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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