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In seeking an imaging solution to the limitations of standard exercise stress testing, echocardiography is attractive on practical grounds. It is the most widely disseminated and inexpensive technique for non-invasive imaging of the heart. It is “patient friendly” because it is rapidly performed, and is highly versatile, being usable in a variety of environments. In combination with various stressors, echocardiography provides a means of identifying myocardial ischaemia by detection of stress induced wall motion abnormalities.
Indeed, an impressive clinical evidence base matches these theoretical benefits. The accuracy of stress echocardiography for detection of significant coronary stenoses ranges from 80–90%, exceeding that of the exercise ECG (especially in women and patients with left ventricular hypertrophy), and being comparable to that of stress myocardial perfusion scintigraphy. Stress echocardiography is a powerful prognostic tool in chronic coronary disease, after myocardial infarction, and in evaluation of patients before major non-cardiac surgery. It is an accurate test for prediction of functional recovery of dyssynergic zones after revascularisation, and also provides valuable physiologic information in patients under consideration for valve surgery.
Unfortunately, however, the disadvantages of the technique are not trivial. Advances in imaging and image processing have solved most—but not all—problems of image quality. Test interpretation remains very much in the eye of the beholder. The only mainstream marker of ischaemia is abnormal wall motion, and the need to induce ischaemia in the metabolic sense limits the accuracy of stress echocardiography in detecting coronary artery disease in patients who exercise submaximally or who are on antianginal treatment.
This article reviews the methodology and the favourable and unfavourable aspects of stress echocardiography. Technological advances in ultrasound and digital technology are likely to refine further the technique and move from a simple test of wall motion to portraying local contractile behaviour and perfusion. The automation of these …
Thomas H Marwick
Video Clip 1
Figure 1: Normal exercise echocardiogram including parasternal (1a), apical 4- and 2-chamber (1b) and apical long axis views (1c). Resting images (left) are compared with post-stress images (left). All segments show augmentation of wall motion and thickening and there is a reduction of LV volume and increment of ejection fraction with stress. Parasternal images are of excellent quality. Although the apical images are of imperfect quality, these are still sufficient for interpretation.
[View Clip 1a] [View Clip 1b] [View Clip 1c]
File Sizes: 1.52MB, 1.67MB, 751KB
Video Clip 2
Figure 2: Exercise echocardiogram (same orientation as figure 1) showing inducible wall motion abnormality in the distal anterior and lateral walls. The parasternal images show no evidence of ischemia in the posterior wall, making the changes more likely due to diagonal than circumflex vessel disease.
[View Clip 2a] [View Clip 2b]
File Sizes: 1.41MB, 1.46MB
Video Clip 3
Figure 4: Loss of contractile reserve in the presence of severe valvular regurgitation and normal resting function. The LV volumes after stress (right) are larger than at rest. As end-diastolic volume increases less than end-systolic volume, this corresponds to a decrement in ejection fraction, signifying decompensation of LV function with stress.
File Size: 921KB