Current status of stress echocardiography

Stress echocardiography is a widely applied technique for the evaluation of individuals with known or suspected coronary artery disease. The technique combines echocardiographic imaging with exercise testing or pharmacologic stress. Advances in digital image acquisition and harmonic imaging have substantially improved the quality of echocardiographic images, and have therefore increased general applicability of stress echocardiography

Clinical relevance of chest pain during dobutamine stress echocardiography in women

Background: Dobutamine stress echocardiography (DSE) is commonly used for diagnosis and management of patients with known or suspected coronary artery disease. Chest pain occurring during DSE potentially provides additional diagnostic accuracy. Our experience suggests that chest pain occurs frequently in women undergoing DSE. Hypothesis: It was the purpose of this study to determine the frequency with which chest pain occurs in women undergoing DSE and the relation to inducible ischemia or coronary artery stenosis. Methods: To determine the prevalence and clinical significance of chest pain during DSE, we reviewed the records of 154 consecutive women undergoing DSE in our laboratory. Of these, 59 patients (37.5%) also underwent coronary angiography. The presence or absence of chest pain was correlated with ECG changes, left ventricular wall motion abnormalities during DSE, and coronary stenosis by angiography. Results: Forty-one women (26%) developed chest pain during DSE. Patients experiencing chest pain were older (58.5 ± 9.3 vs. 54.9 ± 12.6; p = 0.05), and had lower resting heart rates (71 ± 12.2 vs. 77.9 ±14.9; p = 0.008), but received similar maximum doses of dobutamine and reached comparable peak heart rates (131.1 ± 17.4 v s. 133.5 ± 21.7; p = NS). Patients with chest pain more commonly exhibited ST-segment depression ≥1 mm during dobutamine infusion (13/41, 32%, vs. 17/113, 15%; p = 0.02), but chest pain showed no statistically significant correlation with abnormal DSE or with coronary stenosis. Conclusions: In women undergoing DSE, chest pain occurs in 26% and does not appear to be related to inducible myocardial ischemia. Electrocardiographic changes occur more frequently in patients who experience chest pain, but are also often unrelated to inducible myocardial ischemia

Clinical and morphologic expression of hypertrophic cardiomyopathy in patients ≥ 65 years of age

Hypertrophic cardiomyopathy (HC) is most often identified in patients in the second through fifth decades of life, but has been increasingly recognized in older patients. The present report characterizes morphologic and clinical features of HC in 134 consecutively studied patients aged ≥ 65 years referred to a tertiary center. Echocardiographic or clinical evaluation, or both, was performed in 134 patients aged 65 to 85 years (mean 72) at most recent evaluation. Selected findings were compared with those in 64 youthful patients with HC aged 15 to 35 years (mean 25). Most elderly patients (120 of 134, 90%) developed marked symptoms that usually became evident after age 55 years; 94 of 120 experienced sustained improvement with medical treatment or operation. Elderly patients had relatively mild left ventricular (LV) wall thickening (20 ± 3 mm), generally confined to the septum. In most (i.e., 68%), septal hypertrophy was uniformly distributed with parallel right and left borders and associated with elliptical LV cavity shape; however, in 32%, an inhomogeneously hypertrophied septum bulged into the left ventricle, disrupting normal cavity shape. Dynamic subaortic obstruction was present under basal or provocable conditions in a particularly small LV outflow tract in 103 of 134 patients (77%), and was usually produced by relatively restricted excursion of the anteriorly displaced mitral leaflets and posterior septal motion. HC is characterized by age-related differences in both clinical and morphologic expression. Elderly patients with HC characteristically demonstrate onset of cardiac symptoms late in life, as well as distinctive LV morphology and dynamics of outflow obstruction. © 1994

Diversity of patterns of hypertrophy in patients with systemic hypertension and marked left ventricular wall thickening

In selected patients with systemic hypertension it may be difficult to ascertain whether left ventricular (LV) hypertrophy is a secondary end-organ consequence of long-term elevations in blood pressure or, alternatively, a manifestation of a coexistent primary hypertrophic cardiomyopathy. To address this issue and better characterize LV hypertrophy in systemic hypertension, 2-dimensional echocardiography was used to define the patterns of LV hypertrophy in 102 patients with sustained systemic hypertension and marked degrees of wall thickening. Patients ranged in age from 31 to 88 years (mean 61) and were predominantly female (58%); all were black. By selection, each patient had a maximal LV wall thickness of \u3e15 mm (range 16 to 29). Distribution of hypertrophy was judged to be symmetric (i.e., concentric) in most patients (67 of 102, 66%). However, a substantial proportion (35 patients, 34%) demonstrated nonuniform, asymmetric patterns of hypertrophy in which at least 1 segment of the LV wall was at least 1.5 times the thickness of any other. In these 35 patients, the distribution of hypertrophy was similar to that characteristic of the morphologic spectrum of hypertrophic cardiomyopathy, with thickening of portions of both the ventricular septum and free wall in 16 patients, anterior and posterior ventricular septum alone in 11 patients and segmental involvement of only the anterior ventricular septum in 8. Patients with asymmetric patterns of wall thickening did not differ from the patients with symmetric hypertrophy with regard to age, sex or clinical findings. Asymmetric LV hypertrophy appears to represent an important feature of the morphologic spectrum of severe hypertensive heart disease. Moreover, the diverse patterns of hypertrophy observed in hypertensive patients with marked LV wall thickening often cannot be distinguished definitively, on a morphologic basis alone, from those characteristic of hypertrophic cardiomyopathy. © 1990

Elderly patients with hypertrophic cardiomyopathy: A subset with distinctive left ventricular morphology and progressive clinical course late in life

This report describes a subgroup of 52 elderly patients with obstructive hypertrophic cardiomyopathy in whom certain clinical and morphologic features differed importantly from those of many other patients with this disease. Ages ranged from 60 to 84 years (mean 69) and 45 [87%] were women. Echocardiographic examination showed a relatively small heart, having only modest ventricular septal hypertrophy associated with marked distortion of left ventricular outflow tract morphology. By virtue of selection, left ventricular outflow tract size at end-diastole was substantially reduced, and anterior displacement of the mitral valve within the left ventricular cavity was particularly marked. Sizable deposits of calcium in the region of the mitral anulus, posterior to the mitral valve, appeared to contribute to the outflow tract narrowing. Systolic anterior motion of the mitral valve was severe (with apposition of the mitral valve and ventricular septum) in 32 patients and more moderate in 20. The mechanism by which systolic contact between the mitral valve and septum occurred in most patients appeared to differ from that observed more typically in many other patients with hypertrophic cardiomyopathy; in most elderly study patients, anterior excursion of the mitral valve leaflets was relatively restricted, and systolic apposition between the mitral valve and septum resulted from a combination of anterior motion of the mitral valve and posterior excursion of the septum. The vast majority (50 of 52) of the patients remained asymptomatic (or only mildly symptomatic) for most of their lives and often did not develop severe and intractable symptoms until the 6th or 7th decade (ages 56 to 81 years; mean 66). Of the 49 patients with at least 1 year follow-up study, only 12 had improvement with pharmacologic therapy; however, 14 of the 18 patients who underwent ventricular septal myotomy-myectomy or mitral valve replacement obtained symptomatic benefit from operation. In conclusion, obstructive hypertrophic cardiomyopathy in many elderly (and predominantly female) patients may assume a distinctive morphologic appearance and a progressive clinical course. This subgroup of patients appears to constitute an important segment of the disease spectrum of hypertrophic cardiomyopathy of cardiac disease in the elderly that previously has not been precisely defined nor fully appreciated. © 1989

The Women\u27s Ischemia Syndrome Evaluation study: An overview of the impact on detection of ischemic heart disease in women

Coronary artery disease (CAD) is the most common cause of mortality among women in the U.S. However, most major clinical trials addressing the diagnosis and treatment of CAD are composed primarily of men. The Women\u27s Ischemia Syndrome Evaluation (WISE) study, conducted at four university clinical sites, aims to assess the utility of existing tests and evaluate innovative methods to improve testing in women. To date, 161 women have been enrolled at the University of Florida (UF) clinical site. Mean age of participants in the pilot phase was 57.5±10.1 years. Nearly 90% had ≥ 2 risk factors for CAD, and 27% had angiographic evidence of severe coronary stenosis. These women underwent a battery of noninvasive and invasive tests, including dobutamine stress echocardiography (DSE), invasive measures of coronary flow reserve and endothelial function, and noninvasive measure of brachial artery endothelial function. In brief, DSE performed in 92 women demonstrated overall sensitivity (excluding indeterminate tests) of 50% and 81.8% for two or three vessel stenosis, respectively. In a subset who also underwent coronary function studies, abnormal coronary flow reserve or endothelial dysfunction were identified in 67%. In the absence of severe coronary stenosis, these functional abnormalities were uncommonly associated with ischemia during DSE. Moreover, concordant abnormalities of coronary and brachial artery endothelial function were observed in only 24% of patients undergoing both studies. These findings underscore the limitations of current testing in women with chest pain and suspected ischemic heart disease, and the importance of further investigation. The major goals of the ensuing years of the WISE study are to improve the accuracy of DSE using contrast enhancement, and utilize phosphorus-31 nuclear magnetic resonance spectroscopy to determine whether ischemia due to abnormal coronary function occurs in the women without angiographic stenosis

Hypertrophic cardiomyopathy characterized by marked hypertrophy of the posterior left ventricular free wall: Significance and clinical implications

This report describes a subgroup of 17 patients with hypertrophic cardiomyopathy and an unusual and distinctive pattern of left ventricular hypertrophy characterized on echocardiography by marked thickening of the posterior left ventricular free wall and virtually normal or only modestly increased ventricular septal thickness. This distribution of hypertrophy often created a distinctive pattern of inverted asymmetry of the posterior wall relative to the septum. The thickness of the posterior wall was 20 to 42 mm (mean 25), while that of the basal ventricular septum was only 12 to 24 mm (mean 17). The left ventricular outflow tract was narrowed because of anterior displacement of the mitral valve within the small left ventricular cavity. Systolic anterior motion of the mitral valve was present in 16 of the 17 patients. The patients ranged in age from 13 to 54 years (mean 31) at most recent evaluation; most (11 of 17, 65%) were severely symptomatic and had experienced important symptoms early in life (before age 40). The condition of only 4 of these 11 patients improved with medical therapy over an average follow-up period of 9 years; however, 6 of the 7 patients who had unsuccessful medical treatment and underwent operation with mitral valve replacement (5 patients) or ventricular septal myotomy-myectomy (1 patient) experienced symptomatic benefit from surgery. The subgroup of patients described in this report underscores the morphologic and clinical diversity that exists within the overall disease spectrum of hypertrophic cardiomyopathy. Characteristically, the patients were young, severely symptomatic and demonstrated evidence of outflow obstruction and an inverted asymmetric pattern of posterior free wall left ventricular hypertrophy. Because of their relatively modest ventricular septal hypertrophy, mitral valve replacement (rather than myotomy-myectomy) may be the operative procedure of choice in such patients with obstructive hypertrophic cardiomyopathy. © 1991