GUIDELINES AND STANDARDS American Society of Echocardiography Recommendations for Performance, Interpretation, and Application of Stress Echocardiography Patricia A. Pellikka, MD, Sherif F. Nagueh, MD, Abdou A. Elhendy, MD, PhD, Cathryn A. Kuehl, RDCS, and Stephen G. Sawada, MD, Rochester, Minnesota; Houston, Texas; Marshfield, Wisconsin; and Indianapolis, Indiana dvances since the 1998 publication of the TABLE OF CONTENTS A Recommendations for Performance and Interpreta- tion of Stress Echocardiography1 include improve- Methodology....................................................1021 ments in imaging equipment, refinements in stress Imaging Equipment and Technique............1021 testing protocols and standards for image interpre- Stress Testing Methods...... ............................1022 tation, and important progress toward quantitative Training Requirements and Maintenance analysis. Moreover, the roles of stress echocardiog- of Competency...... .....................................1023 raphy for cardiac risk stratification and for assess- Image Interpretation......................................1024 ment of myocardial viability are now well docu- Table 1. Normal and Ischemic mented. Specific recommendations and main points Responses for Various Modalities are identified in bold. of Stress........................................................1025 Quantitative Analysis Methods.....................1025 Accuracy...... .....................................................1026 False-negative Studies...... ..............................1026 METHODOLOGY False-positive Studies...... ...............................1027 Assessment of Myocardial Viability.............1027 Imaging Equipment and Technique Assessment of Patients With Dyspnea, Digital acquisition of images has evolved from the Pulmonary Hypertension, and days of stand-alone computers that digitized analog Valvular Heart Disease...... ........................1028 video signals to the current era in which ultrasound Dyspnea............................................................1028 systems have direct digital output.2 This has resulted Pulmonary Hypertension..............................1029 in significant improvements in image quality. Many Mitral Valve Disease...... .................................1029 ultrasound systems have software to permit acquisi- Aortic Valve Disease.......................................1029 tion and side-by-side display of baseline and stress Evaluation of Prosthetic Valves....................1030 images. However, transfer of images to a computer Stress Echocardiography for Risk workstation for offline analysis is preferred as the Stratification................................................1030 ultrasound equipment can be continuously used for Table 2. Summary of Studies Evaluating imaging. Network systems with large archiving ca- the Value of Stress Echocardiography pacity allow retrieval of serial stress examinations. in Predicting Outcome...... ........................1031 Digital image acquisition permits review of multiple Table 3. Stress Echocardiography cardiac cycles with stress, which maximizes accu- Predictors of Risk.......................................1032 racy of interpretation. Videotape recordings are Women..............................................................1032 recommended as a backup. After Acute Myocardial Infarction...............1032 Advances in imaging technology have improved Elderly...............................................................1033 endocardial border visualization and increased the Patients With Diabetes Mellitus...... .............1033 Before Noncardiac Surgery...........................1033 From the aDivision of Cardiovascular Diseases and Internal Med- After Coronary Revascularization...... .........1033 icine, Mayo Clinic and Foundation; bMethodist DeBakey Heart Patients With Angina...... ...............................1033 Center, Houston (S.F.N.); cMarshfield Clinic (A.A.E.); and dIn- Comparison With Radionuclide Imaging...... ....1033 diana University School of Medicine (S.G.S.). Recent and Future Developments...... .........1034 Reprint requests: Patricia A. Pellikka, MD, Mayo Clinic, 200 First Strain and Strain Rate Echocardiograpy...... ......1034 St SW, Rochester, MN 55905 (E-mail: pellikka.patricia@ Three-Dimensional Echocardiography...... ........1034 mayo.edu). Myocardial Contrast Perfusion Imaging...... ......1034 0894-7317/$32.00 Summary...... ....................................................1034 Copyright 2007 by the American Society of Echocardiography. References........................................................1034 doi:10.1016/j.echo.2007.07.003 1021 Journal of the American Society of Echocardiography 1022 Pellikka et al September 2007 feasibility of imaging. Tissue harmonic imaging W, at peak stress, and in recovery. The workload is should be used for stress echocardiography increased at increments of 25 W every 2 or 3 imaging. This reduces near-field artifact, improves minutes.13 A higher initial workload may be appro- resolution, enhances myocardial signals, and is su- priate for a younger patient. perior to fundamental imaging for endocardial bor- Both types of exercise examinations provide valu- der visualization.3 The improvement in endocardial able information for detection of ischemic heart visualization achieved with harmonic imaging has disease and assessment of valvular heart disease. The decreased interobserver variability and improved workload and maximum heart rate achieved tend to the sensitivity of stress echocardiography.4,5 be higher with treadmill exercise; exercise blood The availability of intravenous contrast agents for pressure is higher with supine bicycle exercise. If left ventricular (LV) opacification represents an- assessment of regional wall motion is the only other advance. When used in conjunction with objective, treadmill exercise is usually used. If addi- harmonic imaging, contrast agents increase the tional Doppler information is desired, bicycle exer- number of interpretable LV wall segments, improve cise offers the advantage that Doppler information, the accuracy of less experienced readers, enhance in addition to assessment of regional wall motion, diagnostic confidence, and reduce the need for can be evaluated during exercise.14 additional noninvasive tests because of equivocal Pharmacologic stress testing. In patients who 6-9 noncontrast stress examinations. Opacification of cannot exercise, dobutamine and vasodilator stress the LV cavity with contrast agents also improves the are alternatives. Although vasodilators may have potential for quantitative assessment of studies. advantages for assessment of myocardial per- Contrast should be used when two or more fusion, dobutamine is preferred when the test segments are not well visualized. With experi- is based on assessment of regional wall mo- ence and well-defined protocols, contrast stress tion. A graded dobutamine infusion starting at echocardiography has been shown to be time-effi- 5 ␮g/kg/min and increasing at 3-minute inter- 10 cient. vals to 10, 20, 30, and 40 ␮g/kg/min is the The baseline echocardiogram performed at standard for dobutamine stress testing.15,16 The the time of stress echocardiography should inclusion of low-dose stages facilitates recogni- include a screening assessment of ventricular tion of viability and ischemia in segments with function, chamber sizes, wall-motion thick- abnormal function at rest, even if viability nesses, aortic root, and valves unless this as- assessment is not the main objective of the test. sessment has already been performed. This End points are achievement of target heart rate examination permits recognition of causes of car- (defined as 85% of the age-predicted maximum heart diac symptoms in addition to ischemic heart disease, rate), new or worsening wall-motion abnormalities including pericardial effusion, hypertrophic cardio- of moderate degree, significant arrhythmias, hypo- myopathy, aortic dissection, and valvular heart dis- tension, severe hypertension, and intolerable symp- ease. toms. Atropine, in divided doses of 0.25 to 0.5 mg to a total of 2.0 mg, should be used as Stress Testing Methods needed to achieve target heart rate. Atropine Exercise stress testing. For patients who are increases the sensitivity of dobutamine echocardiog- capable of performing an exercise test, exer- raphy in patients receiving beta-blockers and in 17 cise stress rather than pharmacologic stress is those with single-vessel disease. The minimum recommended, as the exercise capacity is an cumulative dose needed to achieve the desired heart important predictor of outcome. Either tread- rate effect should be used to avoid the rare compli- mill or bicycle exercise may be used for exer- cation of central nervous system toxicity. Protocols cise stress. Symptom-limited exercise accord- using atropine in early stages of the test, and ac- ing to a standardized protocol in which the celerated dobutamine administration, have been workload is gradually increased in stages is shown to be safe and to reduce infusion times.18,19 recommended. The Bruce protocol is most com- Patients given atropine at the 30-␮g/kg/min stage monly used for treadmill exercise echocardiography reached target heart rate more quickly using lower and the expected exercise level for a given age and doses of dobutamine and with fewer side effects. A sex can be expressed as functional aerobic capa- beta-blocker may be administered to reverse the side city.11 Imaging