How Far Have We Come?
Cardiac imaging using ultrasound (so-called ‘echocardiography’) was introduced more than 50 years ago. Resting echocardiographic detection of myocardial infarction was described as the reduction in regional contractile function,1 and the development of stress echocardiography in the early era was recognised after the introduction of 2D echocardiographic imaging. The initial report in 1979 by Wann et al. demonstrated the value of 2D echocardiography in identifying exercise-induced wall motion abnormalities.2 During the early days of stress echocardiography, problems included imaging quality and techniques. For evaluating patients with known or suspected coronary artery disease (CAD), there was also the need to establish equivalent accuracy and prognostic values to the well-established alternative imaging technique, stress radionuclide myocardial perfusion imaging. The acquisition of stress echocardiographic imaging initially involved continuous videotape recording for sequential evaluation of wall motion; the development of the digital acquisition system for the side-by- side comparison of rest and post-stress imaging was a major advance.
Early studies of stress echocardiography employed exercise as a stressor and were mostly feasibility studies.2–4 Any form of physical exercise that provides an appropriate increase in heart rate and cardiovascular workload can be used in the performance of exercise echocardiography. However, the technique of exercise echocardiography is challenging in terms of image acquisition during physical exercise (either on a treadmill or a bicycle). Furthermore, the feasibility of exercise echocardiography is limited in patients who are unable or unwilling to exercise, or when myocardial viability is an important issue. This led to the development of various forms of pharmacological and other non-exercise stressors (see Table 1).
The advent of offline digital handling for data acquisition, storage and display, further improvements in echocardiographic imaging techniques and the development of a wide variety of stressor modalities contributed to rapid growth in the field of stress echocardiography.
- Kerber RE, Abboud FM, Echocardiographic detection of regional myocardial infarction, Circulation, 1973;47:997–1005.
- Wann LS, Faris JV, Childress RH, et al., Exercise cross-sectional echocardiography in ischemic heart disease, Circulation, 1979;60:1300–1308.
- Armstrong WF, O’Donnell J, Dillon JC, et al., Complementary value of two-dimensional exercise echocardiography to routine treadmill exercise testing, Ann Intern Med, 1986;105:829–35.
- Robertson WS, Feigenbaum H, Armstrong WF, et al., Exercise echocardiography: a clinically practical addition in the evaluation of coronary artery disease, J Am Coll Cardiol, 1983;2:1085–91.
- Pellikka PA, Nagueh SF, Elhendy AA, et al., American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography, J Am Soc Echocardiogr, 2007;20:1021–41.
- Kraunz RF, Kennedy JW, Ultrasonic determination of left ventricular wall motion in normal man. Studies at rest and after exercise, Am Heart J, 1970;79:36–43.
- Mason SJ, Weiss JL, Weisfeldt ML, et al., Exercise echocardiography: detection of wall motion abnormalities during ischemia, Circulation, 1979;59:50–59.
- Gould KL, Westcott RJ, Albro PC, et al., Non-invasive assessment of coronary stenoses by myocardial imaging during pharmacologic coronary vasodilatation, Am J Cardiol, 1978;41:279–87.
- Picano E, Bedetti G, Varga A, et al., The comparable diagnostic accuracies of dobutamine and dipyridamole stress echocardiographies, Coron Artery Dis, 2000;11:151–9.
- Chuah SC, Pellikka PA, Roger VL, et al., Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease, Circulation, 1998;97:1474–80.
- Marwick TH, Case C, Sawada S, et al., Prediction of mortality using dobutamine echocardiography, J Am Coll Cardiol, 2001;37:754–60.
- Marwick TH, Case C, Vasey C, et al., Prediction of mortality by exercise echocardiography: a strategy for combination with the duke treadmill score, Circulation, 2001;103:2566–71.
- McCully RB, Roger VL, Mahoney DW, et al., Outcome after normal exercise echocardiography and predictors of subsequent cardiac events, J Am Coll Cardiol,1998;31:144–9.
- Sawada SG, Ryan T, Conley MJ, et al., Prognostic value of a normal exercise echocardiogram, Am Heart J, 1990;120:49–55.
- Sozzi FB, Elhendy A, Roelandt JR, et al., Long-term prognosis after normal dobutamine stress echocardiography, Am J Cardiol, 2003;92:1267–70.
- Chaowalit N, McCully RB, Callahan MJ, et al., Outcomes after normal dobutamine stress echocardiography and predictors of adverse events: long-term follow-up of 3,014 patients, Eur Heart J, 2006;27:3039–44.
- Arruda-Olson AM, Juracan EM, Mahoney DW, et al., Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference?, J Am Coll Cardiol, 2002;39:625–31.
- Chaowalit N, Arruda AL, McCully RB, et al., Dobutamine stress echocardiography in patients with diabetes mellitus: enhanced prognostic prediction using a simple risk score, J Am Coll Cardiol, 2006;47:1029–36.
- Sicari R, Pasanisi E, Venneri L, et al., Stress echo results predict mortality: a large-scale multicenter prospective international study, J Am Coll Cardiol, 2003;41:589–95.
- Tsutsui JM, Elhendy A, Anderson JR, et al., Prognostic value of dobutamine stress myocardial contrast perfusion echocardiography, Circulation, 2005;112:1444–50.
- Hanekom L, Jenkins C, Jeffries L, et al., Incremental value of strain rate analysis as an adjunct to wall-motion scoring for assessment of myocardial viability by dobutamine echocardiography, Circulation, 2005;112:3892–3900.
- Hoffmann R, Altiok E, Nowak B, et al., Strain rate measurement by doppler echocardiography allows improved assessment of myocardial viability inpatients with depressed left ventricular function, J Am Coll Cardiol, 2002;39:443–9.
- Corsi C, Lang RM, Veronesi F, et al., Volumetric quantification of global and regional left ventricular function from realtime 3D echocardiographic images, Circulation, 2005;112:1161–70.
- Takeuchi M, Otani S, Weinert L, et al., Comparison of contrastenhanced real-time live 3D dobutamine stress echocardiography with contrast 2D echocardiography for detecting stress-induced wall-motion abnormalities, J Am Soc Echocardiogr, 2006;19:294–9.
- Yang HS, Pellikka PA, McCully RB, et al., Role of biplane and biplane echocardiographically guided 3D echocardiography during dobutamine stress echocardiography, J Am Soc Echocardiogr, 2006;19:1136–43.
- Armstrong WF, O’Donnell J, Ryan T, et al., Effect of prior myocardial infarction and extent and location of coronary disease on accuracy of exercise echocardiography, J Am Coll Cardiol, 1987;10:531–8.
- Crouse LJ, Harbrecht JJ, Vacek JL, et al., Exercise echocardiography as a screening test for coronary artery disease and correlation with coronary arteriography, Am J Cardiol, 1991;67:1213–18.
- Marwick TH, Nemec JJ, Pashkow FJ, et al., Accuracy and limitations of exercise echocardiography in a routine clinical setting, J Am Coll Cardiol, 1992;19:74–81.
- Hecht HS, DeBord L, Shaw R, et al., Digital supine bicycle stress echocardiography: a new technique for evaluating coronary artery disease, J Am Coll Cardiol, 1993;21:950–56.
- Beleslin BD, Ostojic M, Stepanovic J, et al., Stress echocardiography in the detection of myocardial ischemia. Head-to-head comparison of exercise, dobutamine, and dipyridamole tests, Circulation, 1994;90:1168–76.
- Luotolahti M, Saraste M, Hartiala J, Exercise echocardiography in the diagnosis of coronary artery disease, Ann Med, 1996;28:73–7.
- Roger VL, Pellikka PA, Bell MR, et al., Sex and test verification bias. Impact on the diagnostic value of exercise echocardiography, Circulation, 1997;95:405–10.
- Cohen JL, Greene TO, Ottenweller J, et al., Dobutamine digital echocardiography for detecting coronary artery disease, Am J Cardiol, 1991;67:1311–18.
- Sawada SG, Segar DS, Ryan T, et al., Echocardiographic detection of coronary artery disease during dobutamine infusion, Circulation, 1991;83:1605–14.
- Marcovitz PA, Armstrong WF, Accuracy of dobutamine stress echocardiography in detecting coronary artery disease, Am J Cardiol, 1992;69:1269–73.
- McNeill AJ, Fioretti PM, el-Said SM, et al., Enhanced sensitivity for detection of coronary artery disease by addition of atropine to dobutamine stress echocardiography, Am J Cardiol, 1992;70:41–6.
- Takeuchi M, Araki M, Nakashima Y, et al., Comparison of dobutamine stress echocardiography and stress thallium-201 single-photon emission computed tomography for detecting coronary artery disease, J Am Soc Echocardiogr, 1993;6: 593–602.
- Previtali M, Lanzarini L, Fetiveau R, et al., Comparison of dobutamine stress echocardiography, dipyridamole stress echocardiography and exercise stress testing for diagnosis of coronary artery disease, Am J Cardiol, 1993;72:865–70.
- Elhendy A, yan Domburg RT, Roelandt JR, et al., Accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery stenosis in patients with myocardial infarction: the impact of extent and severity of left ventricular dysfunction, Heart, 1996;76:123–8.
- Ling LH, Pellikka PA, Mahoney DW, et al., Atropine augmentation in dobutamine stress echocardiography: role and incremental value in a clinical practice setting, J Am Coll Cardiol, 1996;28:551–7.
- Wu CC, Ho YL, Kao SL, et al., Dobutamine stress echocardiography for detecting coronary artery disease, Cardiology, 1996;87:244–9.
- Bigi R, Galati A, Curti G, et al., Prognostic value of residual ischaemia assessed by exercise electrocardiography and dobutamine stress echocardiography in low-risk patients following acute myocardial infarction, Eur Heart J, 1997;18:1873–81.
- Hennessy TG, Codd MB, Kane G, et al., Evaluation of patients with diabetes mellitus for coronary artery disease using dobutamine stress echocardiography, Coron Artery Dis, 1997;8:171–4.
- Smart SC, Knickelbine T, Stoiber TR, et al., Safety and accuracy of dobutamine-atropine stress echocardiography for the detection of residual stenosis of the infarct-related artery and multivessel disease during the first week after acute myocardial infarction, Circulation, 1997;95:1394–1401.
- Elhendy A, Geleijnse ML, van Domburg RT, et al., Gender differences in the accuracy of dobutamine stress echocardiography for the diagnosis of coronary artery disease, Am J Cardiol, 1997;80:1414–18.
- Hennessy TG, Codd MB, Hennessy MS, et al., Comparison of dobutamine stress echocardiography and treadmill exercise electrocardiography for detection of coronary artery disease, Coron Artery Dis, 1997;8:689–95.
- Salustri A, Fioretti PM, McNeill AJ, et al., Pharmacological stress echocardiography in the diagnosis of coronary artery disease and myocardial ischaemia: a comparison between dobutamine and dipyridamole, Eur Heart J, 1992;13:1356–62.
- Dagianti A, Penco M, Agati L, et al., Stress echocardiography: comparison of exercise, dipyridamole and dobutamine in detecting and predicting the extent of coronary artery disease, J Am Coll Cardiol, 1995;26:18–25.
- Pingitore A, Picano E, Colosso MQ, et al., The atropine factor in pharmacologic stress echocardiography. Echo Persantine (EPIC) and Echo Dobutamine International Co-operative (EDIC) Study Groups, J Am Coll Cardiol, 1996;27:1164–70.
- Minardi G, Di Segni M, Manzara CC, et al., Diagnostic and prognostic value of dipyridamole and dobutamine stress echocardiography in patients with Q-wave acute myocardial infarction, Am J Cardiol, 1997;80:847–51.
- Santoro GM, Sciagra R, Buonamici P, et al., Head-to-head comparison of exercise stress testing, pharmacologic stress echocardiography, and perfusion tomography as first-line examination for chest pain in patients without history of coronary artery disease, J Nucl Cardiol, 1998;5:19–27.
- Loimaala A, Groundstroem K, Pasanen M, et al., Comparison of bicycle, heavy isometric, dipyridamole-atropine and dobutamine stress echocardiography for diagnosis of myocardial ischemia, Am J Cardiol, 1999;84:1396–1400.