1
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Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L, Van De Heyning CM, Celutkiene J, Gaibazzi N, Ciampi Q, Senior R, Neskovic AN, Henein M. The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. Eur Heart J Cardiovasc Imaging 2024; 25:e65-e90. [PMID: 37798126 DOI: 10.1093/ehjci/jead250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology of the National Research Council, CNR, Via Moruzzi 1, 56124 Pisa, Italy
| | - Luc Pierard
- University of Liège, Walloon Region, Belgium
| | - Jesus Peteiro
- CHUAC-Complexo Hospitalario Universitario A Coruna, CIBER-CV, University of A Coruna, 15070 La Coruna, Spain
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Centre of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center UPMC Heart & Vascular Institute, Pittsburgh, PA, USA
| | | | | | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, 43100 Parma, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy
| | - Roxy Senior
- Imperial College, UK
- Royal Brompton Hospital Imperial College London, UK
- Northwick Park Hospital, London, UK
| | - Aleksandar N Neskovic
- Department of Cardiology, University Clinical Hospital Center Zemun-Belgrade Faculty of Medicine, University of Belgrade, Serbia
| | - Michael Henein
- Department of Public Health and Clinical Medicine Units: Section of Medicine, Umea University, Umea, Sweden
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2
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O’Driscoll JM, Hawkes W, Beqiri A, Mumith A, Parker A, Upton R, McCourt A, Woodward W, Dockerill C, Sabharwal N, Kardos A, Augustine DX, Balkhausen K, Chandrasekaran B, Firoozan S, Marciniak A, Heitner S, Yadava M, Kaul S, Sarwar R, Sharma R, Woodward G, Leeson P. Left ventricular assessment with artificial intelligence increases the diagnostic accuracy of stress echocardiography. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac059. [PMID: 36284642 PMCID: PMC9580364 DOI: 10.1093/ehjopen/oeac059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/26/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
AIMS To evaluate whether left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS), automatically calculated by artificial intelligence (AI), increases the diagnostic performance of stress echocardiography (SE) for coronary artery disease (CAD) detection. METHODS AND RESULTS SEs from 512 participants who underwent a clinically indicated SE (with or without contrast) for the evaluation of CAD from seven hospitals in the UK and US were studied. Visual wall motion scoring (WMS) was performed to identify inducible ischaemia. In addition, SE images at rest and stress underwent AI contouring for automated calculation of AI-LVEF and AI-GLS (apical two and four chamber images only) with Ultromics EchoGo Core 1.0. Receiver operator characteristic curves and multivariable risk models were used to assess accuracy for identification of participants subsequently found to have CAD on angiography. Participants with significant CAD were more likely to have abnormal WMS, AI-LVEF, and AI-GLS values at rest and stress (all P < 0.001). The areas under the receiver operating characteristics for WMS index, AI-LVEF, and AI-GLS at peak stress were 0.92, 0.86, and 0.82, respectively, with cut-offs of 1.12, 64%, and -17.2%, respectively. Multivariable analysis demonstrated that addition of peak AI-LVEF or peak AI-GLS to WMS significantly improved model discrimination of CAD [C-statistic (bootstrapping 2.5th, 97.5th percentile)] from 0.78 (0.69-0.87) to 0.83 (0.74-0.91) or 0.84 (0.75-0.92), respectively. CONCLUSION AI calculation of LVEF and GLS by contouring of contrast-enhanced and unenhanced SEs at rest and stress is feasible and independently improves the identification of obstructive CAD beyond conventional WMSI.
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Affiliation(s)
| | | | - Arian Beqiri
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
| | - Angela Mumith
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
| | - Andrew Parker
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
| | - Ross Upton
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Annabelle McCourt
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - William Woodward
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Cameron Dockerill
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Nikant Sabharwal
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes MK6 5LD, UK
| | - Daniel X Augustine
- Department of Cardiology, Royal United Hospitals NHS Foundation Trust, Bath BA1 3NG, UK
- Department for Health, University of Bath, Bath BA2 7JU, UK
| | - Katrin Balkhausen
- Department of Cardiology, Royal Berkshire NHS Foundation Trust, Reading RG1 5AN, UK
| | | | - Soroosh Firoozan
- Department of Cardiology, Buckinghamshire Healthcare NHS Trust, High Wycombe HP7 0JD, UK
| | - Anna Marciniak
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Stephen Heitner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Mrinal Yadava
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Sanjiv Kaul
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR 97239, USA
| | - Rizwan Sarwar
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
- Experimental Therapeutics, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rajan Sharma
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - Gary Woodward
- Ultromics Ltd, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Oxford OX4 2SU, UK
| | - Paul Leeson
- Corresponding author. Tel: +44 (0)1865 572846, Fax: +44 (0)1865 740449,
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3
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Lu D, Beyer AT, Pursnani SK, Shaw RE, Fang Q, Bibby D, Rosenblatt A, Schiller NB. Left ventricular end‐systolic volume response post‐stress echocardiography: Dilation as a marker of multi‐vessel coronary artery disease. Echocardiography 2022; 39:215-222. [DOI: 10.1111/echo.15291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/21/2021] [Accepted: 12/26/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Dai‐Yin Lu
- Division of Cardiology University of California San Francisco California USA
- Institute of Public Health National Yang Ming Chiao Tung University Taipei Taiwan
| | - Anna T. Beyer
- Division of Cardiology University of California San Francisco California USA
- Division of Cardiology California Pacific Medical Center San Francisco California USA
| | - Seema K. Pursnani
- Kaiser Permanente Santa Clara Medical Center Santa Clara California USA
| | - Richard E. Shaw
- Division of Cardiology California Pacific Medical Center San Francisco California USA
| | - Qizhi Fang
- Division of Cardiology University of California San Francisco California USA
| | - Dwight Bibby
- Division of Cardiology University of California San Francisco California USA
| | - Andrew Rosenblatt
- Division of Cardiology California Pacific Medical Center San Francisco California USA
| | - Nelson B. Schiller
- Division of Cardiology University of California San Francisco California USA
- Division of Cardiology California Pacific Medical Center San Francisco California USA
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4
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Lu DY, Yalçin H, Sivalokanathan S, Greenland GV, Vasquez N, Yalçin F, Zhao M, Valenta I, Ganz P, Pampaloni MH, Zimmerman S, Schindler TH, Abraham TP, Abraham MR. Higher incidence of vasodilator-induced left ventricular cavity dilation by PET when compared to treadmill exercise-ECHO in hypertrophic cardiomyopathy. J Nucl Cardiol 2020; 27:2031-2043. [PMID: 30456498 DOI: 10.1007/s12350-018-01521-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Vasodilator-induced transient left ventricular cavity dilation (LVCD) by positron emission tomography (PET) is associated with microvascular dysfunction in hypertrophic cardiomyopathy (HCM). Here we assessed whether HCM patients who develop LVCD by PET during vasodilator stress also develop LV cavity dilation by echocardiography (ECHO-LVCD) following exercise stress. METHODS A retrospective analysis of cardiac function and myocardial blood flow (MBF) was conducted in 108 HCM patients who underwent perfusion-PET and exercise-ECHO as part of their clinical evaluation. We performed a head-to-head comparison of LV volumes and ejection fraction (LVEF) at rest and stress (during vasodilator stress, post-exercise), in 108 HCM patients. A ratio > 1.13 of stress to rest LV volumes was used to define PET-LVCD, and a ratio > 1.17 of stress to rest LVESV was used to define ECHO-LVCD. Patients were divided into 2 groups based on the presence/absence of PET-LVCD. MBF and myocardial flow reserve were quantified by PET, and global longitudinal strain (GLS) was assessed by ECHO at rest/stress in the two groups. RESULTS PET-LVCD was observed in 51% (n = 55) of HCM patients, but only one patient had evidence of ECHO-LVCD (ratio = 1.36)-this patient also had evidence of PET-LVCD (ratio = 1.20). The PET-LVCD group had lower PET-LVEF during vasodilator stress, but ECHO-LVEF increased in both groups post-exercise. The PET-LVCD group demonstrated higher LV mass, worse GLS at rest/stress, and lower myocardial flow reserve. Incidence of ischemic ST-T changes was higher in the PET-LVCD group during vasodilator stress (42 vs 17%), but similar (30%) in the two groups during exercise. CONCLUSION PET-LVCD reflects greater degree of myopathy and microvascular dysfunction in HCM. Differences in the cardiac effects of exercise and vasodilators and timing of stress-image acquisition could underlie discordance in ischemic EKG changes and LVCD by ECHO and PET, in HCM.
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Affiliation(s)
- Dai-Yin Lu
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Hulya Yalçin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Sanjay Sivalokanathan
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Gabriela V Greenland
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - Nestor Vasquez
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Fatih Yalçin
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
| | - Min Zhao
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Ines Valenta
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Ganz
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - Miguel Hernandez Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, USA
| | - Stefan Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Thomas H Schindler
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA
| | - M Roselle Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, Johns Hopkins University, Baltimore, MD, USA.
- Division of Cardiology, University of California San Francisco, 555 Mission Bay Blvd South, Smith Cardiovascular Research Building, 452K, San Francisco, CA, 94158, USA.
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5
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Bombardini T, Zagatina A, Ciampi Q, Cortigiani L, D'Andrea A, Borguezan Daros C, Zhuravskaya N, Kasprzak JD, Wierzbowska-Drabik K, de Castro E Silva Pretto JL, Djordjevic-Dikic A, Beleslin B, Petrovic M, Boskovic N, Tesic M, Monte IP, Simova I, Vladova M, Boshchenko A, Ryabova T, Citro R, Amor M, Vargas Mieles PE, Arbucci R, Dodi C, Rigo F, Gligorova S, Dekleva M, Severino S, Torres MA, Salustri A, Rodrìguez-Zanella H, Costantino FM, Varga A, Agoston G, Bossone E, Ferrara F, Gaibazzi N, Rabia G, Celutkiene J, Haberka M, Mori F, D'Alfonso MG, Reisenhofer B, Camarozano AC, Salamé M, Szymczyk E, Wejner-Mik P, Wdowiak-Okrojek K, Kovacevic Preradovic T, Lattanzi F, Morrone D, Scali MC, Ostojic M, Nikolic A, Re F, Barbieri A, DI Salvo G, Colonna P, DE Nes M, Paterni M, Merlo PM, Lowenstein J, Carpeggiani C, Gregori D, Picano E. Feasibility and value of two-dimensional volumetric stress echocardiography. Minerva Cardiol Angiol 2020; 70:148-159. [PMID: 32657562 DOI: 10.23736/s2724-5683.20.05304-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV). METHODS We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638). RESULTS Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume. CONCLUSIONS Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.
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Affiliation(s)
- Tonino Bombardini
- Faculty of Medicine, University of Banja-Luka, Clinical Center of The Republic of Srpska, Banja-Luka, Bosnia-Herzegovina
| | - Angela Zagatina
- Department of Cardiology, Saint Petersburg University Clinic, Saint Petersburg University, Russia
| | - Quirino Ciampi
- Division of Cardiology, Fatebenefratelli Hospital, Benevento, Italy
| | | | - Antonello D'Andrea
- Department of Cardiology, Echocardiography Lab and Rehabilitation Unit, Monaldi Hospital, Second University of Naples, Naples, Italy
| | | | - Nadezhda Zhuravskaya
- Department of Cardiology, Saint Petersburg University Clinic, Saint Petersburg University, Russia
| | | | | | | | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Marija Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Ines P Monte
- Echocardiography Lab, Department of Cardiothoracic and Vascular Medicine, A.O.U. Policlinic Rodolico, University of Catania, Catania, Italy
| | - Iana Simova
- Department of Cardiology, Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | - Martina Vladova
- Department of Cardiology, Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | - Alla Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - Tamara Ryabova
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russia
| | - Rodolfo Citro
- Echocardiography Lab, Department of Cardiology, San Giovanni di Dio e Ruggi d'Aragona University Hospital, Salerno, Italy
| | - Miguel Amor
- Ramos Mejia Hospital, Buenos Aires, Argentina
| | | | - Rosina Arbucci
- Service of Heart Diagnostics, Investigaciones Medicas, Buenos Aires, Argentina
| | - Claudio Dodi
- Casa di Cura Figlie di San Camillo, Cremona, Italy
| | - Fausto Rigo
- Department of Cardiology, Ospedale dell'Angelo, Mestre, Venice, Italy
| | | | | | - Sergio Severino
- Coronary Care Unit, Department of Cardiology, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Marco A Torres
- Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Alessandro Salustri
- Department of Non-invasive Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Albert Varga
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Gergely Agoston
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | | | | | - Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Granit Rabia
- Department of Cardiology, Parma University Hospital, Parma, Italy
| | - Jelena Celutkiene
- Center of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University Hospital, Vilnius, Lithuania
| | - Maciej Haberka
- Department of Cardiology, SHS, Medical University of Silesia, Katowice, Poland
| | - Fabio Mori
- Section of Cardiovascular Diagnostics, Department of Cardiothoracic and Vascular Medicine, Careggi University Hospital, Florence, Italy
| | - Maria G D'Alfonso
- Section of Cardiovascular Diagnostics, Department of Cardiothoracic and Vascular Medicine, Careggi University Hospital, Florence, Italy
| | - Barbara Reisenhofer
- Division of Cardiology, Pontedera-Volterra Hospital, ASL Toscana3 Nord-Ovest, Pontedera, Pisa, Italy
| | - Ana C Camarozano
- Hospital de Clinicas UFPR, Department of Medicine, Federal University of Paranà, Curitiba, Brazil
| | | | - Ewa Szymczyk
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | - Paulina Wejner-Mik
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | | | - Tamara Kovacevic Preradovic
- Faculty of Medicine, University of Banja-Luka, Clinical Center of The Republic of Srpska, Banja-Luka, Bosnia-Herzegovina
| | - Fabio Lattanzi
- Department of Surgical, Medical, Molecular Pathology and Critical Area Medicine, Section of Cardiovascular Diseases, University of Pisa, Pisa, Italy
| | - Doralisa Morrone
- Department of Surgical, Medical, Molecular Pathology and Critical Area Medicine, Section of Cardiovascular Diseases, University of Pisa, Pisa, Italy
| | - Maria C Scali
- Nottola-Montepulciano Hospital, Division of Cardiology, ASL Toscana Centro, Siena, Italy
| | - Miodrag Ostojic
- School of Medicine, Institute for Cardiovascular Disease Dedinje, Belgrade, Serbia
| | - Aleksandra Nikolic
- School of Medicine, Institute for Cardiovascular Disease Dedinje, Belgrade, Serbia
| | - Federica Re
- San Camillo Hospital, Division of Cardiology, Rome, Italy
| | - Andrea Barbieri
- Division of Cardiology, Policlinico University Hospital, Modena, Italy
| | - Giovanni DI Salvo
- Division of Cardiology, Department of Pediatric Cardiology, Brompton Hospital, Imperial College of London, London, UK
| | - Paolo Colonna
- Cardiology Hospital, Policlinico University Hospital, Bari, Italy
| | - Michele DE Nes
- Department of Biomedicine, Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Marco Paterni
- Department of Biomedicine, Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Pablo M Merlo
- Service of Heart Diagnostics, Investigaciones Medicas, Buenos Aires, Argentina
| | - Jorge Lowenstein
- Service of Heart Diagnostics, Investigaciones Medicas, Buenos Aires, Argentina
| | - Clara Carpeggiani
- Department of Biomedicine, Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy
| | - Dario Gregori
- Biostatistics, Epidemiology and Public Health Unit, Padua University, Padua, Italy
| | - Eugenio Picano
- Department of Biomedicine, Institute of Clinical Physiology, National Research Council (CNR), Pisa, Italy -
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Park JR, Chung SP, Hwang SY, Shin TG, Park JE. Myocardial infarction evaluation from stopping time decision toward interoperable algorithmic states in reinforcement learning. BMC Med Inform Decis Mak 2020; 20:99. [PMID: 32487133 PMCID: PMC7472590 DOI: 10.1186/s12911-020-01133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 05/17/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The Elliot wave principle commonly characterizes the impulsive and corrective wave trends for both financial market trends and electrocardiograms. The impulsive wave trends of electrocardiograms can annotate several wave components of heart-beats including pathological heartbeat waveforms. The stopping time inquires which ordinal element satisfies the assumed mathematical condition within a numerical set. The proposed work constitutes several algorithmic states in reinforcement learning from the stopping time decision, which determines the impulsive wave trends. Each proposed algorithmic state is applicable to any relevant algorithmic state in reinforcement learning with fully numerical explanations. Because commercial electrocardiographs still misinterpret myocardial infarctions from extraordinary electrocardiograms, a novel algorithm needs to be developed to evaluate myocardial infarctions. Moreover, differential diagnosis for right ventricle infarction is required to contraindicate a medication such as nitroglycerin. METHODS The proposed work implements the stopping time theory to impulsive wave trend distribution. The searching process of the stopping time theory is equivalent to the actions toward algorithmic states in reinforcement learning. The state value from each algorithmic state represents the numerically deterministic annotated results from the impulsive wave trend distribution. The shape of the impulsive waveform is evaluated from the interoperable algorithmic states via least-first-power approximation and approximate entropy. The annotated electrocardiograms from the impulsive wave trend distribution utilize a structure of neural networks to approximate the isoelectric baseline amplitude value of the electrocardiograms, and detect the conditions of myocardial infarction. The annotated results from the impulsive wave trend distribution consist of another reinforcement learning environment for the evaluation of impulsive waveform direction. RESULTS The accuracy to discern myocardial infarction was found to be 99.2754% for the data from the comma-separated value format files, and 99.3579% for those containing representative beats. The clinical dataset included 276 electrocardiograms from the comma-separated value files and 623 representative beats. CONCLUSIONS Our study aims to support clinical interpretation on 12-channel electrocardiograms. The proposed work is suitable for a differential diagnosis under infarction in the right ventricle to avoid contraindicated medication during emergency. An impulsive waveform that is affected by myocardial infarction or the electrical direction of electrocardiography is represented as an inverse waveform.
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Affiliation(s)
- Jong-Rul Park
- College of Information and Communication Engineering, Sungkyunkwan University, Suwon, 16419 Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University Gangnam Severance Hospital, Seoul, 06273 Republic of Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351 Republic of Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351 Republic of Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, 06351 Republic of Korea
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7
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Picano E, Morrone D, Scali MC, Huqi A, Coviello K, Ciampi Q. Integrated quadruple stress echocardiography. Minerva Cardioangiol 2018; 67:330-339. [PMID: 29642694 DOI: 10.23736/s0026-4725.18.04691-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Stress echocardiography (SE) is an established diagnostic technique. For 40 years, the cornerstone of the technique has been the detection of regional wall motion abnormalities (RWMA), due to the underlying physiologically-relevant epicardial coronary artery stenosis. In the last decade, three new parameters (more objective than RWMA) have shown the potential to integrate and complement RWMA: 1) B-lines, also known as ultrasound lung comets, as a marker of extravascular lung water, measured using lung ultrasound with the 4-site simplified scan symmetrically of the antero-lateral thorax on the third intercostal space, from mid-axillary to anterior axillary and mid-clavicular line; 2) left ventricular contractile reserve (LVCR), assessed as the peak stress/rest ratio of left ventricular force, also known as elastance (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D echocardiography); 3) coronary flow velocity reserve (CFVR) on left anterior descending coronary artery, calculated as peak stress/rest ratio of diastolic peak flow velocity assessed using pulsed-wave Doppler. The 4 parameters (RWMA, B-lines, LVCR and CFVR) now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-SE. IQ-SE optimizes the versatility of SE to include in a one-stop shop the core "ABCD" (asynergy+B-lines+contractile reserve+Doppler flowmetry) protocol. It allows a synoptic assessment of parameters mirroring the epicardial artery stenosis (RWMA), interstitial lung water (B-lines), myocardial function (LVCR) and small coronary vessels (CFVR). Each variable has a clear clinical correlate, different and complementary to all others: RWMA identify an ischemic vs. non-ischemic heart; B-lines a wet vs. dry lung; LVCR a strong vs. weak heart; CFVR a warm vs. cold heart. IQ-SE is highly feasible, with minimal increase in the imaging and analysis time, and obvious diagnostic and prognostic impact also beyond coronary artery disease - especially in heart failure. Large scale effectiveness studies with IQ-SE are now under way with the Stress Echo 2020 Study, and will provide the necessary evidence base prior to large scale acceptance of the technique.
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Affiliation(s)
| | - Doralisa Morrone
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
| | | | - Alda Huqi
- Versilia Hospital, Viareggio, Lucca, Italy
| | - Katia Coviello
- Section of Cardiovascular Disease, Department of Surgery, Medicine, Molecular and Critical Area, Pisa University, Pisa, Italy
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