1. STRESS
ECHOCARDIOGRAPHY
Dr. Muhammad Mobarock Hossain
MBBS(CU), MD (card) phase B
University cardiac centre, BSMMU
DHAKA, BANGLADESH.
Contact: +8801914007246
Email: mobarockdr@gmail.com

2. History

3. History :
The Krannert Institute and Indiana University
introduced the technique of dobutamine stress
echocardiography in the United States over 17 years
ago.
Link: http://medicine.iupui.edu/krannert/programs/echo/dobutamine/

4. Cont…
Cardiac ultrasound is used to image the function of
the heart and
Medicines (dobutamine or dopamine) are used to stress
the heart.
Cardiac ultrasound can detect the presence of
blockages in the arteries to the heart if a region of
the heart is seen to have reduced pumping function
during stress.
Link: http://medicine.iupui.edu/krannert/programs/echo/dobutamine/

5. Stress echocardiography:

6. Definition

7. Definition of stress
echocardiography :
SE is an effective method for the evaluation of
myocardial ischemia, based on the detection of
“ Stress induced regional wall motion
abnormality”.

8. About SE
 Accuracy of SE in the detection of significant
coronary artery disease is 80-90%.
 SE is superior to ETT and can be comparable
to nuclear stress imaging.
 SE is safe and economical.
 Mortality 1 in 1000

9. Pathophysiology

10. Pathophysiology :
Exercise and inotropic stress normally provoke a
generalised increase of regional wall motion and
thickening, with an increment of ejection fraction
mainly caused by a reduction of systolic
dimensions.
Regional systolic dysfunction is usually caused by
coronary artery disease, but cardiomyopathies
may also show regional variation in function.

11. Cont…
The presence of residual viable tissue is more
common in hypo kinetic than akinetic
Segments &
least common in dyskinetic segments.

12. Ischemic cascade
Myocardial ischemia due to coronary luminal obstruction
Decreased myocardial perfusion ――> [NS,PET,CPE]
Metabolic changes ――> [ PET scan]
Diastolic dysfunction ――> [Stress Echo]
Systolic dysfunction ――> [Stress Echo]
ECG change ――> [ECG]
Chest pain ――> [History]

13. Importance of SE:
SE can differentiate viable myocardium from
the scarred myocardium which may help
whether there will be any benefit from the
revascularization or not.

14. Cont…
 The severity of valvular disease
 Hypertrophic cardiomyopathy
 Exercise induced pulmonary hypertension

15. Contraindications to SE:
1. Unstable angina
2. Severe base line hypertension
3. Uncontrolled arrhythmias
4. Mobile LV thrombus
5. SevereAortic stenosis
6. HOCM
7. Decompensated HF.

16. Stressors

17. Stressors :
 Exercise
 Pharmacological agents
 Atrial pacing

18. TREADMILL

19. Methodology

20. Methodology :
 Patient’s preparation
 Equipments
 Performing the test

21. Patient’s
preparation

22. Patient’s preparation
 Written consent from the patient.
 Avoid heavy meal several hours before the
test.
 Rate limiting drugs like beta blockers should
be stopped 3-5 half lives.
 Standard connections for a 12 lead ECG.

23. Equipments

24. Equipments:
 Exercise echocardiographic machine with
standard hemodynamic monitoring
equipment is needed.
 Resuscitation equipments and defibrillator
should be available for emergency crisis.
 Software for the echocardiographic machine
is necessary to acquire digital images and to
allow side by side comparison of pre test with
post peak stress images

25. Performing
the test

26. Exercise stress
echocardiography :
 Treadmill exercise echocardiography
 Upright bicycle echocardiography
 Supine bi cycle exercise echocardiography

27. Treadmill exercise
echocardiography

28. Supine bi cycle exercise
echocardiography

29. Exercise stress test:
 Exercise stress is preferred over non exercise
stress because it is more closely reproduce
daily activities .
 Images are to be obtained at peak exercise
with bicycle ergometry while the patient
continues to exercise.
 Sensitivity will be reduced if the images are
not taken within 90 sec after exercise.

30. End points for exercise SE:
 Target HR (85% of APMHR)
 Chest pain and dyspnoea
 Severe hypertension( Sys>220 mm of Hg,
Dia > 110 mm of Hg)
 Hypotension( Sys < 90 mm of Hg or fall of >
20 mm of Hg from the base line).
 Ventricular tachycardia or sustained SVT
 Developments ofWMA in at least two
contiguous segments

31. Advantages Disadvantages
Treadmill Widely available
High workload
Post stress images
Mild ischemia may
revert
Upright bicycle Imaging during exercise Technically difficult
Supine bicycle Imaging during exercise
Dopplers readily
available
Low workload
Dobutamine Continuous imaging Side effects
Dipyridamole Continuous imaging Side effects

32. Pharmacological stress
echocardiography
 Dobutamine stress echocardiography
 Dipyridamole / adenosine stress
echocardiography

33. American society of
echocardiography (ASE)
In 2007, American society of
echocardiography (ASE) guidelines
recommended “ Dobutamine” as the 1st line
agent for pharmacologic stress
echocardiography.

34. Dobutamine
 Sympathomimetic drugs which causes
increase ionotrophic, increase chronotrophic
and increase Blood pressure.
 Plasma half life is 2-3 minutes
 Low dose dobutamine causes (+) ionotrophic
effect through cardiac α₁ and β₁ receptors
thus causing increase contractality of heart.
 Higher dose causing (+) chronotrophic
effects through cardiac β₂ receptors.

35. Dopamine vs
Dobutamine

37. Contraindication for
dobutamine :
 Unstable ventricular arrhythmias

38. Other factors
1. Unstable angina
2. Severe base line hypertension
3. Uncontrolled arrhythmias
4. Mobile LV thrombus
5. SevereAortic stenosis
6. HOCM
7. Decompensated HF.

39. How to start with
Dobutamine

40. Dobutamine:
 Started with 10 microgram /kg/min and then
increase every 3 minutes to 20,30,40 μgm/kg/min.
 If 85% of APMHR is not achieved at 40 μgm/kg/min
then a 3 min 50 microgram/kg/min may be used.
 If dobutamine alone is not effective then we may
use Inj Atropine (.25-.50 mg) I/V every minute
starting at the 40 μgm/kg/min of dobutamine.
Max 2 mg Atropine can be used.

41. Side effects :
 Most serious- arrhythmia provocation.
 Rare but serious – Cardiac arrest,
Arrhythmia, MI.
 Less serious –Tremor,
nervousness,
marked hypotension( due to ischemia
and dynamic outflow tract obstruction).

42. Combat with the
side effects of
Dobutamine

43. Emergency management for
S/E :
The effect of dobutamine may be reversed if
angina or other severe side effects develops by
Giving…
 Inj Esmolol (0.5 to 1 mg/kg body wt)
over 1 min
or
 Inj Metoprolol ( 2 to 5 mg/kg body wt)
over 2-5 min

44. WMA grading :
 Normal
 Hypokinetic : marked reduction in
endocardial motion and
thickening .
 Akinetic : virtual absence of inward
motion and thickening
 Dyskinetic /paradoxical wall motion during
systole.

45. Interpretation:

46. Causes of false positive and
false negative stress echo:

47. Myocarial zone : coronary
vessels

49. Sample pictures of
DSE

50. Apical 4 chamber view:

51. Apical 2 chamber view :

52. Short axis view :

53. Parasternal long axis view :