Stress Echocardiography-State of the Art

Login or register to view PDF.
Abstract

Stress echocardiography (SE) is a versatile technique with an established role not only in the diagnosis of coronary artery disease (CAD) but also for prognosis and risk stratification in patients with known CAD. Advances in imaging and display technology have strongly established SE as a useful and cost-effective modality in the diagnosis of cardiovascular disease. In this article, we will provide an overview of the diagnostic and prognostic applications of SE and highlight the use of ultrasound contrast agents and their contribution to the feasibility and diagnostic accuracy of SE.

Disclosure
Sahar S Abdelmoneim, MD, MSc, MS, has no conflicts of interest to declare. Sharon L Mulvagh, MD, FACC, FASE, has received research grants from Lantheus Medical Imaging and Astellas Pharma Inc.
Correspondence
Sharon L Mulvagh, MD, FACC, FASE, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E: smulvagh@mayo.edu
Received date
08 September 2009
Accepted date
24 September 2009
Correspondence
Sharon L Mulvagh, MD, FACC, FASE, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E: smulvagh@mayo.edu
References
  1. Fortuin NJ, Weiss JL, Mason SJ, Weisfeldt ML, Studies by echocardiography of regional and global cardiac function during exercise, Trans Am Clin Climatol Assoc, 1979;90: 174–82.
  2. Mason SJ, Weiss JL, Weisfeldt ML, et al., Exercise echocardiography: detection of wall motion abnormalities during ischemia, Circulation, 1979;59(1):50–59.
  3. 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(9):1021–41.
  4. Skolnick DG, Sawada SG, Feigenbaum H, Segar DS, Enhanced endocardial visualization with noncontrast harmonic imaging during stress echocardiography, J Am Soc Echocardiogr, 1999;12(7):559–63.
  5. Mulvagh SL, Rakowski H, Vannan MA, et al., American Society of Echocardiography Consensus Statement on the Clinical Applications of Ultrasonic Contrast Agents in Echocardiography, J Am Soc Echocardiogr, 2008;21(11): 1179–1201, quiz 1281.
  6. Picano E, Mathias W Jr, Pingitore A, et al., Safety and tolerability of dobutamine-atropine stress echocardiography: a prospective, multicentre study. Echo Dobutamine International Cooperative Study Group, Lancet, 1994;344(8931):1190–92.
  7. Geleijnse ML, Fioretti PM, Roelandt JR, Methodology, feasibility, safety and diagnostic accuracy of dobutamine stress echocardiography, J Am Coll Cardiol, 1997;30(3): 595–606.
  8. Picano E, Stress echocardiography. From pathophysiological toy to diagnostic tool, Circulation, 1992;85(4):1604–12.
  9. Rainbird AJ, Pellikka PA, Stussy VL, et al., A rapid stresstesting protocol for the detection of coronary artery disease: comparison of two-stage transesophageal atrial pacing stress echocardiography with dobutamine stress echocardiography, J Am Coll Cardiol, 2000;36(5):1659–63.
  10. Roger VL, Pellikka PA, Oh JK, et al., Stress echocardiography. Part I. Exercise echocardiography: techniques, implementation, clinical applications, and correlations, Mayo Clin Proc, 1995;70(1):5–15.
  11. Park TH, Tayan N, Takeda K, et al., Supine bicycle echocardiography improved diagnostic accuracy and physiologic assessment of coronary artery disease with the incorporation of intermediate stages of exercise, J Am Coll Cardiol, 2007;50(19):1857–63.
  12. 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(1):74–81.
  13. Quinones MA, Verani MS, Haichin RM, et al., Exercise echocardiography versus 201Tl single-photon emission computed tomography in evaluation of coronary artery disease. Analysis of 292 patients, Circulation, 1992;85(3): 1026–31.
  14. Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS, Exercise echocardiography or exercise SPECT imaging? A meta-analysis of diagnostic test performance, J Nucl Cardiol, 2002;9(1):133–4.
  15. Schinkel AF, Bax JJ, Geleijnse ML, et al., Noninvasive evaluation of ischaemic heart disease: myocardial perfusion imaging or stress echocardiography?, Eur Heart J, 2003;24(9):789–800.
  16. Smart SC, Bhatia A, Hellman R, et al., Dobutamineatropine stress echocardiography and dipyridamole sestamibi scintigraphy for the detection of coronary artery disease: limitations and concordance, J Am Coll Cardiol, 2000;36(4):1265–73.
  17. Marwick T, D’Hondt AM, Baudhuin T, et al., Optimal use of dobutamine stress for the detection and evaluation of coronary artery disease: combination with echocardiography or scintigraphy, or both? J Am Coll Cardiol, 1993;22(1):159–67.
  18. Hoffmann R, Lethen H, Kleinhans E, et al., Comparative evaluation of bicycle and dobutamine stress echocardiography with perfusion scintigraphy and bicycle electrocardiogram for identification of coronary artery disease, Am J Cardiol, 1993;72(7):555–9.
  19. Hecht HS, DeBord L, Shaw R, et al., Supine bicycle stress echocardiography versus tomographic thallium-201 exercise imaging for the detection of coronary artery disease, J Am Soc Echocardiogr, 1993;6(2):177–85.
  20. Pozzoli MM, Fioretti PM, Salustri A, Reijs AE, Roelandt JR, Exercise echocardiography and technetium-99m MIBI single-photon emission computed tomography in the detection of coronary artery disease, Am J Cardiol, 1991;67(5):350–55.
  21. Salustri A, Pozzoli MM, Hermans W, et al., Relationship between exercise echocardiography and perfusion single-photon emission computed tomography in patients with single-vessel coronary artery disease, Am Heart J, 1992;124(1):75–83.
  22. Parodi G, Picano E, Marcassa C, et al., High dose dipyridamole myocardial imaging: simultaneous sestamibi scintigraphy and two-dimensional echocardiography in the detection and evaluation of coronary artery disease. Italian Group of Nuclear Cardiology, Coron Artery Dis, 1999;10(3):177–84.
  23. Michael TA, Antonescu A, Bhambi B, Balasingam S, Accuracy and usefulness of atrial pacing in conjunction with transthoracic echocardiography in the detection of cardiac ischemia, Am J Cardiol, 1996;77(2):187–90.
  24. Atar S, Cercek B, Nagai T, et al., Transthoracic stress echocardiography with transesophageal atrial pacing for bedside evaluation of inducible myocardial ischemia in patients with new-onset chest pain, Am J Cardiol, 2000;86(1):12–16.
  25. Senior R, Monaghan M, Main ML, et al., Detection of coronary artery disease with perfusion stress echocardiography using a novel ultrasound imaging agent: two Phase 3 international trials in comparison with radionuclide perfusion imaging, Eur J Echocardiogr, 2009;10(1):26–35.
  26. Marwick TH, Case C, Short L, Thomas JD, Prediction of mortality in patients without angina: use of an exercise score and exercise echocardiography, Eur Heart J, 2003;24(13):1223–30.
  27. Metz LD, Beattie M, Hom R, et al., The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis, J Am Coll Cardiol, 2007;49(2):227–37.
  28. McCully RB, Roger VL, Mahoney DW, et al., Outcome after normal exercise echocardiography and predictors of subsequent cardiac events: follow-up of 1,325 patients, J Am Coll Cardiol, 1998;31(1):144–9.
  29. 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(4):589–95.
  30. Chung G, Krishnamani R, Senior R, Prognostic value of normal stress echocardiogram in patients with suspected coronary artery disease—a British general hospital experience, Int J Cardiol, 2004;94(2–3):181–6.
  31. Shaw LJ, Eagle KA, Gersh BJ, Miller DD, Meta-analysis of intravenous dipyridamole-thallium-201 imaging (1985 to 1994) and dobutamine echocardiography (1991 to 1994) for risk stratification before vascular surgery, J Am Coll Cardiol, 1996;27(4):787–98.
  32. Olmos LI, Dakik H, Gordon R, et al., Long-term prognostic value of exercise echocardiography compared with exercise 201Tl, ECG, and clinical variables in patients evaluated for coronary artery disease, Circulation, 1998;98(24):2679–86.
  33. 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(4):625–31.
  34. Arruda AM, Das MK, Roger VL, et al., Prognostic value of exercise echocardiography in 2,632 patients > or = 65 years of age, J Am Coll Cardiol, 2001;37(4):1036–41.
  35. Marwick TH, Case C, Sawada S, et al., Use of stress echocardiography to predict mortality in patients with diabetes and known or suspected coronary artery disease, Diabetes Care, 2002;25(6):1042–8.
  36. Desideri A, Fioretti PM, Cortigiani L, et al., Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial, Heart, 2005;91(2):146–51.
  37. Arruda AM, McCully RB, Oh JK, et al., Prognostic value of exercise echocardiography in patients after coronary artery bypass surgery, Am J Cardiol, 2001;87(9):1069–73.
  38. Marwick TH, Case C, Sawada S, et al., Prediction of outcomes in hypertensive patients with suspected coronary disease, Hypertension, 2002;39(6):1113–18.
  39. Biagini E, Schinkel AF, Elhendy A, et al., Pacemaker stress echocardiography predicts cardiac events in patients with permanent pacemaker, Am J Med, 2005;118(12):1381–6.
  40. Cortigiani L, Picano E, Vigna C, et al., Prognostic value of pharmacologic stress echocardiography in patients with left bundle branch block, Am J Med, 2001;110(5):361–9.
  41. Poldermans D, Bax JJ, Elhendy A, et al., Long-term prognostic value of dobutamine stress echocardiography in patients with atrial fibrillation, Chest, 2001;119(1):144–9.
  42. Iliceto S, Caiati C, Ricci A, et al., Prediction of cardiac events after uncomplicated myocardial infarction by cross-sectional echocardiography during transesophageal atrial pacing, Int J Cardiol, 1990;28(1): 95–103.
  43. Plonska E, Kasprzak JD, Kornacewicz-Jach Z, Long-term prognostic value of transesophageal atrial pacing stress echocardiography, J Am Soc Echocardiogr, 2005;18(7): 749–56.
  44. Garber AM, Solomon NA, Cost-effectiveness of alternative test strategies for the diagnosis of coronary artery disease. Ann Intern Med, 1999;130(9):719–28.
  45. Patterson RE, Eisner RL, Horowitz SF, Comparison of costeffectiveness and utility of exercise ECG, single photon emission computed tomography, positron emission tomography, and coronary angiography for diagnosis of coronary artery disease, Circulation, 1995;91(1):54–65.
  46. Marwick TH, Shaw L, Case C, Vasey C, Thomas JD, Clinical and economic impact of exercise electrocardiography and exercise echocardiography in clinical practice, Eur Heart J, 2003;24(12):1153–63.
  47. Jeetley P, Burden L, Stoykova B, Senior R, Clinical and economic impact of stress echocardiography compared with exercise electrocardiography in patients with suspected acute coronary syndrome but negative troponin: a prospective randomized controlled study, Eur Heart J, 2007;28(2):204–11.
  48. Sharples L, Hughes V, Crean A, et al., Cost-effectiveness of functional cardiac testing in the diagnosis and management of coronary artery disease: a randomised controlled trial. The CECaT trial, Health Technol Assess, 2007;11(49):iii–iv, ix–115.
  49. Shaw LJ, Marwick TH, Berman DS, et al., Incremental cost-effectiveness of exercise echocardiography vs. SPECT imaging for the evaluation of stable chest pain, Eur Heart J, 2006;27(20):2448–58.
  50. Lauer MS, Elements of danger—the case of medical imaging, N Engl J Med, 2009;361(9):841–3.
  51. Shaw LJ, Hachamovitch R, Berman DS, et al., The economic consequences of available diagnostic and prognostic strategies for the evaluation of stable angina patients: an observational assessment of the value of precatheterization ischemia. Economics of Noninvasive Diagnosis (END) Multicenter Study Group, J Am Coll Cardiol, 1999;33(3):661–9.
  52. Varga A, Garcia MA, Picano E, Safety of stress echocardiography (from the International Stress Echo Complication Registry), Am J Cardiol, 2006;98(4):541–3.
  53. Beckmann SHG, National registry 1995–1998 on 150,000 stress echo examinations: side effects and complications in 60,448 examinations of the registry 1997–1998, Circulation, 1999;100(Suppl.):3401A.
  54. Pellikka PA, Roger VL, Oh JK, et al., Safety of performing dobutamine stress echocardiography in patients with abdominal aortic aneurysm > or = 4 cm in diameter, Am J Cardiol, 1996;77(5):413–16.
  55. Timperley J, Mitchell AR, Thibault H, et al., Safety of contrast dobutamine stress echocardiography: a single center experience, J Am Soc Echocardiogr, 2005;18(2):163–7.
  56. Anselmi M, Golia G, Rossi A, et al., Feasibility and safety of transeophageal atrial pacing stress echocardiography in patients with known or suspected coronary artery disease, Am J Cardiol, 2003;92(12):1384–8.
  57. Mathias W Jr., Arruda A, Santos FC, et al., Safety of dobutamine-atropine stress echocardiography: A prospective experience of 4,033 consecutive studies, J Am Soc Echocardiogr, 1999;12(10):785–91.
  58. Poldermans D, Fioretti PM, Boersma E, et al., Safety of dobutamine–atropine stress echocardiography in patients with suspected or proven coronary artery disease, Am J Cardiol, 1994;73(7):456–9.
  59. Kane GC, Hepinstall MJ, Kidd GM, et al., Safety of stress echocardiography supervised by registered nurses: results of a 2-year audit of 15,404 patients, J Am Soc Echocardiogr, 2008;21(4):337–41.
  60. Katz WE, Gulati VK, Mahler CM, Gorcsan J 3rd., Quantitative evaluation of the segmental left ventricular response to dobutamine stress by tissue Doppler echocardiography, Am J Cardiol, 1997;79(8):1036–42.
  61. 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: a follow-up study after revascularization, Circulation, 2005;112(25):3892–3900.
  62. Ingul CB, Stoylen A, Slordahl SA, et al., Automated analysis of myocardial deformation at dobutamine stress echocardiography: an angiographic validation, J Am Coll Cardiol, 2007;49(15):1651–9.
  63. Reant P, Labrousse L, Lafitte S, et al., Experimental validation of circumferential, longitudinal, and radial 2- dimensional strain during dobutamine stress echocardiography in ischemic conditions, J Am Coll Cardiol, 2008;51(2):149–57.
  64. Davidavicius G, Kowalski M, Williams RI, et al., Can regional strain and strain rate measurement be performed during both dobutamine and exercise echocardiography, and do regional deformation responses differ with different forms of stress testing?, J Am Soc Echocardiogr, 2003;16(4):299–308.
  65. Aggeli C, Giannopoulos G, Misovoulos P, et al., Real-time three-dimensional dobutamine stress echocardiography for coronary artery disease diagnosis: validation with coronary angiography, Heart, 2007;93(6):672–5.
  66. Matsumura Y, Hozumi T, Arai K, et al., Non-invasive assessment of myocardial ischaemia using new real-time three-dimensional dobutamine stress echocardiography: comparison with conventional two-dimensional methods, Eur Heart J, 2005;26(16):1625–32.
  67. Eroglu E, D’Hooge J, Herbots L, et al., Comparison of realtime tri-plane and conventional 2D dobutamine stress echocardiography for the assessment of coronary artery disease, Eur Heart J, 2006;27(14):1719–24.
  68. Gibbons RJ, Miller TD, Hodge D, et al., Application of appropriateness criteria to stress single-photon emission computed tomography sestamibi studies and stress echocardiograms in an academic medical center, J Am Coll Cardiol, 2008;51(13):1283–9.
  69. Douglas PS, Khandheria B, Stainback RF, et al., ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine, J Am Coll Cardiol, 2008;51(11):1127–47.
  70. Hoffmann R, Lethen H, Marwick T, et al., Analysis of interinstitutional observer agreement in interpretation of dobutamine stress echocardiograms, J Am Coll Cardiol, 1996;27(2):330–36.
  71. Rainbird AJ, Mulvagh SL, Oh JK, et al., Contrast dobutamine stress echocardiography: clinical practice assessment in 300 consecutive patients, J Am Soc Echocardiogr, 2001;14(5):378–85.
  72. Falcone RA, Marcovitz PA, Perez JE, et al., Intravenous albunex during dobutamine stress echocardiography: enhanced localization of left ventricular endocardial borders, Am Heart J, 1995;130(2):254–8.
  73. Crouse LJ, Cheirif J, Hanly DE, et al., Opacification and border delineation improvement in patients with suboptimal endocardial border definition in routine echocardiography: results of the Phase III Albunex Multicenter Trial, J Am Coll Cardiol, 1993;22(5):1494–1500.
  74. Uehara H, Yamamoto T, Hirano Y, et al., [Contrast agent improves diagnostic value of dobutamine stress echocardiography], J Cardiol, 2001;37(3):135–41.
  75. Wake R, Takeuchi M, Yoshitani H, et al., Role of contrastenhanced dobutamine stress echocardiography in predicting outcome in patients with known or suspected coronary artery disease, Echocardiography, 2006;23(8): 642–9.
  76. Wake R, Takeuchi M, Yoshikawa J, Yoshiyama M, Effects of gender on prognosis of patients with known or suspected coronary artery disease undergoing contrastenhanced dobutamine stress echocardiography, Circ J, 2007;71(7):1060–66.
  77. Biagini E, Elhendy A, Bax JJ, et al., Seven-year follow-up after dobutamine stress echocardiography: impact of gender on prognosis, J Am Coll Cardiol, 2005;45(1):93–7.
  78. Cortigiani L, Dodi C, Paolini EA, et al., Prognostic value of pharmacological stress echocardiography in women with chest pain and unknown coronary artery disease, J Am Coll Cardiol, 1998;32(7):1975–81.
  79. Shaw LJ, Gillam L, Feinstein S, et al., Use of an intravenous contrast agent (Optison) to enhance echocardiography: efficacy and cost implications. Optison Multicenter Study Group, Am J Manag Care, 1998;4 Spec No:SP169–76.
  80. Kurt M, Shaikh KA, Peterson L, et al., Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort, J Am Coll Cardiol, 2009;53(9):802–10.
  81. Thanigaraj S, Nease RF Jr, Schechtman KB, et al., Use of contrast for image enhancement during stress echocardiography is cost-effective and reduces additional diagnostic testing, Am J Cardiol, 2001;87(12):1430–32.
  82. Bernier M AS, Moir S, McCully R, et al., Contrast Stress Echocardiography in a Large Clinical Experience: Cost- Benefit Ratio and Impact of Microbubble Contrast Agents on Need for Alternative Imaging Modalities, J Am Soc Echocardiogr, 2007;20(5):565.
  83. Wei K, Skyba DM, Firschke C, et al., Interactions between microbubbles and ultrasound: in vitro and in vivo observations, J Am Coll Cardiol, 1997;29(5):1081–8.
  84. Dijkmans PA, Senior R, Becher H, et al., Myocardial contrast echocardiography evolving as a clinically feasible technique for accurate, rapid, and safe assessment of myocardial perfusion: the evidence so far, J Am Coll Cardiol, 2006;48(11):2168–77.
  85. Wei K, Jayaweera AR, Firoozan S, et al., Quantification of myocardial blood flow with ultrasound-induced destruction of microbubbles administered as a constant venous infusion, Circulation, 1998;97(5):473–83.
  86. Abdelmoneim SS, Dhoble A, Bernier M, et al., Quantitative myocardial contrast echocardiography during pharmacological stress for diagnosis of coronary artery disease: a systematic review and meta-analysis of diagnostic accuracy studies, Eur J Echocardiogr, 2009 Jun 23 (Epub ahead of print).
  87. Kowatsch I, Tsutsui JM, Osorio AF, et al., Head-to-head comparison of dobutamine and adenosine stress realtime myocardial perfusion echocardiography for the detection of coronary artery disease, J Am Soc Echocardiogr, 2007;20(9):1109–17.
  88. Tsutsui JM, Elhendy A, Anderson JR, et al., Prognostic value of dobutamine stress myocardial contrast perfusion echocardiography, Circulation, 2005;112(10): 1444–50.
  89. Dawson D, Kaul S, Peters D, et al., Prognostic value of dipyridamole stress myocardial contrast echocardiography: comparison with single photon emission computed tomography, J Am Soc Echocardiogr, 2009;22(8):954–60.
  90. Lang RM, Mor-Avi V, Sugeng L, Nieman PS, Sahn DJ, Three-dimensional echocardiography: the benefits of the additional dimension, J Am Coll Cardiol, 2006;48(10): 2053–69.
  91. Toledo E, Lang RM, Collins KA, et al., Imaging and quantification of myocardial perfusion using real-time three-dimensional echocardiography, J Am Coll Cardiol, 2006;47(1):146–54.
  92. Iwakura K, Ito H, Okamura A, et al., Comparison of twoversus three-dimensional myocardial contrast echocardiography for assessing subendocardial perfusion abnormality after percutaneous coronary intervention in patients with acute myocardial infarction, Am J Cardiol, 2007;100(10):1502–10.
  93. Bhan A, Kapetanakis S, Rana BS, et al., Real-time threedimensional myocardial contrast echocardiography: is it clinically feasible?, Eur J Echocardiogr, 2008;9(6):761–5.
  94. Abdelmoneim SS, Bernier M, Dhoble A, et al., Assessment of myocardial perfusion during adenosine stress using real time three dimensional and two dimensional myocardial contrast echocardiography: comparison with single photon emission computed tomography, J Am Soc Echocardiogr, 2008;21(5):568.
  95. Main ML, Goldman JH, Grayburn PA, Thinking outside the “box”-the ultrasound contrast controversy, J Am Coll Cardiol, 2007;50(25):2434–7.
  96. Administration USFaD, Postmarket Drug Safety Information for patients and Providers. Available at: www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInf ormationforPatientsandProviders/ucm110260.htm (accessed November 6, 2008).
  97. Cohen JL, Cheirif J, Segar DS, et al., Improved left ventricular endocardial border delineation and opacification with OPTISON (FS069), a new echocardiographic contrast agent. Results of a phase III Multicenter Trial, J Am Coll Cardiol, 1998;32(3):746–52.
  98. Feinstein SB, Cheirif J, Ten Cate FJ, et al., Safety and efficacy of a new transpulmonary ultrasound contrast agent: initial multicenter clinical results, J Am Coll Cardiol, 1990;16(2):316–24.
  99. Tsutsui JM, Elhendy A, Xie F, et al., Safety of dobutamine stress real-time myocardial contrast echocardiography, J Am Coll Cardiol, 2005;45(8):1235–42.
  100. Borges AC, Walde T, Reibis RK, et al. Does contrast echocardiography with Optison induce myocardial necrosis in humans? J Am Soc Echocardiogr, 2002;15 (10 Pt 1):1080–86.
  101. van Der Wouw PA, Brauns AC, Bailey SE, Powers JE, Wilde AA, Premature ventricular contractions during triggered imaging with ultrasound contrast, J Am Soc Echocardiogr, 2000;13(4):288–94.
  102. Raisinghani A, Wei KS, Crouse L, et al., Myocardial contrast echocardiography (MCE) with triggered ultrasound does not cause premature ventricular complexes: evidence from PB127 MCE studies, J Am Soc Echocardiogr, 2003;16(10):1037–42.
  103. Abdelmoneim SS, Bernier M, Scott CG, et al., Safety of contrast agent use during stress echocardiography: a cohort study from a single-center, 4-year experience with 26,774 patients, J Am Coll Cardiol Img, 2009; in press.
  104. Abdelmoneim SS, Bernier M, Scott C, et al., Safety of contrast agents during stress echocardiography: a cohort study from single center experience spanning 4 years and 26,774 patients, Circulation, 2008;118:S933.
  105. Armstrong WF, O’Donnell J, Ryan T, Feigenbaum H, Effect of prior myocardial infarction and extent and location of coronary disease on accuracy of exercise echocardiography, J Am Coll Cardiol, 1987;10(3):531–8.
  106. 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(15):1213–18.
  107. Laucevicius A, Berukstis E, Kosinskas E, Jablonskiene D, Ivaskeviciene L, Quantitative assessment of transient left ventricular asynergy in coronary artery disease, Clin Cardiol, 1991;14(2):105–10.
  108. 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(4): 950–56.
  109. Ryan T, Segar DS, Sawada SG, et al., Detection of coronary artery disease with upright bicycle exercise echocardiography, J Am Soc Echocardiogr, 1993;6(2):186–97.
  110. Roger VL, Pellikka PA, Oh JK, Bailey KR, Tajik AJ, Identification of multivessel coronary artery disease by exercise echocardiography, J Am Coll Cardiol, 1994;24(1): 109–14.
  111. 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(3):1168–76.
  112. Marwick TH, Anderson T, Williams MJ, et al., Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women, J Am Coll Cardiol, 1995;26(2):335–41.
  113. Marwick TH, Torelli J, Harjai K, et al., Influence of left ventricular hypertrophy on detection of coronary artery disease using exercise echocardiography, J Am Coll Cardiol, 1995;26(5):1180–86.
  114. Luotolahti M, Saraste M, Hartiala J, Exercise echocardiography in the diagnosis of coronary artery disease, Ann Med, 1996;28(1):73–7.
  115. Roger VL, Pellikka PA, Bell MR, et al., Sex and test verification bias. Impact on the diagnostic value of exercise echocardiography, Circulation, 1997;95(2):405–10.
  116. Marcovitz PA, Armstrong WF, Accuracy of dobutamine stress echocardiography in detecting coronary artery disease, Am J Cardiol, 1992;69(16):1269–73.
  117. Marangelli V, Iliceto S, Piccinni G, et al., Detection of coronary artery disease by digital stress echocardiography: comparison of exercise, transesophageal atrial pacing and dipyridamole echocardiography, J Am Coll Cardiol, 1994;24(1): 117–24.
  118. 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(1):18–25.
  119. Nedeljkovic I, Ostojic M, Beleslin B, et al., Comparison of exercise, dobutamine-atropine and dipyridamole-atropine stress echocardiography in detecting coronary artery disease, Cardiovasc Ultrasound, 2006;4:22.
  120. Picano E, Severi S, Michelassi C, et al., Prognostic importance of dipyridamole-echocardiography test in coronary artery disease, Circulation, 1989;80(3):450–57.
  121. Chuah SC, Pellikka PA, Roger VL, McCully RB, Seward JB, Role of dobutamine stress echocardiography in predicting outcome in 860 patients with known or suspected coronary artery disease, Circulation, 1998;97(15):1474–80.
  122. Poldermans D, Fioretti PM, Boersma E, et al., Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: A single-center experience, Circulation, 1999;99(6):757–62.
  123. Elhendy A, Shub C, McCully RB, et al., Exercise echocardiography for the prognostic stratification of patients with low pretest probability of coronary artery disease, Am J Med, 2001;111(1):18–23.
  124. Marwick TH, Case C, Sawada S, et al., Prediction of mortality using dobutamine echocardiography, J Am Coll Cardiol, 2001;37(3):754–60.
  125. 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(21):2566–71.
  126. Elhendy A, Mahoney DW, Khandheria BK, et al., Prognostic significance of the location of wall motion abnormalities during exercise echocardiography, J Am Coll Cardiol, 2002;40(9):1623–9.
  127. McCully RB, Roger VL, Mahoney DW, et al., Outcome after abnormal exercise echocardiography for patients with good exercise capacity: prognostic importance of the extent and severity of exercise-related left ventricular dysfunction, J Am Coll Cardiol, 2002;39(8): 1345–52.
  128. Yao SS, Qureshi E, Sherrid MV, Chaudhry FA, Practical applications in stress echocardiography: risk stratification and prognosis in patients with known or suspected ischemic heart disease, J Am Coll Cardiol, 2003;42(6):1084–90.
  129. Shaw LJ, Vasey C, Sawada S, et al., Impact of gender on risk stratification by exercise and dobutamine stress echocardiography: long-term mortality in 4234 women and 6898 men, Eur Heart J, 2005;26(5):447–56.
  130. Dolan MS, Riad K, El-Shafei A, et al., Effect of intravenous contrast for left ventricular opacification and border definition on sensitivity and specificity of dobutamine stress echocardiography compared with coronary angiography in technically difficult patients, Am Heart J, 2001;142(5):908–15.
  131. Moir S, Haluska BA, Jenkins C, et al., Incremental benefit of myocardial contrast to combined dipyridamole-exercise stress echocardiography for the assessment of coronary artery disease, Circulation, 2004;110(9):1108–13.
  132. Plana JC, Mikati IA, Dokainish H, et al., A randomized cross-over study for evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease The OPTIMIZE Trial, JACC Cardiovasc Imaging, 2008;1(2): 145–52.
  133. Dolan MS, Gala SS, Dodla S, et al., Safety and efficacy of commercially available ultrasound contrast agents for rest and stress echocardiography a multicenter experience, J Am Coll Cardiol, 2009;53(1):32–8.
  134. Porter TR, Xie F, Silver M, et al., Real-time perfusion imaging with low mechanical index pulse inversion Doppler imaging, J Am Coll Cardiol, 2001;37(3):748–53.
  135. Shimoni S, Zoghbi WA, Xie F, et al., Real-time assessment of myocardial perfusion and wall motion during bicycle and treadmill exercise echocardiography: comparison with singl