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Review
Stress echocardiography in valvular heart disease: a current appraisal Expert Rev. Cardiovasc. Ther. 13(3), 249–262 (2015)
Peyman Naji, Krishna Patel, Brian P Griffin and Milind Y Desai* Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, USA *Author for correspondence: Tel.: +1 216 445 5250 Fax: +1 216 445 6155 [email protected]
Stress echocardiography is increasingly used in the management of patients with valvular heart disease and can aid in evaluation, risk stratification and clinical decision making in these patients. Evaluation of symptoms, exercise capacity and changes in blood pressure can be done during the exercise portion of the test, whereas echocardiographic portion can reveal changes in severity of disease, pulmonary artery pressure and left ventricular function in response to exercise. These parameters, which are not available at rest, can have diagnostic and prognostic importance. In this article, we will review the indications and diagnostic implications, prognostic implications, and clinical impact of stress echocardiography in decision making and management of patients with valvular heart disease. KEYWORDS: stress echocardiography . valvular heart disease
Aortic stenosis Indications & diagnostic implications
Aortic valve stenosis (AS) is a gradually progressive disease, and patients with severe AS who become symptomatic have dismal prognosis and need to undergo aortic valve replacement (AVR) [1,2]. However, since AS is mostly seen in the elderly population, many of the patients may not report symptoms because of sedentary lifestyle or gradual decline in their functional capacity. Therefore, stress testing can have an important role in elucidating symptoms in patients with asymptomatic severe AS. This is also especially important because typical symptoms of AS usually start as dyspnea on exertion and decreased exercise tolerance, and the classic symptoms of angina, syncope and heart failure (HF) are late manifestations of the disease [1]. Stress testing is contraindicated in patients who are clearly symptomatic [1,2], but its safety in asymptomatic patients with severe AS has been well established [3,4]. Development of symptoms such as angina, dyspnea at low workloads, dizziness or syncope can be evaluated during stress testing. About one-third of patients who are otherwise considered to be asymptomatic will develop limiting symptoms during exercise testing, and these patients will have a shorter informahealthcare.com
10.1586/14779072.2015.1013940
symptom-free survival, higher cardiac events and higher need for AVR [5–8]. Stress testing for evaluation and ‘unmasking’ of symptoms in patients with severe asymptomatic AS has been recommended in the 2012 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines [2]. The new 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines has placed additional emphasis on stress testing in these patients and now recommends it as a class IIa indication [1], compared to a class IIb recommendation in 2008 ACC/AHA guidelines [9]. In addition to symptom evaluation, exercise testing can also reveal useful information about electrocardiographic changes and blood pressure (BP) response to exercise, which have prognostic yield. Stress echocardiography has the benefit of supplementing the exercise data with additional information pertaining to changes in left ventricular (LV) function, transvalvular hemodynamics and pulmonary arterial pressure in response to exercise, all of which can be used in clinical decision making. Prognostic implications
Abnormal exercise test in patients with asymptomatic AS is defined as either the development of symptoms or one of the following conditions
2015 Informa UK Ltd
ISSN 1477-9072
249
Review
Naji, Patel, Griffin & Desai
asymptomatic severe AS is provided in TABLE 1. AVR has a class I indication in all patients with severe symptomatic AS. With the new updates implemented in Exercise test or stress AVR recommendation AVR recommendation the 2014 ACC/AHA guidelines, now the echocardiography findings by ACC/AHA by ESC/EACTS American and European guidelines have Development of symptoms Class I Class I more concordant recommendations in during exercise testing the management of asymptomatic Fall in blood pressure Class IIa Class IIa patients. Most importantly, both guidelines now agree that asymptomatic Decrease exercise tolerance Class IIa – patients who develop symptoms during >20 mmHg increase – Class IIb, if low surgical risk stress testing should be considered to in mean gradient have ‘symptomatic disease’ and should ACC: American College of Cardiology; AHA: American Heart Association; AVR: Aortic valve replacement; undergo AVR with a class I indicaEACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology. tion [1,2]. Fall in BP during exercise also has a class IIa indication for AVR in during exercise testing: abnormal BP response to exercise (fall or both guidelines. The European guidelines also add a class IIb 2 mm indication for AVR in patients with >20 mmHg increase in measured 80 ms after the J point) and complex ventricular mean pressure gradient during exercise. While there are no spearrhythmias. Abnormal exercise test can be seen in 37–66% of cific surgical recommendations about patients with low CR or patients with asymptomatic AS and is associated with earlier patients with exercise PHT, these can be used to identify occurrence of clinical symptoms, higher cardiac death and higher higher risk patients who need closer monitoring [20]. need for AVR [5–8]. Development of dizziness during the test seems to have the highest predictive value of early symptomatic Low-flow low-gradient AS disease [5]. Indications & diagnostic implications Regardless of exercise testing or resting echocardiography Low-flow low-gradient (LFLG) AS is generally characterized by results, stress echocardiography can reveal several AS indices an aortic valve area (AVA) £1 cm2 (consistent with severe stewhich are predictive of outcomes. Exercise-induced increase of nosis), but with low mean pressure gradient (
Review
Stress echocardiography in valvular heart disease: a current appraisal Expert Rev. Cardiovasc. Ther. 13(3), 249–262 (2015)
Peyman Naji, Krishna Patel, Brian P Griffin and Milind Y Desai* Department of Cardiovascular Medicine, Cleveland Clinic, Heart and Vascular Institute, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH, USA *Author for correspondence: Tel.: +1 216 445 5250 Fax: +1 216 445 6155 [email protected]
Stress echocardiography is increasingly used in the management of patients with valvular heart disease and can aid in evaluation, risk stratification and clinical decision making in these patients. Evaluation of symptoms, exercise capacity and changes in blood pressure can be done during the exercise portion of the test, whereas echocardiographic portion can reveal changes in severity of disease, pulmonary artery pressure and left ventricular function in response to exercise. These parameters, which are not available at rest, can have diagnostic and prognostic importance. In this article, we will review the indications and diagnostic implications, prognostic implications, and clinical impact of stress echocardiography in decision making and management of patients with valvular heart disease. KEYWORDS: stress echocardiography . valvular heart disease
Aortic stenosis Indications & diagnostic implications
Aortic valve stenosis (AS) is a gradually progressive disease, and patients with severe AS who become symptomatic have dismal prognosis and need to undergo aortic valve replacement (AVR) [1,2]. However, since AS is mostly seen in the elderly population, many of the patients may not report symptoms because of sedentary lifestyle or gradual decline in their functional capacity. Therefore, stress testing can have an important role in elucidating symptoms in patients with asymptomatic severe AS. This is also especially important because typical symptoms of AS usually start as dyspnea on exertion and decreased exercise tolerance, and the classic symptoms of angina, syncope and heart failure (HF) are late manifestations of the disease [1]. Stress testing is contraindicated in patients who are clearly symptomatic [1,2], but its safety in asymptomatic patients with severe AS has been well established [3,4]. Development of symptoms such as angina, dyspnea at low workloads, dizziness or syncope can be evaluated during stress testing. About one-third of patients who are otherwise considered to be asymptomatic will develop limiting symptoms during exercise testing, and these patients will have a shorter informahealthcare.com
10.1586/14779072.2015.1013940
symptom-free survival, higher cardiac events and higher need for AVR [5–8]. Stress testing for evaluation and ‘unmasking’ of symptoms in patients with severe asymptomatic AS has been recommended in the 2012 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines [2]. The new 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guidelines has placed additional emphasis on stress testing in these patients and now recommends it as a class IIa indication [1], compared to a class IIb recommendation in 2008 ACC/AHA guidelines [9]. In addition to symptom evaluation, exercise testing can also reveal useful information about electrocardiographic changes and blood pressure (BP) response to exercise, which have prognostic yield. Stress echocardiography has the benefit of supplementing the exercise data with additional information pertaining to changes in left ventricular (LV) function, transvalvular hemodynamics and pulmonary arterial pressure in response to exercise, all of which can be used in clinical decision making. Prognostic implications
Abnormal exercise test in patients with asymptomatic AS is defined as either the development of symptoms or one of the following conditions
2015 Informa UK Ltd
ISSN 1477-9072
249
Review
Naji, Patel, Griffin & Desai
asymptomatic severe AS is provided in TABLE 1. AVR has a class I indication in all patients with severe symptomatic AS. With the new updates implemented in Exercise test or stress AVR recommendation AVR recommendation the 2014 ACC/AHA guidelines, now the echocardiography findings by ACC/AHA by ESC/EACTS American and European guidelines have Development of symptoms Class I Class I more concordant recommendations in during exercise testing the management of asymptomatic Fall in blood pressure Class IIa Class IIa patients. Most importantly, both guidelines now agree that asymptomatic Decrease exercise tolerance Class IIa – patients who develop symptoms during >20 mmHg increase – Class IIb, if low surgical risk stress testing should be considered to in mean gradient have ‘symptomatic disease’ and should ACC: American College of Cardiology; AHA: American Heart Association; AVR: Aortic valve replacement; undergo AVR with a class I indicaEACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology. tion [1,2]. Fall in BP during exercise also has a class IIa indication for AVR in during exercise testing: abnormal BP response to exercise (fall or both guidelines. The European guidelines also add a class IIb 2 mm indication for AVR in patients with >20 mmHg increase in measured 80 ms after the J point) and complex ventricular mean pressure gradient during exercise. While there are no spearrhythmias. Abnormal exercise test can be seen in 37–66% of cific surgical recommendations about patients with low CR or patients with asymptomatic AS and is associated with earlier patients with exercise PHT, these can be used to identify occurrence of clinical symptoms, higher cardiac death and higher higher risk patients who need closer monitoring [20]. need for AVR [5–8]. Development of dizziness during the test seems to have the highest predictive value of early symptomatic Low-flow low-gradient AS disease [5]. Indications & diagnostic implications Regardless of exercise testing or resting echocardiography Low-flow low-gradient (LFLG) AS is generally characterized by results, stress echocardiography can reveal several AS indices an aortic valve area (AVA) £1 cm2 (consistent with severe stewhich are predictive of outcomes. Exercise-induced increase of nosis), but with low mean pressure gradient (
