Stress echocardiography in heart failure

Abstract

Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.

Figure 1

Physiopathologic components of systolic heart failure that can be potentially explored with stress echocardiography.

Figure 2

Physiopathologic components of diastolic heart failure assessable with stress echo.

Figure 3

A schematic flow chart for searching segmental and global systolic function in chronic ischemic LV dysfunction.

Figure 4

Echocardiographic apical four-chamber images (end-systolic frames) from two patients with and without contractile reserve.

Figure 5

Apical four-chamber view at rest and during exercise in patients with ischemic mitral regurgitation showing a large exercise-induced increase in mitral regurgitation. SPAP = Systolic pulmonary pressure.

Figure 6

Relationship between contractile reserve, mitral regurgitation and pulmonary pressure and its contribution in defining the prognosis in patients with functional mitral regurgitation. MR = mitral regurgitation; sPAP = systolic pulmonary pressure.

Figure 7

Targets and effects of dobutamine stress echo in patients with mitral regurgitation and chronic ischemic left ventricular dysfunction. EROA = Effective regurgitant orifice area.

Figure 8

Schematic diagnostic algorithm in patients with suspected diastolic heart failure. LV = Left ventricle; LVEF = Left ventricular ejection fraction.

Figure 9

Possible results during dobutamine stress echocardiography in presence of aortic stenosis, low cardiac output and low transvalvular gradients. AVA: Aortic valve area; CO: Cardiac output.