Abstract
Cost effective diagnostic detection of coronary artery disease using stress echocardiography combines echocardiography with a physical, pharmacological, or in rare cases pacing stress. Myocardial ischemia is detected by the induction of a transient worsening in regional and potentially global systolic and diastolic function during stress. The diagnostic and prognostic accuracy of stress echocardiography is similar to that of radionuclide stress perfusion imaging, providing a radiation-free, validated diagnostic modality with a favourable cost/risk-benefit ratio. To generate cardiac stress, semisupine exercise, dobutamine or vasodilator agents are commonly used. Both exercise and pharmacological stress echocardiography are suitable to overcome diagnostic limitations in the patient subgroups of females and diabetics, thus increasing the sensitivity of the stress test compared to conventional ergometric ECG based tests. Recent meta analyses have demonstrated that stress echo tests have a high negative predictive value as high as SPECT over periods up to 30 months. Contrast agents are approved for left ventricular opacification, improving the accuracy of regional and global ventricular function analysis. The additional value of myocardial perfusion contrast echocardiography is currently under investigation in two multicenter international trials. New emerging fields that are not yet applicable for clinical routine stress echocardiography include Doppler and speckle analysis of the left-ventricular myocardium and multidimensional image acquisition plus short axis multislice image processing under stress conditions. To date, stress echocardiography is one of the most cost-effective and risk-effective diagnostic cardiac modalities with prognostic implications for patients with coronary artery disease.
Kernaussagen
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Hauptindikationen der Stressechokardiografie unter Prognosegesichtspunkten ist die Beurteilung von bedeutsamen Stenosen bei Patienten mit einer KHK. Es können Patienten bestimmt werden, die von einer therapeutischen Revaskularisierung profitieren. Die Stressechokardiografie ist eine strahlenfreie, validierte und risikoarme Methode. Belastungen können ergometrisch und pharmakologisch eine signifikante Myokardischämie darstellen oder mit einer hohen Sicherheit ausschließen.
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Die Sensitivität der Stressechokardiografie wird von Anzahl und Lokalisation der Stenosen bestimmt. Drei-Gefäß-KHK und RIVA-Stenosen werden mit sehr hoher Sensitivität erkannt. Bei peripheren Stenosen und Eingefäßerkrankungen von RCx und RCA ist die Sensitivität geringer.
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Negative Stressechokardiografien haben für alle Risikogruppen eine gute Prognose. Positive Stressechokardiografien mit größeren Wandbewegungsarealen und bei Verschlechterung der globalen systolischen Funktion identifizieren ein Hochrisikokollektiv, das von einer gerichteten Revaskularisierung stark profitiert.
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Die Methode ist für Frauen und Patienten mit Diabetes mellitus gut geeignet und ermöglicht eine diagnostische Ausbelastung durch pharmakologische Verfahren in beiden Gruppen.
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Neue Ansätze zur weiteren Verbesserung der Testreproduzierbarkeit sind der Einsatz von Doppler- und Gewebetexturanalysen und der Einsatz von Kontrastmitteln zur Konturverbesserung des Endokards und zur Perfusionsanalyse des Myokards.
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Dr. med. Ralph Stephan von Bardeleben
2. Medizinische Klinik und Poliklinik Kardiologie
Johannes-Gutenberg-Universität Mainz
Langenbeckstraße 1
55131 Mainz
eMail: von.Bardeleben@ukmainz.de
