Should a patient with hypertension (HTN) and dyskinesia undergo baseline echocardiogram and stress testing?

Baseline Echocardiography and Stress Testing in HTN with Dyskinesia

A baseline echocardiogram is appropriate for this patient with hypertension and dyskinesia, but routine stress testing is not recommended unless the patient has chest pain or other symptoms suggestive of coronary artery disease. 1

Rationale for Baseline Echocardiography

Echocardiography should be reserved for hypertensive patients in whom hypertensive cardiac disease or cardiac disease in association with comorbidities is suspected. 1 The presence of dyskinesia (which may indicate neurological medication use or other systemic conditions) represents a comorbidity that warrants cardiac assessment. 1

Key Indications Supporting Echocardiography:

• The 2015 European Association of Cardiovascular Imaging/American Society of Echocardiography guidelines assign echocardiography a Class II indication (level of evidence B) for cardiovascular risk assessment in adults with hypertension. 1

• Echocardiography received a high appropriate use criteria score of 8 out of 9 for the initial evaluation of suspected hypertensive heart disease. 1

• The test can identify critical prognostic markers including left ventricular hypertrophy, diastolic dysfunction, and left atrial enlargement—all specific signs of hypertensive heart disease that predict cardiovascular events. 1

• Different patterns of LV remodeling (concentric remodeling, eccentric hypertrophy, concentric hypertrophy) are predictive of cardiovascular event incidence in hypertensive patients. 1

What the Echocardiogram Should Assess:

• A complete 2D and Doppler study should be performed, not limited to just LV mass or LV hypertrophy assessment. 1

• Evaluate left ventricular systolic function, diastolic function parameters, left atrial size, and chamber dimensions. 1, 2

• Assess for global longitudinal strain, which may detect subclinical dysfunction even when ejection fraction appears normal. 2

Position on Stress Testing

Stress testing is NOT routinely recommended for asymptomatic hypertensive patients. 1 The guidelines are explicit on this point:

• Screening for coronary disease is not recommended in asymptomatic hypertensive patients because of the risk of false-positive results and uncertain management responses. 1

• Routine stress testing in hypertension without symptoms or signs of heart disease is characterized as "rarely appropriate" with a value score of 3 out of 10. 1

When Stress Testing WOULD Be Indicated:

• If the patient has chest pain symptoms: Stress echocardiography is preferred over perfusion imaging in hypertensive patients because stress-induced wall motion abnormalities are highly specific for coronary artery disease, while perfusion defects may arise from abnormal myocardial flow reserve not due to epicardial coronary disease. 1

• If symptoms suggest coronary ischemia: A normal stress electrocardiogram performed to high workload has high negative predictive value, but abnormal or ambiguous results warrant stress echocardiography. 1

• Symptomatic patients: Those with dyspnea, palpitations, syncope, or other cardiac symptoms require functional assessment. 3

Critical Pitfalls to Avoid

• Do not order routine stress testing in asymptomatic hypertensive patients—this leads to false-positive results and unnecessary downstream testing. 1

• Hypertension itself can cause false-positive stress test results: A hypertensive response to stress may provoke wall motion abnormalities or global LV dysfunction in the absence of coronary disease, though this is less problematic with stress echocardiography than with perfusion scintigraphy. 1

• Do not use echocardiography findings to routinely monitor antihypertensive therapy—blood pressure remains the primary target, and routine serial echocardiograms are not recommended due to limited reproducibility on an individual patient basis. 1

• Ensure the echocardiogram is performed at an experienced laboratory—variability in LV mass measurements can be significant, requiring expertise in hypertensive heart disease assessment. 2

Clinical Impact on Management

• If LV hypertrophy is detected, optimize therapy with agents shown to promote LVH regression (ACE inhibitors, ARBs, or diuretics). 2

• Detection of cardiac abnormalities justifies more aggressive BP targets (<130/80 mmHg). 2

• If echocardiography shows significant abnormalities, follow-up studies may be warranted if the patient becomes symptomatic or if there are changes in clinical status. 3