Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide

Abstract

Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened.The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.

Computed tomography and nuclear medicine for the assessment of coronary inflammation: clinical applications and perspectives

“…Measurement of FFR correlates with the prediction of acute cardiac events and the FFR value is currently considered the standard reference for guiding revascularization. [68][69][70] Hoshino et al 71 investigated the association between PCAT attenuation, as expressed by the fat attenuation index (FAI), and whole vessel and lesion plaque quantification on CCTA in 187 stable patients with intermediate stenosis evaluated by using FFR. At multivariate analysis, male sex, CCTA-derived positive remodelling, lower minimum lumen area and lower FFR were independent predictors of FAI.…”

Coronary artery disease: novel insights in a long-standing disease

“…Stress-echocardiography is a functional imaging test, characterized by a very favourable balance between low cost and absence of ionizing radiation, ease of performance (even if operator-dependent and influenced by chest shape and thoracic acoustic properties), 21 with very high specificity for severe/obstructive CAD. Stress-echocardiography can be performed using either exercise or pharmacologic stressors, and it also conveys key information regarding noncoronary aspects, such as valvular disease 22 . Stress cardiac magnetic resonance is the best alternative to stress-echocardiography, even if it is a more complicated and costly test.…”

Changing Paradigms in the Diagnosis of Ischemic Heart Disease by Multimodality Imaging

“…Stress echocardiography (SE) is one of the second-line stress tests used for the assessment of patients presenting with chest pain and intermediate pre-test likelihood of obstructive CAD [15]. This technique is characterised by low cost, absence of ionizing radiation, ease of performance [16], good diagnostic results [17] and excellent prognostic implications, either performed with physical exercise or a pharmacological (inotropic or vasodilator) stressor [18][19][20]. However, especially when only regional wall motion abnormalities (RWMA) are investigated, suboptimal images due to poor acoustic windows and submaximal stress are important factors affecting diagnostic accuracy [21].…”