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1.
J Am Coll Cardiol ; 74(18): 2278-2291, 2019 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-31672185

RESUMO

BACKGROUND: The assessment of coronary flow velocity reserve (CFVR) in left anterior descending coronary artery (LAD) expands the risk stratification potential of stress echocardiography (SE) based on stress-induced regional wall motion abnormalities (RWMA). OBJECTIVES: The purpose of this study was to assess the feasibility and functional correlates of CFVR. METHODS: This prospective, observational, multicenter study initially screened 3,410 patients (2,061 [60%] male; age 63 ± 11 years; ejection fraction 61 ± 9%) with known or suspected coronary artery disease and/or heart failure. All patients underwent SE (exercise, n = 1,288; vasodilator, n = 1,860; dobutamine, n = 262) based on new or worsening RWMA in 20 accredited laboratories of 8 countries. CFVR was calculated as the stress/rest ratio of diastolic peak flow velocity pulsed-Doppler assessment of LAD flow. A subset of 1,867 patients was followed up. RESULTS: The success rate for CFVR on LAD was 3,002 of 3,410 (feasibility = 88%). Reduced (≤2.0) CFVR was found in 896 of 3,002 (30%) patients. At multivariable logistic regression analysis, inducible RWMA (odds ratio [OR]: 6.5; 95% confidence interval [CI]: 4.9 to 8.5; p < 0.01), abnormal left ventricular contractile reserve (OR: 3.4; 95% CI: 2.7 to 4.2; p < 0.01), and B-lines (OR: 1.5; 95% CI: 1.1 to 1.9; p = 0.01) were associated with reduced CFVR. During a median follow-up time of 16 months, 218 events occurred. RWMA (hazard ratio: 3.8; 95% CI: 2.3 to 6.3; p < 0.001) and reduced CFVR (hazard ratio: 1.5; 95% CI: 1.1 to 2.2; p = 0.009) were independently associated with adverse outcome. CONCLUSIONS: CFVR is feasible with all SE protocols. Reduced CFVR is often accompanied by RWMA, abnormal LVCR, and pulmonary congestion during stress, and shows independent value over RWMA in predicting an adverse outcome.

2.
J Am Soc Echocardiogr ; 32(10): 1307-1317, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31377069

RESUMO

PURPOSE: Coronary flow velocity reserve (CFVR) of the left anterior descending artery is useful for risk stratification during stress echocardiography (SE) as an add-on to regional wall motion abnormalities (RWMA). We sought to provide sex- and age-specific prognostic cutoff values for CFVR. METHODS: A total of 5,577 patients (2,284 women; 110 age ≥ 85 years) who underwent dipyridamole SE with evaluation of RWMA and CFVR were enrolled in a multicenter prospective SE registry. Death and myocardial infarction were the clinical end points. RESULTS: During 20 months' median follow-up, 649 events (236 deaths, 413 infarctions) occurred: 288 in women and 38 in patients ≥85 years. At receiver operating characteristics analysis, the best prognostic cutoff value for CFVR was similar for men (2.03) and women (2.02) and consistent across all age strata (<45 years: 2.03; 45-54 years: 2.04; 45-64 years: 2.03; 65-74 and 75-84 years: 2.0) except for patients >85 years, who showed 1.90 as the optimal value. Independent predictors of mortality or myocardial infarction were RWMA (hazard ratio [HR] = 5.42), reduced CFVR (HR = 3.26), resting ejection fraction (HR = 0.98), smoking habit (HR = 1.41), age (HR = 1.02), and prior percutaneous coronary intervention (HR = 1.20) in patients age <85 years; and RWMA (HR = 5.42), smoking habit (HR = 3.24), and resting ejection fraction (HR = 0.97) in those age ≥85 years. CFVR added a prognostic contribution over clinical parameters, resting ejection fraction, and stress-induced RWMA in all age and sex groups except men >85 years. CONCLUSIONS: A sex-independent value of CFVR ≤2.0 provides the optimal prognostication across all age groups, except for those ≥85 years in whom a cutoff ≤1.90 is needed. Risk stratification is more effective for all age groups when CFVR is combined with RWMA.

3.
Am J Cardiol ; 124(6): 972-977, 2019 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-31324358

RESUMO

A blunted heart rate (HR) response during dipyridamole myocardial perfusion imaging has been associated with a poor outcome. To assess the value of HR response in patients who underwent high-dose dipyridamole stress echocardiography (SE), we retrospectively selected a sample of 3,059 patients (none with pacemakers or atrial fibrillation; mean age 66 ± 11 years). All underwent high-dose (0.84 mg/kg) dipyridamole SE for evaluation of known or suspected coronary artery disease and/or heart failure in 2 laboratories of Pisa-IFC and Lucca. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio. All patients were followed up. Patients were randomly divided into the modeling and validation group of equal size. During a median follow-up time of 1,004 days, 321 hard events occurred: 231 deaths and 90 nonfatal myocardial infarctions. HRR ≤ 1.22 identified by receiver operating characteristic analysis in the modeling group was an independent predictor of infarction-free survival in the modeling (hazard ratio 1.83, 95% confidence interval [CI] 1.30 to 2.60, p = 0.001), in the validation (hazard ratio 1.47, 95% CI 1.08 to 2.01, p = 0.02), and in the overall group (hazard ratio 1.60, 95% CI 1.27 to 2.02, p <0.0001), either off- or on-ß blockers. Five-year event rate increased from 8% to 24 % from the highest (≥1.41) to the lowest (≤1.14) HRR quartile. In conclusion, blunted HRR is a useful nonimaging predictor of adverse events during high-dose dipyridamole SE, independent of inducible ischemia, and beta-blocker therapy.

4.
Circ Cardiovasc Imaging ; 12(6): e008564, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31167561

RESUMO

Background Cardiology guidelines identify the low-risk response during stress echocardiography as the absence of regional wall motion abnormalities. Methods From 1983 to 2016, we enrolled 5817 patients (age 63±12 years; 2830 males) with suspected coronary artery disease, normal regional, and global left ventricular function at rest and during stress (exercise in 692, dipyridamole in 4291, and dobutamine in 834). Based on timing of enrollment, 4 groups were identified in chronological order of recruitment: years 1983 to 1989, group 1 (n=211); years 1990 to 1999, group 2 (n=1491); years 2000 to 2009, group 3 (n=3285); and years 2010 to 2016, group 4 (n=830). Results There were 240 (4%) events (119 deaths and 121 infarctions) in the follow-up. At 1-year follow-up, the event rate was 0.5% (95% CI, 0.05-0.95), 1.5% (95% CI, -1.18 to 1.82), 1.9% (95% CI, 1.63-2.17), and 1.7% (95% CI, 1.01-2.39; χ2, 9.0; P=0.03) in groups 1 to 4, respectively. At multivariable Cox analysis, independent predictors of future events were age (hazard ratio (HR), 1.05; 95% CI, 1.04-1.07; P<0.0001), male sex (HR, 1.57; 95% CI, 1.20-2.04; P=0.001), diabetes mellitus (HR, 1.78; 95% CI, 1.34-2.37; P<0.0001), smoking habit (HR, 1.40; 95% CI, 1.05-1.85; P=0.02), and ongoing anti-ischemic therapy (HR, 1.50; 95% CI, 1.15-1.97; P=0.003) Conclusions Over the past 3 decades, we observed a progressive decline in the prognostic value of a negative test based on regional wall motion abnormalities, likely reflecting both an increase in risk in patients, as well as a potential decrease in test performance due to concomitant anti-ischemic therapy.

5.
Kardiol Pol ; 77(2): 164-172, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30644080

RESUMO

Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologi-cally critical epicardial artery stenosis which determines subendocardial underperfusion. Recently, the core protocol of SE has been enriched by the addition of left ventricular contractile reserve (LVCR) based on force. Changes in force can be caused by microvascular and/or epicardial coronary artery disease, but also by myocardial scar, necrosis, and/or sub-epicardial layer disease. Left ventricular contractile reserve is calculated as the stress-to-rest ratio of force (systolic arterial pressure measured by cuff sphygmomanometer to end-systolic volume determined by two-dimensional echocardiography). In contrast to the ejection fraction, force is not dependent on changes in preload and afterload. Cut-off values for a preserved LVCR are > 2.0 for dobu-tamine or exercise stress and > 1.1 for vasodilators, which are weaker inotropic stimuli. Patients with a "strong" heart (normal LVCR values) have a better outcome than patients with a "weak" heart (reduced LVCR values), and this is the prognostic "bright side of the force," meaning that the prognostic value of force-based contractile reserve is higher than that of ejection fraction-based contractile reserve or RWMA. The addition of force to standard SE based on RWMA detection increases the spectrum of risk stratification without any signifi-cant increase in imaging time and only a slight increase in analysis time. In both ischaemic (with RWMA) and non-ischaemic (without RWMA) hearts, the preserved force is associated with a more benign prognosis. The prospective multicentre interna-tional Stress Echo 2020 trial which started in September 2016 has already recruited > 5000 patients with dual RWMA-force imaging and will systematically test the impact of force on the prognosis within and beyond coronary artery disease, including heart failure and hypertrophic cardiomyopathy.


Assuntos
Ecocardiografia sob Estresse/métodos , Ventrículos do Coração/fisiopatologia , Contração Miocárdica , Ecocardiografia/métodos , Humanos
6.
Int J Cardiol ; 277: 266-271, 2019 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-30292434

RESUMO

AIMS: To assess the prognostic value of dual imaging stress echocardiography after coronary artery bypass grafting (CABG). Dual imaging stress echocardiography, combining the evaluation of regional wall motion and Doppler echocardiographic derived coronary flow velocity reserve (CFVR) of the left anterior descending artery (LAD), is the state-of-the-art methodology during vasodilatory stress. METHODS AND RESULTS: In a prospective, multicenter, observational study, 349 patients (270 men; 69 ±â€¯9 years; 262 symptomatic) with history of CABG underwent high-dose dipyridamole (0.84 mg/kg over 6 min) stress echocardiography with CFVR evaluation of LAD by Doppler. The composite endpoint of death and myocardial infarction was considered in the survival analysis. Positivity rate with either criteria was 13% in the 262 symptomatic patients with appropriate and 6% in the 87 asymptomatic patients with maybe/rarely appropriate indications on the basis of 2014 American College of Cardiology Foundation guidelines. During a median follow-up of 22 months (1st quartile 8, 3rd quartile 44), there were 56 (16%) events: 21 deaths, and 35 nonfatal myocardial infarctions. At Cox analysis, ischemia at stress echo (HR 4.80, 95% CI 2.69-8.55; p < 0.0001), and CFVR of LAD ≤2 (HR 2.28, 95% CI 1.32-3.95; p = 0.003) were multivariable prognostic predictors. Considering the group with no ischemia, patients with CFVR ≤2 showed 2.5 fold higher yearly hard events as compared to those with CFVR >2 (7.5 vs 2.9%; p = 0.002). CONCLUSIONS: Dual imaging stress echocardiography provides useful prognostic information following CABG. Inducible ischemia and abnormal CFVR are strong and independent prognostic indicators in patients with appropriate and rarely/maybe appropriate indications.


Assuntos
Ponte de Artéria Coronária/tendências , Ecocardiografia sob Estresse/tendências , Cuidados Pós-Operatórios/tendências , Complicações Pós-Operatórias/diagnóstico por imagem , Ultrassonografia Doppler/tendências , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/métodos , Ecocardiografia sob Estresse/métodos , Feminino , Seguimentos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Ultrassonografia Doppler/métodos
7.
Int J Cardiovasc Imaging ; 35(4): 627-632, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30460582

RESUMO

Previous studies have suggested a decline in positivity of stress cardiac imaging based on regional wall motion abnormalities (RWMA). To assess the rate of RWMA positivity of stress echocardiography (SE) over 3 decades in the same primary care SE lab. We retrospectively assessed the rate of SE positivity in 7626 SE tests (dipyridamole in 5053, dobutamine in 2496, exercise in 77) in consecutive patients with known or suspected coronary artery disease and /or heart failure who performed SE in a primary care referral center from April 1991 to May 2018. Starting April 2005, SE based on RWMA was complemented by assessment of coronary flow velocity reserve (CFVR) of the left anterior descending coronary artery. Starting October 2016, we added left ventricular contractile reserve (LVCR). Starting October 2016, we also added B-lines by lung ultrasound. There was a progressive decline over time in the rate of SE positivity based on RWMA from 24% (1991-1999) to 10% (2000-2009) down to 4% (2010-2018) (p < 0.0001). Positivity rate was 29% with CFVR, 16% with LVCR, and 12% with B-lines. Over three decades, we observed a dramatic decline in SE positivity rate based on classical RWMA. In the last decade, the positivity rate rose sharply thanks to the stepwise introduction of CFVR, LVCR and B-lines as additional positivity criteria in integrated quadruple SE.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Contração Miocárdica , Função Ventricular Esquerda , Agonistas de Receptores Adrenérgicos beta 1 , Idoso , Doença da Artéria Coronariana/fisiopatologia , Dipiridamol/administração & dosagem , Dobutamina/administração & dosagem , Exercício , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo , Vasodilatadores/administração & dosagem
8.
J Am Soc Echocardiogr ; 32(1): 81-91, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30482637

RESUMO

BACKGROUND: Vasodilator stress echocardiography (SE) allows combined evaluation of regional wall motion and Doppler coronary flow velocity reserve (CFVR) of both the left anterior descending coronary artery (LAD) and the right coronary artery (RCA). The aim of this study was to prospectively assess the prognostic correlates of LAD and RCA CFVR on SE. METHODS: A total of 1,365 patients with known or suspected coronary artery disease underwent dipyridamole SE with combined evaluation of CFVR in both the LAD and the RCA. RESULTS: Ischemia was present on SE in 263 patients (19%). CFVR was abnormal (≤2.0) in 545 patients (40%): 172 in the LAD only, 149 in the RCA only, and 224 in both the LAD and the RCA. During a median follow-up period of 20 months, 44 deaths and 98 myocardial infarctions occurred. In the overall population, LAD CFVR ≤ 2.0 (hazard ratio [HR], 3.93) and inducible ischemia (HR, 2.74) were multivariate prognostic predictors. In the subset with ischemia on SE, CFVR did not add to peak wall motion score index (HR, 2.23). In patients without ischemia on SE, age (HR, 1.04), anti-ischemic therapy at the time of testing (HR, 1.6) and LAD CFVR ≤ 2.0 (HR, 10.8) were independent prognostic indicators. In patients without ischemia on SE and LAD CFVR >2.0, the 4-year event rate was 4% in those with RCA CFVR > 2.0 and 18% in those with RCA CFVR ≤ 2.0 (P < .0001). CONCLUSIONS: Ischemia on SE with high peak wall motion score index identifies a high-risk subset regardless of the underlying CFVR response. Absence of ischemia on SE is associated with intermediate risk, and LAD CFVR is essential to identify a truly low-risk subset. RCA CFVR is less useful than LAD CFVR but may have a role for further risk stratification in patients without ischemia and normal LAD CFVR.

10.
Cardiovasc Ultrasound ; 16(1): 20, 2018 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-30249305

RESUMO

BACKGROUND: The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion. PURPOSE: To provide web-based upstream quality control and harmonization of B-lines reading criteria. METHODS: 60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics. RESULTS: All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01). CONCLUSIONS: Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.


Assuntos
Ecocardiografia sob Estresse/normas , Pulmão/diagnóstico por imagem , Edema Pulmonar/diagnóstico , Controle de Qualidade , Feminino , Humanos , Internet , Masculino , Pessoa de Meia-Idade
11.
J Am Soc Echocardiogr ; 31(6): 692-701, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29625884

RESUMO

BACKGROUND: Coronary flow velocity reserve (CFVR) and left ventricular contractile reserve (LVCR) have demonstrated prognostic importance in patients with diabetes. The aim of this study was to investigate the prognostic contribution of combined evaluation of CFVR and LVCR in patients with diabetes with nonischemic stress echocardiography. METHODS: Three hundred seventy-five patients with diabetes (mean age, 68 ± 9 years) with nonischemic dipyridamole stress echocardiography underwent assessment of CFVR of the left anterior descending coronary artery (prospectively) and LVCR with left ventricular force (retrospectively) in a multicenter study. RESULTS: On receiver operating characteristic analysis, LVCR ≤ 1.1 was the best prognostic predictor and was considered an abnormal value. CFVR was abnormal (≤2) in 139 patients (37%), LVCR in 156 (42%), neither in 157 (42%), and both in 77 (21%). During a median follow-up period of 16 months, 86 major adverse cardiac events occurred: 16 deaths, 13 myocardial infarctions, and 57 revascularizations. Multivariate prognostic indicators were CFVR ≤ 2 (P < .0001), age (P = .03), and LVCR ≤ 1.1 (P = .04). The 3-year rate of major adverse cardiac events was 63% in patients with both abnormal CFVR and LVCR, 42% in those with abnormal CFVR only, 19% in those with abnormal LVCR only, and 10% in patients with both normal CFVR and LVCR. The 3-year hard event rate was 3% in patients with both normal CFVR and LVCR, fivefold higher in patients with abnormal CFVR or LVCR only, and ninefold higher in patients with both abnormal CFVR and LVCR. CONCLUSIONS: Patients with diabetes with nonischemic dipyridamole stress echocardiography may still have significant risk in presence of abnormal CFVR and/or LVCR, which assess the underlying, largely unrelated, microvascular and myocardial components of coronary circulation.


Assuntos
Doença da Artéria Coronariana/fisiopatologia , Diabetes Mellitus/fisiopatologia , Ecocardiografia sob Estresse/métodos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Ventrículos do Coração/fisiopatologia , Contração Miocárdica/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Circulação Coronária/fisiologia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiopatologia , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Vasodilatadores/farmacologia
13.
Heart ; 104(9): 760-766, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29032362

RESUMO

OBJECTIVES: To assess the value of a simple score integrating non-ischaemia-related variables in expanding the wall motion abnormalities risk power during stress echocardiography (SE). METHODS: Study includes 14 279 patients who underwent SE for evaluation of coronary artery disease. All-cause death was the end point. Patients were randomly divided into the modelling and validation group of equal size. In the modelling group, multivariate analysis was conducted using clinical, rest and SE data, and a score was obtained from the number of non-ischaemia-related independent prognostic predictors. The score prognostic capability was compared in both groups. RESULTS: During a median follow-up of 31 months, 1230 patients died: 622 (9%) in the modelling and 608 (9%) in the validation group (p=0.68). Independent predictors of mortality were ischaemia at SE (HR 1.77, 95% CI 1.49 to 2.12; p<0.0001) and six other parameters: age>65 years, wall motion at rest, diabetes, left bundle branch block, anti-ischaemic therapy and male sex. Risk score resulted prognostically effective in the modelling and validation groups, both with and without inducible ischaemia subset. When risk score was included in the multivariate analysis, besides ischaemia at SE it was the only independent predictor of mortality in the modelling (HR 1.70, 95% CI 1.60 to 1.82; p<0.0001), in the validation (HR 1.77, 95% CI 1.65 to 1.90; p<0.0001) and in the overall group (HR 1.73, 95% CI 1.66 to 1.82; p<0.0001). CONCLUSIONS: Simple clinical variables may be able to optimise SE risk stratification.


Assuntos
Doença da Artéria Coronariana/mortalidade , Ecocardiografia sob Estresse , Adulto , Idoso , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/fisiopatologia , Causas de Morte , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/fisiopatologia , Angiopatias Diabéticas/diagnóstico , Angiopatias Diabéticas/mortalidade , Angiopatias Diabéticas/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Movimento/fisiologia , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Taxa de Sobrevida
14.
Int J Cardiol ; 249: 479-485, 2017 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-28986062

RESUMO

BACKGROUND: The trial "Stress Echo (SE) 2020" evaluates novel applications of SE beyond coronary artery disease. The aim of the study was control quality and harmonize reading criteria. METHODS: One reader from 78 centers of the SE 2020 network asked for credentials to read a set of 20 SE video-clips selected by the core lab. All aspiring centers met the pre-requisite of high-volume and the years of experience in SE ranged from 5 to 31years (mean value 18years). The diagnostic gold standard was a reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%). RESULTS: Of the initial 78 who started, 57 completed the first attempt: individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor correlation between years of experience and the reader's score on first attempt (r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it again after the web-based session and their accuracy improved (74% vs. 96%, p<0.001). The kappa inter-observer agreement before and after web-based training was 0.59 on first attempt and rose to 0.91 on the last attempt. CONCLUSIONS: In SE reading, the volume of activity or years of experience is not synonymous with diagnostic quality. Qualitative analysis and operator-dependence can become a limiting weakness in clinical practice, in the absence of strict pathways of learning, credentialing and audit.


Assuntos
Cardiologistas/normas , Competência Clínica/normas , Doença das Coronárias/diagnóstico por imagem , Ecocardiografia sob Estresse/normas , Controle de Qualidade , Doença das Coronárias/epidemiologia , Ecocardiografia sob Estresse/métodos , Humanos , Internacionalidade , Reprodutibilidade dos Testes
15.
J Am Heart Assoc ; 6(7)2017 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-28663250

RESUMO

BACKGROUND: The aim of our study was to evaluate the relationship of pulse pressure (PP), a raw index of arterial stiffness, with noninvasively determined coronary flow reserve (CFR) and its components, in patients with angiographically normal epicardial coronary arteries. METHODS AND RESULTS: The study population included 398 patients without angiographic evidence of coronary stenosis, who underwent high-dose dipyridamole stress echocardiography with transthoracic-derived CFR evaluation on the left anterior descending artery. CFR was calculated as the ratio between high-dose dipyridamole and resting coronary diastolic peak velocities. Patients were divided into 2 groups: the first group included the first and second PP tertiles (n=298, PP ≤60 mm Hg) and the second group included the highest PP tertile (n=100, PP >60 mm Hg). Mean blood pressure, systolic blood pressure (both P<0.0001), age (P<0.002), and left ventricular mass index (P=0.013) were higher in the highest PP tertile, which also showed higher resting coronary flow velocity (31.6±9.6 cm/s versus 27.7±6.4 cm/s, P<0.0001) and marginally lower CFR (2.5±0.6 versus 2.6±0.6, P=0.044). Hyperemic coronary flow velocity did not differ between the 2 groups. By separate multiple linear regression analyses, after adjusting for sex, age, the highest systolic blood pressure tertile (≥140 mm Hg), left ventricular mass index, and cardiovascular risk factors, the highest PP tertile was associated with resting coronary flow velocity (P=0.003) and only marginally with hyperemic coronary flow velocity (P<0.02), whereas its association with CFR was not significant. CONCLUSIONS: In patients without epicardial coronary artery stenosis, the highest PP tertile is associated with an increased coronary flow velocity at rest.


Assuntos
Pressão Sanguínea/fisiologia , Circulação Coronária/fisiologia , Angina Pectoris/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Angiografia Coronária , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/fisiologia , Ecocardiografia , Ecocardiografia sob Estresse , Feminino , Humanos , Hipertensão/fisiopatologia , Hipertensão/radioterapia , Masculino , Pessoa de Meia-Idade , Imagem Multimodal
17.
Int J Cardiovasc Imaging ; 33(11): 1731-1736, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28550586

RESUMO

The diffusion of smart-phones offers access to the best remote expertise in stress echo (SE). To evaluate the reliability of SE based on smart-phone filming and reading. A set of 20 SE video-clips were read in random sequence with a multiple choice six-answer test by ten readers from five different countries (Italy, Brazil, Serbia, Bulgaria, Russia) of the "SE2020" study network. The gold standard to assess accuracy was a core-lab expert reader in agreement with angiographic verification (0 = wrong, 1 = right). The same set of 20 SE studies were read, in random order and >2 months apart, on desktop Workstation and via smartphones by ten remote readers. Image quality was graded from 1 = poor but readable, to 3 = excellent. Kappa (k) statistics was used to assess intra- and inter-observer agreement. The image quality was comparable in desktop workstation vs. smartphone (2.0 ± 0.5 vs. 2.4 ± 0.7, p = NS). The average reading time per case was similar for desktop versus smartphone (90 ± 39 vs. 82 ± 54 s, p = NS). The overall diagnostic accuracy of the ten readers was similar for desktop workstation vs. smartphone (84 vs. 91%, p = NS). Intra-observer agreement (desktop vs. smartphone) was good (k = 0.81 ± 0.14). Inter-observer agreement was good and similar via desktop or smartphone (k = 0.69 vs. k = 0.72, p = NS). The diagnostic accuracy and consistency of SE reading among certified readers was high and similar via desktop workstation or via smartphone.


Assuntos
Ecocardiografia sob Estresse/instrumentação , Aplicativos Móveis , Isquemia Miocárdica/diagnóstico por imagem , Consulta Remota/instrumentação , Smartphone , Brasil , Angiografia Coronária , Europa (Continente) , Estudos de Viabilidade , Humanos , Isquemia Miocárdica/fisiopatologia , Variações Dependentes do Observador , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes
18.
Cardiovasc Ultrasound ; 15(1): 7, 2017 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-28327159

RESUMO

Stress echocardiography is an established technique for the assessment of extent and severity of coronary artery disease. The combination of echocardiography with a physical, pharmacological or electrical stress allows to detect myocardial ischemia with an excellent accuracy. A transient worsening of regional function during stress is the hallmark of inducible ischemia. Stress echocardiography provides similar diagnostic and prognostic accuracy as radionuclide stress perfusion imaging or magnetic resonance, but at a substantially lower cost, without environmental impact, and with no biohazards for the patient and the physician.The evidence on its clinical impact has been collected over 35 years, based on solid experimental, pathophysiological, technological and clinical foundations. There is the need to implement the combination of wall motion and coronary flow reserve, assessed in the left anterior descending artery, into a single test. The improvement of technology and in imaging quality will make this approach more and more feasible. The future issues in stress echo will be the possibility of obtaining quantitative information translating the current qualitative assessment of regional wall motion into a number. The next challenge for stress echocardiography is to overcome its main weaknesses: dependance on operator expertise, the lack of outcome data (a widesperad problem in clinical imaging) to document the improvement of patient outcomes. This paper summarizes the main indications for the clinical applications of stress echocardiography to ischemic heart disease.


Assuntos
Ecocardiografia sob Estresse , Isquemia Miocárdica/diagnóstico por imagem , Humanos , Isquemia Miocárdica/etiologia , Isquemia Miocárdica/fisiopatologia , Sensibilidade e Especificidade
19.
Eur J Heart Fail ; 19(11): 1468-1478, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28198075

RESUMO

AIMS: Exercise stress echocardiography (ESE) is recommended by the European Society of Cardiology guidelines for the evaluation of heart failure (HF) patients. Recently, lung ultrasound (LUS) has been proposed for the assessment of extravascular lung water through B-lines. The aim of this study was to assess B-lines during ESE in HF. METHODS AND RESULTS: Standard transthoracic and LUS evaluation was performed during semi-supine ESE in 103 NYHA class I-III HF patients (76 male; mean age 64 ± 12 years) with depressed left ventricular ejection fraction (35 ± 8%). B-lines were measured by scanning 28 intercostal spaces on antero-lateral chest, both at rest and at peak stress. Resting plasma B-type natriuretic peptide (BNP) levels and exercise capacity during cardiopulmonary testing with peak oxygen uptake (peak VO2 ) were assessed in all patients. All patients were followed up for a median of 8 months (first quartile, 6; third quartile, 11). LUS was feasible and interpretable in all subjects. The overall number of B-lines increased from rest (median 5, interquartile range 0-10) to peak stress (median 12, interquartile range 0-45) (P < 0.0001). The number of stress B-lines was closely correlated with resting log-BNP (r = 0.88, P < 0.0001) and peak VO2 (r = -0.90, P < 0.0001). During follow-up, 37 events occurred: 10 deaths, 23 re-hospitalizations for acute HF, and 4 non-fatal myocardial infarctions. Twelve-month event-free survival was 95% in the 36 patients with stress B-lines <30 (best cut-off identified by receiver operating characteristic curve analysis) vs. 7% in patients with ≥30 B-lines (P < 0.0001). CONCLUSION: B-lines are easy to obtain, frequent in HF patients, and often increase during ESE. Adverse events were more frequent in patients with more B-lines during ESE.


Assuntos
Ecocardiografia sob Estresse/métodos , Tolerância ao Exercício/fisiologia , Insuficiência Cardíaca/fisiopatologia , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Progressão da Doença , Teste de Esforço , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Curva ROC , Fatores de Tempo
20.
Cardiovasc Ultrasound ; 15(1): 3, 2017 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-28100277

RESUMO

BACKGROUND: Stress echocardiography (SE) has an established role in evidence-based guidelines, but recently its breadth and variety of applications have extended well beyond coronary artery disease (CAD). We lack a prospective research study of SE applications, in and beyond CAD, also considering a variety of signs in addition to regional wall motion abnormalities. METHODS: In a prospective, multicenter, international, observational study design, > 100 certified high-volume SE labs (initially from Italy, Brazil, Hungary, and Serbia) will be networked with an organized system of clinical, laboratory and imaging data collection at the time of physical or pharmacological SE, with structured follow-up information. The study is endorsed by the Italian Society of Cardiovascular Echography and organized in 10 subprojects focusing on: contractile reserve for prediction of cardiac resynchronization or medical therapy response; stress B-lines in heart failure; hypertrophic cardiomyopathy; heart failure with preserved ejection fraction; mitral regurgitation after either transcatheter or surgical aortic valve replacement; outdoor SE in extreme physiology; right ventricular contractile reserve in repaired Tetralogy of Fallot; suspected or initial pulmonary arterial hypertension; coronary flow velocity, left ventricular elastance reserve and B-lines in known or suspected CAD; identification of subclinical familial disease in genotype-positive, phenotype- negative healthy relatives of inherited disease (such as hypertrophic cardiomyopathy). RESULTS: We expect to recruit about 10,000 patients over a 5-year period (2016-2020), with sample sizes ranging from 5,000 for coronary flow velocity/ left ventricular elastance/ B-lines in CAD to around 250 for hypertrophic cardiomyopathy or repaired Tetralogy of Fallot. This data-base will allow to investigate technical questions such as feasibility and reproducibility of various SE parameters and to assess their prognostic value in different clinical scenarios. CONCLUSIONS: The study will create the cultural, informatic and scientific infrastructure connecting high-volume, accredited SE labs, sharing common criteria of indication, execution, reporting and image storage of SE to obtain original safety, feasibility, and outcome data in evidence-poor diagnostic fields, also outside the established core application of SE in CAD based on regional wall motion abnormalities. The study will standardize procedures, validate emerging signs, and integrate the new information with established knowledge, helping to build a next-generation SE lab without inner walls.


Assuntos
Cardiomiopatias/diagnóstico , Ecocardiografia sob Estresse/métodos , Ventrículos do Coração/diagnóstico por imagem , Isquemia Miocárdica/diagnóstico , Idoso , Cardiomiopatias/fisiopatologia , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/fisiopatologia , Estudos Prospectivos , Reprodutibilidade dos Testes
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