1. Eugenio Picano Institute of Clinical Physiology, CNR Pisa, Italy
Gramado, Brazil ,
19 May 2016,h 10 am
Stress echo 2020:
above and beyond coronary artery disease
Eugenio Picano
Institute of Clinical Physiology, CNR
Pisa, Italy

2. Stress echo lab 1.0: One patient, one technology, one sign
Rest
Stress
Adapted from Picano E. Am J Med 2003

3. Stress echo lab 2.0: versatility
(Picano E, Pellikka P,
Eur Heart J 2014)
Stress echo lab 2.0: versatility
Ischemia
Viability
CFVR
Mitral Insufficiency
200
LV elastance
Extravascular lung water
CAD
CMD
Valvular HD
Congenital HD
Athletes, divers, climbers
Secondary pulmonary
hypertension (SScl, PPH)
Heart Transplant pts

4. Stressecho beyond CAD
Started as early as stress echo in CAD (in the eighties, mainly on mitral stenosis and valves)
Small part (<1/10 ) of stress echo guidelines (ASE 2007 Pellikka et al; EACVI Sicari et al)
Special Focus in EHJ clinical review 2014 (Picano E, Pellikka P, EHJ 2014)
Targeted by joint ASE-EACVI recommendation (Lancellotti P., Pellikka P, Tsutsui J, Picano E et al, EHJ-CV imaging 2016)
Now it is multicenter trial time: SE 2020
Exercise-induced symptons
Exercise-induced hypotension
ECG changes
LVOT obstruction development
New wall motion abnormalities
Coronary flow velocity reserve (CFRV) 4

5. Stress echo 2020 pedigree: si parva licet componere magnis …
SE a step-child of GISSI:
1 - Sponsored by a respected, independent, not-for-profit national professional society (it was ANMCO; it is SIEC)
2 - Scientific coordination from a distinguished research institute (it was Mario Negri in Milan, it is CNR-IFC Pisa)
3 - Inclusivity (it was all CCU’s, it is all SE labs of the nation)
4 – Emphasis on clinical relevant outcomes changing patient care (it was thrombolytic therapy in acute myocardial infarction, it is cardiac imaging within and beyond CAD)
Braunwald E, Am Heart J, 2004:
The GISSI twentieth birthday

6. EPIC, the father of Stress echo 2020
1 - simple protocols without economic induction can change guidelines (it was in CAD, it is also beyond CAD for SE 2020)
2 - Italians do it (SE) better, we have cultural and technological infrastructure (it was analogic dip and dob, it is digital and also semi-supine exercise)
3 - Echo people like to do extra-work that make their practice better if clinically worthwhile (it was RWMA , it is also CFVR, B-lines, SPAP, LV elastance index, etc)
4 – We need the fruit of effectiveness (real world data), not the seed of efficacy (virtual reality of journals written by enthousiastic fellows and presented by gray-haired opinion leaders paid by industry) to feed our patients
30 EPIC-EDIC papers with over 75 authors of 4 continents and 12 countries on top-ranked journals over a 20 years span ( ) changing clinical practice

7. The 10 protocols, 100 centers and 10,000 patients
STRESSECHO 2020
The 10 protocols, 100 centers and 10,000 patients
Running title : Italians still do it better? ( ,000)

8. Contractile reserve and CRT response
(Ciampi Q et al, 2016, ESC abstract)

9. Stress B- lines in Heart Failure
Scali MC,Marzilli M et al, ESC 2016 (abstract)

10. Stress echo in HCM : coronary flow reserve makes the difference
Ciampi Q et al, ESC meeting 2016

11. HFrEF: EDV reserve matters (diastolic pressure-volume better than pressure only!)
HFpEF
HFrEF
Controls
(Shimiaie et al, JACC heart fail 2015)

12. Beneficial effects of TAVI on MR
Costantino F et al, CardioUltra 2015

13. Stress echo Outdoor * * * 5130 4790 3440 1350 1350 m s.l. days
18 subjects (10 males)
mean age 45±10 years
m s.l.
Gokyo
5130
Namche Bazaar
4790 *
Gorak Shep
3440 *
Kathmandu *
1350
Kathmandu
1350
days
Cardiac and chest echo
Pratali L. et al Critical Care Medicine 2010 13

14. SE in adult repaired ToF
RV FAC decreases at exercise
RV FAC increases at exercise
RV FAC at Rest
RV FAC at Exercise
RV FAC at Rest
RV FAC at Exercise
NON RESPONDERS (49 pts)
RESPONDERS (74 pts)
L. Ait Ali et al, J Am Soc Echocardiogr. 2014

15. SE in patients at risk for pulmonary arterial hypertension
Figure 2. Changes in PASP values from rest to peak exercise for each individual patient.
Luna Gargani, Alberto Pignone, Gergely Agoston, Antonella Moreo, Eugenia Capati, Luigi P. Badano, Marica Doveri, Laura Bazzichi, Marco Fabio Costantino, Andrea Pavellini, Francesco Pieri, Francesco Musca, Denisa Muraru, Oscar Epis, Eleonora Bruschi, Benedetta De Chiara, Federico Perfetto, Fabio Mori, Oberdan Parodi, Rosa Sicari, Stefano Bombardieri, Albert Varga, Marco Matucci Cerinic, Eduardo Bossone, Eugenio Picano
American Heart Journal, Volume 165, Issue 2, 2013, 200–207

16. Incremental value of CFR over wall motion to predict mortality
Cortigiani. JACC Cardiovasc Imaging 2012;5:1079

17. Genetic stress echo in HCM, PPH and DCM

18. Stress Echo Computerized Software 2.0

19. Allo studio partecipano alcuni dei migliori ricercatori italiani nei rispettivi settori, di tutte le età (dai 30 ai 60 anni), tutte le appartenenze (ospedalieri, universitari, CNR) e tutte le provenienze geografiche (da Potenza a Venezia), secondo un principio elementare (ma raramente applicato) di rispetto delle competenze, condivisione dei saperi e ottimizzazione delle risorse

20. Conclusions
Stress-echo 2020 will help the Italian SE community in tailoring the right stress to the right patient with the right technology, used by the right (properly trained and certified) cardiologist.
SE has today an unprecedented advantage of economic sustainability, lack of radiation, portability and versatility making it potentially dominant in the current era of societal pressures on cardiac imaging costs and risks.
Stressecho will recruit 10,000 patients by 2020 spread over 10 subprojects and should create a SE lab without walls 20

21. Nunca procures saber por quem os sinos dobram; eles dobram por ti
Marco Antonio, Liz, Monica, Pedro, Adriana, Patricia, Leticia, Wilson, Lucas, and many others:
EPIC EDIC and Brazil, 20 years after here we go again
Nunca procures saber por quem os sinos dobram;
eles dobram por ti