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Exercise testing among the pediatric congenital heart disease population continues to transform and expand the way patients are evaluated and managed. We describe a case where a stress echocardiogram was performed while successfully collecting data from a previously implanted CardioMEMS™ HF system which helped guide decision-making.

Coronary artery disease (CAD) is a common and important condition, associated with high morbidity and mortality. Appropriate diagnosis, assessment, and evaluation of CAD using noninvasive cardiovascular imaging are critical in guiding optimal patient management. A diverse range of multimodality cardiovascular imaging techniques is available for the evaluation of CAD, including stress echocardiogram, cardiac computed tomography, stress cardiac magnetic resonance imaging (MRI), single-photon emission computed tomography, or a combination of positron emission tomography (PET) and computed tomography or PET with MRI. This chapter presents a practical contemporary review of the roles of these various imaging modalities for the evaluation and management of CAD.

Resumo Fundamento Em 2007, a Food and Drug Administration (FDA) determinou revisões sobre segurança dos agentes de contraste ecocardiográfico (ACE) disponíveis no mercado após relatos de mortes. Ao longo desses anos, diversos estudos comprovaram a segurança dos ACE, porém com poucos estudos relacionados ao SonoVue®. Objetivos Avaliar a segurança do SonoVue® durante o ecocardiograma sob estresse farmacológico (EEF) por meio da análise da incidência de reações alérgicas e da comparação entre os grupos quanto ao surgimento de arritmia, efeitos colaterais menores e eventos adversos. Métodos Estudo observacional, prospectivo, no qual 2.346 pacientes foram submetidos ao EEF e divididos em dois grupos: grupo 1 com ACE (n=1.099) e grupo 2 sem ACE (n=1.247). Os pacientes foram avaliados durante o EEF – 24 horas e 30 dias. Foi definido p significativo quando

Clinical guidelines recommend that the exercise protocol of a stress echocardiogram is selected to induce volitional exhaustion after a target duration of at least 8 minutes. While the Bruce protocol is very commonly used for clinical stress tests, it is known to be "steep", and many patients therefore fail to reach 8 minutes. We studied predictors of failure and developed a method for identifying patients not suitable for Bruce protocol which was accurate and yet simple enough to be used as a point-of-care decision support tool.We studied data out-patients undergoing Bruce protocol stress echocardiograms (n = 11 086) and analyzed predictors of inappropriate early termination (defined as test duration 8 min as per current practice guidelines) using logistic regression. A prediction model was constructed as follows: .5 points were given for each of hypertension, diabetes, smoking, and E/e' 7.9 in the resting echocardiogram; .1 point was added for each 1-unit increment in body mass index; 1 point was added for patient age by decade; 2.0 points were subtracted for male sex (p for all 0.001). In tests on held-out validation data, the model was well calibrated (in plots of predicted vs actual risk) and discriminated failure versus non-failure well (C-statistic .86 for a score of 6.0 points; p 0.001).These data may help to standardize protocol selection in stress echocardiography, by identifying patients pre-hoc where Bruce protocol will be inappropriately steep.

Background: A negative result on stress echocardiography (SE) is generally associated with a low risk of cardiovascular events and carries a favorable prognosis. The present study was conducted to identify clinical and echocardiographic characteristics associated with increased risk of myocardial injury following a negative SE (NSE). Methods: We retrospectively identified a total of 4130 SEs performed between 2013 and 2017 at a tertiary care center. NSE was defined as the absence of a new or worsening wall motion abnormality (WMA) with stress. Patients with resting WMA on SE were excluded. The occurrence of myocardial injury following index SE within 1 year was then recorded. Myocardial injury was defined as an elevated (>99 th percentile of the upper reference limit of normal) and changing troponin value (a rise and/or fall of the troponin value observed) following index SE. Results: During the study period, 2962 patients with NSE met inclusion criteria (median age 58 years-old; 50% females). Baseline characteristics were as follows: 35% diabetic, 49% hyperlipidemic, 62% hypertensive, 41% had a history of smoking, 21% had a history of coronary artery disease (CAD), 24% had end-stage liver disease (ESLD), 5% had end-stage renal disease (ESRD) and 1.5% had a left ventricular ejection fraction (LVEF) < 50%. Around 5% of patients developed myocardial injury within 1 year of NSE. Age, diabetes mellitus, ESLD and a LVEF Conclusion: Patients with age > 65 years, diabetes mellitus, ESLD and a LVEF

Background: Cardiac complications are the leading cause of mortality after orthotopic liver transplantation (OLT). In the general population, a positive dobutamine stress echocardiogram (DSE) in the absence of coronary artery disease (CAD) still identifies a high risk group whose outcome is similar to those with positive DSE and CAD. DSE is widely employed as a screening method prior to OLT but less is known about the prognostic impact of a positive DSE in the end stage liver disease (ESLD) population and whether CAD also influences their outcome. We investigated the prognostic impact of a positive DSE and clinical factors including CAD in patients with ESLD. Methods: Follow-up data was obtained in 61 liver transplant candidates with positive DSE and coronary angiography for cardiovascular events including angina requiring revascularization, heart failure, infarction, and cardiac death. Event free survival was compared between patients with (22 patients >70% stenosis) and without (39 patients) obstructive CAD and Cox regression was used to identify factors associated with events. Results: Over a mean follow-up of 27 + 28 months, 21 % (8/39) of patients with positive DSE and no CAD had events compared with 46% (10/22) of patients with positive DSE and CAD, p = 0.04. At one year of follow-up, cardiac death had occurred in 8% (3/39) of patients with positive DSE and no CAD, and in 9% (2/22) of those with positive DSE and CAD. Overall, event free survival was significantly better in those without CAD (p = 0.014). Beta blocker use (HR: 4.1, 95% CI: 1.7 - 9.9, p-value = 0.010), CAD (HR: 4.4 95% CI: 1.8- 10.8, p-value = 0.008), and non-alcoholic steatohepatitis (NASH) (HR: 4.9, 95% CI: 2.0 - 11.7, p-value = 0.04) were independently associated with cardiac events. Conclusion: ESLD patients with a positive DSE and no CAD had a one year cardiac mortality that was similar to patients that had a positive DSE and CAD. However, the overall prevalence of cardiac events and the event free survival was significantly worse in the CAD group. Thus, ESLD patients with a positive DSE are at increased risk and the presence of CAD further increases their risk. In addition to CAD, beta blocker use and NASH were independently associated with cardiac events.

In 2007, the United States Food and Drug Administration mandated safety reviews of commercially available echocardiographic contrast agents (ECA), following reports of death. During the past years, different studies have proven the safety of ECA, but there have been few studies on SonoVue®.To evaluate the safety of SonoVue® during pharmacological stress echocardiography (PSE), by analyzing the incidence of allergic reactions and comparing groups regarding the appearance of arrhythmia, minor side effects and adverse events.In this observational, prospective study, 2346 patients underwent PSE, and they were divided into the following 2 groups: group 1 with ECA (n = 1099) and group 2 without ECA (n = 1247). Patients were evaluated during PSE, at 24 hours, and at 30 days. Statistical significance was defined as p0.05.Group 1 had fewer minor side effects, such as headache (5/0.5% versus 19/1.5%, p = 0.012) and less reactive hypertension (3/0.3% versus 19/1.5%, p = 0.002); fewer arrhythmias, such as ventricular extrasystoles (180/16.4% versus 247/19.8%, p = 0.032) and paroxysmal supraventricular tachycardia (2/0.2% versus 15/1.2%, p = 0.003); and no adverse events, such as acute myocardial infarction (AMI) or death. In group 2, 1 patient had AMI in24 hours (1/01%), and there were 2 deaths in30 days (2/0.1%). SonoVue®-related urticaria was seen in 3 (0.3%) patients, without anaphylactic reaction.SonoVue® demonstrated safety during PSE. No cases of death, AMI, or anaphylactic reaction were observed. There was a lower incidence of minor side effects and arrhythmias in the group that received ECA, as well as a low incidence of mild allergic reactions.Em 2007, a Food and Drug Administration (FDA) determinou revisões sobre segurança dos agentes de contraste ecocardiográfico (ACE) disponíveis no mercado após relatos de mortes. Ao longo desses anos, diversos estudos comprovaram a segurança dos ACE, porém com poucos estudos relacionados ao SonoVue®.Avaliar a segurança do SonoVue® durante o ecocardiograma sob estresse farmacológico (EEF) por meio da análise da incidência de reações alérgicas e da comparação entre os grupos quanto ao surgimento de arritmia, efeitos colaterais menores e eventos adversos.Estudo observacional, prospectivo, no qual 2.346 pacientes foram submetidos ao EEF e divididos em dois grupos: grupo 1 com ACE (n=1.099) e grupo 2 sem ACE (n=1.247). Os pacientes foram avaliados durante o EEF – 24 horas e 30 dias. Foi definido p significativo quando0,05.O grupo 1 apresentou efeitos colaterais mais leves, como cefaleia (5/0,5% vs. 19/1,5%, p=0,012) e hipertensão reativa (3/0,3% vs . 19/1,5%, p=0,002), menos arritmias como extrassístoles ventriculares (180/16,4% vs . 247/19,8%, p=0,032) e taquicardia paroxística supraventricular (2/0,2% vs . 15/1,2%, p=0,003), assim como nenhum evento adverso como infarto agudo do miocárdio (IAM) e óbito. No grupo 2, um paciente apresentou IAM24h (1/01%) e dois óbitos30 dias (2/0,1%). Urticária relacionada ao SonoVue® foi observada em 3 (0,3%) pacientes sem reação anafilática.SonoVue® demonstrou segurança durante o EEF, não sendo observados morte, IAM ou reação anafilática. Observou-se menor incidência de efeitos colaterais mais leves e arritmias no grupo que utilizou o ACE, assim como baixa incidência de reações alérgicas leves.

Background:Dobutamine stress echocardiography (DSE) services have traditionally been medically led. In some UK institutions, DSE lists are led by physiologists with medical support. In our tertiary cardiac centre at New Cross Hospital (NCH), the DSE service was established by a consultant echocardiographer. Following intensive training and assessment, the Trust approved drug administration by named senior cardiac physiologists. We believe this is the first report of a cardiac physiologist-managed DSE service, including physiologist drug administration. We have assessed the feasibility, safety and validity of this physiologist-led DSE service. Methods: Retrospective analysis of 333 patients undergoing stress echocardiogram for inducible reversible ischaemia, myocardial viability and valvular heart disease over 6 months. Patients’ case notes review after 18–24 months. Results: Overall, 92% of all cases (306) were performed by physiologists. In 300 studies, dobutamine was administered. The majority of the referrals were for coronary artery disease (CAD) assessment (281). In 235 cases, the study was uncomplicated. Sixty-seven patients developed dobutamine-related side effects. In 16 cases, complications led to early termination of the study. In two cases, urgent medical review was needed. Of the 281 studies for CAD assessment, 239 were negative for ischaemia, 28 were positive and 14 inconclusive. In 5 out of 28 cases with echocardiogram, evidence of inducible ischaemia, coronary angiography revealed unobstructed coronary arteries. Conclusion: This study demonstrates the safety and effectiveness of this practice and provides potential for the expansion of the physiologists’ role and physiologist-led DSE services in other hospitals.

Key Clinical Message Patients with peripartum cardiomyopathy (PPCM) often express a desire to conceive again, and the risk of relapse in future pregnancies should be disclosed. No consensus is available that can determine that risk. Adequate contractile reserve, evidenced by a stress echocardiogram (exercise or dobutamine), can identify those with lower relapse risk.

Mestrado em Gestão e Avaliação de Tecnologias em Saúde Submitted by Maria da Luz Antunes (mluz.antunes@estesl.ipl.pt) on 2021-03-04T12:32:32Z No. of bitstreams: 1 Análise de minimização de custos em doentes com suspeita de doença coronária estável.pdf: 2494823 bytes, checksum: 759b7be5196387002ebe8dc974b4bffa (MD5) Made available in DSpace on 2021-03-04T12:32:32Z (GMT). No. of bitstreams: 1 Análise de minimização de custos em doentes com suspeita de doença coronária estável.pdf: 2494823 bytes, checksum: 759b7be5196387002ebe8dc974b4bffa (MD5) Previous issue date: 2020 N/A

Functional classification of children and adults with repaired and unrepaired congenital heart disease is a challenge for clinicians, due to the heterogeneity of congenital heart disease. Functional studies may be complemented with a stress echocardiogram, which analyzes the hemodynamic behavior of surgical repair zones, residuals, and sequelae. The integration of the anatomical and functional classification criteria developed for congenital heart disease and the results of a stress echocardiogram can establish a more precise functional classification. Stress echocardiograms also provide early diagnosis of functional complications of the congenital heart, allowing timely management decisions. This paper reviews the most important aspects of stress echocardiograms in pediatric and adult congenital heart disease, seeking to spark cardiologists’ interest in extending its applications in congenital heart disease.

The presence of angina with remarkably positive treadmill stress echocardiogram (TSE) carries a high specificity for flow-limiting coronary artery disease (CAD). However, angina due to aortic pathology is unusual. A 55 years old male with history of CAD and coronary artery bypass grafting

Purpose To derive specific maximal heart rate (HRmax) prediction equations for a coronary artery disease (CAD) population based upon status of β-blocker (BB) therapy and to compare these to prior HRmax equations (Fox and Brawner-specific for CAD). Methods We retrospectively reviewed stress echocardiogram treadmill tests in patients with CAD, dividing subjects into 3 groups based upon BB use on test day: not prescribed BB therapy (no BB group; n = 110); held for 12 to 24 hr prior (held BB group; n = 155); and continued taking (took BB group; n = 72). Results Derived HRmax equations for our CAD population were no BB = 200 - 0.79 × age; held BB = 193 - 0.71 × age; and took BB = 168 - 0.51 × age. Achieved HRmax mean was not significantly different between held BB and no BB groups; however, HRmax in the took BB group was significantly lower. Fox and Brawner (no BB)-HRmax equations significantly overestimated (+6 and +9 mean bias) and underestimated (-8 and -6 mean bias) achieved HRmax in no BB and held BB groups, respectively. The Brawner (no BB) equation intercept and slope were not significantly different from our CAD-held BB and no BB equations. The Brawner (on BB) equation intercept and slope were similar to our took BB equation, but greatly underestimated achieved HRmax (-17 mean bias). Conclusion For patients holding BB therapy on test day, a similar CAD HRmax estimation equation to those patients never on BB can be used, comparable to the Brawner (no BB) equation. Further research is needed to determine when patients should take their BB therapy in conjunction with exercise testing.

Anomalous aortic origin of a coronary artery (AAOCA) occurs in approximately 1% of coronary angiograms. Clinical manifestations include Sudden Cardiac Death (SCD) as well as ischemia and arrhythmias, especially during exercise and in those with an interarterial course between the aorta and the

Residual angina after PCI is a frequently-occurring disease. Ivabradine improves symptoms but its role in patients without left-ventricular systolic dysfunction is still unclear. The aim was to quantify the effects of ivabradine in terms of MVO2 indicators and diastolic function. Twenty-eight

Introduction We hypothesized that coronary flow reserve (CFR) in the left anterior descending artery (LAD) can be effectively measured during an accelerated dipyridamole-atropine stress echocardiography (DASE) protocol to improve the diagnostic performance of the test. Material and methods In 64 patients with suspected or known coronary artery disease scheduled for coronary angiography DASE with concomitant CFR measurement in LAD was performed. Results Coronary flow reserve measurement and calculation were feasible in 83% of patients. The positive predictive value of undetectable LAD flow was 81% for severe LAD disease. Measured values of CFR were in the range 1.3–4.1 (mean: 2.2 ±0.7). Significantly lower CFR was found in patients with LAD disease (1.97 ±0.62 vs. 2.55 ±0.57, p = 0.0015). The optimal cutoff for detecting ≥ 50% stenosis was CFR ≤ 2.1 (ROC AUC 0.776), corresponding with 68% sensitivity and 84% specificity. In patients with negative DASE results 67% of patients with LAD disease had abnormal CFR, whereas in patients with a positive DASE result 92% of patients with normal LAD had normal CFR. The DASE diagnostic accuracy for the detection of coronary artery disease (CAD) increased from 75% to 85% when CFR measurement was added to wall motion abnormality (WMA) analysis. No test with both abnormalities was false positive for the detection of coronary disease. Conclusions Incorporation of CFR measurement into WMA-based stress echocardiography is feasible even in an accelerated DASE protocol and can be translated into an approximate gain of 10% in overall test accuracy.

Given the wide knowledge gaps in the evaluation of patients with low and intermediate pretest probability stable chest pain and the ubiquity of noninvasive imaging the below mentioned largest, most comprehensive and timely randomized clinical trials (RCTs), provide valuable insights into risk stratification, diagnosis, management, prognostication, and outcomes. Rapid clinical assessment of patients with low/intermediate-risk stable chest pain can identify high-risk individuals. However, about 33% of patients labeled as noncardiac chest pain die from cardiovascular disease or develop acute coronary syndrome (ACS) during 5 years' follow-up. About 1.5% of patients with ACS are missed even after extensive testing leading to potential medical, legal, and psychological sequelae. As a result, clinicians have a low threshold to admit even low risk patients for prolonged expensive observation and testing leading to unnecessary admissions, false-positive test results, and unnecessary invasive downstream investigations. This scenario gives a clarion call for improving the diagnostic accuracy, risk stratification, and prognostication in low/intermediate-risk stable chest pain patients. The most common clinical scenario most of us come across is a middle-aged patient with new onset/recurrent low/intermediate-risk stable chest pain attending the emergency department (ED). Issues which are head scratching and mindboggling about this scenario is the ability of the clinician to optimally utilize the appropriate tests from the available armamentarium of functional, anatomical and biochemical diagnostic strategies (exercise electrocardiogram, stress echocardiogram, nuclear stress test, computed tomographic coronary angiography, and circulating biomarkers) to arrive at accurate diagnosis for flawless management. One of the main purposes of the article is to avoid underdiagnosis, overdiagnosis, and misdiagnosis in patients with stable chest pain. We have cherry-picked four large recent landmark RCTs to help the clinician to sharpen his clinical skills, maximize diagnostic accuracy, speed up emergent interventions, assist in surgical planning, and optimize medical therapies. Unfortunately, physical examination for determining the cause of low/intermediate-risk stable chest pain is neither sensitive nor specific to identify obstructive coronary artery disease (CAD). The four recent RCTs are as follows: (1) PROspective Multicenter Imaging Study for Evaluation of Chest Pain trial; (2) Scottish COmputed Tomography of the History, Electrocardiogram, Age, Risk factors, and initial Troponin Trial; (3) Impact on Management of the HEART Risk Score in Chest Pain Patients trial; and (4) Randomized Investigation of Chest Pain Diagnostic Strategies, Shared Decision-Making in the ED: Chest Pain Choice trial.

Introduction. A Standardized Clinical Assessment and Management Plan (SCAMP) is a novel quality improvement initiative that standardizes the assessment and management of all patients who carry a predefined diagnosis. Based on periodic review of systemically collected data the SCAMP is designed to be modified to improve its own algorithm. One of the objectives of a SCAMP is to identify and reduce resource utilization and patient care costs. Methods. We retrospectively reviewed resource utilization in the first 93 arterial switch operation (ASO) SCAMP patients and 186 age-matched control ASO patients. We compared diagnostic and laboratory testing obtained at the initial SCAMP clinic visit and control patient visits. To evaluate the effect of the SCAMP over time, the number of clinic visits per patient year and echocardiograms per patient year in historical control ASO patients were compared to the projected rates for ASO SCAMP participants. Results. Cardiac magnetic resonance imaging (MRI), stress echocardiogram, and lipid profile utilization were higher in the initial SCAMP clinic visit group than in age-matched control patients. Total echocardiogram and lung scan usage were similar. Chest X-ray and exercise stress testing were obtained less in SCAMP patients. ASO SCAMP patients are projected to have 0.5 clinic visits and 0.5 echocardiograms per year. Historical control patients had more clinic visits (1.2 vs. 0.5 visits/patient year, P < .01) and a higher echocardiogram rate (0.92 vs. 0.5 echocardiograms/ patient year, P < .01) Conclusion. Implementation of a SCAMP may initially lead to increased resource utilization, but over time resource utilization is projected to decrease.

Stress-echocardiography und myocardial scintigraphy provide similar information on the prognosis of patients with and without heart disease. A normal stress echocardiogram does not exclude coronary stenoses but indicates a prognostically favourable outcome. Patients with a normal stress echocardiogram usually do not need further invasive assessment of coronary artery disease. There is an increasing risk of cardiac mortality and myocardial infarction depending on extent of abnormal findings during stress echocardiography. Stress echocardiography can be used to assess the short term prognosis of patients undergoing major non-cardiac surgery. The results of the stress echocardiogram identify those patients, in major surgery is of high risk. Newer echocardiographic technologies like Doppler tissue imaging, speckle tracking imaging and myocardial contrast echocardiography are promising, but still need to be validated in larger studies.

Objetivo. El objetivo del presente trabajo se dirige a revisar las indicaciones, protocolos y aplicaciones del ecocardiograma de estrés.materiales y métodos. Con las palabras clave “ecocardiograma de estrés”, “ecocardiograma de esfuerzo” y “prueba de estres farmacológico” se hizo una búsqueda de información en la bases de datos de Pubmed/ Medline, Cochrane, SciELO, y en referencias de artículos de revistas y textos, principalmente de los últimos cinco años en inglés y en español. El resultado de esta búsqueda arrojó 203 referencias, de las cuales se tomaron las 46 más relevantes, teniendo en cuentra principalmente metanálisis, artículos de revision, actualizaciones, estudios aleatorios doble ciego y guías clínicas.Resultados. Los datos obtenidos de la función ventricular regional o global en el pico máximo de ejercicio son factores predictores importantes de eventos cardíacos, además de las variables clínicas, en el seguimiento de los pacientes. Un puntaje de motilidad parietal de esfuerzo mayor de 1,4 o una fracción de eyección de esfuerzo menor de 50%, implican un pronóstico significativamente adverso. Por otra parte, los indicadores de viabilidad miocárdica, mediante el estímulo farmacológico del miocardio, predicen la recuperación de la función cardiaca luego de los procedimientos de revascularización. Conclusión. El ecocardiograma de estrés es una técnica complementaria, útil para el diagnóstico y pronóstico del paciente con enfermedad coronaria. El fundamento de su uso consiste en que, al desencadenar isquemia, se produce una alteración de la motilidad parietal distal a la lesión coronaria obstructiva. Además, puede emplearse para evaluar la gravedad de una valvulopatía y para establecer el diagnóstico de la hipertensión pulmonar oculta. Objective: the objective of this Project is to review the indications, protocols and applications of the stress echocardiogram. methods and materials: research on the following words was done in the PUBMED/Medline, Cochrane, SciELO databases, as well as in references in journal articles and texts mainly from texts from the last five years in English and in Spanish: stress echocardiogram, effort echocardiogram and pharmacological stress test. The result of this search returned 203 references, 46 of which were taken as the most relevant, taking into consideration mainly, meth analysis, revision articles, state of the art, random studies, DOBLE CIEGO, and clinical guides. Results: The data obtained from the regional ventricular function in the maximum peak of exercise, are important predictors of cardiac events; this, in addition to all of the clinical variables during patient follow up. A score of parietal motility, higher than 1.4, or a ejection fraction lower than 50%, imply a significant adverse forecast. On the other hand, the myocardiál an viábility indicators, through the pharmacologic stimulus of the myocardium, predict the recovery of the cardiac function after revascularization procedures. Conclusion: The stress echocardiogram (ECO) is a complementary technique, useful for the diagnose and forecast fo patients with coronary disease. The principles of its use consist on the basics that upon the creation of ischemia, an alteration in the distal parietal motility will be produced to the obstructive coronary injury. Furthermore, it can be used to evaluate the severity of a vulvopathy and to establish the diagnose of the hidden pulmonary hypertension.

The current study reports on the operative experience of patients with coronary artery fistulas between the anterior intraventricular coronary artery and pulmonary trunk. Of the five patients operated, 60% were women and the ages ranged form 40 to 46 years old. Stress echocardiogram and coronary cineangiography were accomplished for all patients. No deaths occurred in the postoperative period nor were symptoms reported. We believe that the surgical procedure is the first choice treatment for coronary artery fistulas, as it safely and effectively prevents the complications of arteriovenous shunts.

This retrospective study constituted of 144 patients who were recruited at the University of California Davis Medical Center (UCDMC) Echo and Stress Laboratory during a 10-month period by referrals for standard ESE to assess for CAD. Participation criteria included referral for a standard ESE, age older than 18 years, and the same criteria as standard stress tests. Standard stress test exclusion criteria were applied as well (Table 1).12 All patients gave informed consent. The study group, called the 80-lead BSM group, consisted of 72 participants. Seventy-two random participants comprised the 12lead ECG group (see Table 2). Twenty-two participants in the 80-lead group had poor image quality ESE or incomplete data for exercise cessation and/or image acquisition real time; as a result, these participants were excluded from the study. None of the ESE of the 12-lead ECG group was considered of poor image quality, nor were any data incomplete. STRESS ECHOCARDIOGRAMS

Patients with medically stabilized unstable angina and a negative stress echocardiogram have a favourable outcome as a whole. This study sought to identify which subsets of patients are associated with serious events at long-term within this population.We studied and followed-up 128 patients (mean 2.2 +/- 1.3 years) with medically stabilized unstable angina and a negative dipyridamole stress echocardiogram. Cumulative survival rates were 98.2 +/- 1.3%, 96.0 +/- 2.2% and 93.2 +/- 3.2%, at 1, 2 and 4 years, respectively. Freedom from events (death, myocardial infarction, and revascularization) were 98.2 +/- 1.3%, 96.0 +/- 2.2% and 86.3 +/- 6.0%, at 1, 2, and 4 years, respectively. Cumulative mortality rate was higher in men (3.6 +/- 2.5%, 8.5 +/- 4.1%, and 12.2 +/- 5.4% at 1, 2, and 4 years, vs. 0% at the end of the follow-up in women; p = 0.034), and in those with previous myocardial infarction (4.3 +/- 4.3%, 9.1 +/- 6.2%, and 18.2 +/- 2.3% at 1, 2 and 4 years, vs. 1.1 +/- 1.1%, 2.9 +/- 2.1%, and 2.9 +/- 2.1% in those without previous myocardial infarction, respectively; p = 0.047).Among patients with medically stabilized unstable angina and a negative dipyridamole stress echocardiogram, male gender and previous myocardial infarction are associated with a non-favourable outcome.

Background: Stress echocardiography (SE) is commonly used in ED patients with symptoms concerning for acute coronary syndrome (ACS). Prior studies have found the false positive (FP) rate of SE, as well as other stress testing modalities, in this setting, is greater than 50%. We sought to determine

Preexcitation syndromes pose a diagnostic challenge for exercise stress testing. We present stress echocardiographic findings in patient with Wolff–Parkinson–White (WPW) pattern on surface electrocardiogram (EKG). Echocardiogram at rest demonstrated paradoxical septal motion which disappeared during peak exercise and reappeared during rest. Preexcitation pattern on EKG also disappeared at peak stress. We tried to explain the underlying mechanisms of the above abnormality and the usefulness of stress testing in this group of patients.

Echocardiography has become the primary imaging tool in the diagnosis and assessment of congenital and acquired heart disease in infants, children, and adolescents. Transthoracic echocardiography (TTE) is an ideal tool for cardiac assessment, as it is noninvasive, portable, and efficacious in providing detailed anatomic, hemodynamic, and physiologic information about the pediatric heart. Recommendations for standards in the performance of a routine 2-dimensional (2D) echocardiogram, 1 fetal echocardiogram, pediatric transesophageal echocardiogram, intraoperative transesophageal echocardiogram, and stress echocardiogram exist, as do guidelines for appropriate training in various echocardiographic disciplines. As part of the accreditation process for echocardiography laboratories, the Intersocietal Commission for the Accreditation of Echocardiography Laboratories has established basic performance standards for pediatric TTE, 13 but no other standards document exists for the performance of a pediatric TTE. The pediatric echocardiogram is a unique examination with features that distinguish it from other echocardiograms. There is a wide spectrum of anomalies encountered in patients with congenital heart disease. Certain views are of added importance

A clinical appraisal and clinical application of Marcovitz PA, Armstrong WF. Accuracy of dobutamine stress echocardiography in detecting coronary artery disease. Am J Cardiol. 1992;69:1269-1273

In a patient with a recently placed stent, a stress echocardiogram clearly indicated ischemia in the territory of the stented vessel. Subsequent coronary angiography, undertaken because of presumed restenosis, showed the stented area to be widely patent. This prompted a review of stress echocardiograms performed in patients within 6 weeks of coronary stenting. Of 21 such cases, 3 additional patients were found to have false-positive results in the territory served by the stented vessel. (J Am Soc Echocardiogr 2001;14:948-50.)

We followed 108 patients presenting to the emergency department with atypical chest pain and triaged with stress echocardiography. One-year cardiac event-free survival was 100% with a negative stress echocardiogram and 25% with a positive study.

“Words, words, words, I’m so sick of words”, said Eliza Doolittle, which could well refer to the number of articles on the merits of testing by use of the electrocardiogram (rest, exercise and dynamic), Tl-201 and Tc-99m-MIBI perfusion scans, the rest and stress echocardiogram (transthoracic and transesophageal), arterial calcification etc., and reports on the various advantages of specific stress interventions (pacing, pharmacologic, psychologic) to uncover evidence of ischemia and other physiologic or anatomic abnormalities. A literature review gives the impression that initial reports are later superseded by newer reports claiming superiority in aspects such as diagnostic and prognostic evaluation, and shows that many “successful” testing options first enthusiastically reported, are later criticized, then abandoned or replaced by the latest “fashion” in diagnostics or risk stratification.

A 39-year-old cardiologist with no cardiovascular risk factors presented with a 6-month history of exertional chest pain. A stress echocardiogram was negative at a high workload, and she subsequently underwent 320-slice coronary CT for persistent symptoms. This revealed an anomalous right coronary artery (RCA) originating from the left aortic sinus. The course of the proximal RCA was anterior to the aorta and posterior to the right ventricular …