1. Stress Echo Primer: before taking the test
Stress Echo 2020, Pisa October 2016
Stress Echo Primer: before taking the test
Eugenio Picano, MD
CNR, Istituto di Fisiologia Clinica

2. 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

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

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

5. Stress echocardiography: the normal pattern
REST
STRESS
normal

6. Stress echocardiography: the ischemic pattern
REST
STRESS
ischemic

7. Stress echocardiography: the viable pattern
REST
STRESS
viable

8. Stress echocardiography: the necrotic pattern
REST
STRESS
necrotic

9. 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)

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

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

13. 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)

14. CORRECT INCORRECT Pseudo hypo Pseudo hyper 4C 2C LAX SAXPM Septobasal
Laterobasal
Apex
Inferobasal
Anterobasal 2C
Apex
Septobasal
Posterobasal
LAX
Apex
SAXPM
Inferoseptal
Inferoposterior
Anterior

15. 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 ; 16;

16. 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

17. 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
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:

18. 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:

19. 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

20. 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

21. 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

22. 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)

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