Contraindications to Stress Echocardiography
Stress echocardiography is contraindicated in patients with acute coronary syndrome, decompensated heart failure, severe/symptomatic aortic stenosis, uncontrolled arrhythmias, severe hypertension (≥200/110 mmHg), acute aortic dissection, pericarditis/myocarditis, pulmonary embolism, and severe pulmonary hypertension. 1
General Contraindications (Apply to All Stress Testing Modalities)
- Acute coronary syndrome (ACS) or high-risk unstable angina 1
- Acute myocardial infarction within the last 2 days 1
- Decompensated heart failure 1
- Severe or symptomatic aortic stenosis 1
- Uncontrolled cardiac arrhythmias 1
- Severe systemic arterial hypertension (≥200/110 mmHg) 1
- Acute aortic dissection 1
- Acute pericarditis or myocarditis 1
- Acute pulmonary embolism 1
- Severe pulmonary hypertension 1
Specific Contraindications for Exercise Stress Echocardiography
- Inability to exercise 1
- Abnormal ST changes on resting ECG that would interfere with interpretation 1
- Inability to achieve ≥5 METs or unsafe to exercise 1
- Significant cardiac arrhythmias or high risk for arrhythmias due to QT prolongation 1
- Limited acoustic windows (e.g., in COPD patients) 1
Specific Contraindications for Dobutamine Stress Echocardiography
- Critical aortic stenosis 1
- Hemodynamically significant left ventricular outflow tract (LVOT) obstruction 1
- Hypokalemia 1
- Uncontrolled congestive heart failure 1
- Uncontrolled dysrhythmias 1
- Respiratory failure 1
- Known hypersensitivity to dobutamine 1
Specific Contraindications for Vasodilator Stress Echocardiography
- Second or third-degree atrioventricular block (without permanent pacemaker) 1
- Significant arrhythmias 1
- Significant hypotension (SBP <90 mmHg) 1
- Known or suspected bronchoconstrictive or bronchospastic disease 1
- Recent use of dipyridamole or dipyridamole-containing medications 1
- Use of methylxanthines (e.g., aminophylline, caffeine) within 12 hours 1
- Chronic asthma or severe chronic obstructive lung disease 1
- Narrow-angle glaucoma 1
- Obstructive uropathy 1
Special Considerations
- For patients with limited acoustic windows, ultrasound-enhancing agents may be considered to improve image quality 1
- In patients with coronary artery disease and chronic left ventricular dysfunction, dobutamine stress echocardiography can help distinguish between viable and fibrotic tissue, but should be used cautiously 2
- For patients with valvular heart disease, exercise is the preferred stressor, especially for mitral valve disease assessment 3
- In patients with aortic stenosis and reduced ejection fraction, dobutamine stress echo can be useful for assessing contractile reserve, but critical aortic stenosis remains a contraindication 3
Safety Considerations
- Stress echocardiography should be performed by an appropriately trained cardiologist assisted by a nurse or another doctor 4, 3
- The laboratory should be equipped with a defibrillator and resuscitation kit with pharmaceuticals, intubation kit, and AMBU bag 4
- For pacing stress echocardiography, an external programmer for the implanted permanent pacemaker is required 4
Understanding these contraindications is crucial for patient safety and obtaining reliable diagnostic information when performing stress echocardiography.