Docstoc

Stress Echo Contrast Echo

Document Sample
Stress Echo Contrast Echo Powered By Docstoc
					Stress Echo & Contrast Echo
 Eleventh Annual Cardiac Imaging Symposium


     Dr. CB Johnson MD FRCP
   Assistant Professor of Medicine
        University of Ottawa
          Case 1

•   45 year old female
•   Palpitations
•   No exertional symptoms
•   No risk factors
•   Positive TMT
•   Duke treadmill score = 0
What do you recommend ?

(a) No tests - patient education
(b) Exercise nuclear scan
(c) Cardiac CT scan
(d) Exercise stress echo
  Which of the following is true
 about radiation dose / risk with
  exercise MPI or cardiac CT ?
(a) 3 - 4 years of background radiation
(b) 1 / 5th radiation worker annual dose
    limit
(c) lifetime attributable risk of cancer
    probably not increased
(d) low dose radiation may protect
    against future cancer
(e) all of the above
Effects of Medical Radiation




Circulation 2007;116;1290-1305   J Am Coll Cardiol Img
                                    2010;3;528-35
    Why choose exercise echo ?
•   No radiation
•   Cheaper
•   Probably higher specificity
•   Uncover structural heart problems
•   Preferred strategy when pre-test is low
•   Young & healthy = nice echo images !
  Exercise Echo: Exercise Stress




Treadmill:              Supine Bike:
  - 85 % predicted HR     - RPP > 25000
  - Post stress           - Peak stress
Exercise Echo: Imaging

           • Rest, stress,
             recovery
           • 2 parasternal views
           • 2 apical views
           • 17 segment model
           • Radial function:
             – Thickening
             – Endocardial
               excursion
Case 1: Exercise Stress Echo




  Parasternal Long Axis
  Case 1: Exercise Stress Echo




Parasternal Short Axis – Mid LV
Case 1: Exercise Stress Echo




    Apical 4 Chamber
Case 1: Exercise Stress Echo




  Apical 2 Chamber View
 Case 1: Exercise Stress Echo




Apex (Parasternal / Apical Window)
Case 1: Normal Exercise Echo


                                    • Normal:
                                      –   Reassure
                                      –   Stop testing
                                      –   No treatment
                                      –   Risk factors




 J Am Coll Cardiol 2007;49;227-37
               Case 2


•   60 year old male
•   Prior MI and RCA PCI
•   Atypical chest pain & dyspnea
•   Positive Stress Test…
         Case 1: Treadmill

•   6 minutes
•   Stopped due to dyspnea
•   No chest pain
•   Maximum 2 mm ST segment depression
What is his Duke treadmill score ?

  (a) Low risk (score = 6)
  (b) Intermediate risk (score = 0)
  (c) Intermediate risk (score = - 4)
  (d) High risk (score = -12)
 Intermediate Risk Duke Treadmill Score:
Ischemia Imaging Adds Prognostic Value




                   Exercise Echo:
                   - Incremental Value over TMT
                   - Most valuable in Intermediate Risk



          Marwick: Circulation. 2001;103;2566-2571
Case 2: Exercise Stress Echo




  Parasternal Long Axis
 Case 2: Exercise Stress Echo




Parasternal Short Axis – Mid LV
Case 2: Exercise Stress Echo




    Apical 4 Chamber
Case 2: Exercise Stress Echo




  Apical 2 Chamber View
Case 2: Abnormal & High Risk




               RCA: Scar & Ischemia

               LAD: Ischemia

               CFX: Ischemia
Case 2: Abnormal & High Risk



                         • Multi-vessel CAD
                         • Refer For Cardiac Cath




 Marwick: Circulation.
 2001;103;2566-2571
            Case 3
•   70 year old woman
•   Moderately Obese
•   Asthma
•   Remote MI – Medical Therapy
•   Atypical Chest Pain
Which test do you recommend
  for ischemia evaluation ?


  (a) Cardiac CT
  (b) Persantine MPI
  (c) Dobutamine stress echo
  (d) Bicycle stress echo
     Case 3: Resting Echo




Parasternal Long Axis   Parasternal Short Axis – Mid LV

           Technically Difficult Study !
  Case 3: Resting Echo
No Contrast:                  Contrast:




           Apical 4 Chamber




         Apical 2 Chamber View
Echo Contrast
      • I.V. Injection
      • Vibrate In Ultrasound
      • Up To 3 Minutes
      • Safe
      • LV Opacification:
        Clinical Use
      • Myocardial
        Perfusion: Research
        Setting
 Contrast & Stress Echo: Increased
Image Quality & Reader Confidence




Rainbird: J Am Soc Echo
     2001;14;378-85
 Case 3: Exercise Echo




Parasternal Long Axis
     Case 3: Exercise Echo




Parasternal Short Axis – Mid LV
Case 3: Exercise Echo




Apical 4 Chamber
 Case 3: Exercise Echo




Apical 2 Chamber View
Case 3: Abnormal, Low Risk
 • Abnormal:
   – Resting Wall Motion Abnormality
 • Low Risk:
   – Normal EF
   – No ischemia
 • Recommendation:
   – Medical therapy
   – No benefit to cardiac catheterization
       Case 4: Possible H.C.M.

• 42 year old
  male
• Class II
  dyspnea
• BP 110 / 70          Parasternal Long Axis
• Latent Murmur
• LVH On ECG
• IVSd 1.4 cm
• LVPWd 1.4 cm


                  2 Chamber               4 Chamber
Case 4: H.C.M. With Latent Obstruction
  Rest        Pre-Peak Exercise    Peak Exercise




No Dyspnea    Dyspnea 4 / 10      Dyspnea 8 / 10
9 / 5 mm Hg   67 / 32 mm Hg       88 / 45 mm Hg
             Key Points
• Local expertise and availability: key
  determinants of ischemia imaging
  modality.
• Stress echo preferred ischemia
  evaluation strategy in low risk patients.
• Accuracy is patient and sonographer
  specific.
• Permits direct observation of the heart
  during exertional symptoms.

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:53
posted:12/5/2011
language:English
pages:38