Transcript

1 Κ. ΑΓΓΕΛΗ

2 Echocardiography is. Echocardiography is well recognized for its noninvasive application. It does not require isotopes-there is no risk of radiation It does not require magnetic resonance It s patient-friendly It s portable It provides both anatomy and function It s the sine qua not to detect and elucidate or to exclude structural cardiac disease. It s the tool to follow up

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8 Protocols of Stress Echocardiography

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11 Protocols of Stress Echocardiography

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16 Ποτε διακοπτετε η δοκιμασια κοπωσης ή φορτισης? Α. ΣΕ ΕΜΦΑΝΙΣΗ ΠΑΡΑΤΕΤΑΜΕΝΟΥ ΠΡΟΚΑΡΔΙΟΥ ΑΛΓΟΥΣ Β. ΣΕ ΕΜΦΑΝΙΣΗ ΕΠΕΙΣΟΔΙΟΥ ΚΟΙΛΙΑΚΗΣ ΤΑΧΥΚΑΡΔΙΑΣ Γ. ΣΕ ΕΜΦΑΝΙΣΗ ΣΥΜΠΤΩΜΑΤΙΚΟΥ ΒΑΓΟΤΟΝΙΚΟΥ ΕΠΕΙΣΟΔΙΟΥ Δ. ΣΕ ΕΜΦΑΝΙΣΗ ΕΚΤΑΚΤΩΝ ΚΟΙΛΙΑΚΩΝ ΣΥΣΤΟΛΩΝ

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19 The EAE acreditation exam is highly recommended. The basic skills required for imaging the heart under resting conditions The diagnostic accuracy of an experienced echocardiographer who is an absolute beginner is stress echocardiography is more or less equivalent to that achieved by tossing a coin

20 Start with low-dose tests for viability and later progress to tests for ischemia Start with safer and easier vasodilator tests and later progress to adrenergic stresses Start with pharmacological and then progress to physical exercise stress echocardiography

21 ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCC M/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography Appropriate echocardiograms are those that are likely to contribute to improving patients clinical outcomes, and importantly, inappropriate use of echocardiography may be potentially harmful to patients and generate unwarranted costs to the healthcare system. Appropriate test for specific indication (Median score 7-9) Uncertain for specific indication (Median score 4-6) Inappropriate test for specific indication (Median score 1-3)

22 STRESS ECHOCARDIOGRAPHY-CAD APPROPRIATE TEST FOR SPECIFIC INDICATION Intermediate pretest probability of CAD A(9) ECG uninterpretable or unable to exercise A(9) Coronary stenosis of unclear significance A(8) Assessment of viability in patients eligible for revascularization A(8) Equivocal or borderline stress testing A(8) Post revascularization risk assessment for symptomatic patients A(8)

23 STRESS ECHOCARDIOGRAPHY-CAD INAPPROPRIATE TEST FOR SPECIFIC INDICATION Low global CAD risk in asymptomatic patients I(1) Asymptomatic patients < 2 years after PCI I(1) Asymptomatic patients < 5 years after CABG I(1) Perioperative risk assessment for low risk non-cardiac surgery in patients without active cardiac conditions I(1)

24 STRESS ECHOCARDIOGRAPHY FOR CHRONIC VALVULAR DISEASE Low cardiac output or LV ejection fraction ( low gradient aortic stenosis ) Asymptomatic severe mitral stenosis, severe mitral regurgitation, severe aortic regurgitation A(7) A(8) Symptomatic moderate mitral stenosis or MR A(7) Asymptomatic moderate mitral stenosis or regurgitation Asymptomatic moderate aortic stenosis or regurgitation U(5) U(5) Symptomatic severe mitral stenosis or regurgitation I(3) Acute moderate/severe mitral or aortic regurgitation I(3) Severe aortic stenosis I(1)

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26 ΣΕLBBB ΠΟΙΑΜΟΡΦΗΦΟΡΤΙΣΗΣΉ ΑΣΚΗΣΗΣΠΡΟΤΙΜΑΤΑΙ? Α. ΔΟΚΙΜΑΣΙΑ ΦΟΡΤΙΣΗΣ ΜΕ ΔΟΒΟΥΤΑΜΙΝΗ, ΑΠΟΚΛΕΙΣΤΙΚΑ Β. ΑΣΚΗΣΗ ΜΕ ΤΑΠΗΤΑ, ΑΠΟΚΛΕΙΣΤΙΚΑ Γ. ΑΣΚΗΣΗ ΜΕ ΠΟΔΗΛΑΤΟ, ΑΠΟΚΛΕΙΣΤΙΚΑ Δ. ΟΠΟΙΑΔΗΠΟΤΕ ΜΟΡΦΗ ΑΡΚΕΙ ΝΑ ΜΕΛΕΤΑΤΑΙ ΤΑΥΤΟΧΡΟΝΑ ΚΑΙ Η ΑΙΜΑΤΩΣΗ ΜΥΟΚΑΡΔΙΟΥ

27 Αντενδειξειςτουstress echo ΕΠΕΙΣΟΔΙΟ ΠΡΟΚΑΡΔΙΟΥ ΑΛΓΟΥΣ ΜΕ ΑΥΞΗΣΗ ΤΡΟΠΟΝΙΝΗΣ ΤΟ ΤΕΛΕΥΤΑΙΟ 24ΩΡΟ ΜΕΤΑ ΑΠΟ 24 ΩΡΕΣ ΕΠΕΙΣΟΔΙΟΥ ΠΡΟΚΑΡΔΙΟΥ ΑΛΓΟΥΣ ΧΩΡΙΣ ΑΥΞΗΣΗ ΤΡΟΠΟΝΙΝΗΣ. ΑΝΕΥΡΥΣΜΑ ΚΟΙΛΙΑΚΗΣ ΑΟΡΤΗΣ ΑΝΕΥΡΥΣΜΑ ΘΩΡΑΚΙΚΗΣ ΑΟΡΤΗΣ

28 Αποτελουναντενδειξειςοι κατωθι? ΟΙ ΕΚΤΑΚΤΕΣ ΚΟΙΛΙΑΚΕΣ ΣΥΣΤΟΛΕΣ Η ΠΑΡΟΥΣΙΑ ΣΤΟ HOLTER ΕΠΕΙΣΟΔΙΩN NSVT Η ΠΑΡΟΥΣΙΑ ΕΠΕΙΣΟΔΙΩΝ ΔΙΑΤΑΡΑΧΩΝ ΚΟΛΟΚΟΙΛΙΑΚΗΣ ΑΓΩΓΙΜΟΤΗΤΑΣ Η ΝΟΣΟΣ ΦΛΕΒΟΚΟΜΒΟΥ

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31 The Ischaemic Cascade Rest Stress Perfusion abnormality Metabolic disorder Diastolic dysfunction Systolic dysfunction ECG alterations Anginal pain MCE, SPECT PET Stress echo ECG stress test Clinical syndrome

32 The assessment of two of the main features of myocardial viability, i.e. maintained resting perfusion and residual inotropic reserve.

33 Echocardiography in the Emergency Room Acute chest pain is one of the most common reasons for presentation to the Emergency Department (ED) accounting for approximately 7 million ED visits per year in the United States. The challenge for the clinician is to identify those patients with a serious cause of chest pain requiring intervention, particularly when acute coronary syndromes (ACSs) present with atypical symtoms, or diagnostic changes in the electrocardiogram(ecg) or cardiac enzyme markers are lacking.

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35 Adenosine Stress Myocardial Contrast Echocardiography for the Detection of a Coronary Artery Disease A Comparison With Coronary Angiography and Cardiac Magnetic Resonance Arnold JR, et al., JACC, 2010

36 Characteristics and Outcomes of Patients With Abnormal Stress Echocardiograms and Angiographically Mild Coronary Artery Disease (<50% Stenoses) or Normal Coronary Arteries 1477 consecutive patients with abnormal stress echocardiography underwent coronary angiography 997 (67.5%) had true positive results (stenoses >50%) 480 (32.5%) had false positive (<50% stenoses or normal coronary arteries) Conclusions: A sizable proportion of patients with abnormal stress echocardiographic results who are referred for coronary angiography have false-positive findings. The outcomes of patients with false-positive results were similar to those of patients with true-positive results. This finding suggests that patients with false-positive results on stress echocardiography should still receive intensive risk factor management and careful clinical follow-up. From AM,, McCully RB., J Am Soc Echocardiogr. 2010

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44 MYOCARDIAL CONTRAST ECHO Safety of myocardial flash-contrast echocardiography in combination with dobutamine stress testing for detection of ischemia in 5250 studies. C. Aggeli, Giannopoulos G, Roussakis G., et al. Heart 2008 Adverse bioeffects of ultrasound contrast agents used in echocardiography: true safety issue or much ado about nothing C. Aggeli, G. Giannopoulos, K. Lampropoulos, C. Pitsavos, C. Stefanadis. Curr Vasc Pharmacol 2009 Contrast echo: Really safe after all? C. Aggeli, J. Felekos, C. Pitsavos, C. Stefanadis. Minnerva Cardiologica 2011

45 contractile reserve ECHO SPECT MRI PET Residual metabolic activity Radioisotope uptake

46 Multimodality echo approach of myocardial viability

47 Assessment of myocardial viability is another area in which echocardiography plays an important diagnostic role. It indeed allows for the assessment of two of the main features of myocardial viability, i.e. maintained resting perfusion and residual inotropic reserve.

48 Resting myocardial perfusion MCE PET Resting flow measurements obtained in viable myocardium have been markedly variable, about half of the segments showing reduced perfusion, the other half displaying only minor or no reduction in MBF.

49 Myocardial perfusioncontraction patterns Perfusion-contraction mismatch (stunning) Moderate parallel reductions in perfusion and contraction (hibernation)

50 Myocardial flow reserve Perfusion reserve is always reduced in viable myocardium, albeit more severely in segments with low rest perfusion. The severity of flow reserve reduction directly impacts on contractile reserve, as this requires increases in MBF and oxygen consumption.

51 Microcirculation (several structural alterations) The microvasculature is usually better preserved in viable than in non-viable segments. The major determinant of capillary density is the severity of interstitial fibrosis.

52 We learn more about the pathophysiologic mechanisms behind myocardial viability, research is being directed into understanding the clinical manifestations of the data, interpretations, and clinical recommendations that these modalities provide.

53 The patterns of chronic ischemic dysfunction

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55 Representative CE-3D-Echo and DE-CMr

56 ΠΟΙΑΕΚΤΩΝΚΑΤΩΘΙΕΙΝΑΙΣΩΣΤΑΓΙΑΤΗΝ ΒΙΩΣΙΜΟΤΗΤΑ ΜΥΟΚΑΡΔΙΟΥ? Α. Η ΔΙΦΑΣΙΚΗ ΑΠΑΝΤΗΣΗ ΑΠΟΤΕΛΕΙ ΤΟΝ ΚΑΛΥΤΕΡΟ ΠΡΟΓΝΩΣΤΙΚΟ ΔΕΙΚΤΗ ΓΙΑ ΤΗΝ ΑΝΑΔΕΙΞΗ ΒΙΩΣΙΜΟΤΗΤΑΣ ΜΥΟΚΑΡΔΙΟΥ ΤΟ ΟΠΟΙΟ ΘΑ ΑΝΑΛΑΒΕΙ ΤΗΝ ΣΥΣΤΟΛΙΚΗ ΤΟΥ ΑΠΟΔΟΣΗ ΜΕΤΑ ΤΗΝ ΕΠΑΝΑΙΜΑΤΩΣΗ. Β. Η ΣΥΝΕΧΗΣ ΒΕΛΤΙΩΣΗ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣ ΤΩΝ ΔΥΣΛΕΙΤΟΥΡΓΟΥΝΤΩΝΤΜΗΜΑΤΩΝΧΑΡΑΚΤΗΡΙΖΕΙΤΟSTUNNED MYOCARDIUM. Γ. Η ΣΥΝΕΧΗΣ ΕΠΙΔΕΙΝΩΣΗ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣ ΤΩΝ ΜΥΟΚΑΡΔΙΑΚΩΝ ΤΜΗΜΑΤΩΝ ΑΠΟΤΕΛΕΙ ΤΟΝ ΚΑΛΥΤΕΡΟ ΠΡΟΒΛΕΠΤΙΚΟ ΔΕΙΚΤΗ ΒΕΛΤΙΩΣΗΣ ΤΗΣ ΣΥΣΤΟΛΙΚΗΣ ΑΠΟΔΟΣΗΣ ΜΕΤΑ ΤΗΝ ΕΠΑΝΑΙΜΑΤΩΣΗ. Δ. ΤΟ ΠΑΧΟΣ ΤΩΝ ΔΥΣΛΕΙΤΟΥΡΓΟΥΝΤΩΝ ΜΥΟΚΑΡΔΙΑΚΩΝ ΤΜΗΜΑΤΩΝ ΣΥΝΕΚΤΙΜΑΤΑΙ ΣΤΗΝ ΜΕΛΕΤΗ ΒΙΩΣΙΜΟΤΗΤΑΣ ΜΥΟΚΑΡΔΙΟΥ

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