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Exercise EchocardiographyExercise EchocardiographyCardiac Issues 2011Cardiac Issues 2011
Douglass A Morrison, MD, PhDDouglass A Morrison, MD, PhD
Exercise EchocardiographyExercise EchocardiographyTopicsTopics
• Indications
• Assessing Prognosis with exercise echo
• Limitations
• Appropriateness
Indications for Indications for Exercise EchocardiographyExercise Echocardiography
• Reserve of Ventricular Function
• Detection of coronary artery disease/ myocardial ischemia
• Risk assessment/ prognosis
• Viability/ suitability for revascularization
• Timing of intervention in valvular heart disease
• Adequacy of therapy
Limitations of Exercise EchocardiographyLimitations of Exercise Echocardiography
• Inability to exercise: orthopedic, neurological, pulmonary or psychological
• Inability to image: acoustic windows; hyperinflation, obesity
• Delay in getting into position for imaging, after completing exercise
• Inability to lie on side and/or breath-hold (briefly)
Echo acoustic images:Echo acoustic images:identifying endocardium and myocardiumidentifying endocardium and myocardium
from ACCSAP7from ACCSAP7
Echo contrast to aid in identifying endocardiumEcho contrast to aid in identifying endocardiumACCSAP7ACCSAP7
Sensitivity and SpecificitySensitivity and Specificity
• Disease Present Disease Absent
• Positive test true positive (TP) false positive (FP) PPV• Negative test false negative (FN) true negative (TN) NPV
• Sensitivity = TP/ (TP +FN) Specificity = TN/ (TN +FP)
Sensitivity and Specificity (continued)Sensitivity and Specificity (continued)
• SpPin: for a specific test (few false positives); positive test, rules in
• SnNout: for a sensitive test (few false negatives); negative test, rules out
• Wall motion (echocardiography) is more specific than symptoms or ECG
• Sensitivity is greatly influenced by adequacy of exercise, in terms of both exercise duration/ level, and double product (peak systolic blood pressure x peak exercise heart rate).
• Positive predictive value (PPV) = TP/ (TP = FP)• Negative predictive value (NPV) = TN/ (TN + FN)
Bayesian principleBayesian principleConditional ProbabilityConditional Probability
• All good clinicians use all the diagnostic information they have; test results should be taken ‘in-context’.
• Accuracy of any test depends not only on the test’s sensitivity/ specificity, but also the pre-test probability of disease.– Consider the clinical usefulness of screening
for lung cancer in kindergarten children.
Exercise vs. Pharmacological EchoExercise vs. Pharmacological Echoas reported in JACC (2003;42:954-970) and cited by ACCSAP7as reported in JACC (2003;42:954-970) and cited by ACCSAP7
Exercise myocardial perfusion imaging (nuclear) vs. Exercise myocardial perfusion imaging (nuclear) vs. echocardiographyechocardiography
as reported in Eur Heart J(2003;24;789-800) and cited by as reported in Eur Heart J(2003;24;789-800) and cited by ACCSAP7ACCSAP7
““Party Line”Party Line”
• Nuclear stress testing is more sensitive for detecting myocardial ischemia. Echo has more false negatives.
• Exercise echo is more specific for myocardial ischemia than nuclear. Nuclear has more false positives.
Guideline and Appropriateness Concepts regarding Guideline and Appropriateness Concepts regarding work-up of suspected coronary artery disease (CAD)work-up of suspected coronary artery disease (CAD)
• Careful history is most important.
• Further work-up should be guided by clinical likelihood of CAD.
• Exercise ECG is preferred, if patient can exercise and resting-ECG is normal.
• Value of stress testing, to infer CAD, is highest among intermediate probability patients.
Guideline and Appropriateness Concepts regarding Guideline and Appropriateness Concepts regarding work-up of suspected coronary artery disease (CAD) (2)work-up of suspected coronary artery disease (CAD) (2)
• Stress imaging should NOT be used as initial evaluation of low probability patients, because of high likelihood of false positives leading to unnecessary work-up.
• Coronary angiography is recommended for high-risk (of events) patients, regardless of symptom severity.
• However, among patients with known CAD looking for silent ischemia, among asymptomatic patients is eschewed.
Pre-test likelihood of coronary artery disease Pre-test likelihood of coronary artery disease (CAD) (NEJM 1979;300:1350-1358(CAD) (NEJM 1979;300:1350-1358
Prognosis: Duke score of exercise ECGPrognosis: Duke score of exercise ECG
• Duration of exercise on Bruce protocol
• - 5X (ST depression in mm)
• - 4x (angina index; 1 point for any chest pain; 2 points if angina was limiting symptom).
• Low risk >+5 annual mortality 0.25%
• Intermediate -10 to +4 annual mortality 1.25%
• High risk <-10 annual mortality 5.0%
Predicting multi-vessel CAD, from Stress Test Predicting multi-vessel CAD, from Stress Test ResultsResults
• Early positive= Stage I of Bruce or ‘low-level’
• Markedly positive ECG: ST >2 mm depression or ST-elevation
• Prolonged: ST depression >8 minutes into recovery
• Fall in systolic blood pressure, with exercise; especially if accompanied by signs or symptoms
Prognosis: Exercise Duration + 2 mm ST Prognosis: Exercise Duration + 2 mm ST depressiondepression
from JACC (2000;36:2140-2145) as cited in ACCSAP7from JACC (2000;36:2140-2145) as cited in ACCSAP7
Prognosis: Chronotropic incompetencePrognosis: Chronotropic incompetencefrom Circulation (1996;93:1520-1526) as cited in ACCSAP7from Circulation (1996;93:1520-1526) as cited in ACCSAP7
Prognosis: Exercise ST-elevationPrognosis: Exercise ST-elevationas shown in ACCSAP7as shown in ACCSAP7
Prognosis: extent of echo wall motion abnormalityPrognosis: extent of echo wall motion abnormalityreported in JACC (2003;42:1084-1090) and cited in ACCSAP7reported in JACC (2003;42:1084-1090) and cited in ACCSAP7
YHC Exercise Echo ReportYHC Exercise Echo Report
• Duration• Limiting symptom• Heart rate response• BP response• ST-segments• Disclaimers: weight• Rest wall motion• Exercise wall motion
• Prognosis and RX efficacy• What limits this pt.?• Chronotropic reserve• Inotropic reserve• ECG-ischemia• Technical limitations • Prior infarction• Reversible ischemia
Exercise Echocardiography: AppropriatenessExercise Echocardiography: AppropriatenessJACC 2008;51:1127-1147.JACC 2008;51:1127-1147.
• Indication categories– Detection of CAD/Risk Assessment: symptomatic– Detection of CAD/Risk Assessment: asymptomatic– Detection of CAD/Risk Assessment: co morbidities– Risk assessment with prior test results– Risk assessment: Pre-operative for non-cardiac surgery– Risk assessment: after acute coronary syndrome (ACS)– Risk assessment: after revascularization (PCI or CABG)– Assessment of viability/ Ischemia– Hemodynamic assessment
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