Неинвазивная оценка параметров коронарного кровотока во время тестов с физической нагрузкой в популяции здоровых лиц

The aim: to define 1) coronary artery flow velocity values in healthy group at rest and during exercise tests; 2) differences of these values in the different age and sex groups. Materials and methods. There is a single center study of 145 consecutive healthy patients who underwent a bicycle exercise echocardiography with the analysis of coronary artery flow velocity in left anterior coronary artery (LAD). Coronary flow velocities were measured before and at the peak of exercise at the medium segment of the LAD. In addition, the coronary flow velocity reserve (CFVR) was calculated. Results. The rest velocity in LAD was 31.9 ± 8.3 cm/s, at the peak of exercise 77.4 ± 15.3 cm/s, ΔV 45.3 ± 13.4 cm/s, and CFVR 2.51 ± 0.59. There was not a significant difference in the subgroups of the different ages. Women had a lower CFVR in comparison with men (2.32 ± 0.55 vs 2.63 ± 0.58; p < 0.02). Conclusion. There are the values of Doppler coronary artery velocity of the healthy subjects for exercise tests. The study does not demonstrate the impact of aging on CFVR. Women have a lower CFVR during exercise tests.Цель исследования: определить нормальные значения неинвазивно определенных величин скоростей коронарного кровотока в покое и на пике тестов с физической нагрузкой для здоровых лиц различного возраста и пола. Материал и методы. 145 пациентам с отсутствием сердечно-сосудистой патологии и сахарного диабета выполнялась стресс-эхокардиография с физической нагрузкой на горизонтальном велоэргометре. В состоянии покоя и на пике нагрузки регистрировался коронарный кровоток в средней трети передней межжелудочковой артерии, с помощью допплерографии вычисляли величину коронарного резерва. Группа была разделена на 4 подгруппы по возрастным квартилям. Также проводился анализ распределения величин по полу. Результаты. В покое скорость коронарного кровотока в группе здоровых лиц в срединном сегменте передней межжелудочковой артерии была 31,9 ± 8,3 см/с, скорость на пике нагрузки - 77,4 ± 15,3 см/с, разница скорости на пике и до нагрузки - 45,3 ± 13,4 см/с, значение коронарного резерва - 2,51 ± 0,59. Не было получено значимого влияния возраста на величины скоростей на пике нагрузки и коронарного резерва. У женщин по сравнению с мужчинами была большая скорость кровотока в коронарной артерии в покое, скорость кровотока на пике нагрузки достоверно не отличалась, определялась меньшая величина коронарного резерва (2,32 ± 0,55 против 2,63 ± 0,58; р < 0,02). Выводы. Определены нормальные показатели скоростей коронарного кровотока для здоровых лиц во время физической нагрузки. Данные показатели достоверно не меняются в различных возрастных группах. Женщины имеют меньшие величины коронарного резерва, измеренного с помощью импульсноволнового допплера во время тестов с физической нагрузкой

Неинвазивная оценка кровотока в левой коронарной артерии во время физической нагрузки. Трехлетний прогноз

Assessment of coronary flow is used during pharmacological tests. Nevertheless, supine bicycle tests have allowed the application of coronary flow assessments during exercise. The aim of the study was to define the outcomes of the consecutive cohort in three years period after coronary artery flow velocity analysis during exercise tests. Materials and methods. There is a single center prospective cohort study of 299 patients who underwent a bicycle exercise echocardiography with the analysis of coronary artery flow velocity in left anterior coronary artery (LAD). Coronary flow velocities were measured before and at the peak of exercise at the medium segment of the LAD. In addition, the coronary flow velocity reserve (CFVR) and the differences between the peak and rest velocities (ΔV) were calculated. Two hundred and fifty-nine patients were accessible for follow-up analysis (56 ± 9 years, 167 men). Cardiovascular death, nonfatal myocardial infarction, revascularization or cardiac arrests with cardiopulmonary resuscitation were defined as major adverse cardiac events (MACE). The period after stress test was 3.0 ± 0.1 years. Results. There were 77 patients with MACE. The group with MACE vs the rest patients had a lower velocity in LAD at the peak of exercise (58 ± 30 vs 68 ± 26 cm/s, p 2.1% had myocardial infarction, death or coronary artery bypass grafting in 3-year period. The group with CFVR ≤ 2 had МАСЕ in 40% of cases (p 2 1% пациентов имели неблагоприятные исходы, тогда как группа с КР ≤ 2 достигала конечных точек в 40% (р < 0,000001). Выводы. Анализ коронарного кровотока в ПМЖА на пике нагрузке может использоваться для определения трехлетнего прогноза

Left atrial volume changes during exercise stress echocardiography in heart failure and hypertrophic cardiomyopathy

We assessed feasibility and functional correlates of LAVI (left atrial volume index) changes during exercise stress echocardiography (ESE).ESE on bike or treadmill was performed in 363 patients with heart failure with preserved ejection fraction (HFpEF, n = 173), reduced ejection fraction (HFrEF, n = 59) or hypertrophic cardiomyopathy (HCM, n=131). LAVI stress-rest increase ≥ 6.8 ml/m2 was defined as dilation.LAVI measurements were feasible in 100%. LAVI did not change in HFrEF being at rest 32 (25-45) vs. at stress 36 (24 - 54) ml/m2, P = NS and in HCM at rest 35 (26 - 48) vs. at stress 38 (28 - 48) ml/m2, P = NS whereas it decreased in HFpEF from 30 (24 -40) to 29 (21 - 37) ml/m2 at stress, P = 0.007. LA dilation occurred in 107 (30%) patients (27% with treadmill vs. 33% with bike ESE, P = NS): 26 with HFpEF (15%), 26 with HFrEF (44%) and 55 with HCM (42%) with P 14 at rest with OR 4.4, LVEF < 50% with OR 2.9, and LAVI at rest < 35 ml/m2 with OR 2.7.LAVI assessment during ESE was highly feasible and dilation equally frequent with treadmill or bike. LA dilation was threefold more frequent in HCM and HFrEF and could be predicted by increased resting E/e' and impaired EF as well as smaller baseline LAVI

Impact of platelet phenotype on myocardial infarction

In acute myocardial infarction patients the injured vascular wall triggers thrombus formation in the damage site. Fibrin fibers and blood cellular elements are the major components of thrombus formed in acute occlusion of coronary arteries. It has been established that the initial thrombus is primarily composed of activated platelets rapidly stabilized by fibrin fibers. This review highlights the role of platelet membrane phenotype in pathophysiology of myocardial infarction. Here, we regard platelet phenotype as quantitative and qualitative parameters of the plasma membrane outer surface, which are crucial for platelet participation in blood coagulation, development of local inflammation and tissue repair

Quality control of B-lines analysis in stress Echo 2020

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.info:eu-repo/semantics/publishedVersio

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study

Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging

Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral

Multi-step web-based training: the road to Stress Echo 2020

Background: A standardized training platform helps to achieve reading harmonization in stress echocardiography (SE) beyondregional wall motion abnormalities (RWMA).Objective: To harmonize SE reading criteria across different laboratories.Methods: The core lab prepared for readers an obligatory 2-hour web-based learning module for 5 parameters: RWMA; B-lines;coronary flow velocity reserve (CFVR) based on peak diastolic flow velocity on the left anterior descending coronary artery;left ventricular contractile reserve (LVCR, from raw measurements of end-systolic volume, ESV); systolic arterial pulmonarypressure (from raw measurements of peak tricuspid regurgitant jet velocity, TRV). The quality control test consisted of 20cases selected by the coordinating center. The a priori determined pass threshold was 18/20 (≥90%) with intra-class correlationcoefficient between the coordinating lab and the peripheral reader >0.90.Results: The certification was completed by 84 readers for RWMA, 65 for B-lines, 30 for CFVR, 24 for ESV and 20 for TRV.The mean reading time per attempt was shorter for TRV (9±4 min), CFVR (13±6 min) and B-lines (17±3 min), intermediatefor ESV (24±7 min), and longer for RWMA (29±12 min, p 0.90 Resultados: Ochenta y cuatro lectores completaron la certificación para las AMPR, 65 para las líneas B, 30 para la RVFC, 24 para el VFS y 20 para la VRT. El tiempo de lectura medio por intento fue más corto para la VRT (9 ± 4 min), la RVFC (13 ± 6 min) y las líneas B (17 ± 3 min), intermedio para el VFS (24 ± 7 min), y más prolongado para las AMPR (29 ± 12 min, p < 0.01). La tasa de acierto del primer intento fue más alta para la RVFC (85%), intermedia para la VRT (75%) y las líneas B (43%), menor para el VFS (35%) y más baja para las AMPR (28%, p < 0.01). Conclusiones: La plataforma de aprendizaje basada en la web mejora las habilidades de interpretación de imágenes sin necesidad de un equipamiento de imágenes costoso o de estudiar un paciente. El camino hacia la certificación es más largo para las AMPR, intermedio para el VFS y más corto para la VRT, la RVFC y las líneas B.