Methodology...... 1021 Imaging Equipment and Technique 1021 Stress Testing Methods...... 1022 Training Requirements and Maintenance of Competency...... 1023 Image Interpretation 1024 Table 1. Normal and Ischemic Responses for Various Modalities of Stress 1025 Quantitative Analysis Methods 1025 Accuracy...... 1026 False-negative Studies...... 1026 False-positive Studies...... 1027 Assessment of Myocardial Viability 1027 Assessment of Patients With Dyspnea, Pulmonary Hypertension, and Valvular Heart Disease...... 1028 Dyspnea 1028 Pulmonary Hypertension 1029 Mitral Valve Disease...... 1029 Aortic Valve Disease...... 1029 Evaluation of Prosthetic Valves 1030 Stress Echocardiography for Risk Stratification 1030 Table 2. Summary of Studies Evaluating the Value of Stress Echocardiography in Predicting Outcome...... 1031 Table 3. Stress Echocardiography Predictors of Risk 1032 Women 1032 After Acute Myocardial Infarction...... .........1032 Elderly 1033 Patients With Diabetes Mellitus...... 1033 Before Noncardiac Surgery...... 1033 After Coronary Revascularization...... .........1033 Patients With Angina...... 1033 Comparison With Radionuclide Imaging...... ....1033 Recent and Future Developments...... .........1034 Strain and Strain Rate Echocardiograpy...... ......1034 Three-Dimensional Echocardiography...... ........1034 Myocardial Contrast Perfusion Imaging...... ......1034 Summary...... 1034 References 1034 Advances since the 1998 publication of the Recommendations for Performance and Interpretation of Stress Echocardiography include improvements in imaging equipment, refinements in stress testing protocols and standards for image interpretation, and important progress toward quantitative analysis. Moreover, the roles of stress echocardiography for cardiac risk stratification and for assessment of myocardial viability are now well documented. Specific recommendations and main points are identified in bold.

https://www.asefoundation.org/wp-content/uploads/2013/05/Performance-Interpretation-and-App-of-Stress-Echo.pdf

American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography.

Stress echocardiography is the combination of 2D echocardiography with a physical, pharmacological or electrical stress. The diagnostic end point for the detection of myocardial ischemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician. Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the potential of adding – coronary flow reserve evaluation of left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage from the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence upon operator’s training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of noninvasive diagnosis of coronary artery disease.

Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC).

MENSAGEM DOS COORDENADORES Departamento de Aterosclerose da Sociedade Brasileira de Cardiologia (SBC), acompanhando o amplo cenario de publicacoes cientificas sobre o tratamento das dislipidemias e prevencao da aterosclerose, bem como a importância de seu impacto sobre o risco cardiovascular, e reconhecendo a necessidade de atualizacao de sua ultima diretriz, publicada em 2013, em conformidade com as recomendacoes da SBC, reuniu um comite de especialistas, da clinica e do laboratorio clinico, a partir de janeiro de 2016, para a elaboracao deste [...]

Atualização da Diretriz Brasileira de Dislipidemias e Prevenção da Aterosclerose – 2017.

Stress echocardiography is the combination of echocardiography with a physical, pharmacological, or electrical stress. The diagnostic endpoint for the detection of myocardial ischaemia is the induction of a transient worsening in regional function during stress. Stress echocardiography provides similar diagnostic and prognostic accuracy to radionuclide stress perfusion imaging, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician.

Among different stresses of comparable diagnostic and prognostic accuracy, semisupine exercise is the most used, dobutamine the best test for viability, and dipyridamole the safest and simplest pharmacological stress and the most suitable for combined wall motion coronary flow reserve assessment. The additional clinical benefit of myocardial perfusion contrast echocardiography and myocardial velocity imaging has been inconsistent to date, whereas the possibility of performing coronary flow reserve evaluation of the left anterior descending coronary artery by transthoracic Doppler echocardiography adds another potentially important dimension to stress echocardiography. New emerging fields of application taking advantage of the versatility of the technique are Doppler stress echo in valvular heart disease and in dilated cardiomyopathy. In spite of its dependence on the operator's training, stress echocardiography is today the best (most cost-effective and risk-effective) possible imaging choice to achieve the still elusive target of sustainable cardiac imaging in the field of non-invasive diagnosis of coronary artery disease.

In 1935, Tennant and Wiggers1 demonstrated that coronary occlusion immediately resulted in instantaneous abnormality of wall motion. A large body of evidence2–5 recognized for the first time that transient dys-synergy was an early, sensitive, specific marker of transient ischaemia, clearly more accurate than ECG changes and pain. In European clinical practice,6–10 stress echo has been embedded in the legal and cultural framework of existing European laws and medical imaging referral guidelines. The …

/pdf/stress-echocardiography-expert-consensus-statement-executive-rzrwilqahx.pdf

Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC).

AIMS To determine the safety of high-dose dobutamine-atropine stress cardiovascular magnetic resonance (stress-CMR), which recently emerged as a highly accurate modality for diagnosis of inducible myocardial ischaemia. METHOD AND RESULTS From 1997 to 2002, 1000 consecutive stress-CMR examinations were performed. Images were acquired at rest and during a high-dose dobutamine-atropine protocol in 3 short-axis, a 4- and a 2-chamber view. Stress testing was discontinued when > or =85% of age-predicted heart rate was reached, on patient request, maximum pharmacologic infusion, or when new or worsening wall motion abnormalities, severe angina, dyspnoea, increase or decrease in blood pressure, or severe arrhythmias occurred. Stress-CMR was successfully performed in all but four patients (0.4%; insufficient ECG-triggering). Target heart rate was not reached in 95 cases (9.5%), due to maximum pharmacologic infusion in submaximal negative examinations in 21 cases (2.1%), and limiting side effects in 74 (7.4%). Side effects included one case (0.1%) of sustained and four cases (0.4%) of non-sustained ventricular tachycardia, 16 cases (1.6%) of atrial fibrillation, and two cases (0.2%) of transient second degree AV block. CONCLUSION The safety profile of stress-CMR is similar to other methodologies using dobutamine infusions. Patients must be closely monitored, and resuscitation equipment and trained personnel must be available.

/pdf/safety-and-feasibility-of-high-dose-dobutamine-atropine-owzfb3xbpa.pdf

Safety and feasibility of high-dose dobutamine-atropine stress cardiovascular magnetic resonance for diagnosis of myocardial ischaemia: experience in 1000 consecutive cases.

Dobutamine-atropine stress echocardiography (DASE) is an established method and has been shown to be accurate for the detection of coronary artery disease. Still, there are few large clinical studies that analyze the safety of DASE in general or the safety of performing it on an ambulatory basis. Most studies use a target heart rate as the primary end point regardless of whether asymptomatic ischemia occurs. Such studies have shown a serious cardiac event rate of approximately 0.3%. We prospectively studied 4,033 consecutive patients on an ambulatory basis and in the hospital with the use of DASE from July 1991 to December 1998. All tests were performed by an experienced physician, and all clinical and DASE data were stored in a large database organized at the beginning of the study. Dobutamine was infused in scalar doses of 5, 10, 20, 30, and 40 microg/kg per minute in 3-minute stages. Development of a new wall motion abnormality, achievement of 85% of target heart, and end of the DASE infusion protocol were used as an end point. If 85% of the target heart rate was not achieved, atropine was infused up to 1 mg in the absence of myocardial ischemia, which was used in 1,280 studies. There were 3,645 diagnostic tests, and 388 (10%) were found to be nondiagnostic. This result was due to poor image quality in 115 (3%), end of protocol in negative-submaximal examinations in 124 (3%), and limiting side effects in 149 (4%). Thirty-seven percent of the tests showed positive results for myocardial ischemia. Major test-related cardiac complications occurred in 10 (0.25%) patients and included 1 ventricular fibrillation, 1 case of myocardial infarction, and 8 cases of sustained ventricular tachycardia. Atropine poisoning was observed in 5 (0.12%) patients. No deaths occurred as a direct or indirect consequence of DASE. We conclude that dobutamine-atropine stress echocardiography is a reasonably safe method for detection of coronary artery disease in the hospital or in an ambulatory basis. The use of new wall motion abnormality as 1 of the end points may prevent further ischemia-related complications.

Safety of Dobutamine-Atropine Stress Echocardiography: A Prospective Experience of 4033 Consecutive Studies

Although dobutamine–atropine stress echocardiography (DASE) is an established method for evaluating patients who have coronary artery disease (CAD), it can increase test duration and a patient's exposure to large doses of dobutamine. New protocols, including the early injection of atropine during dobutamine stress echocardiography (EA-DSE), have been proposed to decrease test duration. This study compared the safety, efficacy, and accuracy of EA-DSE with those of DASE. We retrospectively evaluated 3,163 patients who underwent DASE and 1,664 patients who underwent EA-DSE over a period of 12 years. In EA-DSE, atropine at a dose ≤2 mg was started with 20 μg/kg/min of dobutamine if heart rate was 50% stenosis) was assessed in patients who underwent quantitative angiography ≤3 months of stress testing. The dobutamine dose used in EA-DSE was smaller than that used in DASE (31 ± 6 vs 36 ± 6 μg/kg/min, p

Comparison of safety and efficacy of the early injection of atropine during dobutamine stress echocardiography with the conventional protocol

We sought to compare the feasibility and accuracy of myocardial blood flow reserve (MBFR) measured by quantitative real-time myocardial contrast echocardiography with those of coronary flow velocity reserve (CFVR) obtained by transthoracic Doppler echocardiography for detecting left anterior descending coronary artery (LAD) stenosis. We studied 71 patients who underwent adenosine stress contrast echocardiography, transthoracic Doppler echocardiography, and quantitative coronary angiography within 1 month. An index of myocardial blood flow (A×β) was determined by quantification of peak plateau acoustic intensity (A) and microbubble replenishment velocity (β) by contrast echocardiography. Feasibilities of qualitative analysis of myocardial perfusion, and CFVR and MBFR measurements were 98%, 83%, and 94%, respectively. Patients with LAD stenosis had lower CFVR (1.1 ± 0.4 vs 2.7 ± 0.8, P P P

Evaluation of blood flow reserve in left anterior descending coronary artery territory by quantitative myocardial contrast and Doppler echocardiography.

We sought to determine the value of dobutamine versus adenosine real-time myocardial perfusion (MP) echocardiography for detecting coronary artery disease and the value of quantitative analysis of MP over electrocardiography, wall motion, and qualitative MP. We studied 54 patients by real-time MP echocardiography and coronary angiography. Replenishment velocity (β) and an index of myocardial blood flow (A n ×β) were derived from quantitative MP. During dobutamine stress, β (1.7 ± 0.7 vs 2.7 ± 1.2; P n ×β (2.2 ± 1.0 vs 3.5 ± 1.6; P P n ×β (1.9 ± 0.7 vs 3.2 ± 1.4; P 2 23.7-38.4; P 2 26.7-59.4; P

Head-to-head comparison of dobutamine and adenosine stress real-time myocardial perfusion echocardiography for the detection of coronary artery disease.

Altamiro F.F. Osório

Papers

Safety of Dobutamine-Atropine Stress Echocardiography: A Prospective Experience of 4033 Consecutive Studies

Comparison of safety and efficacy of the early injection of atropine during dobutamine stress echocardiography with the conventional protocol

Evaluation of blood flow reserve in left anterior descending coronary artery territory by quantitative myocardial contrast and Doppler echocardiography.

Head-to-head comparison of dobutamine and adenosine stress real-time myocardial perfusion echocardiography for the detection of coronary artery disease.