Evolution of stress echocardiography.
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Echocardiography↗
Biomedical subjects
H Feigenbaum
Publications and source records attributed to H Feigenbaum.
Catecholamine stress echocardiography.
Two-dimensional echocardiographic monitoring during catecholamine infusion has shown promise as a safe and accurate method for detection of coronary artery disease. The clinical application of catecholamine stress echocardiography has been facilitated by the development of digital image processing techniques. The sensitivity of this method of stress testing has been improved by drug infusion protocols that are designed to maximize myocardial stress. Recent investigations have demonstrated the value of dobutamine stress echocardiography for detection of multivessel disease following myocardial infarction and for assessment of cardiac risk before noncardiac surgery. Evaluation of changes in wall motion and thickening that occur during low dose dobutamine infusion may enable detection of viable myocardium after thrombolytic treatment of acute myocardial infarction. Compared to alternative noninvasive diagnostic methods, catecholamine stress echocardiography permits continuous acquisition of high-quality information on regional and global systolic function. This and other advantages have prompted the search for broader applications of this technique.
Animals↗
Evolution of stress testing.
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Coronary Disease↗
Dobutamine stress echocardiography for assessment of cardiac risk before noncardiac surgery.
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Adult↗
Segmental wall motion abnormalities in the absence of clinically documented myocardial infarction: clinical significance and evidence of hibernating myocardium.
To determine the frequency and significance of left ventricular wall motion abnormalities in patients without clinical evidence of myocardial infarction, we reviewed the two-dimensional echocardiograms of 252 patients who had no history or electrocardiographic evidence of myocardial infarction and who subsequently underwent coronary angiography. Seventy-seven patients (31%) had one or more segmental wall motion abnormalities. Sixty-six of the 77 patients (86%) had significant coronary artery disease (greater than or equal to 50% luminal diameter stenosis). Seventy-four percent of the patients with coronary artery disease had multivessel disease. The left ventricle was divided into anterior and posterior regions. In the 66 patients, there were 77 separate regions with wall motion abnormalities (49 hypokinesis, 22 akinesis, 6 dyskinesis), including 60 regions (78%) supplied by coronary vessels with greater than or equal to 70% stenosis. Thirty-two patients underwent coronary artery bypass surgery or percutaneous transluminal coronary angioplasty. Follow-up echocardiograms were obtained in 19 patients who had wall motion abnormalities involving 22 regions. Twenty of the 22 regions were revascularized. Wall motion improved in 17 of 20 regions (85%) and returned to normal in 15 regions (75%). We conclude that segmental wall motion abnormalities may be detected by echocardiography in up to one third of patients evaluated for suspected coronary artery disease without documented myocardial infarction. These abnormalities are associated with a high likelihood of multivessel disease as well as with significant narrowing of the artery supplying the region demonstrating abnormal wall motion. Improvement in segmental wall motion abnormalities after revascularization suggests that these areas represent regions of hibernating myocardium.
Adult↗
Echocardiographic detection of coronary artery disease during dobutamine infusion.
BACKGROUND: Two-dimensional echocardiography performed during dobutamine infusion has been proposed as a potentially useful method for detecting coronary artery disease. However, the safety and diagnostic value of dobutamine stress echocardiography has not been established. METHODS AND RESULTS: In this study, echocardiograms were recorded during step-wise infusion of dobutamine to a maximum dose of 30 micrograms/kg/min in 103 patients who also underwent quantitative coronary angiography. The echocardiograms were digitally stored and displayed in a format that allowed simultaneous analysis of rest and stress images. Development of a new abnormality in regional function was used as an early end point for the dobutamine infusion. No patient had a symptomatic arrhythmia or complications from stress-induced ischemia. Significant coronary artery disease (greater than or equal to 50% diameter stenosis) was present in 35 of 55 patients who had normal echocardiograms at rest. The sensitivity and specificity of dobutamine-induced wall motion abnormalities for coronary artery disease was 89% (31 of 35) and 85% (17 of 20), respectively. The sensitivity was 81% (17 of 21) in those with one-vessel disease and 100% (14 of 14) in those with multivessel or left main disease. Forty-one of 48 patients with abnormal echocardiograms at baseline had localized rest wall motion abnormalities. Fifteen had coronary artery disease confined to regions that had abnormal rest wall motion, and 26 had disease remote from these regions. Thirteen of 15 patients (87%) without remote disease did not develop remote stress-induced abnormalities, and 21 of 26 (81%) who had remote disease developed corresponding abnormalities. CONCLUSIONS: Echocardiography combined with dobutamine infusion is a safe and accurate method for detecting coronary artery disease and for predicting the extent of disease in those who have localized rest wall motion abnormalities.
Adrenergic beta-Antagonists↗
Stress echocardiography: an overview.
Stress echocardiography has come a long way in the past ten to twelve years since it first began. There have been many procedural and technical advances. The results being obtained by those laboratories with active programs are very gratifying. Stress echocardiography is proving to be particularly valuable in women and in evaluating coronary angioplasty. Although the comparison between stress echocardiography and stress nuclear cardiology is actively being debated, the available data would suggest that the results are grossly comparable. There are certain subsets of patients which may be identified where one technique might excel over the other. The most important factor is undoubtedly the competence of the laboratory performing the test. A high quality nuclear study is clearly going to be better than a poor quality echocardiogram and vice versa. However, assuming a high degree of competence in either technique, stress echocardiography has many obvious practical advantages. There is no reperfusion necessary so that the patient does not have to return in four hours. There is no radiation involved. And the results are available immediately after the examination. For all of these reasons it is not surprising that stress echocardiography is gaining in popularity and should play an increasingly important role in the management of patients with coronary artery disease.
Coronary Disease↗
Role of echocardiography in acute myocardial infarction.
Interventional therapies such as thrombolytic agents, angioplasty and surgery have emerged as important options in the management of patients with myocardial infarction. These therapies are aimed at improving myocardial perfusion with the ultimate improvement or restoration of myocardial function. Two-dimensional echocardiography with digital storage and display is an ideal technique for temporally monitoring regional ventricular function and the effectiveness of interventional therapy. By design, 2-dimensional echocardiography is noninvasive and can be performed conveniently at the bedside. For these reasons, echocardiography is the principal imaging technique at Indiana University Hospital for patients with acute myocardial infarction. Computer retrieval of echocardiograms can be achieved in about 10 seconds at the nurses' station in the coronary care unit. With the availability of such an examination, the physician has a better understanding of the site, size and function of the infarct area. The state of the noninfarcted myocardium is also assessed and may be critical to the patient's prognosis. With the digital recordings, serial studies can be displayed side-by-side, making it easier for the physician to follow the natural history or to judge the effect of therapy. Echocardiography also is useful in identifying many complications that can occur with myocardial infarction. For these reasons, and because echocardiography will also show related cardiac problems, it is indispensable in the management of acute myocardial infarction.
Echocardiography↗
Comparison of contrast angiography and two-dimensional echocardiography for the evaluation of left ventricular regional wall motion abnormalities after acute myocardial infarction.
Regional left ventricular wall motion abnormalities were assessed using 2-dimensional echocardiography and contrast ventriculography within 12 hours of the onset of chest pain in 20 patients with acute myocardial infarction (AMI); 10 patients had anterior infarctions and 10 had inferior. End-diastolic and end-systolic sinus beats from right anterior oblique contrast ventriculograms were analyzed using the center-line chord technique with both a standard overlap method of chord assignment and a nonoverlap method. Echocardiograms were obtained in parasternal long- and short-axis and apical 2- and 4-chamber views and analyzed using a 16-segment scoring system to derive anterior and infero-posterolateral wall motion indexes using both overlap (10 segments for anterior, 8 inferior) as well as nonoverlap (9 segments anterior, 7 inferior) methods of segment assignment. There was a significant inverse correlation between the standard (nonoverlap) echocardiographic analysis and the standard (overlap) angiographic analysis for infarct regions (y = -0.43 X +1.11, r = -0.59, p less than 0.05). Fifteen of 18 patients with angiographic infarct regional score less than or equal to -1 standard deviation/chord had an echocardiographic index greater than or equal to 1.5, while 15 of 16 patients with echocardiographic regional infarct index greater than or equal to 1.5 had an angiographic score less than or equal to -1 standard deviation/chord. Correlation between the 2 methods for noninfarct territories was poor (r = -0.34) because the angiographic method assesses hyperkinesis while the echocardiographic method does not.(ABSTRACT TRUNCATED AT 250 WORDS)
Contrast Media↗
Improvement in rest and exercise-induced wall motion abnormalities after coronary angioplasty: an exercise echocardiographic study.
Exercise echocardiography was performed in 36 patients to evaluate functional improvement after coronary angioplasty. Thirty-one patients (86%) had provokable ischemia before angioplasty including 22 with an abnormal exercise electrocardiographic test (angina or ST depression), 25 with an abnormal exercise echocardiogram (exercise-induced wall motion abnormalities) and 16 with both tests abnormal. Nineteen patients had no induced ischemia after angioplasty. Seventeen (47%) continued to have ischemia that was limited in 12 to exercise-induced wall motion abnormalities, which were less severe compared with those of preangioplasty studies. Fifteen (65%) of 23 patients had improvement in rest wall motion abnormalities after angioplasty. The rest to immediate postexercise change in global wall motion score was significantly improved after angioplasty. The change in regional wall motion score was significantly improved after angioplasty in patients with single vessel right or left circumflex coronary artery disease and approached significant improvement (p = 0.06) in those with single vessel disease of the left anterior descending coronary artery. Exercise echocardiography improves the sensitivity of functional testing for ischemia, aids in localizing the ischemic zone and documents improvement in regional function after coronary angioplasty.
Angioplasty, Balloon, Coronary↗
Prognostic value of a normal exercise echocardiogram.
Follow-up information was obtained from 148 patients who had normal resting and post-treadmill exercise echocardiograms to determine the prognostic value of a normal exercise echocardiogram in patients evaluated for suspected coronary artery disease. There were 77 men and 71 women with a mean age of 52.5 years and a pretest likelihood of coronary artery disease of 39%. Patients were followed for a mean duration of 28.4 +/- 8.5 months. The exercise ECG was abnormal in 69 patients (47%) including 28 who had ischemic responses. Cardiac events occurred in six patients, three with normal and three with abnormal exercise ECGs. Events occurred only in those patients (6 of 68) who exercised to work loads less than 6 METs or who achieved less than 85% of the age-predicted maximal heart rate. Three patients had coronary artery bypass grafting for angina from 10.5 to 22.5 months after echocardiography. A fourth patient had bypass grafting for mild single-vessel disease at the time of mitral valve replacement. Two patients had myocardial infarctions (0.85% per year) at 7.5 and 41 months after echocardiography. There were no deaths. Coronary revascularization is infrequently required in the 28 months after a normal exercise echocardiogram. A normal exercise echocardiogram in a patient with good exercise capacity was predictive of an excellent prognosis, even in those who had abnormal exercise ECGs. Myocardial infarction and death were rare events, even in patients with decreased exercise capacity.
Adult↗
Balloon valvuloplasty.
Percutaneous balloon valvuloplasty has been used for several years for the treatment of stenosis of all four cardiac valves. It has been particularly effective in pulmonary stenosis in children and in rheumatic mitral stenosis, especially in the younger age groups without severe calcification. After initial enthusiasm, results have not been as good in severe calcific aortic stenosis, although there is a place for aortic valvuloplasty in patients who are truly inoperable for reasons of age or coexisting disease. The procedure also may be applicable to occasional cases of tricuspid stenosis. The techniques used and results obtained with these procedures at Indiana University are described.
Adolescent↗
Upright bicycle exercise echocardiography after coronary artery bypass grafting.
Upright bicycle exercise echocardiography and coronary angiography were performed in 42 patients from 1 month to 15 years (mean 6.3 years) after coronary artery bypass grafting (CABG) to determine if exercise-induced wall motion abnormalities could be correlated with the presence and location of nonrevascularized vessels. Nonrevascularized vessels were defined as obstructed vessels without grafts, obstructed grafts or native vessels obstructed distal to bypass graft insertion. Adequate quality echocardiograms were recorded at rest, peak exercise and after exercise in 38 patients (90%). Rest and postexercise echocardiograms were adequate in 3 others. Only 1 patient was excluded from analysis for inadequate peak and postexercise echocardiograms. Exercise-induced wall motion abnormalities were present in 33 of 35 patients (94%) who had 1 or more nonrevascularized vessels and these abnormalities were absent in 5 of 6 (83%) who had all vessels revascularized. Wall motion abnormalities were localized to the territory of the left anterior descending (LAD) artery or to a combined right (R) coronary-left circumflex (LC) region of circulation. Exercise-induced wall motion abnormalities were present in 24 of 27 LAD artery regions (89%) and 23 of 26 R-LC regions (88%) that had nonrevascularized vessels. These abnormalities were absent in 13 of 14 LAD regions (93%) and in 12 of 15 R-LC regions (80%) that had only revascularized vessels. Upright bicycle exercise echocardiography was successfully performed after CABG. The technique detected and accurately localized nonrevascularized and revascularized vessels.
Adult↗
Exercise echocardiographic detection of coronary artery disease in women.
The utility of exercise echocardiography for the diagnosis of coronary artery disease has been demonstrated in populations consisting largely of men with a high prevalence of disease. To determine the diagnostic value of exercise echocardiography in women, 57 women who presented with chest pain were studied with coronary cineangiography and echocardiography combined with either treadmill (n = 38) or bicycle exercise (n = 19). Significant coronary artery disease (greater than or equal to 50% reduction in luminal diameter) was present in 28 (49%) of 57 patients, including 16 (84%) of 19 who had typical angina, and 12 (32%) of 38 who had atypical chest pain. The overall sensitivity and specificity of echocardiography were both 86%. Exercise echocardiography correctly determined the presence or absence of coronary artery disease in 32 (84%) of 38 patients who had atypical chest pain and in 17 (89%) of 19 who had typical angina (p = NS). The exercise electrocardiogram (ECG) was nondiagnostic in 17 patients (30%) who had rest ST segment depression or ST depression with exercise that could also be induced by hyperventilation or changes in position. The correct diagnosis was made by echocardiography in 14 (82%) of 17 patients with a nondiagnostic exercise ECG. In conclusion, exercise echocardiography has a clinically useful level of sensitivity and specificity for the detection of coronary artery disease in women. The technique provides diagnostic information in women presenting with atypical chest pain and in those who have a nondiagnostic exercise ECG.
Adult↗
Early recovery of regional left ventricular function after reperfusion in acute myocardial infarction assessed by serial two-dimensional echocardiography.
Although global and regional left ventricular (LV) function has been demonstrated to improve after reperfusion in acute myocardial infarction (AMI), the timing of these changes has not been well established. In this study, serial 2-dimensional echocardiography was used to assess regional LV function in 23 patients with AMI in whom reperfusion was accomplished by thrombolysis alone, by coronary angioplasty alone or by both interventions within 6 hours after onset of chest pain. Echocardiograms were performed before or within 6 hours after reperfusion (n = 23) and at 1 (n = 19), 3 (n = 21) and 7 (n = 20) days after reperfusion. Wall motion index and percentage of normally functioning muscle were calculated using a 16-segment scoring system analyzed in blinded fashion without knowledge of patient identity, therapy or time of study. The mean wall motion index improved from 1.78 +/- 0.48 to 1.56 +/- 0.38 at 1 day (n = 19, p less than 0.01), and to 1.48 +/- 0.37 at 3-7 days (p less than 0.01), with no significant difference between 3 days (1.49 +/- 0.39) and 7 days (1.42 +/- 0.30). There was a corresponding improvement in the percentage of normally functioning muscle, from 53 +/- 24% at 6 hours to 62 +/- 20% at 1 day (p less than 0.05) and to 67 +/- 18% at 3-7 days (p less than 0.01), again with no significant difference between 3 days (67 +/- 21) and 7 days (70 +/- 20).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Echocardiographic evaluation of left ventricular diastolic function.
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Amyloidosis↗
Non-invasive diagnosis of ischemic heart disease using stress thallium scintigraphy and digital exercise 2-dimensional echocardiography.
The introduction of computer technology has overcome many of the technical difficulties in performing and interpreting echocardiograms obtained from exercising individuals and has made stress echocardiography a potentially practical examination. Additional data, however, are necessary to establish the accuracy of exercise echocardiography. The purpose of this study is to compare exercise echocardiography and planar thallium studies for accuracy in detecting coronary artery disease. The study was performed on 50 patients, 41 of whom underwent coronary angiography. For the remaining 9 patients accuracy was defined as concordance of clinical information, treadmill ECG results, thallium data and the exercise echocardiogram. If there was any discrepancy among these tests, the patient was not included in the analysis. The sensitivity of exercise 2D digital echocardiography was comparable to stress thallium (0.86 vs 0.85) and was better than treadmill test alone (0.66). There were no false positive tests with echocardiographic study, while 1 false positive thallium examination was detected. The diagnostic accuracy of stress echocardiography was 0.90, stress thallium 0.85 and treadmill test only 0.75. In conclusion, exercise echocardiography appears to give results comparable to stress planar thallium studies. In addition, the ultrasonic procedure has several advantages: it is totally non-invasive, does not require a reperfusion study 4 hours later, avoids radiation and is less expensive.
Adult↗
Improvement in regional wall motion after percutaneous transluminal coronary angioplasty during acute myocardial infarction: utility of two-dimensional echocardiography.
In the setting of acute myocardial infarction, 16 patients undergoing successful coronary angioplasty (PTCA) within 6 hours of presentation (group I) and eight patients receiving conventional medical therapy (group II) were studied by serial two-dimensional (2D) echocardiography to assess the functional recovery of myocardium. All patients underwent 2D echocardiograms within 24 hours of presentation and at a minimum of 6 days after admission. Wall motion analysis was quantified with a wall motion score index based on 16 left ventricular wall segments. Wall motion score index improved significantly from early to late echocardiographic study in the patients undergoing PTCA (1.65 +/- 0.29 to 1.40 +/- 0.30; p less than 0.001), whereas the index did not improve in the conventionally treated group (1.54 +/- 0.26 to 1.58 +/- 0.25; p = NS). One patient in group II had a greater than or equal to 10% improvement in wall motion score index compared to 11 of 16 in group I (p less than 0.01). In all cases improvement in wall motion score index was due to improvement in regional wall motion in the area of infarction. In group I, 40 of 77 (52%) infarct zone segments showed improvement of at least one grade, versus 4 of 28 (14%) segments in group II (p less than 0.001). These data indicate that regional myocardial function improves in the majority of patients undergoing successful PTCA as emergency therapy for acute myocardial infarction and that serial 2D echocardiography is an excellent means to quantify this improvement.
Adult↗