Heart Scan Cardiac Services Stress Echocardiography, London, UK, Europe

Topic	Description
More on Stress Echocardiography	The efficiency and reliability of stress echocardiography tests for the detection of coronary artery disease is expressed as the sensitivity and specificity of this procedure for the detection of angiographically demonstrated stenoses. People with multi-vessel coronary disease and previous myocardial infarction are more likely to develop ischaemia in response to stress, and referral bias may also affect the recorded accuracy. As stress echo is based on the induction of ischaemia, the amount of stress has a pivotal influence on sensitivity. The accuracy of the test will also be influenced by echocardiographic factors including image quality and left ventricular morphology; the lateral wall is a frequent site of fake negatives and the inferior wall for fake positives. Research with these techniques have included populations having a high prevalence of extensive coronary disease or prior infarction—both of which are linked with a high sensitivity. Single vessel disease is however not easy to detect using this technique. There are limitations in the diagnostic use of stress echocardiography. Although the presence of coronary artery disease is easily determined in the setting of multivessel disease, and multivessel pathology is readily recognised in the presence of prior infarction (“ischaemia at a distance”), the technique has a sensitivity of only 50% for the recognition of multivessel disease in ventricles with no abnormality. The detection of single vessel stenoses may also be too difficult, and the sensitivity of stress echo here is less than that of myocardial perfusion scintigraphy. At present, however, the best way to deal with this is to focus on the prognostic, rather than the diagnostic, implications of the test.
Echocardiography in Assessing the Outcome of Bronchopulmonary Dysplasia of the Newborn	Cardiac catheterization of infants with bron-chopulmonary dysplasia has depicted right ventricular hypertrophy and pulmonary hypertension in most of the survivors. This study was planned to find out whether continuous echocardiographic assessments of the pulmonary vascular bed could help to determine short-term prognosis of bronchopulmonary dysplasia and to evaluate myocardial function of the survivors. Ten preterm infants were observed for this study. They were classified according to four radiologic stages. A total of 50 echocardiographs were recorded so serial measurements of the right systolic time intervals could be carried out. Cardiac catheterization of infants with bron-chopulmonary dysplasia has displayed right ventricular hypertrophy and pulmonary hypertension. This study was planned to find out if serial echocardiography assessments of the pulmonary vascular bed could help to establish short-term prognosis of bronchopulmonary dysplasia and to evaluate myocardial function of the survivors. Ten preterm infants were again included in this study. They were classified according to four radiologic stages. A total of 50 echocardiographs were recorded for the purpose of serial measurements of the right systolic time intervals. The lungs as seen on chest x-rays of this patient remained unaltered (moderate stage IV) during six months, while the echocardiograph showed a rapid increase in right pre-ejection period to right ejection time ratio. This infant now has cor pulmonale. Myocardial function evaluated on the last echocardiograph of the four infants who were considered cured was within the permissive limits. Thus it can be concluded that indirect assessment of pulmonary pressure by echocardiography can be used for clinical evaluation and ultimate prognosis of bronchopulmonary dysplasia and should be part of the follow-up evaluation of infants suffering from this health condition.
Stress echocardiography	Cardiologist Dr Maria Prokudina, of the Almazof Federal Centre of Heart, Blood and Endocrinology, when invited by Professor John Elefteriades MD, head of Department of Cardiothoracic Surgery at Yale-New Haven Hospital (University School of Medicine) to lecture about Stress Echocardiography in Clinical Practice, exclaimed her surprise as she knew American cardiologists widely applied this method practically and so she did not have anything new to tell them. But Dr Elefteriades, a world renowned surgeon in this field, insisted that she had unique personal insights and experience and they were all waiting for her. The Russian doctor then explained that it was about the way of working. Ischaemic disease is the main cause of the high morbidity rate (25,300:100,000). About 35 million Russians suffer from cardiovascular disease and about a million die each year. The huge problem for us is inadequate diagnostics. It’s well-known that more than 50% of patients do not have any ECG changes when resting. But ECG and exercise ECG testing are traditional methods of diagnoses in Russia, although these tests are able to detect ischaemia in the later stages of the ischaemic cascade, contributing acknowledged limitation in diagnostic accuracy (decreased sensitivity). For this reason, Russian specialists have been using the latest IT methods for the last few years, Dr Prokudina pointed out. She continued that stress echocardiography is a non-invasive diagnostic method that combines a baseline echocardiogram with a peak/post exercise echocardiogram to detect and assess coronary artery disease. We choose the treadmill or bicycle test as a stress-agent, but American colleagues pick the pharmacologic test with dobutamine or dipyridamole. If a patient with coronary artery disease (CAD) exercises, ischemia will be induced in the region subtended by a critically stenosed coronary artery. This will be shown as an abnormality of cardiac function, which can be found out by echocardiographic imaging. With exercise, there is usually an increase in left ventricular contractility. In the presence of CAD, stress induced myocardial ischaemia results in a decrease/cessation of contractility in the myocardial region supplied by the stenosed vessel. The ischaemic wall(s) appears hypokinetic, akinetic or diskinetic. The key to success is having the patient reach 90% of the age-predicted maximum heart rate for at least one minute and double outcome greater than 25,000. The patient's symptoms during exercise (e.g. workload performed, heart rate, blood pressure response) should be noted. Exercise electrocardiography information (e.g. EKG changes, presence of arrhythmias) should be evaluated. Overall and segmental left ventricular systolic function pre- and post exercise) should also be evaluated. A wall motion score should be assigned to each wall segment visualised, and a wall motion score index must be calculated. Dr Prokudina continued that many physicians are afraid to give patients stress-echo tests thinking it may be dangerous for them, especially after having had a heart attack. But this method is not dangerous – the patient is under the control of the specialist and equipment every moment. There were more than 5,000 heart attacks in St. Petersburg last year and everyone understands that it is possible to avoid heart disaster if the right diagnostics are used.
Stress Echocardiography	Echocardiography, stress: A supplement to the routine exercise cardiac stress test. During stress echocardiography, the sound waves of ultrasound are used to produce images of the heart at rest and at the peak of exercise. In a heart with normal blood supply, all segments of the left ventricle (the major pumping chamber of the heart) exhibit enhanced contractions of the heart muscle during peak exercise. Conversely, in the setting of coronary artery disease (CAD), if a segment of the left ventricle does not receive optimal blood flow during exercise, that segment will demonstrate reduced contractions of heart muscle relative to the rest of the heart on the exercise echocardiogram. Stress echocardiography is very useful in enhancing the interpretation of the routine exercise cardiac stress test (ECST). It can be used to exclude significant CAD in patients who are suspected of having a "false-positive" ECST, a falsely abnormally result on the screening ECST test.
Reason for performing the test	A stress echocardiogram is usually done to find out if you might have decreased blood flow to your heart (coronary artery disease, or CAD). Coronary artery disease is caused by the buildup of plaque on the inside of the coronary arteries, the blood vessels that supply oxygen-rich blood to the heart muscle. Plaque is made up of excess cholesterol, calcium, and other substances that float in blood and, over time, build up on the inside walls of the coronary arteries and other arteries. This process of plaque buildup is called hardening of the arteries, or atherosclerosis. The plaque deposits decrease the space through which blood can flow. Poor blood flow can "starve" the heart muscle and lead to chest pain. A heart attack results when blood flow is completely blocked, usually by a blood clot forming over a plaque that has broken open (ruptured). Coronary artery disease is treated with lifestyle changes, such as increasing exercise, eating a heart-healthy diet, and stopping smoking. Coronary artery disease also is treated with medications to help reduce high cholesterol, control high blood pressure, and manage other risk factors.
How is a Stress Echo performed	An Echo Stress can be obtained in a physician's office or in the hospital. Imaging tests are generally obtained when a physician wishes to confirm or rule out the presence of coronary artery disease. A Stress Echo is also performed in patients who have disease involving the heart muscle or valve, or if a patient is having inappropriate shortness of breath and a cardiac cause is suspected. The patient is brought to the Echo laboratory where a "resting" study is performed. This provides a baseline examination and demonstrates the size and function of various chambers of the heart. Particular attention is paid to the movement of all walls of the left ventricle (LV). Similar to a regular echo test, sticky patches or electrodes are attached to the chest and shoulders and connected to electrodes or wires to record the electrocardiogram (EKG or ECG). The EKG helps in the timing of various cardiac events (filling and emptying of chambers). A colorless gel is then applied to the chest and the echo transducer (as described in the Echocardiogram section) is placed on top of it. The echo technologist then makes recordings from different parts of the chest to obtain several views of the heart. You may be asked to move form your back and to the left side. Instructions may also be given for you to breathe slowly or to hold your breath. This helps to obtain higher quality pictures. The images are constantly viewed on the monitor. It is also recorded on photographic paper, on videotape and on a computer disk. 12 leads of the EKG are recorded on paper and the blood pressure is taken. Exercise is then initiated using a treadmill (most common) or a stationary bicycle. In patients who are unable to complete a high level of exercise because of physical limitations, stress to the heart is provided by pharmaceutical or chemical stimulation of the heart. Stress Echo is made up of three parts: A resting Echo study, Stress test, and a repeat Echo while the heart is still beating fast. Exercise stress testing usually employs the "Bruce" or a similar protocol, as described in the Regular Stress Test section. Exercise is started at a slower "warm-up" speed. The speed of the treadmill and it's slope or inclination is increased every 3 minutes. The treadmill is abruptly stopped when the patient exceeds 85% of the target rate (based upon the patient's age). Exercise may be stopped earlier if the patient develops alarming symptoms (chest discomfort, marked shortness of breath, weakness, dizziness, etc.), if there is dangerous elevation or drop in the blood pressure, significant EKG changes or a potentially dangerous irregular heart rhythm. Please remember that you have a physician in attendance (although an experienced assistant may perform the test if the physician is tied up with an emergency). The above problems are uncommon and you are far safer if they occur in the presence of an experienced medical team rather than having them happen while you are exercising in a spa, jogging, or running up a flight of office stairs. EKG recordings are made during every minute of exercise and then again after exercise is stopped. The blood pressure is recorded at three minute intervals during exercise and then again at rest. Immediately after stopping the treadmill, the patient moves directly to the examination table and lays on the left side. The Echo examination is immediately repeated. Images are stored and then played back by the computer. A video clip of multiple views of the resting and exercise study are compared side-by-side. They are analyzed by the physician. Normally, one expects an increased EF or ejection fraction (a measure of how well the heart is pumping). Also, the LV walls do not show any exercise-induced abnormal movement. In contrast, a drop in EF and/or a new wall motion abnormality is an indicator of disease.
Preparing for the Echo Stress Test	The following recommendations are "generic" for all types of cardiac stress tests: Do not eat or drink for three hours prior to the procedure. This reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use insulin, will need special instructions from the physician's office. Specific heart medicines may need to be stopped one or two days prior to the test. Such instructions are generally provided when the test is scheduled. Wear comfortable clothing and shoes that are suitable for exercise. An explanation of the test is provided and the patient is asked to sign a consent form.
How safe is a Stress Echo test	There are no known adverse effects from the ultrasound used during Echo imaging. The risk of the stress portion of the test is rare and similar to what you would expect from any strenuous form of exercise (jogging in your neighborhood, running up a flight of stairs, etc.). As noted earlier, experienced medical staff is in attendance to manage the rare complications like sustained abnormal heart rhythm, unrelieved chest pain or even a heart attack. These problems could potentially have occurred if the same patient performed an equivalent level of exercise at home or on a jogging track.
What is the reliability of Stress Echo	If a patient is able to achieve the target heart rate and if the ECHO images are of good technical quality, a Stress Echo is capable of diagnosing important disease in more than 85% of patients with coronary artery disease. Also, it can exclude important disease in more than 90% of cases when the test is absolutely normal.
How quickly will I get the results and what will it mean	The physician conducting the test will be able to give you the preliminary results before you leave the Stress Echo laboratory. However, the official result may take a few days to complete. The results of the test may help confirm or rule out a diagnosis of heart disease. In patients with known coronary artery disease (prior heart attack, known coronary blockages, previous treatment with angioplasty, stents or bypass surgery, etc.), the study will help confirm that the patient is in a stable state, or that a new blockage is developing. The results may influence your physician's decision to change your treatment or recommend additional testing such as cardiac catheterization

No.	Location		Description
1	London, UK	Stress Echocardiography	How is a Stress Echo performed? An Echo Stress can be obtained in a physician's office or in the hospital. Imaging tests are generally obtained when a physician wishes to confirm or rule out the presence of coronary artery disease. A Stress Echo is also performed in patients who have disease involving the heart muscle or valve, or if a patient is having inappropriate shortness of breath and a cardiac cause is suspected.
2	United Kingdom	stress echo scan	The patient is brought to the Echo laboratory where a "resting" study is performed. Similar to a regular echo test, sticky patches or electrodes are attached to the chest and shoulders and connected to electrodes or wires to record the electrocardiogram.
3	Europe	Echogram of the heart	A colorless gel is then applied to the chest and the echo transducer ( Echocardiogram section) is placed on top of it. The echo technologist then makes recordings from different parts of the chest to obtain several views of the heart.
4	England	Stress Echocardiogram	Exercise stress testing usually employs a similar protocol, as described in the Echo Stress Test section. How safe is a Stress Echo test? There are no known adverse effects from the ultrasound used during Echo imaging. The risk of the stress portion of the test is rare and similar to what you would expect from any strenuous form of exercise.
5	London, UK	Stress Echocardiography	An echocardiogram (also called an echo) is a type of ultrasound test that uses high-pitched sound waves that are sent through a device called a transducer. The device picks up echoes of the sound waves as they bounce off the different parts of your heart. These echoes are turned into moving pictures of your heart that can be seen on a video screen.
6	UK, London	heart echocardiography test	Transthoracic echocardiogram (TTE). This is the most common type. Views of the heart are obtained by moving the transducer to different locations on your chest or abdominal wall. Stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine that makes your heart beat harder and faster. A stress echocardiogram is usually done to find out if you might have decreased blood flow to your heart.
7	Europe	echo stress test	Doppler echocardiogram. This test is used to look at how blood flows through the heart chambers, heart valves, and blood vessels. The movement of the blood reflects sound waves to a transducer. The ultrasound computer then measures the direction and speed of the blood flowing through your heart and blood vessels. Doppler measurements may be displayed in black and white or in color.
8	England	heart stress test	Transesophageal echocardiogram (TEE). For this test, the probe is passed down the esophagus instead of being moved over the outside of the chest wall. TEE shows clearer pictures of your heart, because the probe is located closer to the heart and because the lungs and bones of the chest wall do not block the sound waves produced by the probe. Echo can be used as part of a stress test and with an electrocardiogram to help your doctor learn more about your heart.

Echocardiography in Assessing the Outcome of Bronchopulmonary Dysplasia of the Newborn