Key result
The addition of force-based left ventricular contractile reserve to standard stress echocardiography improves prognostic risk stratification, with normal values indicating a more benign prognosis.
Why the study?
Does the addition of force-based left ventricular contractile reserve (LVCR) assessment to standard stress echocardiography improve prognostic risk stratification in patients undergoing stress echocardiography?
Does the addition of force-based left ventricular contractile reserve (LVCR) assessment to standard stress echocardiography improve prognostic risk stratification in patients undergoing stress echocardiography?
Force-based left ventricular contractile reserve is a simple, load-independent parameter that enhances the prognostic value of standard stress echocardiography.
May support adjunctive LVCR use in stress echocardiography; leaves open prospective validation before practice change.
Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologi-cally critical epicardial artery stenosis which determines subendocardial underperfusion. Recently, the core protocol of SE has been enriched by the addition of left ventricular contractile reserve (LVCR) based on force. Changes in force can be caused by microvascular and/or epicardial coronary artery disease, but also by myocardial scar, necrosis, and/or sub-epicardial layer disease. Left ventricular contractile reserve is calculated as the stress-to-rest ratio of force (systolic arterial pressure measured by cuff sphygmomanometer to end-systolic volume determined by two-dimensional echocardiography). In contrast to the ejection fraction, force is not dependent on changes in preload and afterload. Cut-off values for a preserved LVCR are > 2.0 for dobu-tamine or exercise stress and > 1.1 for vasodilators, which are weaker inotropic stimuli. Patients with a "strong" heart (normal LVCR values) have a better outcome than patients with a "weak" heart (reduced LVCR values), and this is the prognostic "bright side of the force," meaning that the prognostic value of force-based contractile reserve is higher than that of ejection fraction-based contractile reserve or RWMA. The addition of force to standard SE based on RWMA detection increases the spectrum of risk stratification without any signifi-cant increase in imaging time and only a slight increase in analysis time. In both ischaemic (with RWMA) and non-ischaemic (without RWMA) hearts, the preserved force is associated with a more benign prognosis. The prospective multicentre interna-tional Stress Echo 2020 trial which started in September 2016 has already recruited > 5000 patients with dual RWMA-force imaging and will systematically test the impact of force on the prognosis within and beyond coronary artery disease, including heart failure and hypertrophic cardiomyopathy.
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Picano et al. (2019) conducted a review in Coronary artery disease and heart failure. Force-based left ventricular contractile reserve (LVCR) assessment vs. Standard stress echocardiography (regional wall motion abnormalities alone) was evaluated. The addition of force-based left ventricular contractile reserve to standard stress echocardiography improves prognostic risk stratification, with normal values indicating a more benign prognosis.
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