Stress echocardiography: Indications, imaging techniques and safety
- Nelson B Schiller, MD
Nelson B Schiller, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine, Anesthesia, and Radiology
- University of California, San Francisco
- Xiushui Ren, MD
Xiushui Ren, MD
- Associate Research Director, Cardiology Fellowship
- California Pacific Medical Center
- Bryan Ristow, MD, FACC, FASE, FACP
Bryan Ristow, MD, FACC, FASE, FACP
- Associate Clinical Professor of Medicine
- University of California, San Francisco
- Alexis Beatty, MD
Alexis Beatty, MD
- Assistant Professor, University of Washington
Echocardiography enables dynamic evaluation of cardiac structure and function at rest and during stress provoked by exercise or a pharmacologic agent. Two-dimensional echocardiographic imaging performed during or immediately after stress is used primarily to detect the presence (or absence) and extent of ischemia secondary to obstructive coronary artery disease and to measure or estimate overall ventricular systolic function. In addition, Doppler echocardiographic imaging performed during or after exercise stress allows for evaluation of valvular function, pulmonary artery pressure, and left ventricular diastolic function.
The two major types of stress echocardiography are exercise (treadmill or bicycle) stress echocardiography and pharmacologic (predominantly dobutamine) stress echocardiography. The indications for stress echocardiography, along with the imaging technique and safety of the procedure, will be discussed here. Details of specific stress echocardiography protocols along with the advantages and disadvantages of stress echocardiography as compared to other stress modalities are also discussed separately. (See "Overview of stress echocardiography" and "Stress echocardiography in the diagnosis and prognosis of coronary heart disease", section on 'Stress test options' and "Selecting the optimal cardiac stress test".)
Stress testing is a common procedure with a variety of indications. Most commonly, however, stress testing is performed to estimate the likelihood of obstructive coronary artery (CAD) in patients who present with symptoms suggesting this diagnosis, or to estimate the ischemic burden and the prognosis in a patient with known CAD. The indications for stress testing are discussed in detail separately. (See "Stress testing for the diagnosis of obstructive coronary heart disease", section under construction and "Stress testing to determine prognosis and management of patients with known or suspected coronary heart disease".)
There are several specific indications for stress echocardiography as noted in the 2007 American Society of Echocardiography (ASE) stress echocardiography guidelines :
- Risk stratification for patients with known or suspected coronary artery disease. The presence and extent of ischemic myocardium, as well as dysfunctional but viable (ie, hibernating) myocardium, can be evaluated. (See "Stress echocardiography in the diagnosis and prognosis of coronary heart disease" and "Dobutamine stress echocardiography in the evaluation of hibernating myocardium".)
- Dyspnea of possible cardiac origin. Exercise echocardiography may be helpful in some cases when data from the resting echocardiogram is not sufficient to make a diagnosis.
- Pulmonary hypertension. Pulmonary artery systolic pressure can be estimated at rest and with exercise.
- Mitral stenosis. Stress echocardiography is indicated in asymptomatic patients with echocardiographically severe lesions as well as for patients with symptoms disproportionate to resting Doppler hemodynamics. (See "Medical management and indications for intervention for mitral stenosis" and "Echocardiographic evaluation of the mitral valve".)
- Mitral regurgitation. Exercise stress testing may aid in evaluation of symptoms including change in exercise tolerance. (See "Overview of the management of chronic mitral regurgitation" and "Echocardiographic evaluation of the mitral valve".)
- Aortic stenosis. Exercise testing should NOT be performed in patients with symptomatic aortic stenosis . However, there are circumstances in which stress echocardiography may be reasonable in patients with aortic stenosis:
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- IMAGING TECHNIQUE
- Two-dimensional stress echocardiography
- Interpretation of two-dimensional images
- Use of contrast agents
- Doppler stress echocardiography
- Evolving technologies
- - Evaluation for resynchronization therapy by stress echocardiography
- - Myocardial perfusion imaging
- - Three-dimensional imaging
- - Strain imaging
- Safety of dobutamine administration
- Contrast agent safety