Exercise Stress Echocardiography for Stable Coronary Artery Disease: Succumbed to the Modern Conceptual Revolution or Still Alive and Kicking?

Fig. 1.. The dimensions of sustainability in ESE. Like all imaging modalities, exercise stress echocardiography can be categorized in a system with different dimensions including diagnostic/prognostic accuracy from physician perspective, economic/costs from payer perspective, radiation exposure from patient perspective, environmental footprint, from planet perspective. The green area subtended supports a leading and current role of exercise stress echocardiography in patients with stable coronary artery disease. CO2, carbonic oxide; ESE, exercise stress echocardiography.

Fig. 2.. Echocardiographic data acquisition with semi supine bicycle. ESE is conducted with a adjustable load supine bicycle ergometer on a reclining seat position to find satisfactory echocardiographic views. A standard exercise protocol is applied with a rise of 25-Watt every two minutes, while the patient sustained a fixed rhythm at 50–60 rotation/minute. Two-dimensional images are acquired in 4-standard views at baseline, at each step and in the recovery phase. During every step of exercise and recovery, any eventual symptoms or arrhythmias are recorded together with blood pressure, heart rate, and 12- lead ECG. ESE, exercise stress echocardiography; ECG, electrocardiogram.

Fig. 3.. Application of strain analysis during ESE in patients with severe obstruction of the LAD and RCA. Upper panels show normal resting apical chambers view during end-systole (a), and strain analysis performed simultaneously, showing a significant reduction in the septal and inferior segments (b). Lower panels: immediate post-exercise apical chambers view depicting a normal WM response with decreased LVESV (c). Strain analysis performed immediately post-exercise showed a well-defined segmental worsening in the LAD and RCA territory compared to baseline values (d). Also note the significant decrease in GLS which points to an increased risk of multivessel coronary heart disease. ESE, exercise stress echocardiography; LAD, left anterior descending coronary artery; RCA, right coronary artery; WM, left ventricular wall motion; LVESV, left ventricular end-systolic volume; GLS, global left ventricular longitudinal strain.

Fig. 4.. Patient first strategy for stable coronary artery disease evaluation. Only the main factors that influence the final decision are mentioned. The length and direction toward CTTA or functional test of the yellow box enlisting variables illustrated the “weight” of each variable in the decision whether to perform a functional or anatomical noninvasive test. CCTA, coronary computed tomography angiography; PCI, percutaneous coronary intervention, CABG, coronary artery bypass graft; GFR, glomerular filtration rate in ml/min/1.73 m2; BMI, body mass index; LV, left ventricle.

Fig. 5.. The suggested algorithm for the use of ESE. In our institution, subjects with resting ECG changes, known CAD, unexplained exertional dyspnea, or intermediate pre-test probability of CAD are preferentially referred for ESE. ESE is also the most appropriate second-line stress test after inconclusive exercise ECG. The diagnostic test option considers our site-specific availability. CAD, coronary artery disease; DASI, Duke activity status index; METs, metabolic equivalents; ECG, electrocardiogram; ESE, exercise stress echocardiography. CCTA, coronary computed tomography angiography.