Ruth Pérez

Accuracy of peak treadmill exercise echocardiography to detect multivessel coronary artery disease: comparison with post-exercise echocardiography

AIMS Although peak exercise echocardiography has been reported for both bicycle and treadmill exercise and has shown higher sensitivity than post-exercise imaging, little is known about its utility for identifying multivessel involvement. We sought to compare feasibility and accuracy of peak treadmill exercise echocardiography vs post-exercise echocardiography for identification of multivessel coronary artery disease and to assess its incremental value when combined with clinical and exercise test variables. METHODS AND RESULTS The study group included 335 patients (228 men; mean (+/- SD) age 60 +/- 11 years). Two hundred and seventy-nine patients were included on the basis of having had an exercise echocardiography and a coronary angiography within 4 months of the exercise test. To avoid bias to coronary angiography, a subgroup of 56 consecutive non-diabetic patients referred for exercise echocardiography with pretest probability of coronary artery disease <10% and had atypical chest pain or were asymptomatic were also included and considered as having no coronary artery disease. Multivessel coronary artery disease (> or = 50% diameter stenosis in >1 vessel) was confirmed in 170 patients, whereas 165 patients were considered to have one-vessel coronary artery disease or no coronary lesions. Positive exercise echocardiography was defined as ischaemia or necrosis in at least two coronary territories. Post-exercise images were acquired within 125 s after exercise (49 +/- 15). Mean heart rate (bpm) was 139 +/- 19 at peak vs 117 +/- 22 at post-exercise imaging (P<0.001). Interpretable peak and post-exercise images were obtained for all patients. Sensitivity for predicting multivessel disease was higher with peak than with post-exercise imaging (79 vs 55%, P<0.001), with lower specificity (79 vs 88%, P<0.05). Predictive positive value was similar (80 vs 83%). Negative predictive value was again higher with peak imaging (78 vs 66%, P<0.01). Total accuracy was not different (79 vs 72%). A stepwise logistic regression analysis identified peak exercise echocardiography positivity for multivessel coronary artery disease as the strongest independent predictor of multivessel disease (odds ratio (OR): 7.36); also significant were male gender (OR: 4.22), diabetes mellitus (OR: 4.28), previous myocardial infarction (OR: 3.12) and increment of product heart rate x blood pressure (OR: 1.00). CONCLUSIONS Peak treadmill exercise echocardiography is technically feasible and has higher sensitivity and negative predictive value for predicting multivessel disease than post-treadmill exercise echocardiography. This method adds independent and incremental values to clinical and exercise variables for the diagnosis of multivessel coronary artery disease. Therefore, in the clinical setting, peak exercise echocardiography should be performed to diagnose multivessel coronary artery disease.

Prognostic value of exercise echocardiography in patients with left bundle branch block.

OBJECTIVES Our aim was to evaluate the role of exercise echocardiography for predicting outcome in a cohort of patients with left bundle branch block (LBBB). BACKGROUND Although the prognostic value of exercise echocardiography has been well established in several subgroups of patients, it has not been specifically assessed in patients with LBBB. METHODS Of the 8,050 patients who underwent treadmill exercise echocardiography, 618 demonstrated complete LBBB. Nine patients were lost to follow-up and 609 patients were included in this study. Wall motion score index (WMSI) was evaluated at rest and at peak exercise, and the difference (DeltaWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (including cardiac death, myocardial infarction, or cardiac transplantation). Mean follow-up was 4.6 +/- 3.4 years. RESULTS Mean age was 66 +/- 10 years, and 331 patients (54%) were men. A total of 177 patients (29%) developed ischemia with exercise. During follow-up, 124 deaths occurred, and 74 patients had a major cardiac event before any revascularization procedure. Patients with ischemia had a greater 5-year mortality rate (24.6% vs. 12.6%, p < 0.001) and 5-year major cardiac events rate (18.1% vs. 9.7%, p = 0.003). In multivariate analysis, DeltaWMSI remained an independent predictor of mortality (hazard ratio: 2.42, 95% confidence interval: 1.21 to 4.82, p = 0.012) and major cardiac events (hazard ratio: 3.38, 95% confidence interval: 1.30 to 8.82, p = 0.013). Exercise echocardiographic results also provided incremental value over clinical, resting echocardiographic, and treadmill exercise data for the prediction of mortality (p = 0.014) and major cardiac events (p = 0.017). CONCLUSIONS Exercise echocardiography provides significant prognostic information for predicting outcome in patients with LBBB. As compared to patients with normal exercise echocardiograms, patients with abnormal results are at increased risk of mortality and major cardiac events.

Comparison of exercise echocardiography to exercise electrocardiographic testing added to echocardiography at rest for risk stratification after uncomplicated acute myocardial infarction

Recommendations for risk assessment after acute myocardial infarction (AMI) include electrocardiographic (ECG) exercise testing. We hypothesized that a more sensitive technique, exercise echocardiography (EE), would refer a greater number of patients to invasive procedures. Therefore, we compared a strategy based on EE with a strategy based on ECG exercise testing for patients with uncomplicated AMI. A series of 164 patients referred for exercise testing after AMI were randomized to treadmill EE (strategy 2) or baseline echocardiography and ECG treadmill exercise testing (strategy 1). Ischemic response was more frequently detected with strategy 2 (59% vs 27%, p <0.001), and consequently angiography and revascularization procedures were more commonly performed (59 vs 32 procedures, p <0.01 and 46 vs 19 procedures, p <0.001, respectively). Fourteen percent and 15% of patients experienced soft events (unstable angina, heart failure, or late revascularization) after strategy 1 and strategy 2, respectively (p = NS); 6% and 9% of patients had hard events (nonfatal AMI or cardiovascular death) at follow-up (p = NS). In conclusion, a strategy based on EE detected more patients with ischemia; therefore, more patients were submitted to coronary angiography and revascularization procedures. No differences were detected in cardiac events when we compared this strategy with the less expensive ECG exercise testing after uncomplicated AMI.

Ecocardiografía de perfusión miocárdica en tiempo real para la predicción de la recuperación de la función ventricular después del infarto agudo de miocardio reperfundido

Introduccion y objetivos La ecocardiografia de perfusion en tiempo real (EPTR) es un metodo reciente. Los objetivos fueron estudiar: a) si la EPTR predice la recuperacion despues de infarto agudo de miocardio (IAM), y b) si los datos son comparables a los obtenidos con la tomografia computarizada por emision de fotones simples (SPECT) marcada con 99mTc-sestamibi y la resonancia magnetica (RM). Pacientes y metodo Hemos incluido a 85 pacientes con IAM sometidos a angioplastia coronaria transluminal percutanea (ACTP). La EPTR se realizo 7 ± 4 dias despues del IAM. Se utilizo ecocardiografia a la vez que la perfusion y a las 10 ± 4 semanas de esta. La SPECT y la RM se realizaron despues del IAM en 18 y 32 pacientes, respectivamente. Resultados Al finalizar el seguimiento dispusimos de ecocardiografia de 82 pacientes, a los que dividimos en: grupo con recuperacion (GR) (n = 49) y grupo sin recuperacion (GNR) (n = 33). El indice de motilidad segmentaria (IMS) regional mejoro desde 1,75 ± 0,49 a 1,32 ± 0,36 (p Conclusion La EPTR tiene valor moderado para predecir la recuperacion funcional despues del IAM reperfundido.

Feasibility of Pulsed‐Doppler Tissue Imaging of the Interventricular Septum During Exercise Echocardiography

Background: A limitation of exercise echocardiography (EE) is its semiquantitative approach in analyzing wall‐motion abnormalities. However, pulsed‐Doppler tissue imaging is capable of a systolic and diastolic regional quantitative assessment. Methods: To investigate the feasibility of performing pulsedDoppler tissue imaging sampling of the basal left ventricular (LV) septum during EE, we studied 105 consecutive patients (71 men, 34 women, aged 61 ± 11 years). Harmonic two‐dimensional (2‐D) echocardiography was performed at rest and peak EE, whereas pulsed‐Doppler tissue imaging was performed at rest and immediately after EE. Adequate recordings for peak systolic velocity (Vs) were possible in all patients, but peak early diastolic (Ve) and peak late diastolic (Va) velocities were possible in 78 (74%) patients. Positive 2‐D echocardiography was considered as infarction or an ischemic response. Results: Forty‐five (43%) patients (Group 1) had wall‐motion abnormalities involving the left anterior descending artery (LAD) territory (29 with ischemia, 11 with ischemia and necrosis, and 5 with necrosis), 21 (20%) (Group 2a) had wall‐motion abnormalities involving the left circumflex (LCX) and/or the right coronary artery (RCA) territories, and 39 (37%) (Group 2b) had normal EE. Heart rate increased from 72 ± 17 beats/min to 143 ± 18 beats/min (P < 0.0001) and systolic blood pressure from 129 ± 19 mmHg to 174 ± 26 mmHg (P < 0.001). Coronary angiography was performed in 30 (29%) patients, 29 of whom had positive findings on EE. LAD or diagonal branch coronary artery disease (CAD) (≥ 50% luminal narrowing) was present in 22 patients, 10 of whom had proximal severe stenosis (≥ 70% luminal narrowing). Vs increase was significatively lower in Group 1 (40 ± 35%, from 6.0 ± 1.5 cm/sec to 8.1 ± 2.2 cm/sec) than Group 2a (75 ± 35%, from 6.3 ± 1.4 cm/sec to 10.8 ± 2.1 cm/sec, P < 0.0001) and Group 2b (64 ± 27%, from 6.7 ± 1.3 cm/sec to 10.9 ± 2.0 cm/sec, P < 0.001). Ve was not different at rest and at postexercise between groups. Va was similar at rest but higher at postexercise in Group 2b than Group 1 (11.8 ± 2.3 cm/sec vs 10.3 ± 3.0 cm/sec, P < 0.05). Failure to achieve Vs ≥9.5 cm/sec after exercise was found to be the more accurate limit to detect necrosis or ischemia in the LAD territory according to EE criteria (sensitivity 76%, specificity 78%). When analysis was limited to the 30 patients who underwent angiography, we found that the 10 patients with proximal severe LAD or diagonal branch stenosis showed blunted increases in Vs (increase 9.4 ± 19%, from 6.5 ± 1.2 cm/sec at rest to 7.4 1.7 cm/sec at post‐EE; P < 0.17) in contrast to the 20 patients having moderate or nonsignificant stenosis (increase 31 ± 20%, from 6.2 ± 1.5 cm/sec at rest to 9.3 ± 1.8 cm/sec at post‐EE, P < 0.0001). A failure to increase Vs ≥ 30% had a sensitivity of 90% and a specificity of 80% in detecting proximal severe stenosis. Conclusion: Pulsed‐Doppler tissue imaging sampling of the LV septum is feasible technically during EE and allows quantification of the regional response. This method may be accurate for detecting proximal severe stenosis in vessels supplying the LAD territory.

Real Time Myocardial Contrast Echocardiography to Predict Left Ventricular Wall Motion Recovery After Reperfused Acute Myocardial Infarction

INTRODUCTION AND OBJECTIVES Real time myocardial contrast echocardiography (RTMCE) is a recently developed method. We sought to determine: a) whether RTMCE predicts recovery of left ventricular function after acute myocardial infarction (AMI), and b) whether data obtained with this method are comparable to those obtained with 99mTc-sestamibi single photon emission computed tomography (SPECT) and magnetic resonance. PATIENTS AND METHOD We studied 85 patients with AMI who underwent angioplasty. RTMCE was performed 7 (4) days after AMI. Two-dimensional echocardiography was performed at the time of the RTMCE study and at follow-up (10 [4] weeks). SPECT and magnetic resonance were performed after AMI in 18 and 32 patients, respectively. RESULTS Follow-up two-dimensional echocardiography results were available for 82 patients, who were subdivided into 2 groups: recovery (n=49) and no recovery (n=33). Regional (AMI-related) wall motion score index improved from 1.75 (0.49) to 1.32 (0.36) (P< .001) in the recovery group, and worsened from 1.85 (0.39) to 1.95 (0.36) in the no recovery group (P< .001). RTMCE perfusion score was 0.8 (0.3) in the recovery group, and 0.6 (0.4) in the no recovery group (P< .001). Concordance between RTMCE and SPECT in a segmental analysis was 78% (P< .001; kappa=0.49), whereas concordance between RTMCE and hyperenhancement with delayed contrast magnetic resonance findings was 70% (P< .001; kappa =0.35). Independent predictors of recovery were peak creatine kinase (OR=1.4 per 1000 UI; 95% CI, 1.0-1.9; P< .05) and RTMCE score (OR=8.8; 95% CI, 1.9-39.3; P< .01). A RTMCE score > or = 0.60 had a positive predictive value of 73% and a negative predictive value of 69% (P< .001; area under the curve 0.70). CONCLUSION RTMCE showed a modest predictive value for recovery of left ventricular function after reperfused AMI.

695 Comparison of peak treadmill exercise echocardiography and peak supine bicycle exercise echocardiography for the detection of ischaemia

whole S group. Among the patients with ventricular aneurysm, 6 (54.5%) of those in S group and 12 (85.7%) of those in C group were smokers and 4 (36.3%) in S group and 12 (85.7%) in C group had dyslipidemia. The association of other adverse events among the patients with patent coronary arteries and ventricular aneurysm vs. the rest of the study group was: 5 (45.4%) intraventricular thrombi vs. 3 (5.8%); 6 (54.5%) arrhythmias vs 12 (23.5%); 3 (27.2%) peripheral emboli vs. 2 (3.9%); 3 (27.2%) haemodynamic disturbances vs. 8 (15.7%); 4 (36.3%) ischaemic events vs. 20 (40.3%). Conclusions: The incidence of the mechanical complications in patients with AMI and patent coronary arteries was comparable with the one in the group with significant stenoses. The subgroup with patent coronary arteries and ventricular aneurysm had a higher average age than the group with significant stenoses and ventricular aneurysm and also than the whole study group. The ventricular aneurysm was associated with a higher incidence of other complications, outlining a subgroup at important risk after the AMI with patent coronary arteries.

710 Comparison of peak and postexercise imaging during treadmill exercise echocardiography with the use of continuous harmonic imaging acquisition.

worse at Pk than at post-exercise in patients with positive EE (1.5±0.3 vs. 1.4±0.3, and 50±13 vs. 54±13, respectively, both p 49% diameter stenosis in at least 1 vessel) was confirmed in 46 patients, whereas 47 patients were considered to have no CAD. Positive EE was defined as ischemia or necrosis in at least 1 coronary artery territory. Sensitivity, specificity and accuracy for CAD were 91%, 81% and 86% with Pk-EE and 75%, 85% and 82% with post-EE, respectively (p=0.08 for sensitivity). Sensitivity for the prediction of multivessel CAD was 74% with Pk-EE and 63% with post-EE (p=NS). Conclusion: Peak treadmill EE is as feasible as post-EE. Ischemia is more easily detected at peak than at postexercise. Therefore, in the clinical setting peak-EE should be peformed for diagnostic purposes.