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The prognostic value of estimating stroke volume before and after exercise during treadmill stress echocardiography
Benjamin T Fitzgerald1,2,3, Jelena K Logan1,2, Ashleigh Weldon1,2
1GenesisCare Cardiology, Auchenflower, QLD, Australia.
Insights
Measuring left ventricular stroke volume change during stress echocardiography (SE) can help identify coronary artery disease (CAD). An abnormal stroke volume response during SE predicts adverse cardiac events, improving diagnostic and prognostic value.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- Stress echocardiography (SE) is a key tool for diagnosing coronary artery disease (CAD).
- Interpreting SE can be challenging.
- Left ventricular stroke volume (SV) estimation via Doppler echocardiography is feasible and may aid SE interpretation.
Purpose of the Study:
- To evaluate the utility of stroke volume (SV) changes during SE for CAD detection.
- To determine if incremental change in SV (ΔSV) with exercise has diagnostic and prognostic value.
Main Methods:
- Patients underwent Bruce protocol SE with SV measured pre- and post-exercise.
- Regional wall motion analysis was performed.
- Incremental change in SV (ΔSV) was calculated and analyzed.
Main Results:
- A derivation cohort established an optimal cutoff for inducible ischemia at ΔSV ≤ +10 mL.
- In a validation cohort (n=1093), an abnormal ΔSV (≤10 mL) was associated with a 10.3-fold increased risk of adverse cardiac events (P < .0001).
- This ΔSV cutoff identified 192 patients with abnormal responses.
Conclusions:
- Stroke volume assessment is feasible and practical during SE.
- Adding SV analysis to exercise regional wall-motion analysis provides incremental diagnostic and prognostic value for CAD.
Background:
Stress echocardiography (SE) is an established technique for assessment of coronary artery disease (CAD) which is difficult to perform and interpret. Left ventricular stroke volume (SV) is readily estimated with Doppler echocardiography. It can be affected by myocardial ischemia, with possible adjunctive value during SE.
Methods:
Patients underwent Bruce protocol SE with SV estimated before and after maximal treadmill exertion post routine regional wall analysis. Incremental change in SV (ΔSV) with exercise was measured.
Results:
A derivation cohort (n = 273) was established to test the hypothesis. An optimal cutoff for detection on inducible ischemia was ΔSV ≤ +10 mL. The validation cohort of consecutive patients (n = 1093, 376 [34%] female; age 59 ± 12 years) were followed clinically after SE for 20 460 patient-months. There were 1000 patients with nonischemic SE, and 93 patients with studies suggestive of myocardial ischemia. Secondary analysis yielded 831 patients with a normal exercise response (ΔSV > +10 mL) and 192 with an abnormal ΔSV ≤ +10 mL. Time to first combined adverse cardiac event (composite of angina, acute coronary syndrome, cardiac revascularization, worsening New York Heart Association (NYHA) class, a reduction in EF, and cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. The hazard ratio for an adverse event with an abnormal ΔSV response (≤10 mL) was 10.3 (95% confidence intervals 5.6-19.1, P < .0001).
Conclusions:
Stroke volume assessment during SE is feasible and readily performed. It is simple, practical, and has incremental diagnostic and prognostic value when added to exercise regional wall-motion analysis.
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