Professional Documents
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Echocardiography
• Other methods - hand grips & treadmill (1981), pacing (1983), upright bicycle & cold
pressor test (1984)
• Pharmacologic
Dobutamine infusion (+/- atropine)
Dipyradimole (+/- atropine)
Adenosine (+/- atropine)
Combined Dobu – Dipyradimole
Arbutamine
• Other
Transesophageal atrial pacing
Transvenous pacing (temp/permanent)
Ergonovine
Hyperventilation
Cold pressor
Mental Stress
Indication for using stress echo
• Unable to exercise
• Complete LBBB
• Bicycle
Sensitivity 76 - 100% PPV 71 – 97%
Specificity 67 - 96% NPV 44 – 100%
Accuracy 81 - 94%
• Protocol –
• Contraindications
• Ongoing ACS
• Uncontrolled HF
• Uncontrolled dysrhythmias
• Severe HTN
• HOCM
• Severe AS
Accuracy of DSE for detecting CAD
Meta-analysis 0f 28 studies (1997)
• Flow maldistribution –
• coronary steal (vertical & horizontal) / Reverse Robinhood
efect
• Diagnostic Accuracy –
• Sensitivity 73%
− lower than dobu for SVD & similar for MVD
• Contrindications-
• SSS / high grade AV block
• Asthma
• No adenosine testing for 24 hrs
• Compared to DSE -
• Easier, cheaper, short imaging time (10mins) and safe.
Number of institutions with agreement on
positivity or negativity of dobutamine stress
European Heart Journal (2002) 23, 821–829
Limitations of Stess echo
• Subjective nature of visual interpretation.
• Side effects
Quantification of wall motion
• Two techniques:
• Voigt et al., compared the sensitivity and specificity S/SR imaging in 44 patients
• 2D Echo - 97% segments assessed, sensitivity and specificity of 81% and 82%
• TDI - 92% of segments assessed . Sensitivity of 74% and specificity of 63%.
• S/SR - only 85% of segments assessed.
A post-systolic/ max systolic strain ratio >35% showed the highest sensitivity
and specificity (82% and 85%,resp).
• When visual inspection suggests a regional RWMA, the regional long-axis velocity
responses during DSE should be used . If this is abnormal then S/SR imaging
• Sensitivity 79 -88%
• Specificity 37 – 86%
• NPV 54 – 89%
• PPV 66 – 86%
• Accuracy 63 – 86%
• DSE
• Sensitivity 68 – 93%
• Spec city 55 – 100%
• NPV 68 – 90%
• PPV 64 – 100%
• Accuracy 58 – 95%
• Specificity 67%
• Accuracy 80%
• Pacing initiated at 10 beats/min above the patient’s baseline heart rate and at 3
to 5 mA above the threshold for atrial capture
• 2-min stages with 20 beats/min increments at every stage until THR or another
end point
• End points –
THR, new or worsening WMA, VT/SVT, ECG of severe ischemia,
severe angina, intolerable symptoms, SBP 240 mmHg, DBP 120
mmHg and SBP <90 mmHg
Diagnostic accuracy of PASE for CAD
JACC 2000;36:1935– 41
• Requires intact AV
• No adverse drug effects and the
prolonged recovery period conduction
• Senstivity 90%
• Specificty 93%
• Dipyridamole
• Sensitvity 92%
• Specificity 100%
• Dobtamine
• Sensitivity 89%
• Specificity 100%
• Accuracy 91% (higher than thallium)
Clinical Uses
• Chest pain evlauation
• Known CAD
• Myocardial viability
• Post MI residual ischemia
• Post revascularization residual ischemia
• Risk Stratification
• Chest pain
• Known CAD
• Known LV dysfunction
• Preop for noncardiac surgery
• TAP
• AS – low grad with LV dysf
• PPV 62 – 65%
cause of angina (Dip)
• NPV 76 – 92%
Real-Time 3D DSE vs. 2D DSE
JACC 2001;37;1303-1309
• Advantages -
• rapid acquisition, simultaneous visualization of the same
segments in different planes, superior interobserver
agreement, Short learning curve
• Tissue Doppler
• Stress & strain rate imaging
• contrast echo
• 3D imaging.
• Color kinesis