Stress echocardiography

ABCIC

Case Report

Apical Hypertrophic Cardiomyopathy with Microfistulas: Correlation Between Coronary Flow Steal, Positive Inotropic Effect, and Normalization of T-Wave Polarity

José Sebastiao de Abreu et al. Tereza Cristina Pinheiro Diógenes Marília Esther Benevides Abreu Isadora Sucupira Machado Chagas Mateus Paiva Marques Feitosa

Introduction

Apical hypertrophic cardiomyopathy (HCM) with microfistulas is a rare condition, and the incidence of multiple microfistulas draining into the left ventricle (LV) ranges from 0.07% to 0.09%.^, Diagnosis can be established via contrast ventriculography, coronary angiography, and echocardiography.^–

Two-dimensional echocardiography with color and pulsed-wave Doppler allows visualization of microfistula flow and measurement of diastolic flow velocity (DFV) using the same approach as for the left anterior descending artery (LAD).

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ABCIC

Editorial

Myocardial Work During Isometric Exercise: From Physiology to Clinical Practice

Rodrigo Bellio de Mattos Barretto et al. Carlos Eduardo Suaide Silva

Assessment of left ventricular function by echocardiography has advanced remarkably in its ability to characterize aspects that extend beyond traditional measures of volume and ejection fraction (EF). Among these advances, the evaluation of contractility through two-dimensional strain analysis has gained particular prominence. Technological developments now allow this measure to be adjusted for afterload through myocardial work (MW), providing greater potential to identify subtle changes in ventricular function.

Isometric exercise represents a strategy to increase afterload through handgrip, proving particularly useful in echocardiography because it enables the identification of functional changes in different clinical settings, including coronary artery disease, assessment of diastolic function, hypertension, athletes, and even atrial functional mitral regurgitation.^–

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ABCIC

Original Article

Safety of dobutamine stress echocardiography using a modified protocol in a large unselected population

José Sebastião de Abreu et al. Tereza Cristina Pinheiro Diógenes Marília Esther Benevides Abreu Isadora Sucupira Machado Chagas … Sarah Gomes Diógenes Ana Gardenia Liberato Ponte Farias Marcia Maria Carneiro

Abstract

Background

Dobutamine stress echocardiography (DSE) using the conventional protocol (CP-DSE) may lead to important adverse effects.

Objective

This study was aimed at assessing the safety of DSE using a modified protocol (MP-DSE).

Methods

Data were collected from our institutional database to compare MP-DSE with the CP-DSE. In the CP-DSE, atropine could be administered during the fourth stage or its extension. In the MP-DSE, atropine was initiated at the beginning of the third stage, and there was no stage extension. Upon completion of DSE or for arrhythmia control, metoprolol was administered in the CP-DSE and esmolol in the MP-DSE. In cases of typical angina, nitroglycerin was administered at the examiner’s discretion in the CP-DSE, whereas its use was predetermined in the MP-DSE. A p-value < 0.05 was considered statistically significant.

Results

Of 17,811 tests performed, 9,121 were conducted using the MP-DSE. During DSE, myocardial oxygen consumption, represented by the rate-pressure product, was significantly higher in the MP-DSE group (22,530 ± 4,575 vs 23,037 ± 4,072 bpm.mmHg; p < 0.001). Hypertensive peak (1% vs 0.4%; p = 0.0001) and nonsustained ventricular tachycardia (0.6% vs 0.1%; p = 0.0001) were more frequent in the CP-DSE, while supraventricular tachyarrhythmia (2.1% vs 3.78%; p = 0.0001) and atrial fibrillation (0.8% vs 1.3%; p = 0.003) were more common in the MP-DSE. These arrhythmias resolved spontaneously or with medication. In the CP-DSE, two patients had ventricular fibrillation and one, acute coronary syndrome.

Conclusion

In our study, the modified protocol for DSE proved to be a safe option, with no severe adverse effects observed, despite the presence of an elevated rate-pressure product.

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ABCIC

Case Report

Coronary Artery Dissection Following Pharmacologic Stress Echocardiography and the Follow-Up of Clinical Management: A Case Report

Thiago Artioli et al. Bruno Querido Marcondes Santos Denis Cárdenas Monteiro Layane Bonfante Batista … Matheus Zavaris Lorenzoni Hsu Gwo Jen Kelvyn Melo Vital Kelvin Henrique Vilalva

Introduction

Spontaneous coronary artery dissection (SCAD) remains a diagnostic and therapeutic challenge in the evaluation of chest pain. Misinterpretation of symptom characteristics and failure to consider the patient’s epidemiological profile may lead to inappropriate diagnostic workups and treatment strategies. The case described herein represents only the second report with similar characteristics published in major medical databases. This case underscores the importance of considering uncommon causes of chest pain and acute coronary syndrome (ACS), while also providing a brief review of relevant literature. The report was prepared in accordance with the CAse REport (CARE) guidelines.

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ABCHF

Review Article

Theoretical Concepts of Lung Ultrasound in the Diagnosis of Congestion

Willian Roberto Menegazzo et al. Marina Petersen Saadi Gustavo Paes Silvano Vinícius Leite Gonzalez Anderson Donelli da Silveira

Abstract

Accurate detection of pulmonary congestion remains a challenge in cardiology, despite advances in diagnostic methods. Traditional approaches, such as physical examination and chest radiography, have limitations in real-time assessment and dynamic monitoring of volume status. Lung ultrasound (LUS) has emerged as a promising tool, offering a non-invasive, bedside approach to detect pulmonary congestion with greater diagnostic accuracy, providing valuable information about volume status. In patients with heart failure, LUS has demonstrated high sensitivity and specificity in detecting pulmonary congestion, contributing to more accurate differential diagnosis and streamlining clinical decision-making. In the context of stress echocardiography, LUS improves risk stratification, identifying patients with a greater likelihood of adverse cardiovascular events. Beyond the context of heart failure, LUS has also been applied in other clinical scenarios, such as acute coronary syndrome and assessment of volume status in patients on dialysis. This expanded use reflects the potential of LUS as a versatile and valuable tool in different clinical settings, offering an earlier, more accurate, and more effective approach to cardiology care.

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ABC

Original Article

Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography

Cláudia Bispo Martins-Santos et al. Lara Teles Alencar Duarte Cleovaldo Ribeiro Ferreira-Junior Allexa Gabriele Teixeira Feitosa … Edvaldo Victor Gois Oliveira Iana Carine Machado Bispo Campos Enaldo Vieira de Melo Stephanie Macedo Andrade Antônio Carlos Sobral Sousa Joselina Luzia Menezes Oliveira

Abstract

Background

The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome.

Objective

To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE).

Methods

This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student’s t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test.

Results

Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009).

Conclusion

Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.

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ABCIC

Case Report

Coronary Flow Velocity Reserve and Myocardial Contractility Under Stress in the Post-Infarction Ischemic Memory Dilemma

Marilia Esther Benevides de Abreu et al. Tereza Cristina Diógenes Pinheiro Antônio Augusto Lima Guimarães José Sebastião de Abreu

Introduction

After acute myocardial infarction (AMI), some cases progress with deep T wave inversions on electrocardiogram (ECG). This electrocardiographic abnormality can continue for a prolonged period, even if a coronary intervention within a short time of AMI progression results in successful myocardial reperfusion. However, these deep T wave inversions can raise management questions when the patient is already being followed up in an outpatient clinic, particularly in the absence of relevant symptoms to support the resurgence of an ischemic process. In this context, a safe noninvasive assessment such as dobutamine stress echocardiography (DSE) associated with the analysis of coronary flow velocity reserve (CFVR) may be an option for this dilemma between myocardial ischemia and the possible post-infarction ischemic memory.^–

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ABCIC

Case Report

Analysis of Post-Systolic Shortening, Myocardial Strain, and Arterial Flow to Assess Myocardial Ischemia during Stress Echocardiography

Marilia Esther Benevides de Abreu et al. Renan Abreu Ponte Freire Luana Priscila G. Santos Isadora Sucupira Machado … Tereza Cristina Diógenes Pinheiro Antônio Augusto Guimarães Lima José Sebastião de Abreu

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IJCS

Original Article

Early Use of Handgrip Exercise Associated with Dobutamine Stress Echocardiography in Women

Isabela de Andrade Lindner et al. Patricia Sens de Oliveira Caroline de Oliveira Fischer Bacca Josie Budag Matsuda … Franciani Rodrigues da Rocha Jeancarlo Visentainer Luiz Eduardo Bacca

Abstract

Background

Coronary artery disease (CAD) is an important cause of morbidity and mortality in women and requires early diagnosis for defining the appropriate treatment.

Objective

To identify the positive predictive value (PPV) and safety of the early use of handgrip exercise in pharmacological stress echocardiography using dobutamine (early-ECHO) in women.

Methods

Positive ischemic early-ECHO records from 111 women were evaluated from January 2012 to March 2018. Subsequently, the hospital medical records were verified to locate patients who underwent conventional coronary angiography (CCA), and we analyzed the medical conduct adopted for these patients. Statistical analyses were performed using SPSS employing one-way analysis of variance (ANOVA), Fisher’s exact test, or Pearson’s chi-square test. The level of statistical significance was set at p < 0.05 for all analyses.

Results

Four patients (4.4%) presented serious complications during the examination. Out of 90 patients who underwent CCA, 71 (78.9%) had CAD. Among these 71 patients, 58 (81.7%) had severe lesions and 13 (18.3%) presented moderate CAD. Moreover, CCA did not demonstrate relevant coronary lesions in 19 of the 90 patients (21.1%). Among patients with severe CAD, 16 (27.6%) underwent myocardial revascularization surgery; 34 (58.6%) underwent percutaneous coronary angioplasty; and 08 (13.7%) had their clinical treatments intensified. The PPV for early-ECHO was 78.9%.

Conclusions

Early-ECHO showed a high PPV for diagnosing myocardial ischemia in women. It presented a low complication rate and provided rapid disease identification, allowing the early treatment of injuries and potentially preventing CAD complications.

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ABC

Artigo Original

Feasibility, safety and accuracy of dobutamine/atropine stress echocardiography for the detection of coronary artery disease in renal transplant candidates

Pedro Antonio Muniz Ferreira et al. Valter Correia de Lima Orlando Campos Filho Manuel Adan Gil … Adriana Cordovil Cristiano Vieira Machado José Osmar Medina Pestana Antonio Carlos de Camargo Carvalho

OBJECTIVE: To evaluate the feasibility, safety and accuracy of dobutamine/atropine stress echocardiography (DASE) for the detection of coronary artery desease (CAD) in renal transplant candidates. METHODS: Patients candidates to renal transplant were submitted consecutively to DASE and coronary angiography. The adopted angiographic criteria for CAD were an obstructive lesion of > 50% and > 70%. RESULTS: 148 patients underwent the DASE and the coronary angiography. Mean age was 52 ± 9 years, 69% of the patients were males; 27% had diabetic nephropathy and 73% had LVH; 63% were asymptomatic; 36% and 22% presented coronary obstructions > 50% and 70%, respectively. The DASE performance was 91% and major complication rate was 2.7%. The sensibility, specificity and accuracy for the diagnosis of coronary obstruction > 50% were 53% (CI:45-61), 87% (CI:81-93), and 75% (CI:63-83) respectively. For coronary obstruction > 70% these values were, respectively, 71% (CI:64-92), 85% (CI:79-91) and 81% (CI:75-87). The sensibility to detect univessel and multivessel disease was 41% (CI:19-63) and 78% (CI:64-92), respectively. CONCLUSION: The DASE was practical and safe; however, it presented a poor result for the detection of CAD regarding obstructions > 50%. It can be a useful screening for the detection of CAD in candidates with obstructions > 70% and multivessel disease.

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ABC

Artigo Original

Stratifying the risk in unstable angina with dobutamine stress echocardiography

Brivaldo Markman Filho et al. Maria Celita Almeida Manuel Markman Andrea Chaves … Miguel A. Moretti José A. F. Ramires Luiz A. César

OBJECTIVE: To evaluate the role of dobutamine stress echocardiography (DSE) in the risk stratification of low to moderate risk unstable angina (UA) patients, to predict the combined clinical outcome of cardiovascular death, myocardial infarction (MI), recurrent UA and the need of revascularization procedures in a 6 month period. METHODS: Multicenter prospective study. Patients should be admitted to the hospital and asymptomatic in the last 24 hours. The exam was performed up to 72 hours from the hospital admission and no medication was stopped prior to the test. RESULTS: Ninety-five consecutive patients were evaluated by DSE. Forty patients (42,1%) had a positive ischemic test and fifty five (57,9%) had a negative one. Clinical events occurred in twenty eight patients, twenty six of whom had a positive test. The rest of the patients (67) did not have clinical events and fifty three of them, had a negative test. The sensibility, specificity, accuracy, positive predictive value and negative predictive value of the test related to the clinical events were: 92,9%, 79,1%, 83,2%, 65% and 96,4%, respectively. Event-free survival after 6 months for pacients with a negative DSE was 96% compared to 35% for those with a positive DSE (p<0,001). The UA classification, left ventricular ejection fraction, rest and peak wall motion score index, DSE result and history of previous MI were associated with the combined end point by univariate analysis. The test result was the only independent predictor of cardiac events by multivariate analysis (p<0.001). CONCLUSION: O DSE has shown an excellent negative predictive value allowing for early hospital discharge without further exams. The positive test result was the only independent predictor for adverse cardiac events.

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ABC

Artigo Original

Myocardial viability in a single-vessel disease: the role of a dobutamine stress echocardiography

Márcia Bueno Castier et al. José Raul Alves Carrinho Márcia Alves Carrinho Francisco Manes Albanesi Filho … Álvaro Villela de Moraes Fernando Portugal Morcerf

OBJECTIVE: To investigate a group of patients that have a significant lesion in a single-vessel and to demonstrate whether or not the sensitivity and specificity of a dobutamine stress echocardiography (DSE) was valuable in the evaluation of myocardial viability for these patients. METHODS: Twenty patients who had undergone percutaneous transluminal coronary angioplasty (PTCA) were studied. This group was evaluated 2 to 7 days (3.65 ± 1.69) before the procedure and 2 to 5 days (4 ± 0.80) after the procedure with a DSE. Myocardial viability was assessed three months after the procedure using a two dimensional echocardiogram. Twelve patients underwent PTCA on the left anterior descending artery (LAD), 7 on the right coronary artery (RC) and 1 on the circumflex artery (CX). Only one right coronary artery procedure was not 100% successful. RESULTS: From the 340 segments that were studied, 99 (29.18%) demonstrated contractile alterations of which 63 were hypokinetic (63.4%), 28 akinetic (28.28%) and 8 dyskinetic (8.08%). In reference to the segments involved, we obtained a sensitivity of 92.59%, specificity of 84.45%, and accuracy of 88.88% for the DSE. The solitary case of PTCA for the circumflex artery demonstrated 100% sensitivity. The LAD demonstrated a sensitivity of 88.58%, specificity of 95% and accuracy of 90.91%. For the RC segments, sensitivity was 91.30%, specificity 83.33% and accuracy 88.71%. All dyskinetic segments were unviable. The DSE predicted a 91.48% recovery rate for the 63 hypokinetic segments. CONCLUSION: The DSE is an effective test for evaluating myocardial viability in patients with a significant single-vessel disease.

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