Cases in Stress Echo DISCLOSURE
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1 Cases in Stress Echo Susan Wilansky, MD, FRCP(C), FACC, FASE Mayo Clinic, AZ DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None 1
2 Exercise Testing in Patients with HCM (Class IIa) Reasonable to assess functional capacity and response to Rx Reasonable to assess for SCD risk Reasonable in those whose LVOT obstruction is < 50 mmhg to detect and quantify magnitude of gradient 2011 ACCF/AHA Guidelines JACC 2011; 58(25):e212 Case 73 year old male DOE with near syncope PMH: angioplasty 22 years prior and stent LAD 2009.? Hypertension Family hx SCD (grandfather age 60) Echo: septum 15 mmhg; EF 73%. No gradient at rest/valsalva MRI c/w HCM (10% delayed hyperenhancement) 2
3 Exercise Stress Test Exercise time: 5:32 min/sec Peak HR: 73% maximal predicted 6.5 METS; 84% FAC BP (rest): 126/80 mmhg BP (stress): 80/48 mmhg All exercise-induced symptoms reproduced 3
4 4
5 REST STRESS No LVOT gradient LVOT gradient: 96 mmhg What to do next? (cath: 70% LAD lesion) 1. Stop exercise 2. Increase B blocker (average HR on holter 55 BPM) 3. Refer for IV alcohol ablation 4. Myectomy/ LIMA to LAD 5
6 Survival Free From Death and Aborted Sudden Cardiac Death Including Appropriate Defibrillator Shocks 2/14/2017 ACC /ESC Guidelines Septal Reduction therapy Resting/provokable gradient > 50 mmhg and NYHA III-IV on max medical therapy Exertional syncope (gradient > 50 mmhg on max medical therapy JACC 2011;58(25):e212 Eur Heart Journal 2014;35(39):2733 Surgical Myectomy vs Alcohol Ablation? 100 Myectomy Log-rank test P=0.01 ASA Follow-up Time (yrs) Circ Heart Fail. 2010;3:
7 PRE-OP POST-OP Case 60 year old man: progressive DOE 1 year prior, during pickle ball game, acute dyspnea and near syncope. ER, positive trops; negative cath One month prior: unexplained syncope at work Typical murmur of HCM 7
8 Echo: HCM, neutral septum (15 mm), resting gradient 50 mmhg (Valsalva 62 mmhg) Started on B blocker Stress Bruce protocol: 6:44 min:sec 81% FAC 83% maximal predicted HR 7.7 METS; DP Normal BP response Dyspnea/mild lightheadedness 8
9 9
10 Resting gradient 30 mmhg Gradient (Valsalva) 52 mmhg Gradient (Stress) 120 mmhg 10
11 Interpretation 1. Negative for ischemia; stress induced obstruction due to cavity obliteration 2. Negative for ischemia; stress induced gradient due to SAM 3. Positive for ischemia; who cares about the gradient? What to Advise? Intolerant of more β blocker 1. Myectomy 2. Admit for trial of Disopyramide 3. IV alcohol ablation 4. Disopyramide and ICD 11
12 ACC/ESC Guidelines Disopyramide is recommended in addition to β blocker to improve symptoms (resting/provokable gradients) JACC 2011;58(25):e212 Eur Heart Journal 2014;35(39):2733 Case 58 year old male Dizziness/near syncope with circuit training. No syncope Hypertension (Diltiazem CD) No family hx HCM/SCD 12
13 Stress Echocardiogram Bruce Protocol: 49 seconds 56% max predicted HR Lightheaded, diaphoretic and slow to respond No change in SBP Septum 15 mm EF 65% 13
14 14
15 LVOT (rest) Valsalva 59 mmhg Stress/Valsalva 78 mmhg 15
16 What to do next? 1. Switch to Disopyramide 2. Switch to B blocker 3. Myectomy 4. Alcohol ablation Medical Management of HCM: Class I β blockers for Rx symptoms (angina or dyspnea) in patients with obstructive and non-obstructive adult HCM. Use with caution with sinus brady or severe conduction system disease If low dose ineffective in controlling symptoms, titrate to resting HR BPM JACC 2011;58(25):e212 Eur Heart Journal 2014;35(39):
17 Comparison of Resting and Exercise Echo Parameters as Indicators of Outcome in HCM JASE 2015; 28(2):194 GLS < -15% (HR 3.84) Peak exercise LVOT gradient > 50 mmhg (HR 3.29) Case 68 year old woman: preop hip OR PMH: type II DM, hypertension, hyperlipidemia ECG: old inferior MI 17
18 Septum 14 mm Posterior wall 12 mm 18
19 19
20 Peak velocity: 6m/s What to do in the lab? Resting SBP: 96 mmhg; Peak SBP 154 mmhg 1. Stop Dobutamine 2. Give fluids 3. Stop dobutamine; reverse with β blocker 20
21 N=57 Obstruction: 21% Mechanism: SAM (3/12); cavity obliteration (9/12) Resting EF higher with gradient (65% vs 55%) Circulation 1992;86:1429 LVOT Obstruction During DSE Predicts Future Chest Pain, Syncope + Near Syncope AHJ 2005;149:908 N=237 followed prospectively months Independent positive predictor for chest pain, near syncope + syncope. Not so for the cavity obliteration group. 21
22 Sensitivity of DE for Detection of CAD : Presence or Absence of LV Cavity Obliteration 100 Cavity obliteration No cavity obliteration Any vessel disease (%) One vessel disease (%) Multivessel disease (%) AJC 1998;81: MFMER
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