From the Guidelines
A stress echocardiogram should be used to detect myocardial ischemia by assessing regional systolic wall-thickening abnormalities during stress, particularly in patients with intermediate risk factors or symptoms suggestive of cardiac ischemia, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.
Key Indications for Stress Echocardiogram
- Evaluating patients for coronary artery disease
- Assessing the functional significance of known coronary artery stenosis
- Evaluating exercise capacity
- Determining the effectiveness of medical therapy for cardiac conditions
- Risk-stratifying patients before non-cardiac surgery
Advantages of Stress Echocardiography
- Widely available and low-cost
- Can be performed and interpreted at the bedside
- Rapid and free of ionizing radiation
- Can be repeated without safety concerns
Stress Modalities
- Exercise (treadmill or bicycle)
- Pharmacological stress using dobutamine, or vasodilators (adenosine, dipyridamole, regadenoson) combined with atropine
Important Considerations
- Operator-dependent, which may compromise reproducibility
- Compromised image quality, especially in obese and chronic obstructive pulmonary disease subjects, is a significant concern
- Contraindications to exercise echocardiography are similar to those for exercise ECG testing, and adrenergic-stimulating agents should be avoided in patients with unstable angina, hypokalemia, uncontrolled hypertension, uncontrolled congestive heart failure, and uncontrolled dysrhythmias 1.
From the Research
Indications for Stress Echocardiogram
- Stress echocardiography is used for the initial detection of coronary disease, determining prognosis, and therapeutic decision making in patients with known or suspected coronary artery disease 2.
- It is primarily used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease 3.
- Stress echocardiography is also used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease 3.
- Additionally, it is used to assess myocardial viability, valvular heart disease, and diastolic function 4.
Patient Selection
- Patients with intermediate probability of coronary artery disease are suitable candidates for stress echocardiography 3.
- Patients with known ischaemic heart disease who present with chest pain can also undergo stress echocardiography for risk stratification and guidance on revascularisation 3.
- Patients with lesions of uncertain functional significance and those with known ischaemic heart disease can benefit from stress echocardiography 3.
Clinical Applications
- Stress echocardiography is used to assess coronary artery disease, including diagnosis, risk stratification, and guiding revascularisation 3, 5.
- It is also used to evaluate valvular heart disease, diastolic function, and myocardial viability 4, 6.
- The ABCDE protocol, which includes assessment of regional wall motion abnormality, regional perfusion, diastolic function, left ventricular contractile and preload reserve, Doppler-based coronary flow velocity reserve, and ECG-based heart rate reserve, allows for comprehensive risk stratification of patients with chronic coronary syndromes 6.