The clinical impact of contemporary stress echocardiography in morbid obesity for the assessment of coronary artery disease

Abstract

Contemporary SE has excellent feasibility and positive predictive value and resulted in appropriate risk stratification of symptomatic patients with significant obesity. A normal SE portends an excellent outcome over the short-intermediate term in this high-risk patient population.

Ultrasound contrast during stress echo: for obese patients, but not only

“…The study by Shah et al 2 definitely confirms that the addition of contrast for left ventricle opacification makes stress echocardiography feasible in this subset of patients too, either using pharmacological or exercise stress, which is possibly even more impressive, since exercise is the most demanding stressor to acquire good-quality images. In this specific regard, I would add a word of caution on the use of exercise echo in such morbidly obese subjects, since having such patients both exercise sufficiently and at the same time acquiring high-quality images is achievable only by very skilled operators, even with the aid of ultrasound contrast media.…”

“…This extreme obesity category was also the specific target population of the interesting study by Shah et al 2 in their Heart publication.…”

The clinical efficacy and long-term prognostic value of stress echocardiography in octogenarians

“…All SE studies were performed using either treadmill exercise or pharmacological (dobutamine-atropine) stress as we have previously described 10. In summary, exercise stress was the preferred modality, and in patients unsuitable for exercise, dobutamine was infused in 3 min dose increments, starting from 10 µg/kg/min and increasing to 20, 30 and 40 µg/kg/min if there were no resting wall motion abnormalities, otherwise a viability protocol was used commencing at 5 µg/kg/min.…”

Effect of Coronary Revascularization on the Prognostic Value of Stress Myocardial Contrast Wall Motion and Perfusion Imaging

“…Contrast stress echocardiography with additional myocardial perfusion assessment (cSE‐WMP) has demonstrated further increase in predictive accuracy for hard cardiac events in patients with suspected or known CAD, either during dobutamine10, 11 or vasodilator12, 13, 14 stress. As far as WM assessment is concerned, cSE‐WMP also has the advantage of maximizing test feasibility over standard stress echocardiography, with quality of acoustic windows not representing an issue when taking advantage of ultrasound contrast media 15. Still, the few studies assessing cSE‐WMP for prognosis do not address its value specifically in predicting true ischemic events (cardiac death and nonfatal acute myocardial infarction [MI]),10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and it is not known how the use of cSE‐WMP as a gatekeeper to coronary angiography and subsequent revascularization does relate to long‐term outcome in subsequently revascularized and nonrevascularized patients.…”

“…As far as WM assessment is concerned, cSE‐WMP also has the advantage of maximizing test feasibility over standard stress echocardiography, with quality of acoustic windows not representing an issue when taking advantage of ultrasound contrast media 15. Still, the few studies assessing cSE‐WMP for prognosis do not address its value specifically in predicting true ischemic events (cardiac death and nonfatal acute myocardial infarction [MI]),10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and it is not known how the use of cSE‐WMP as a gatekeeper to coronary angiography and subsequent revascularization does relate to long‐term outcome in subsequently revascularized and nonrevascularized patients. Previous cSE‐WMP studies reported only on combined end points with prevalence of all‐cause deaths, half of them represented by cancer deaths, pneumonia, or other diseases that may not be directly influenced by coronary ischemia at stress testing 10, 11, 12, 13, 14.…”