Stress Echo Primer: before taking the test Stress Echo 2020, November 10 , 2016 Stress Echo Primer: before taking the test Eugenio Picano, MD CNR, Istitute of Clinical Physiology

Stress echocardiography in four equations REST + STRESS = DIAGNOSIS Normokinesis Normo-Hyperkinesis Normal Hypo, A, Dyskinesis Ischemia Akinesis Hypo, Normokinesis Viable A-Dyskinesis A-, Dyskinesis Necrosis

REST STRESS normal ischemic viable necrotic (Picano E, Stress echocardiography, VI ed, Springer Verlag, 2015)

End-Systolic Frames REST STRESS normal ischemic viable necrotic (Picano E, Stress echocardiography, VI ed, Springer Verlag, 2015)

Stress echocardiography: the normal pattern REST STRESS normal

Stress echocardiography: the ischemic pattern REST STRESS ischemic

Stress echocardiography: the viable pattern REST STRESS viable

Stress echocardiography: the necrotic pattern REST STRESS necrotic

Se2020 adopts the 17-segment model of left ventricle antero- lateral Infero- inferior infero. septal antero-septal 2 1 5 6 4 3 8 7 16 13 9 11 10 12 14 anterior 15 antero- lateral Infero- inferior infero. septal antero-septal 2 1 5 6 4 3 8 7 16 13 9 11 10 12 14 anterior 15 17 Se2020 adopts the 17-segment model of left ventricle All models basal anterior basal antero-septal basal infero-septal basal inferior basal infero-lateral basal antero-lateral 16- and 17-models apical lateral apical septal apical inferior apical anterior 17-segment model only 17. apex mid anterior mid antero-septal mid infero-septal mid inferior mid infero-lateral mid antero-lateral (Lang R et al, ASE-EACVI guidelines, Eur Heart J CV imaging, 2015)

Cerqueira MD et al. Circulation 2002; 105:539-42

LAD RCA LCX (Picano E, Stress echocardiography, VI ed, Springer Verlag, 2015)

Left ventricular segments and coronary distribution territories Basal (segment 6) or mid (segment 12) antero-lateral wall or apical lateral segment (16) are overlapping CX or LAD territory (Lang R et al, ASE-EACVI guidelines, Eur Heart J CV img, 2015)

The segmental scoring system Score: 1 = Normal/hyperkinetic: normal/increased systolic endocardial excursion and myocardial thickening   2 = Hypokinetic: decreased systolic endocardial excursion (< 5mm) and myocardial thickening (<30%) 3 = Akinetic: absent systolic endocardial excursion (< 2 mm) and myocardial thickening 4 = Dyskinetic: outward systolic wall motion and absent myocardial thickening (Pellikka P et al ASE stress echo guidelines JASE 2007; Sicari R. et al, EACVI stress echo guidelines Eur HJ 2009)

CORRECT INCORRECT Pseudo hyper Pseudo hypo 4C 2C LAX SAXPM Basal anteroseptal Basal anterolateral Apex 2C Apex Basal inferior Basal anterior Basal antero-septal Basal inferolateral LAX Apex SAXPM Inferoseptal Inferolateral Anterior

Not all segments were created equal Rest (NORMALS) Dobutamine stress Heterogeneity in regional thickening is present at rest and magnified during stress: Some regions have physiological relative hypokinesis also in normals. Beware especially of basal infero-septal and basal inferior segment Borges A, Picano E, et al. Eur Heart J 1995; 16; 1726 - 1730

Power to the People (stressism-leninism) Professional restrictions are absent and all who are willing to invest in the equipment can apply it. This total lack of controls and review, compounded by the performance of most such studies in the office or laboratory of the private cardiologist, strongly increases the possibility for abuse. E.H. Botvinick, J Nucl Cardiol, 1994; 1: S147-70

Stress echo reading: madness and method 140 Agreement is lowest for poor quality images,basal infero-septal and basal inferior (number 3 and 4), and for mild hypokinesis. In all these cases, conservative reading criteria are warranted Number of studies Positive Negative 1 2 3 4 5 Centers 100 100 100 83 100 100 74 72 55 Agreement (%) 43 24 80 3 and 4 Excellent uninterpretable LV Segments Hypo- Aki- Dys-kinesia Hoffmann R, Picano E, et al JACC 1996; 27: 330-336

Stress echo and the human factor: Trainer explains, trainee learns, accuracy increases after 100 cases P<0.01 P=ns % 83 86 61 85 Picano E, et al JACC 1991;17:666-669

Quality control High volume centers are not necessarily top-players 100 80 % Concordance 50 Candidate centers in year 2000 (EPIC-EDIC) (N=20) 100 500 1000 SE studies per year per lab

Quality control High volume centers are not necessarily top-players 100 80 % Accuracy 50 Candidate centers in year 2016 (SE2020) (N=20) Center 20 Center 1 High volume (>100 SE/year) centers

Stress echo reading: Shared criteria lead to harmonization of results SE2020 suggested reading policy: ignore mild hypo,isolated basal infero-septal or basal inferior, or questionable regional wall motion abnormalities VARIABILITY Relative hypokinesis 1 segment enough All segments equal Reading deregulation Marked hypokinesis 2 contiguous segments Not all created equal Explicit reading criteria 88% Agreement 33% VARIABILITY Varga A, Picano E et al. Madness and method in stress echo reading. Eur Heart J 1999

Positivity criteria in the literature: Not good for SE2020 “Relative hypokinesis” is not a positivity criterion “Lack of hyperkinesis” is not a positivity criterion “Tardokinesis” is not a positivity criterion Isolated hypokinesis of only 1 segment out of 17 Mild hypokinesis of infero-basal septum Mild hypokinesis of basal inferior wall You judge what you see : what you don’t see, you cannot call If you use overtly aggressive reading, every stress will turn out positive

Readers’ comments (October 2016) “Some images are old ” (but interpretable) “Not the same projection” (as it usually happens in real life) “Low quality ” (in real life of high volume labs, 20 % of studies are readable but low quality: if you only select excellent images, you loose a lot of patients) “This study is uninterpretable” (some segments are not interpretable, you have to read what you see) “I am the Head of this, Chief of that, I am too old for being quality controlled by anybody” (you are never too old to be quality controlled, in science, in life and in stress echocardiography, and peers always see and judge you)

Only when it is done right Is stress echo dirty? Only when it is done right