ECHO 2013 / Stress Echocardiography

•Post exercise E/e’ > 13

–Highly specific (90%)

•Elevated LVEDP during exercise

•Reduced exercise capacity

–Sensitivity 63%

Burgess et al JACC 2006;47:1891-900

Kane and Oh, Curr Cardiol Rep 2012;14:359-365

The diastolic dysfunction may be due to CAD so need to assess for WMA also

Valuable to differentiate cardiac from non-cardiac etiologies for dyspnea

Stress echo

•Its not easy

•More than just CAD detection

•Maximize value

–For CAD – focus on wall thickening

–Integrate all the data

–Use contrast when appropriate

•Understand its limitations

•Consider pre-test probability of disease you are trying to detect

CASES !!

A typical Friday afternoon in MGH echo lab

•55 yo M oncologist (htn and hyperchol) notes for the last year increasing dyspnea when walking long distances and vague chest pain

(improves with rest). Hx of GERD.

•Referred for stress echo

–Supine bike for 11 min 49 secs

–HR 70 to 137 (>85% MPHR)

–BP 137/84 – 150/90 mm HG

–CP early in recovery that resolves

•ECG

–normal at rest

–Peak stress

•2 mm ST Depression II, III, aVF and V4-V6

•Asks for name of an interventional cardiologist. Walks to office (3:30 PM). Cath lab that afternoon.

•LAD 95% proximal stenosis involving takeoff of D2 and 2 large septal branches. 70% stenosis in D2. anatomy not ideal for PCI

•Following Monday

–Off-pump LIMA to LAD (robotic LIMA harvest)

–Home Friday