Multiparametric Stress Echocardiography in the Diagnosis of IOCA and INOCA

Figure 1. Patient 1: Dobutamine Stress Echocardiography Dobutamine stress echocardiography with ultrasound-enhancing agent. End-systolic frames at different views and stages. (A) Apical 4-chamber view. (B) Apical 2-chamber view. (C) Apical 3-chamber view. The quad images represent resting, low-dose, peak stress, and recovery stages of the protocol. The yellow arrows indicate extensive area of apical thinning and dyskinesis at peak stress in all the views (5/17 segments ischemia).

Figure 2. Patient 1: Coronary Flow Velocity by Doppler Echocardiography (A) Coronary flow velocity (CFV) by color Doppler echocardiography of the distal left anterior descending coronary artery. Yellow arrows indicate distal left anterior descending coronary artery color Doppler flow in diastole. (B) Doppler velocity was 10 cm/s at baseline, indicating very low distal flow, consequently severe proximal stenosis of the left anterior descending coronary artery.

Figure 3. Patient 1: Invasive Coronary Angiography Invasive coronary angiography showing severe proximal left anterior descending stenosis (yellow arrow) and moderate proximal left circumflex coronary artery disease (A) and moderate nonocclusive right coronary arteries (B).

Figure 4. Patient 1 Follow-Up: Dobutamine Stress Echocardiography Dobutamine stress echocardiography with an ultrasound enhancing agent, end-systolic frames at different views and stages. (A) Apical 4-chamber view. (B) Apical 2-chamber view. (C) Apical 3-chamber view. The quad images represent the resting, low-dose, peak stress, and recovery stages of the protocol. One year after percutaneous coronary intervention to proximal the left anterior descending coronary artery with symptomatic improvement to assess bystander left circumflex coronary artery and right coronary artery stenosis.

Figure 5. Patient 1 Follow-Up: Coronary Flow Velocity by Doppler Echocardiography One year after percutaneous coronary intervention to proximal left anterior descending coronary artery (LAD) with symptomatic improvement to assess bystander left circumflex coronary artery and right coronary artery stenosis. Coronary flow velocity by Doppler echocardiography in the distal LAD 12 cm/s, indication very low distal flow, consequently severe proximal stenosis. Yellow arrows indicate distal LAD color Doppler flow in diastole. Coronary flow reserve of 44 cm/s/17 cm/s = 2.59 (normal).

Figure 6. Patient 1 Follow-Up: Invasive Coronary Angiography The patient underwent percutaneous coronary intervention to his proximal left anterior descending coronary artery with good results and symptomatic improvement (A). The bystander moderate proximal left circumflex coronary artery and right coronary artery disease (B) were treated with tight secondary preventative medications.

Figure 7. Patient 2: Dobutamine Stress Echocardiography Dobutamine stress echocardiography with ultrasound-enhancing agent, end-systolic frames at different views and stages. (A) Apical 4-chamber view. (B) Apical 2-chamber view. (C) Apical 3-chamber view. The quad images represent the resting, low-dose, peak stress, and recovery stages of the protocol. The yellow arrows indicate small area of apical thinning and dyskinesis at peak stress in all the views.

Figure 8. Patient 2: Coronary Flow Velocity by Doppler Echocardiography Coronary flow velocity by Doppler echocardiography in the distal left anterior descending coronary artery (LAD) (yellow arrows indicate distal LAD color Doppler flow in diastole). LAD flow velocity reserve (CFVR) = baseline CFV/peak CFV: 37/21 = 1.76 (abnormal).

Figure 9. Patient 2: Invasive Coronary Angiography Invasive coronary angiography showing nonocclusive left (A) and right (B) coronary arteries with patent left circumflex coronary artery stent (yellow arrow).

Figure 10. Patient 3: Dobutamine Stress Echocardiography Dobutamine stress echocardiography with ultrasound enhancing agent, end-systolic frames at different views and stages. (A) Apical 4-chamber view. (B) Apical 2-chamber view. (C) Apical 3-chamber view. The quad images represent the resting, low-dose, peak stress, and recovery stages of the protocol. The yellow arrow indicates small area of apical thinning and dyskinesis at peak stress in all the views. The changes in apical kinesis can be more appreciated if the same regions are compared between low dose and peak stress.

Figure 11. Patient 3: Coronary Flow Velocity by Doppler Echocardiography Coronary flow velocity by Doppler echocardiography in the distal left anterior descending coronary artery (LAD) (yellow arrows indicate distal LAD color Doppler flow in diastole). LAD flow velocity reserve (CFVR) = baseline CFV/peak CFV: 77/33 = 3.35 (normal).

Figure 12. Patient 3: Invasive Coronary Angiography Invasive coronary angiography showing nonocclusive left (A) and right (B) coronary arteries.