STRESS

ECHOCARDIOGRAPHY
Dyna Evalina Syahlul, BMedSci, SpJP
RSPAD Gatot Soebroto - DITKESAD

INTRODUCTION
Stress echocardiography causal relationship
between induced myocardial ischemia and left
ventricular wall motion abnormalities

Physiologic stress results in :

- heart rate
- contractility maintained via an increase
in myocardial blood flow
- systolic wall thickening
- endocardial excursion
- global contractility
In the presence of coronary stenosis
myocardial oxygen demand is not matched by
an appropriate increase in supply wall
motion abnormality will occur

Wall motion abnormality reduction in systolic

thickening & endocardial excursion
Deterioration in regional wall motion specific and
predictable marker of regional ischemia
The utility of echocardiography in conjunction with
stress testing the ability to record wall motion
and left ventricular function

Wall motion abnormalities at rest

Wall motion abnormalities during

exercise

Infarction
Cardiomyopathy
Myocarditis
Left bundle branch block
Hypertension/ afterload mismatch
Hibernating myocardium
Stunned myocardium
Toxins
Postoperstive stage
Paced rhytm
Right ventricular volume/ Pressure
overload

Ischemia
Translational cardiac motion
Marked increased in blood
pressure
Cardiomyopathy
Rate-dependent left bundle branch
block

Indications
The most common :
- Evaluation of myocardial ischemia or
coronary artery disease
Diagnostic, Prognostic and Risk stratification
Also used :
- Evaluate valvular heart disease
- Pulmonary hypertension
- Exertional dyspnea
- LV pressure filling

Methodology

Exercise
Treadmill
Supine bicycle
Upright bicycle
Handgrip
Stair step

Nonexercise stress
Dobutamin
Dipyridamole
Dipyridamole/ dobutamin
combination
Adenosin
Pacing
Ergonovine

Protocol for Treadmill Exercise Echocardiography

- Patient is prepared for treadmill stress testing
- Instruction provided on transition from the treadmill to
the examination table after exercise
- Rest echo images obtained, reviewed and stored (both
digitally and on videotape)
- Standard treadmill exercise examination performed
- Patient moves as quickly as possible after exercise to
the examination table
- Postexercise imaging acquired and recorded on
videotape and digitally
- Digital images reviewed and representative loops
selected
- Digital images stored on permanent medium

Treadmil Exercise Echocardiography

Protocol for supine Bicycle Exercise

Echocardiography
Patient prepared for standard stress testing
Patient instructed how to perform bicycle exercise
Patient positioned on supine ergometer and secured in
place
Rest images obtained
Exercise protocol begins at a workload of 25 W and a
cadence of 60 rpm
Workload increased by 25 W every 2 minutes
Images monitored throughout exercise
At peak exercise, a full series of images is obtained
After cessation of exercise, wall motion is monitored to
document resolution of induced ischemia
Representative images are selected and rearranged for
digital storage

Supine Bicycle Exercise

Echocardiography

Protocol for Dobutamine Stress

Echocardiography
Patient is prepared for standard stress testing
Intravenous access is obtained
Digital images are acquired at baseline (these loops are
displayed and used as reference throughout the
infusion)
Continuous Electrocardiogram and blood pressure
monitoring are established
Dobutamine infusion is begun at a dose of 5 ( or 10 / Kg/
min )
The infusion rate is increased every 3 minutes to doses of
10, 20, 30 and 40 / Kg/ min
The echocardiogram, electrocardiogram and blood
pressure are monitored continuously

Protocol
Low dose images are acquired at either 5 or 10 / Kg/ min
( at the first sign of increased contractility )
Atropine in aliquots of 0.5 to 1.0 mg can be given during
the mid and high-dose stages to augment the heart rate
response
Mid dose images are acquired at either 20 or 30 / Kg/ min
Peak images are acquired before termination of the
infusion
Post-stress images are recorded after return to baseline
The patient is monitored until he or she returns to
baseline status

Dobutamine Stress
Echocardiography

End Points and Reasons to Terminate the

Dobutamine Infusion During Stress Testing
- Exceeding target heart rate of 85 % age-predicted
maximum
- Development of significant angina
- Recognition of a new wall motion abnormality
- A decrease of systolic blood pressure > 20 mmHg from
baseline
- Arrhytmias such as atrial fibrillation or nonsustained VT
- Limited side effects or symptoms

Interpretation of stress
Echocardiography
Stress echocardiograms are analyzed based
on a subjective assessment of regional wall
motion
comparing wall thickening and endocardial
excursion at baseline and during stress
The presence of baseline wall motion
abnormalities previous myocardial
infarction
The normal response the development of
hyperdynamic wall motion

Combination of Rest and Stress Wall

Motion Responses
Rest
Normal
Normal
Akinetic
Hypokinetic
Hypokinetic/
Akinetic

Stress
Hyperkinetic
Hypo/ Akinetic
Akinetic
Akinetic/
Dyskinetic
Normal

Interpretation
Normal
Ischemic
Infarction
Ischemia and/
Infarction
Viable

REFERENCES :
- Feigenbaums Echocardiography, 6th
Edition
- Tajik A, The Echo Manual, 3rd Edition
- Scott D Solomon, Essential
Echocardiography
- Hamed Oemar, Textbook of
Echocardiography