Exercise stress echocardiography: Where are we now?

Evaluation of Coronary Artery Disease and Ischemia by Echocardiography: Advances in Technology and Techniques

This review describes the role of echocardiography in the diagnosis and prognostication of coronary artery disease (CAD). It describes the diagnostic capabilities of echocardiography using rest and stress imaging, speckle tracking strain imaging with myocardial work index, as well as the use of myocardial perfusion imaging. It also evaluates the use of echocardiography in the assessment of common complications from CAD and the incremental value of incorporating right ventricular, left atrial, and diastolic function assessment in these patients. In addition, the review aims to highlight the prognostic value of echocardiography, especially in the determination of myocardial viability.

Unraveling the Role of Oxygen Pulse Variability in Endurance Exercise Training in Individuals with COPD: A Novel Approach to Response of Oxygen Pulse and Quality of Life in Pulmonary Rehabilitation

Background

Chronic obstructive pulmonary disease (COPD) is characterized by airway inflammation, airflow limitation, reduced health-related quality of life (HRQL), and exercise intolerance. Pulmonary rehabilitation (PR) is essential for COPD management, but outcomes may be influenced by individual physiological factors. Cardiopulmonary exercise testing (CPET) measures oxygen pulse (O2P), an indicator of stroke volume, yet the impact of baseline O2P on PR effectiveness remains unclear.

Methods

This retrospective study included 97 participants with COPD who had received PR, of whom 48 were classified as Group 1 (normal O2P) and 49 as Group 2 (low O2P). PR involved 12 weeks of hospital-based endurance training on a bike, performed twice a week. Participants were assessed before and after PR using spirometry, respiratory muscle strength measurements, CPET, and HRQL evaluation with the St. George's Respiratory Questionnaire (SGRQ).

Results

PR significantly improved exercise capacity (peak work rate and oxygen consumption), dyspnea score, and all domains of the SGRQ, maximum expiratory pressure, ventilatory equivalent, respiratory rate, and mean blood pressure at rest in both groups (p < 0.05). However, improvements in O2P, maximal inspiratory pressure, and tidal volume at rest were observed only in Group 2 but not in Group 1.

Conclusion

PR improves exercise capacity, HRQL and specific respiratory function in participants with COPD, regardless of baseline O2P levels. Individuals with lower baseline O2P experience more benefits from PR, including a significant increase in O2P.

Risk factors associated with the false positive of cardiopulmonary exercise test in the diagnosis of coronary heart disease

PURPOSE

Cardiopulmonary exercise test (CPET) is a common method for preliminary evaluating coronary heart disease (CHD), but it may experience false positive. The present study aimed to reveal the potential factors relating to the false positive of CPET, including blood glucose and lipids.

METHODS

This observational cohort study included 103 subjects with false positive of CPET and 65 subjects with true positive of CPET. The baseline characteristics, blood glucose, and blood lipids between the true and false positive groups were compared. After adjusting for the age and sex, logistic regression analysis was performed to reveal the potential risk factors of false positive. Receiver operating characteristic curve analysis was performed to evaluate the potential of related factors in distinguishing between true and false positive results.

RESULTS

Males, smokers, and patients with diabetes were less likely to suffer from false positive of CPET. Compared with the true positive group, the false positive group exhibited significantly higher levels of high-density lipoprotein (HDL) and apolipoprotein A1 (Apo-A1), and lower levels of fasting blood glucose (FBG) and glycosylated hemoglobin (GHb). After adjustment, FBG and GHb were protective factors of the true positive of CPET, and they both had moderate ability to distinguish false positive from true positive in females. However, their combination did not improve the discriminative effect more obviously than FBG alone.

CONCLUSIONS

Sex, smoking, diabetes, and blood glucose were associated with the false positive of CPET. FBG was valuable in predicting the risk of false positive of CPET in females with suspected CHD.

TRIAL REGISTRATION

The present study is registered in Chinese Clinical Trial Register (ChiCTR2400089239).

Clinical Application of Exercise Stress Echocardiography in an Outpatient Pediatric Population

Background: Exercise stress echocardiography (ESE) is commonly employed in adults, but its applicability in pediatric populations remains to be clarified. Methods: A total of 309 consecutive children (C), with a mean age of 14.1 ± 2.6 years (range 6-17 years), underwent treadmill ESE starting in 2002. They were divided into two groups: Group I comprised 258 children, including 237 with symptoms related to exercise (such as chest pain, fatigue, lipothymia/syncope, or one aborted sudden death), 15 with electrocardiogram (ECG) abnormalities, and 6 with a positive ECG stress test showing ST changes. Group II consisted of 10 asymptomatic children whose parents requested routine screening, 11 with symptoms unrelated to exercise, 12 with a family history of sudden death, and 17 with known pathologies (including 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, and the remainder with various conditions, such as Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, and aortic switch operation). Regional wall motion abnormalities (RWMAs) and transvalvular or intraventricular (IVG) gradients were assessed using 2D and continuous-wave Doppler, respectively, in all cases. Results: The success rate was 100% (309/309). Stress-induced RWMAs were observed in two children. A significant IVG (>30 mmHg) was detected in 101 out of the 258 children (39%) in Group I, who presented with exercise-related symptoms, ECG abnormalities, or positive stress ECG. In Group I, the odds ratio (OR) of ESE reproducing the symptoms in children with IVG compared to those without IVG was 8.22 (95% CI: 4.84-13.99, p < 0.001). Conclusions: Treadmill ESE is both feasible and safe for pediatric populations. RWMAs demonstrated limited utility in our cohort of children, while IVG induced by exercise was frequently observed in symptomatic children.

[Stress-Echocardiography in Low-risk Acute Coronary Syndrome Without Persistent ST-segment Elevation Diagnostic Algorithm]

This review addresses the capabilities of stress EchoCG as a simple, non-invasive, non-radiation method for diagnosing occult disorders of coronary blood flow in patients with non-ST-elevation acute coronary syndrome on a low-risk electrocardiogram. The capabilities of the enhanced stress EchoCG protocol are based on supplementing the standard detection of transient disturbances of local contractility, generally associated with coronary artery obstruction, with an assessment of the heart rate reserve, coronary reserve and other parameters. This approach is considered promising for a more complete characterization of heart function during exercise and an accurate prognosis of the clinical case, which allows determining the tactics for patient management not limited to selection for myocardial revascularization.

A Tale of Three Chambers: Cor Triatriatum Sinistrum

•Cor triatriatum is an important cause of HF and atrial arrhythmias in young adults. •Misdiagnosis can cause inappropriate interventions and delay in surgical treatment. •Integrated imaging is useful in describing anatomy and associated abnormalities. •Collaboration between hospitals and cardiac specialties helps prevent poor outcomes.

The role of stress echocardiography in identifying cardiotoxicity: an in-depth exploration

Cancer treatment might cause heart failure and deteriorate the patients' quality of life. Despite the wide use of conventional echocardiography, it often fails to detect cardiotoxicity until advanced cardiac dysfunction at potentially irreversible stages. Advanced techniques, such as three-dimensional imaging and strain analysis in stress echocardiography, have shown promise in identifying cardiotoxicity at subclinical stages, even when traditional measures remain within normal ranges. These novel techniques have been shown to identify cardiac impairment in 30%-50% of the patients undergoing potentially cardiotoxic chemotherapy, which allows for early intervention and enhanced patient management. Although professional societies are advocating for the inclusion of these techniques into routine monitoring protocols, more research is needed to optimize and standardize their use across various centers and chemotherapeutic agents. This review explores the role of stress echocardiography in the early detection and monitoring of chemotherapy-induced cardiotoxicity. It delves into current knowledge and emerging research, aiming to provide a comprehensive understanding and to highlight areas worthy of further investigation.

Exercise Stress Echocardiography in Athletes: Applications, Methodology, and Challenges

This comprehensive review explores the role of exercise stress echocardiography (ESE) in assessing cardiovascular health in athletes. Athletes often exhibit cardiovascular adaptations because of rigorous physical training, making the differentiation between physiological changes and potential pathological conditions challenging. ESE is a crucial diagnostic tool, offering detailed insights into an athlete's cardiac function, reserve, and possible arrhythmias. This review highlights the methodology of ESE, emphasizing its significance in detecting exercise-induced anomalies and its application in distinguishing between athlete's heart and other cardiovascular diseases. Recent advancements, such as LV global longitudinal strain (GLS) and myocardial work (MW), are introduced as innovative tools for the early detection of latent cardiac dysfunctions. However, the use of ESE also subsumes limitations and possible pitfalls, particularly in interpretation and potential false results, as explained in this article.

The Importance of Left Ventricular Outflow Tract and Mid-Ventricular Gradients in Stress Echocardiography: A Narrative Review

This review aims to serve as a guide for clinical practice and to appraise the current knowledge on exercise stress echocardiography in the evaluation of intraventricular obstruction in HCM, in patients with cardiac syndrome X, in athletes with symptoms related to exercise, and in patients with normal left ventricular systolic function and exercise-related unexplained tiredness. The appearance of intraventricular obstruction while exercising is considered rare, and it usually occurs in patients with hypertrophy of the left ventricle. The occurrence of intraventricular obstruction when exercising has been evidenced in patients with hypertrophic cardiomyopathy, athletes, patients with cardiac syndrome X, patients with syncope or dizziness related to exercise, and patients with dyspnea and preserved ejection fraction. The clinical significance of this observation and the exercise modality that is most likely to trigger intraventricular obstruction remains unknown. Supine exercise and lying supine after exercise are less technically demanding, but they are also less physiologically demanding than upright exercise. Importantly, in everyday life, human beings generally do not become supine after exercise, as takes place in post-exercise treadmill stress echocardiograms in most echocardiography labs. The presence of induced intraventricular obstruction might be considered when patients have exercise-related symptoms that are not understood, and to assess prognosis in hypertrophic cardiomyopathy.

Complications of exercise and pharmacologic stress echocardiography

Stress echocardiography is a diagnostic cardiovascular exam that is commonly utilized for multiple indications, including but not limited to the assessment of obstructive coronary artery disease, valvular disease, obstructive hypertrophic cardiomyopathy, and diastolic function. Stress echocardiography can be performed via both exercise and pharmacologic modalities. Exercise stress is performed with either treadmill or bicycle-based exercise. Pharmacologic stress is performed via either dobutamine or vasodilator-mediated (i.e., dipyridamole, adenosine) stress testing. Each of these modalities is associated with a low overall prevalence of major, life-threatening adverse outcomes, though adverse events are most common with dobutamine stress echocardiography. In light of the recent COVID-19 pandemic, the risk of infectious complications to both the patient and stress personnel cannot be negated; however, when certain precautions are taken, the risk of infectious complications appears minimal. In this article, we review each of the stress echocardiographic modalities, examine major potential adverse outcomes and contraindications, assess the risks of stress testing in the setting of a global pandemic, and examine the utilization and safety of stress testing in special patient populations (i.e., language barriers, pediatric patients, pregnancy).