Exercise stress echocardiography: Where are we now?

Abstract

Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.

Keywords: Athletes; Children; Coronary artery disease; Exercise stress echocardiography; Intraventricular gradients; Valve disease.

Figure 1

Echocardiographic data acquisition with the patient in the orthostatic position during exercise on a treadmil. Citation: Cotrim C, João I, Fazendas P, Almeida AR, Lopes L, Stuart B, Cruz I, Caldeira D, Loureiro MJ, Morgado G, Pereira H. Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise. Cardiovasc Ultrasound 2013; 11: 26 [PMID: 23875614 DOI: 10.1186/1476-7120-11-26] Copyright © The Author (s) 2013. Published by BMC part of Springer Nature.

Figure 2

Systolic anterior movement of the mitral valve and significant intraventricular gradient detected at peak exercise. Citation: Cotrim C, João I, Fazendas P, Almeida AR, Lopes L, Stuart B, Cruz I, Caldeira D, Loureiro MJ, Morgado G, Pereira H. Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise. Cardiovasc Ultrasound 2013; 11: 26 [PMID: 23875614 DOI: 10.1186/1476-7120-11-26] Copyright © The Author (s) 2013. Published by BMC part of Springer Nature.

Figure 3

Intraventricular gradient present in the orthostatic position before exercise in an athlete, decreased during the initial phase of exercise testing. Citation: Cotrim C, João I, Fazendas P, Almeida AR, Lopes L, Stuart B, Cruz I, Caldeira D, Loureiro MJ, Morgado G, Pereira H. Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise. Cardiovasc Ultrasound 2013; 11: 26. [PMID: 23875614 DOI: 10.1186/1476-7120-11-26] Copyright © The Author (s) 2013. Published by BMC part of Springer Nature.

Figure 4

Intraventricular gradient increased during the last portion of the exercise test and after exercise in the orthostatic position. Obstruction suddenly disappeared after placing the athlete in decubitus. Citation: Cotrim C, João I, Fazendas P, Almeida AR, Lopes L, Stuart B, Cruz I, Caldeira D, Loureiro MJ, Morgado G, Pereira H. Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise. Cardiovasc Ultrasound 2013; 11: 26. [PMID: 23875614 DOI: 10.1186/1476-7120-11-26] Copyright © The Author (s) 2013. Published by BMC part of Springer Nature.

Figure 5

Intraventricular gradient in an athlete assessed before and on beta-blocker therapy. Citation: Cotrim C, João I, Fazendas P, Almeida AR, Lopes L, Stuart B, Cruz I, Caldeira D, Loureiro MJ, Morgado G, Pereira H. Clinical applications of exercise stress echocardiography in the treadmill with upright evaluation during and after exercise. Cardiovasc Ultrasound 2013; 11: 26. [PMID: 23875614 DOI: 10.1186/1476-7120-11-26] Copyright © The Author (s) 2013. Published by BMC part of Springer Nature.

Figure 6

Significant increase in the mean gradient (from 8 mmHg to 28 mmHg) and appearance of severe symptoms with exercise in one patient with a mechanical mitral prosthesis with “pannus”.

Figure 7

The exercise Doppler data in conjunction with the exercise data and clinical data led us to keep the patient in close clinical follow-up. A: Intraauricular septum in “cor triatriatrium”; B: Color flow before exercise; C: Color flow at peak exercise; D: CW flow before exercise; E: CW flow at peak exercise.

Figure 8

Aortic gradient evaluated in a patient previously treated with a stent. Based on the exercise stress echocardiography results, the patient was treated again.