Sensitivity of dipyridamole stress echocardiography (SE) is often lower than required. The aim of the present work is the evaluation of the association of dipyridamole and exercise echocardiography.

Methods:

From June 2007 to January 2011, 259 consecutive patients referred to Camposampiero Echocardiography Laboratory underwent SE. Stress protocol started with dipyridamole infusion of 0.84 mg/kg over 6 min. In patients without a new dyssynergy after dipyridamole, SE was carried on with supine exercise. If endocardial border detection was suboptimal, ultrasound contrast agent was used. Coronary angiography was performed in positive patients. The events recorded during the follow-up were cardiac death, nonfatal myocardial infarction (hard events), and coronary revascularization.

Results:

Of 259 patients, 74 had a positive result: 37 were positive after infusion of dipyridamole, and 37 became positive during exercise. All 74 positive patients underwent coronary angiography: 67 had significant coronary artery disease (36 positive with dipyridamole, and 31 positive with exercise), and 7 had not significant artery disease. In positive patients, the coronary revascularizations were 40. Furthermore, 3 of the 185 negative patients underwent coronary revascularization. During follow-up of 20 ± 10 months, 6 (8.1%) hard events occurred in positive patients. No hard event was observed in negative patients.

Conclusions:

Dipyridamole SE with the addition of exercise can be proposed as a strategy to carry on the ischemic cascade and to identify the patients who elude the dipyridamole alone SE. A negative result is suggestive of a very good prognosis, free from hard events at 20 ± 10 months.

ANMCO-SIMEU Consensus Document: in-hospital management of patients presenting with chest pain

Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. However, the evaluation of acute chest pain remains challenging, despite many new insights over the past two decades. The percentage of patients presenting to the emergency departments because of acute chest pain appears to be increasing. Nowadays, there are two essential chest pain-related issues: (i) the missed diagnoses of acute coronary syndromes with a poor short-term prognosis; and (ii) the increasing percentage of hospitalizations of low-risk cases. It is well known that hospitalization of a low-risk chest pain patient can lead to unnecessary tests and procedures, with an increasing trend of complications and burden of costs. Therefore, the significantly reduced financial resources of healthcare systems induce physicians and administrators to improve the efficiency of care protocols for patients with acute chest pain. Despite the efforts of the Scientific Societies in producing statements on this topic, in Italy there is still a significant difference between emergency physicians and cardiologists in managing patients with chest pain. For this reason, the aim of the present consensus document is double: first, to review the evidence-based efficacy and utility of various diagnostic tools, and, second, to delineate the critical pathways (describing key steps) that need to be implemented in order to standardize the management of chest pain patients, making a correct diagnosis and treatment as uniform as possible across the entire country.

Cardiac Imaging in the Diagnosis of Coronary Artery Disease

Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.

Peripartum cardiomyopathy, what if your patient plans to reconceive?

Patients with peripartum cardiomyopathy (PPCM) often express a desire to conceive again, and the risk of relapse in future pregnancies should be disclosed. No consensus is available that can determine that risk. Adequate contractile reserve, evidenced by a stress echocardiogram (exercise or dobutamine), can identify those with lower relapse risk.

Predictors and prognostic significance of atrial fibrillation developed during dobutamine stress echocardiography: A propensity score-matched comparison

AIMS

Atrial fibrillation (AF) uncommonly occurs during dobutamine stress echocardiography (DSE). We aimed to characterize the predictors and long-term prognostic significance of AF during DSE.

METHODS

The clinical, echocardiographic, and outcome data of patients in sinus rhythm who developed AF during DSE were reviewed and compared to a propensity score-matched group of controls.

RESULTS

Atrial fibrillation developed in 73 (1% of 7026) patients (age 70±10 years, 58% men). Compared to 144 propensity score-matched controls without AF during DSE, those with AF were more likely to have had history of prior AF (23% vs 8%, P=.002), known coronary artery disease (CAD; 22% vs 10%, P=.037), enlarged left ventricle (LV; 27% vs 9%, P=.002), LV wall-motion abnormality (33% vs 12%, P<.0001), enlarged aortic root (22% vs 8%, P=.009), or dilated left atrium (52% vs 30%, P=.002). Multivariate logistic regression analysis identified prior history of AF (OR=3.7, 95% CI 1.5-9.0, P=.005), larger LV size (OR=3.1, 95% CI 1.3-7.3, P=.009), and lower LV ejection fraction (OR=-0.95, 95% CI -0.92 to -0.99, P=.02) as independent predictors of AF during DSE. At a mean follow-up period of 3.4 (0.5-7.3) years, those with AF during DSE were more likely to develop new coronary events (22% vs 10%, P=.0372), new-onset heart failure (19% vs 4%, P=.0003), or die from any cause (27% vs 6%, P<.0001). Kaplan-Meier curves demonstrated significantly lower event-free survival in patients compared to controls (P by log-rank test=.001) over the follow-up period.

CONCLUSION

Dobutamine-induced AF occurs more commonly in those with prior history of AF and remodeled LV and is associated with unfavorable outcomes.

Assessment of global left ventricular excursion using three-dimensional dobutamine stress echocardiography to identify significant coronary artery disease

BACKGROUND

Quantitative three-dimensional (3D) dobutamine stress echocardiography (DSE) for myocardial ischemia detection may be an adjuvant to left ventricular (LV) wall-motion analysis. The aim of the current study was to assess the association between global 3D LV excursion during DSE and the presence of significant coronary artery disease (CAD) on coronary angiography.

METHODS

Three-dimensional DSE was performed in 40 patients (67±12 years, 68% male) who underwent subsequent coronary angiography (median 1.6 months later). Using 3D echocardiography, global LV excursion was measured (in a total of 680 segments) at rest and peak dose and the change between stages was calculated (peak-rest=∆global LV excursion). Significant CAD was defined as >70% stenosis on coronary angiography.

RESULTS

In total, 25 patients (63%) demonstrated significant CAD on coronary angiography. At rest, global LV excursion was similar in patients with and without significant CAD (5.1±0.2 vs 5.0±0.2 mm, P=.74). However, patients with significant CAD demonstrated a worsening in global LV excursion from rest to peak stress (from 5.1±0.2 to 4.1±0.2 mm, P<.001), while global LV excursion in patients without significant CAD remained unchanged (from 5.0±0.2 to 5.5±0.2 mm, P=.10). After adjusting for clinically relevant characteristics, ∆global LV excursion was independently associated with significant CAD (odds ratio 0.29, 95% confidence interval 0.12-0.72, P=.008).

CONCLUSIONS

Analysis of 3D echocardiographic LV excursion at global level on full-protocol DSE may be a helpful tool to detect CAD on coronary angiography.

The declining frequency of inducible myocardial ischemia during stress echocardiography over 27 consecutive years (1983-2009)

BACKGROUND

Previous studies have suggested a decline in positivity of stress cardiac imaging, suggesting the need for developing better strategies for test selection to achieve acceptable cost-effectiveness balance. The aim of this retrospective study was to assess the rate of positivity of stress echocardiography (SE) over 27 consecutive years.

METHODS

We assessed the rate of SE positivity in 2007 patients without previous myocardial infarction or coronary revascularization who performed SE in a tertiary care referral center from 1983 to 2009. SE was performed with dipyridamole (1427), dobutamine (136) or exercise (444).

RESULTS

There was a progressive decline over time in the rate of SE positivity from 42% (1983-1991) to 22% (2001-2009), with a relative increase of patients with low pre-test probability of disease (from 5% to 27%). The percentage of patients studied with SE under anti-ischemic therapy increased markedly (from 8% in the first to 61% in the last nine years).

CONCLUSION

Over 27 consecutive years, we observed a steady decline in SE positivity rate (with >5-fold increase of low probability patients), with almost 8-fold increase in anti-ischemic therapy at testing. We probably need refined criteria of referral for testing and/or better ways to titrate the negative response beyond wall motion abnormalities during SE.

Pressure-volume Relationship in the Stress-echocardiography Laboratory: Does (Left Ventricular End-diastolic) Size Matter?

INTRODUCTION AND OBJECTIVES

The variation between rest and peak stress end-systolic pressure-volume relation is an afterload-independent index of left ventricular contractility. Whether and to what extent it depends on end-diastolic volume remains unclear. The aim of this study was to assess the dependence of the delta rest-stress end-systolic pressure-volume relation on end-diastolic volume in patients with negative stress echo and all ranges of resting left ventricular function.

METHODS

We analyzed interpretable data obtained in 891 patients (593 men, age 63 ± 12 years) with ejection fraction 47% ± 12%: 338 were normal or near-normal or hypertensive; 229 patients had coronary artery disease; and 324 patients had ischemic or nonischemic dilated cardiomyopathy. They were studied with exercise (n = 172), dipyridamole (n = 482) or dobutamine (n = 237) stress echocardiography. The end-systolic pressure-volume relation was evaluated at rest and peak stress from raw measurement of systolic arterial pressure by cuff sphygmomanometer and end-systolic volume by biplane Simpson rule 2-dimensional echocardiography.

RESULTS

Absolute values of delta rest-stress end-systolic pressure-volume relation were higher for exercise and dobutamine than for dipyridamole. In the overall population, an inverse relationship between end-systolic pressure-volume relation and end-diastolic volume was present at rest (r² = 0.69, P < .001) and peak stress (r² = 0.56, P < .001), but was absent if the delta rest-stress end-systolic pressure-volume relation was considered (r² = 0.13).

CONCLUSIONS

Left ventricular end-diastolic volume does not affect the rest-stress changes in end-systolic pressure-volume relation in either normal or abnormal left ventricles during physical or pharmacological stress.

Layer-specific analysis of dobutamine stress echocardiography for the evaluation of coronary artery disease

Although dobutamine stress echocardiography (DSE) is a well-defined tool for the diagnosis of coronary artery disease (CAD), false-negative and false-positive results still occur. This study investigated the diagnostic role of layer-specific analysis using 2-dimensional speckle-tracking echocardiography (STE) during DSE.A total of 121 patients who underwent DSE and showed normal wall motion and ejection fraction during baseline echocardiography were enrolled. All patients underwent coronary angiography after DSE within 2 weeks. The patients were divided into the following 4 groups according to DSE results and CAD status: negative DSE with no significant CAD (n = 73), positive DSE with significant CAD (n = 16), negative DSE with significant CAD (n = 17), and positive DSE with no significant CAD (n = 15). Layer-specific global longitudinal strain (GLS) was assessed in the endocardium, mid-myocardium, and epicardium by STE techniques.Patients with significant CAD were older, more male and showed higher glucose level compared to patients without CAD. But coronary risk factors and previous medications were not different between patients with and without CAD. There were no significant differences in whole myocardium or layer-specific GLS found in the baseline echocardiography. During recovery echocardiography, endocardial GLS was significantly different between patients with and without CAD, regardless of the DSE results. A receiver-operating characteristic curve analysis showed that endocardial GLS (>-16%) was superior for identifying significant CAD during the DSE recovery stage. Diagnostic accuracy was improved by applying the results of endocardial GLS compared with visual estimation of DSE.The assessment of layer-specific strain by STE during DSE was feasible, and the evaluation of poststress endocardial function is a more sensitive tool for the detection of CAD.

[Is stress cardiovascular magnetic resonance really useful to detect ischemia and predict events in patients with different cardiovascular risk profile?]

OBJECTIVE

The aim of this study was to evaluate the diagnostic and prognostic usefulness of stress cardiovascular magnetic resonance (stress CMR) in patients with different cardiovascular risk profile and to assess if the degree of hypoperfusion is important to guide clinical decisions.

METHOD

We included patients submitted to adenosine stress CMR to rule out myocardial ischemia. We evaluated its diagnostic accuracy with likelihood ratio (LR) and its prognostic value with survival curves and a Cox regression model.

RESULTS

295 patients were studied. The positive LR was 3.40 and the negative one 0.47. The maximal usefulness of the test was found in patients without previous ischemic cardiomyopathy (positive LR 4.85), patients with atypical chest pain (positive LR 8.56), patients with low or intermediate cardiovascular risk (positive LR 3.87) and those with moderate or severe hypoperfusion (positive LR 8.63). Sixty cardiovascular major events were registered. The best survival prognosis was found in patients with a negative result (p=0.001) or mild hypoperfusion (p=0.038). In the multivariate analysis, a moderate or severe hypoperfusion increased cardiovascular event probability (HR=2.2; IC 95% 1.26-3.92), with no differences between a mild positive and a negative result (HR=0.93; IC 95% 0.38-2.28).

CONCLUSIONS

Stress CMR was specially useful in patients with low or intermediate cardiovascular risk, patients with atypical chest pain, patients without previous ischemic cardiomyopathy and those with moderate or severe hypoperfusion. Hypoperfusion degree was the main issue factor to guide clinical decisions.