When to use stress echocardiography in the evaluation of patients with valvular heart disease

Stress testing and stress echocardiography are firmly established diagnostic tests in the evaluation of patients with suspected or known coronary artery disease, but less established in the evaluation of patients with valvular heart disease. However, there is emerging data supporting the incremental benefit of stress testing and stress echocardiography in patients with known valvular heart disease. Particular applications include hemodynamic assessment of valve function and pulmonary response during exercise induced or chemically-induced stress to correlate with the patient’s exertional symptoms. In addition, stress testing affords the opportunity for functional assessment of ventricular systolic function for prognostication and planning for surgery

Exercise echocardiographic findings and outcome of patients referred for evaluation of dyspnea

AbstractObjectivesThe purpose of this study was to characterize the outcome of patients referred for exercise echocardiographic evaluation of dyspnea.BackgroundLittle information exists regarding outcome of patients with dyspnea.MethodsWe identified 443 patients with unexplained dyspnea, 2,033 with chest pain, and 587 with both symptoms referred for exercise echocardiography.ResultsCompared to those with chest pain alone, patients referred for dyspnea alone were older, predominately men, and had lower workload, lower ejection fraction (EF), more prior myocardial infarction (MI), and abnormal rest electrocardiograms. Patients with both symptoms were similar to those with dyspnea, but more had prior revascularization. Exercise echocardiography showed ischemia in 42% of patients with dyspnea, 19% with chest pain, and 58% with both symptoms. During 3.1 ± 1.8 years follow-up, cardiac death (5.2% vs. 0.9%, p < 0.0001) and nonfatal MI (4.7% vs. 2.0%, p < 0.0001) occurred more often in patients with dyspnea. Events in patients with both symptoms were similar to those with dyspnea, except for revascularization (20% vs. 13%, p = 0.0004). For patients with dyspnea, independent predictors of events were previous MI (hazard ratio [HR] 3.35, p < 0.0001), male gender (HR 1.94, p = 0.0252), EF (HR 0.95/10% increment, p < 0.0001), and increase in wall motion score index with exercise (HR 4.19/0.25 U, p < 0.0001), but not chest pain.ConclusionsPatients with unexplained dyspnea have a high likelihood of ischemia and an increased incidence of cardiac events. Exercise echocardiography provides independent information for identifying patients at risk. In patients with known or suspected coronary artery disease, dyspnea is a symptom requiring investigation

Application of Appropriateness Criteria to Stress Single-Photon Emission Computed Tomography Sestamibi Studies and Stress Echocardiograms in an Academic Medical Center

ObjectivesThe purpose of this study was to apply published appropriateness criteria for single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) in a single academic medical center.BackgroundThe American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) have developed appropriateness criteria for stress SPECT MPI to address concern about the growth in cardiac imaging studies.MethodsWe retrospectively examined 284 patients who underwent stress SPECT MPI and 298 patients who underwent stress echocardiography before publication of these criteria.ResultsThe overall level of agreement in characterizing appropriateness between 2 experienced cardiovascular nurse abstractors was modest (kappa = 0.56), but noticeably poorer (kappa = 0.27) for patients with previous SPECT or echo studies. Similar percentages of each imaging modality were assigned to the 3 appropriateness categories: 64% of stress SPECT and 64% of stress echo studies were classified appropriate; 11% of stress SPECT and 9% of stress echo were of uncertain appropriateness; and 14% of stress SPECT and 18% of stress echo were inappropriate. Of the inappropriate studies, 88% were performed for 1 of 4 indications. Approximately 10% of the patients were unclassifiable.ConclusionsApplication of existing SPECT MPI appropriateness criteria is demanding and requires an established database or detailed data collection, as well as a number of assumptions. Fourteen percent of stress SPECT studies and 18% of stress echo studies were performed for inappropriate reasons. Quality improvement efforts directed at reducing the number of these inappropriate studies may improve efficiency in the health care system

Wellness and Multiple Sclerosis: The National MS Society Establishes a Wellness Research Working Group and Research Priorities

Background: People with multiple sclerosis (MS) have identified “wellness” and associated behaviors as a high priority based on “social media listening” undertaken by the National MS Society (i.e. the Society). Objective: The Society recently convened a group that consisted of researchers with experience in MS and wellness-related research, Society staff members, and an individual with MS for developing recommendations regarding a wellness research agenda. Method: The members of the group engaged in focal reviews and discussions involving the state of science within three approaches for promoting wellness in MS, namely diet, exercise, and emotional wellness. Results: That process informed a group-mediated activity for developing and prioritizing research goals for wellness in MS. This served as a background for articulating the mission and objectives of the Society’s Wellness Research Working Group. Conclusion: The primary mission of the Wellness Research Working Group is the provision of scientific evidence supporting the application of lifestyle, behavioral, and psychosocial approaches for promoting optimal health of mind, body, and spirit (i.e. wellness) in people with MS as well as managing the disease and its consequences

763-6 Septal Myectomy for Hypertrophic Cardiomyopathy: Echocardiographic Predictors of Postoperative Outcome

Although septal myectomy (SM) reduces the left ventricular outflow tract (LVOT) pressure gradient and relieves symptoms in the majority of patients with severe hypertrophic cardiomyopathy (HCM). there remains a subset of patients who will continue to have residual limiting symptoms.In order to determine whether echo/Doppler (ECHO) can predict outcome after surgical treatment of HCM, we analyzed the clinical and ECHO characteristics of 47 consecutive HCM patients aged 20 to 70 years (mean 47±15 years, M:F=1:1) undergoing isolated SM from 1986 to 1992 for NYHA class 3 or 4 symptoms. Preoperative symptoms included dyspnea (100%), angina (64%), near syncope (62%), and syncope (23%).At postoperative follow-up (12±4 months). there was marked overall improvement; 94% were NYHA class 1 or 2. Persistent symptoms were dyspnea (55%), angina (15%), and near syncope (15%). By multivariate analysis of all clinical and ECHO parameters, only the preoperative ECHO variable of hypertrophy pattern (diffuse hypertrophy≥15mm versus septal localization±anterolateral extension) emerged as an independent predictor of residual dyspnea postoperatively (p=0.05). Variables not predictive included peak rest and provoked LVOT gradient, ejection time, mitral regurgitation severity, mitral flow velocity curves, left atrial volume, and left ventricular mass index.ConclusionsWith the successful relief of LVOT obstruction by SM, most HCM patients experience significant improvement in symptoms of angina. near syncope, and syncope. The morphological characteristic of diffuse (concentric) left ventricular hypertrophy is a superior predictor of residual postoperative dyspnea as compared to Doppler parameters. This diffuse hypertrophy may be indicative of severe diastolic filling abnormalities which are unchanged by SM

Pretest Score for Predicting Microbubble Contrast Agent Use in Stress Echocardiography: A Method to Increase Efficiency in the Echo Laboratory

Background. In stress echocardiography, contrast agents are used selectively to improve endocardial border definition. Early identification of candidates may facilitate use of these agents in small and medium volume laboratories where resources are limited. Methods. We studied 15232 patients who underwent stress echocardiography. Contrast agent was used if 2 or more ventricular segments were not adequately visualized without contrast. Logistic regression models were used to evaluate the association between individual characteristics and contrast use. An 11-point score was derived from the significant characteristics. Results. Variables associated with microbubble use were age, sex, smoking, presence of multiple risk factors, bodymass index (BMI), referral for dobutamine stress echocardiography, history of coronary artery disease, and abnormal baseline electrocardiogram. All variables except BMI were given a score of 1 if present and 0 if absent; BMI was given a score of 0 to 4 according to its value. An increased score was directly proportional to increased likelihood of contrast use. The score cutoff value to optimize sensitivity and specificity was 5. Conclusions. A pretest score can be computed from information available before imaging. It may facilitate contrast agent use through early identification of patients who are likely to benefit from improved endocardial border definition

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Background. In stress echocardiography, contrast agents are used selectively to improve endocardial border definition. Early identification of candidates may facilitate use of these agents in small and medium volume laboratories where resources are limited. Methods. We studied 15232 patients who underwent stress echocardiography. Contrast agent was used if 2 or more ventricular segments were not adequately visualized without contrast. Logistic regression models were used to evaluate the association between individual characteristics and contrast use. An 11-point score was derived from the significant characteristics. Results. Variables associated with microbubble use were age, sex, smoking, presence of multiple risk factors, bodymass index (BMI), referral for dobutamine stress echocardiography, history of coronary artery disease, and abnormal baseline electrocardiogram. All variables except BMI were given a score of 1 if present and 0 if absent; BMI was given a score of 0 to 4 according to its value. An increased score was directly proportional to increased likelihood of contrast use. The score cutoff value to optimize sensitivity and specificity was 5. Conclusions. A pretest score can be computed from information available before imaging. It may facilitate contrast agent use through early identification of patients who are likely to benefit from improved endocardial border definition

Diving into the vertical dimension of elasmobranch movement ecology

Knowledge of the three-dimensional movement patterns of elasmobranchs is vital to understand their ecological roles and exposure to anthropogenic pressures. To date, comparative studies among species at global scales have mostly focused on horizontal movements. Our study addresses the knowledge gap of vertical movements by compiling the first global synthesis of vertical habitat use by elasmobranchs from data obtained by deployment of 989 biotelemetry tags on 38 elasmobranch species. Elasmobranchs displayed high intra- and interspecific variability in vertical movement patterns. Substantial vertical overlap was observed for many epipelagic elasmobranchs, indicating an increased likelihood to display spatial overlap, biologically interact, and share similar risk to anthropogenic threats that vary on a vertical gradient. We highlight the critical next steps toward incorporating vertical movement into global management and monitoring strategies for elasmobranchs, emphasizing the need to address geographic and taxonomic biases in deployments and to concurrently consider both horizontal and vertical movements