Cardiovascular Imaging Stress Echo

Transcription

1 Cardiovascular Imaging Stress Echo Theodora A Zaglavara, MD, PhD Cardiac Imaging Department INTERBALKAN MEDICAL CENTER Thessaloniki GREECE

2 Evolution of Stress Echo: From Innovation to a Widely Established Technique

3 Contrast Echo/ Flow reserve Increasing Workload

4 Goals of Cardiac Imaging in Coronary Artery Disease Direct imaging of coronary arteries Coronary Flow Reserve? Myocardial Perfusion? Assessment of Ischaemic Burden Prognosis / risk startification in patients with known or suspected CAD Ventricular dimensions and overall function Coexisting significant valve disease Detection of myocardial viability/myocardial scar

5 New 2017!!!!! Diastolic function Hypertrophic Cardiomyopathy Heart Failure, Cardiomyopathy Cardiac Resynchronization Therapy Response to Therapy Native Valve Disease (MR, AR, MS, AS) Low flow, Low gradient Aortic Stenosis Prosthetic Heart Valves Pulmonary Hypertension and Pulmonary Arterial Pressure Assessment Athletes heart Congenital Heart Disease

6 Myocardial Response to Dobutamine Infusion

7 Normal Response to Stress: Increase in EF and Decrease in End-Systolic Volume REST- HR 78/min STRESS- HR 142/min

8 Abnormal Response Inducible Ischaemia at a Low Ischaemic Threshold REST HR 70/min LOW DOSE PEAK STRESS HR 100/min

9 A High Risk Coronary Lesion Detected in a 46 year old Man with Multiple Risk Factors including Diabetes Ischaemic threshold : HR age % Heart rate (dobutamine dose) at which ischaemia develops Correlates both with number of stenosed vessels and EF response to exercise (Panza, Circ 1995)

10 3-D Echocardiography Volumetric Calculation of LV Ejection Fraction and Volumes

11 3D Stress Echo: Dynamic Slices

12 Normal Response to Stress: Enhanced Radial Strain

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14 The Impact of Contrast Use on ASE strongly supports the use of contrast agents in clinical practice. Stress Echo Quality These agents assist physicians in maximizing the accuracy of information obtained from echocardiograms and thus optimizing patient care. ASE also believes that these agents are generally safe and well tolerated

15 Myocardial Contrast Stress Echocardiography

16 Prognostic Stratification of a Negative Stress Echo Test Maximal Stress Achieved Resting EF> 50% Anti- ischeamic Therapy Off Very Low Risk of Hard Cardiac Events (<0.5%/year)

17 Abnormal Response- Inducible Ischaemia

18 Stress Echo High Risk Characteristics (High Annual Risk >10%) A High Risk Coronary Lesion Detected Low Dose/Workload (Ischaemic Threshold) Resting EF<40% Anti ischaemic Therapy On LAD Coronary Territory High Peak WMSI Slow Recovery Heterozonal Positivity or Baseline Dyssynergy The assessment and quantification of ischaemic burden rather than the pure detection of myocardial ischaemia, is the next important step towards optimizing therapy strategies in patients with CAD

19 Cumulative effect of ischemic extent and maximal severity (jeopardized myocardium) of wall motion abnormalities on event rate/year Yao SS et al. Am J Cardiol 2004

20 Cardiac Mortality Based on Dobutamine Stress Echocardiography (3156 patients) Marwick T, et al. J Am Coll Cardiol 2001

21 Independent and incremental value of stress echocardiography over clinical and stress ECG parameters for the prediction of hard cardiac events in new-onset suspected angina with no history of CAD All Patients:547 Exercise cohort:347 Chelliah R et al. Eur J Echocardiography 2010

22 Risk Stratification after Myocardial Infarction EPIC/EDIC Groups. J Am Soc Echocardiogr 2004;17:

23 Stress Echocardiography: Effective Risk Stratification in Women Bangalore s et al. ASE 2007

24 Stress Echocardiography: A Powerful Prognostic Tool in High Risk Populations DIABETES MELITUS Cortigianni L et al. JACC 2006

25 Stress echocardiography for detection of CAD/Risk assessment: Symptomatic or ischaemic equivalent Journal of the American Society of Echocardiography, March 2011

26 Stress echocardiography following prior treadmill ECG, coronary calcium scoring, or carotid intimal medial thickness test results Journal of the American Society of Echocardiography, March 2011

27 Stress echocardiography following prior stress imaging or coronary angiogram test results. Journal of the American Society of Echocardiography, March 2011

28 Stress Echocardiography for risk assessment Perioperative evaluation for noncardiac surgery without active cardiac conditions Journal of the American Society of Echocardiography, March 2011

29 Stress echocardiography for risk assessment Postrevascularization (PCI or CABG) Journal of the American Society of Echocardiography, March 2011

30 Circulation 2012

31 2014

32 Assessment of Myocardial Viability with Dobutamine Stress Echocardiography Chaudhry FA, Tauke JT, Alessandrini RS, et al: J Am Coll Cardiol 34: ,1999 Cusick et al. J Heart Lung Transpant 1997 Melutzin et al. J Am Coll Cardiol 1997

33 Prediction of Viable Myocardium in Akinetic Segments: Incremental Value of Diastolic Wall Thickness Measurement 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 92% 90% 92% 80% 82% 78% 75% 71% 60% 51% 52% DWT>0.6 DSE DSE or DWT> 0.8 Sensitivity Specificity PPV NPV Zaglavara et al. Heart 2005

34 Algorithm of Management of Patients with Ischaemic LV dysfunction Rahimtoola SH, et al. JACC Cardiovascular Imaging 2008

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37 Ionizing Radiation in Cardiac Imaging. American Heart Association Recommendations: Cardiac imaging studies that expose patients to ionizing radiation should be ordered only after thoughtful consideration of the potential benefit to the patient and in keeping with established appropriatness criteria (Class I) Considerations should include options for answering the clinical question at hand by means that do not use ionizing radiation or choosing the type of study that exposes the patient to the lowest amount of radiation (Class I) Routine surveillance radionuclide stress tests or cardiac CTs in asymptomatic patients at low risk for ischaemic heart disease are not recommended (Class I) Healthcare providers should discuss the risks and benefits of planned imaging procedures with patients whenever practical or appropriate (Class I) Circulation 2009

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39 Multimodality Cardiovascular Imaging in CAD

40 Trends in the Use of Cardiac Imaging up to the Year 2020 (British Cardiovascular Society Working Group)

41 The right test for the right patient at the right time!

42 First Do Not Harm! Ωφελέειν, ή Μη Βλάπτειν The art (medicine) consists in three things: the disease, the patient and the physician. Hippocrates, Epidemics, 5 th century B.C