Dr.

Satyam Rajvanshi
Dr. Ram Manohar Lohia Hospital, New Delhi
 Physiological Basis
 ‘Stress’ Methodology
 Safety & Hazards
 Protocol
 Interpretation
 Applications and Evidence
OF STRESS ECHOCARDIOGRAPHY
 Based on fundamental causal relation
between induced myocardial ischemia and
left ventricular regional wall motion
abnormalities (LV-RWMA)

 The “Ischemic Cascade”

 1930’s – Wiggers and Tenant – showed
relationship between systolic contraction and
myocardial blood supply

 Experimental induction of ischemia - rapid

and predictable development of systolic
bulging (now called Dyskinesis)
 1979 – Mason et al demonstrated earliest
proof of concept by echocardiographic
imaging of this relation
 Studied 13 CAD pts and 11 controls
 M-mode echo and supine bicycle exercise
 Stress induced RWMA seen in 19 of 22
segments supplied by stenotic coronary
arteries
 1979-80 – Wann et al demonstrated similar
findings on early 2D imaging

 1980-90 –
 Improvements in image acquisition techniques –
2D, 3D
 Digital acquisition – Reviewing rest and stress cine
loops side by side; eliminating respiratory
interference by ECG gated selection of cardiac
cycle
 On Physiological stress - No flow limiting
stenosis
 Demand supply MATCH - increase in
HR; Global Contractility
Systolic wall thickening
Endocardial excursion

Decrease in End Systolic Volume

 Hypercontractile response to stress
 Maybe blunted - Advanced Age
Uncontrolled Hypertension
Beta blocker
 Absence – usually abnormal
 On Physiological stress - with flow limiting
stenosis
 Demand supply MISMATCH -
 Ischemic Cascade

 Parameters overlap
 Sequence and timing of events may vary – early
or late; may occur simultaneously; may not
occur at all
 Persistent demand supply MISMATCH
 Reduction in systolic thickening; endocardial
excursion
 Regional WMA – Accurate predictor of regional
ischemia – usually occurs prior to ST-T changes,
Angina
 Elimination of stress
 Rapid normalization of WMA
Depends on Ischemia severity and duration
Typically – Complete recovery 1-2 min.
If longer – Stunned myocardium – can rarely last
for days!
 Exercise - Treadmill
Bicycle (Supine/Upright)

 Pharmacological - Dobutamine
Dipyramidole; Adenosine

 Pacing (transesophageal)

 Others - Handgrip; Stair step; Ergonovine

 Combination modalities
 Most common form of stress testing
 Diagnostic and immensely valuable
prognostic information
▪ Exercise capacity; BP response; Arrhythmias

 Imaging – Just before and immediately after

treadmill exercise
 False – negative test
 Main disadvantage
 Resolution of WMA before imaging

 ‘Rapid recovery’ variants – unknown cause

Exercise duration; extent of disease; medical
therapy – none predictive

 ‘Late recovery’ – poor prognostic

Severe/Extensive CAD
 Stationary Bicycle ergometry

 Upright
 Supine / 30º tilt
 Greater BP response – WMA at lower HR and
workload
 Imaging at each stage and at peak workload
possible
 Disadvantage – Low workload achieved;
tolerability
 Less
myocardial
dysfunction
More More
myocardial blood flow
dysfunction heterogeneity
• Sometimes even
without wall
motion
abnormalities
Less • Still supply is
blood flow sufficient for the
heterogeneity
demand

Dobutamine Dipyridamole
 Hyperventilation

Hypercontractility
of Normal Walls

Circumvented by
Exercise stress False negative post
stress Imaging
Pharmacological
Drawbacks
Stressers

Excessive chest
wall movement

Unable to exercise
at all or maximally
 Dobutamine Stress  Dipyridamol Stress
Preferred Preferred
 Conduction disturbances  Hypertension
 Bronchospastic diseases  Atrial and Ventricular
Arrhythmias
 On Xanthine
medications
 Caffeine containing
drinks
▪ Tea/Coffee/Cola
OF STRESS ECHOCARDIOGRAPHY
Safety of Pharmacological Stress
Echo
 Safety of Pharmacological Stress
Echo

Pharmacological stress is reasonably safe

Physical stress with exercise is probably

safer than pharmacological testing

Lattanzi F, Picano E, Adamo E, Varga A. Dobutamine stress echocardiography: safety in diagnosing coronary artery disease. Drug Saf 2000;
22:251–62.
Varga A, Garcia MA, Picano E. International Stress Echo Complication Registry. Safety of stress echocardiography (from the International
Stress Echo Complication Registry). Am J Cardiol 2006;98:541–3
DOBUTAMINE STRESS ECHOCARDIOGRAPHY
 Exceeding THR
 Development of significant angina or new
RWMA
▪ Depending on patients’ clinical status and
presence/extent/severity of WMA
 Decrease in SBP>20 mmHg from baseline
▪ Depending on patients’ clinical status and LV
function/LVOT gradient
 Arrhythmias: AF; NSVT
 Limiting Side effects and Symptoms
Dipyridamol Stress Echo Protocol
Ergonovine Stress Protocol for Coronary Vasospasm
 Traditionally – PLAX, PSAX, A4C, A2C views
 Other views maybe used at discretion of
operator
 By convention – 4 quadrant view of above 4
views compiled
 During comparison – Each view side by side –
Rest image (left) and stress image (Right)
Quad screen Format
Normal response to Exercise, Dobutamine or Pacing Stress Echo
Excessive Gain setting spoiling the
Endocardial border definition
Comparing Similar looking but totally
different views
 Quality issues inherent to 2D Echo
 Suboptimal visualisation (10-15% studies)
 Inability to visualise >1 segment (upto 30% studies)
 Contrast Echo and 3D Imaging

LV Opacification by Improved Wall

micro bubbles motion detection
Contrast Echo in
Stress Echo
Simultaneous Targetted approach
perfusion analysis to assess wall motion
 Contrast Echo
improves Endocardial
border definition
OF STRESS ECHOCARDIOGRAPHY
 Hypokinesis
▪ Mildest WMA
▪ Some degree of preserved systolic thickening and
inward endocardial excursion – but less than normal
▪ Various definitions
Less than 30% systolic thickening
Less than 5 mm endocardial excursion
▪ Distinction from Normal is subtle – Hypokinesis truly
abnormal if corresponds to a coronary territory +
normal (or hyperdynamic) motion elsewhere
 Akinesis
▪ Various definitions
Absence of systolic myocardial thickening and
endocardial excursion
<10% myocardial thickening
▪ Thickening - better measure than endocardial excursion
 Dyskinesis
▪ Most extreme WMA
▪ Systolic thinning and Systolic outward motion/bulging

 Scar
▪ Thin and/or highly echogenic segment
▪ Usually akinetic or severely hypokinetic;
maybe diskinetic
 Tardokinesis
▪ Form of hypokinesis
▪ Delayed systolic thickening or inward motion
▪ Maybe reported (false) negative
▪ To avoid error –
Analyse frame by frame
Trim cine loop to include 1st half of systole
 Early Relaxation
▪ Normal variant – No Ischemia
▪ Normal contacting segment in early systole – relaxes
earlier
▪ Maybe reported (false) positive
▪ To avoid error –
Analyse frame by frame
Trim cine loop to include 1st half of systole
 Normal
Normal segments with hypercontractility on stress
 Ischemia
Normal segment with WMA on stress
 Prior Nontransmural Infarct with Ischemia
Hypokinetic areas that worsen on stress
 Infarct/scar
Akinetic/Dyskinetic segment that worsen on stress
 Normal segment – unchanged on stress
Neither hypo – nor hyperkinetic
Maybe abnormal – Ischemia
Maybe false positive
Causes of lack of hyperkinesis
Low workload
delayed post-stress imaging (TMT)
Beta blockade
Cardiomyopathy
Elderly females
 Hypokinetic segment – improves on stress
 Exercise stress
Either reported Normal
Localised abnormality improved by tethering (adjacent
myocardial pull)

 Dobutamine stress
May indicate VIABILITY – potential for revascularization
 Hypokinetic segment – improves on stress
 16 or 17 segment models
 Both endorsed by ASE
 17 segment model includes Apical cap
More compatible with nuclear imaging views
 WMSI = Sum of all segments’ score
No. of segments scored
 WMSI generated at baseline and at peak
stress
 On stress, hyperkinesis is given 1 scoring
 Normal WMSI = 1

 Normal study = WMSI of 1 at both

baseline and stress

 No Ischemia = No increase in stress

WMSI from baseline
 Abnormal Baseline WMSI (>1)
Resting Abnormality present

 Any increase in WMSI on stress

Increase in Extent/Severity of WMA

 This approach – Systematic; standardized;

quantitative reporting despite subjective
analysis; allows comparison between studies
OF STRESS ECHOCARDIOGRAPHY
 Sensitivity – MV-CAD > SV-CAD

 In SV-CAD – LAD > RCA > LCX

 Due to variable distribution – Difficult to

differentiate RCA from LCX territory
 For CAD detection
WMA more sensitive and specific than
either Symptoms or ST segment changes

 WMA without symptoms

PAINLESS ISCHEMIA
Ischemia in absence of ST changes and
symptoms – less extensive (than with these)
 ST segment changes without WMA
Low risk group (eg. young women)
Strong evidence against CAD

Mod-high risk group (ST changes likely to be

reliable; or with symptoms)
Consider False negative stress echo

To answer this….
In general
Most cases – Stress ECG and ECHO agree!

If they disagree
- Usually Echo is t0 be believed! (More
sensitive and specific)

- If markedly positive stress ECG, esp with

symptoms – Do not ignore!
 Overall sensitivity 72-96% (similar to exercise
stress echo)
 Resting RWMA – highly predictive of CAD
Extent rather than presence important
(Including such patients increases sensitivity)

 False –ve MC cause - HTN

Concentric remodelling
 Sensitivity – MV-CAD > SV-CAD
 In SV-CAD – LAD > RCA > LCX
 Due to variable distribution – Difficult to
differentiate RCA from LCX territory

In contrast,
Anterior or Posterior circulation (LCA or RCA)
differentiation – highly accurate!
 Overall specificity 75-90%
 Normalcy rate – 92-100%
(Likelihood of normal stress echo in pts
with very low pretest risk)

 Also, Normal stress echo in known CAD –

Prognosis Favourable
 False +ve Stress echo
(Nonischemic causes of WMA)

LBBB – MC cause – Maybe rate dependent

Marked hypertensive response (afterload
mismatch)
Nonischemic Cardiomyopathy
Pulmonary HTN
 High degree of concordance – 87%
 In general
Nuclear MPI – more sensitive
Stress echo – more specific
(Exercise & Dob-stress similar)

 Metaanalysis (Fleischmann et al, 1998)

Stress echo similarly sensitive, more
specific, more cost-effective than SPECT!
 Exercise-Stress has more robust data
compared to Dob-Stress
 Normal Ex-stress echo (in Intermediate-High
pretest risk groups)
Event free survival at 1,2,3 yrs – 99%, 98%, 97%
Predictors of event – Age; Low achieved
workload; Angina; LVH
Post stress WMSI – linearly relates to CVE rate

(Mc Cully et al, 1998)

 Positive Ex-stress Echo with Negative TMT
(Intermediate risk patients)
Relatively common – 16.7%
High risk of CVE

(Bouzas Mosquera et al, 2009)

(Marwick et al, 1997)
 Event rates after Dob-stress echo – higher
than Ex-stress
 Normal Dob-stress echo – more modest
event free survival than normal Ex-stress

 Patients referred for Dob-stress – relatively

worse prognosis at baseline – inability to
exercise itself an ominous sign!
 Adding contrast perfusion echo to Dob-stress
echo – increases prognostic value
 3-year vent free survival

Normal wall motion + Normal perfusion 95%

Normal wall motion + Abnormal perfusion 82%
Abnormal wall motion + perfusion 68%

(Tsutsui et al, 2007)

 Usually resting RWMA present
 ‘Normal’ response – Hyperdynamic wall
motion in all regions remote from infarct

 Goal – identify ‘Ischemia at a distance’

Inducible ischemia and/or MV-CAD
All these are High-risk groups
Resting RWMA (high risk)
Low achievable workload (higher risk)
Inducible ischemia (highest risk cohort) – according
to extent
 Dob-Stress Echo post MI
Inducible ischemia on echo – better CVE risk
predictor than angiographic MV-CAD

Patients recovering from MI

Normal DSE – conservative management
reasonable
DSE +ve – CAG warranted

(Carlos et al, 1997)

 Risk of Perioperative CVE
No inducible ischemia – 93-100% NPV
Inducible Ischemia – 7-33% PPV
Resting RWMA – much lower PPV than
inducible ischemia; almost similar to ‘normal’

 DSE has better NPV than SPECT

 Risk not only confined to perioperative
period, but upto 3 yrs
 VIABLE Myocardium
Hypokinetic/Akinetic myocardium that has
the potential for functional recovery –
Stunned or Hybernating

 Resting echo
More severe the WMA – less likely the viability
Thin and scarred – less likely the viability
 Dob-stress Echo Principle

‘Viable’ myocardium – contractility augments

on Beta-adrenergic stimulation

‘Non-viable’ myocardiam – no augmentation

 ‘Biphasic’ response
Most predictive of functional recovery after
revascularization

 ‘Sustained improvement’ or ‘No change’

Correlate with Non-viability – lack of
improvement after revascularization
 Post MI and ICMP
For functional recovery
DSE – sensitivity 80-85%
specificity 85-90%y
Highest PPV & NPV for functional recovery

SPECT/PET – Higher sensitivity; identify

more viable segments
Less specific; identified segments
need not necessarily regain function
 MS of borderline severity – when symptoms
do not match the objective evidence –
(Supine Bicycle ergometry is best)

 Dynamic MR
 Low Output/Low Gradient Severe AS

Principle - Increase in flow rate will normally

cause increase in valve area

Dobutamine – Low to mid dose

5 to 20 ug/kg/min
‘True’ Severe AS
Area <1 sq.cm
LVOT/AV peak jet velocity ratio unchanged

‘Pseudosevere’ AS/Cardiomyopathy
Area increases to > 1 sq.cm (Moderate AS)
LVOT/AV peak jet velocity ratio decreases
(LVOT jet velocity increases but AV jet velocity decreases)

AVA = CSA-LVOT x (TVI-LVOT/TVI-AV)

 Diastolic dysfunction – early and sensitive
marker for ischemia; maybe more quantitative
Impaired myocardial relaxation
Post-systolic shortening – ‘Ischemic Memory’
Increase in E/e’ ratio on exercise
Strain imaging

 Less reproducible
Not yet standardized
 Pharmacological stress echo is a safe,
informative, cost-effective, special
investigation with varied indications

 Further research needed to make this

versatile investigation even more relevant for
diagnostic and prognostic purpose
 TDI in Stress Echo

Normally interval
decreases by 34% ± 10%
TDI or Strain Rate QRS to onset of
Imaging Relaxation = 350 – 400ms
In Ischemia – 12% ± 18%

Diastolic stunning

Speckle Tracking
Lasts longer than wall
motion abnormalities
Applying Strain Rate Imaging in Stress Echo
Resting
Applying Strain Rate Imaging in Stress Echo
Low dose Dobutamine
Applying Strain Rate Imaging in Stress Echo
High dose Dobutamine
Indications of Stress Echo

CAD
• Diagnosis
• Prognostica
tion