Stress Echo Cases Sunday, October 8, :10 3:30 PM 20 min
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1 2017 ASE Echo Florida, Orlando, FL Stress Echo Cases Sunday, October 8, :10 3:30 PM 20 min 1 M U H A M E D S A R I Ć, M D, P H D D i r e c t o r o f E c h o c a r d i o g r a p h y L a b A s s o c i a t e P r o f e s s o r o f M e d i c i n e N e w Y o r k U n i v e r s i t y L a n g o n e M e d i c a l C e n t e r NYU Leon H. Charney Division of Cardiology
2 Disclosures 2 M e d t r o n ic & P h i l i p s S p e a k e r s B u r e a u s NYU Division of Cardiology
3 Stress Case #1 3 NYU Division of Cardiology
4 CASE PRESENTATION 82-year-old man with history of hypertension, presents with exertional chest pain. *** Referred for exercise stress echo NYU Leon H. Charney Division of Cardiology 4
5 EXERCISE STRESS ECHO A4C VIEW REST STRESS STRESS STRESS NYU Division of Cardiology 5
6 EXERCISE STRESS ECHO A2C VIEW NYU Division of Cardiology 6
7 EXERCISE STRESS ECHO PLAX VIEW NYU Division of Cardiology 7
8 EXERCISE STRESS ECHO PSAX VIEW NYU Division of Cardiology 8
9 CONCLUSION Normal stress echocardiogram NYU Leon H. Charney Division of Cardiology 9
10 EXERCISE STRESS ECHO A4C VIEW REST STRESS STRESS STRESS NYU Division of Cardiology 10
11 STRESS ECHO LV CONTRACTILITY DATA NYU Leon H. Charney Division of Cardiology 11
12 TEACHING POINTS NORMAL STRESS ECHOCARDIOGRAM Global increase in LV and RV contractility with exercise Decrease in LV cavity size Maintenance of triangular LV shape TECHNICAL POINTS View hierarchy A4C > A2C > PLAX > PSAX NYU Leon H. Charney Division of Cardiology 12
13 Stress Case #2 13 NYU Division of Cardiology
14 CASE PRESENTATION 60 y/o male with hypertension, diabetes mellitus and obesity presents with exertional dyspnea. *** Referred for exercise stress echo NYU Leon H. Charney Division of Cardiology 14
15 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 15
16 EXERCISE STRESS ECHO A2C VIEW NYU Division of Cardiology 16
17 EXERCISE STRESS ECHO PLAX VIEW NYU Division of Cardiology 17
18 EXERCISE STRESS ECHO PSAX VIEW NYU Division of Cardiology 18
19 CONCLUSION Normal contrast stress echocardiogram NYU Leon H. Charney Division of Cardiology 19
20 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 20
21 TEACHING POINTS NORMAL STRESS ECHOCARDIOGRAM Global increase in LV and RV contractility with exercise Decrease in LV cavity size Maintenance of triangular LV shape TECHNICAL POINTS View hierarchy A4C > A2C > PLAX > PSAX NYU Leon H. Charney Division of Cardiology 21
22 Stress Case #3 22 NYU Division of Cardiology
23 CASE PRESENTATION 75-year-old man with CAD, s/p CABG with subsequent RCA stent. Presents with exertional dyspnea *** Referred for exercise stress echo NYU Leon H. Charney Division of Cardiology 23
24 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 24
25 EXERCISE STRESS ECHO A2C VIEW NYU Division of Cardiology 25
26 CONCLUSION No stress-induced LV wall motion abnormalities. But Is this a normal stress echocardiogram? NYU Leon H. Charney Division of Cardiology 26
27 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 27
28 TEACHING POINTS Absence of stress-induced LV wall motion abnormalities does NOT exclude occlusive coronary artery disease. Always comment on workload at which stress images were obtained. NYU Leon H. Charney Division of Cardiology 28
29 STRESS ECHO WORKLOAD DATA GOOD WORKLOAD DPP > 20,000 GOOD WORKLOAD Peak HR > 85% max DPP = DOUBLE PRESSURE PRODUCT PEAK SBP X PEAK HR NYU Leon H. Charney Division of Cardiology 29
30 Stress Case #4 30 NYU Division of Cardiology
31 CASE PRESENTATION 50-year-old man, previously healthy, referred for evaluation of syncope following an episode of rapid heart beat. *** Referred for exercise stress echo NYU Leon H. Charney Division of Cardiology 31
32 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 32
33 EXERCISE STRESS ECHO A2C VIEW NYU Division of Cardiology 33
34 EXERCISE STRESS ECHO PLAX VIEW NYU Division of Cardiology 34
35 EXERCISE STRESS ECHO PSAX VIEW NYU Division of Cardiology 35
36 EXERCISE STRESS ECHO WALL SCORING NYU Leon H. Charney Division of Cardiology 36
37 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 37
38 EXERCISE STRESS ECHO EKG AT PEAK STRESS Deep horizontal ST depressions NYU Leon H. Charney Division of Cardiology 38
39 CONCLUSION Stress echo positive for LAD ischemia. NYU Leon H. Charney Division of Cardiology 39
40 CORONARY ANGIOGRAPHY LAD STENOSIS LAO VIEW NYU Leon H. Charney Division of Cardiology 40
41 CORONARY ANGIOGRAPHY LAD STENOSIS RAO VIEW NYU Leon H. Charney Division of Cardiology 41
42 Stress Case #5 42 NYU Division of Cardiology
43 CASE PRESENTATION 69-year-old man with CAD, s/p PCI to LAD with recent recurrence of exertional chest pain. *** Referred for exercise stress echo NYU Leon H. Charney Division of Cardiology 43
44 EXERCISE STRESS ECHO EKG AT PEAK STRESS NYU Leon H. Charney Division of Cardiology 44
45 EXERCISE STRESS ECHO A4C VIEW NYU Division of Cardiology 45
46 EXERCISE STRESS ECHO A2C VIEW NYU Division of Cardiology 46
47 EXERCISE STRESS ECHO PLAX VIEW NYU Division of Cardiology 47
48 EXERCISE STRESS ECHO PSAX VIEW NYU Division of Cardiology 48
49 QUESTION Is this a positive stress echo? Positive EKG + Negative LV wall motion abnormalities NYU Leon H. Charney Division of Cardiology 49
50 TEACHING POINTS Absence of stress-induced LV wall motion abnormalities typically implies a negative stress echo irrespective of stress-induced EKG changes. NYU Leon H. Charney Division of Cardiology 50
51 SEVERITY OF ISCHEMIA ISCHEMIC CASCADE DURATION OF ISCHEMIA NYU Leon H. Charney Division of Cardiology 51
52 Stress Case #6 52 NYU Division of Cardiology
53 CASE PRESENTATION 82-year-old woman with CAD, s/p multiple coronary stents presents with heart failure. *** Referred for dobutamine stress echo; cannot exercise due to severe hip pain. NYU Leon H. Charney Division of Cardiology 53
54 DOBUTAMINE STRESS ECHO A4C VIEW REST LOW DOSE INTERMEDIATE DOSE PEAK DOSE NYU Division of Cardiology 54
55 DOBUTAMINE STRESS ECHO A2C VIEW NYU Division of Cardiology 55
56 DOBUTAMINE STRESS ECHO PLAX VIEW NYU Division of Cardiology 56
57 DOBUTAMINE STRESS ECHO PSAX VIEW NYU Division of Cardiology 57
58 QUESTION There are stress-induced LV wall motion abnormalities in the LAD territory. Is this a positive stress echo? NYU Leon H. Charney Division of Cardiology 58
59 DOBUTAMINE STRESS ECHO A4C VIEW REST LOW DOSE INTERMEDIATE DOSE PEAK DOSE NYU Division of Cardiology 59
60 DOBUTAMINE STRESS ECHO EKG AT PEAK STRESS LBBB NYU Leon H. Charney Division of Cardiology 60
61 TEACHING POINTS LBBB may lead to LV wall motion abnormalities that mimic LAD ischemia If possible, patients with baseline LBBB should undergo a form of stress testing that does NOT rely on heart rate increase. Baseline LBBB >>> order vasodilator stress test (vasodilator nuclear in the United States; vasodilator echo in Europe). NYU Leon H. Charney Division of Cardiology 61
62 Thank you 62 New York University Medical Center NYU Leon H. Charney Division of Cardiology
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