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MINERVA CARDIOANGIOLOGICA

Rivista sulle Malattie del Cuore e dei Vasi


Official Journal of the Italian Society of Angiology and Vascular Pathology
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Minerva Cardioangiologica 2018 Apr 11

DOI: 10.23736/S0026-4725.18.04691-1

Copyright © 2018 EDIZIONI MINERVA MEDICA

lingua: Inglese

Integrated quadruple stress echocardiography

Eugenio PICANO 1 , Doralisa MORRONE 2, Maria C. SCALI 3, Alda HUQI 4, Katia COVIELLO 2, Quirino CIAMPI 5

1 CNR Institute of Clinical Physiology, Pisa, Italy; 2 Surgery, Medicine, Molecular and Critical Area Department, Cardiovascular Disease Section-Pisa University, Pisa, Italy; 3 Ospedale Nottola, Siena, Italy; 4 Ospedale Versilia, Viareggio, Italy; 5 Ospedale Fatebenefratelli, Benevento, Italy


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Stress Echocardiography (SE) is an established diagnostic technique. For 40 years, the cornerstone of the technique has been the detection of regional wall motion abnormalities (RWMA), due to the underlying physiologically-relevant epicardial coronary artery stenosis. In the last decade, three new parameters (more objective than RWMA) have shown the potential to integrate and comple- ment RWMA: 1- B-lines, also known as ultrasound lung comets, as a marker of extra-vascular lung water, measured using lung ultrasound with the 4-site simplified scan symmetrically of the antero- lateral thorax on the third intercostal space, from mid-axillary to anterior axillary and mid- clavicular line; 2-left ventricular contractile reserve (LVCR), assessed as the peak stress/rest ratio of left ventricular force, also known as elastance (systolic arterial pressure by cuff sphygmomanome- ter/end-systolic volume from 2D echocardiography); 3- coronary flow velocity reserve (CFVR) on left anterior descending coronary artery, calculated as peak stress/rest ratio of diastolic peak flow velocity assessed using pulsed-wave Doppler. The 4 parameters (RWMA, B-lines, LVCR and CFVR) now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-SE. IQ-SE optimizes the versatility of SE to include in a one-stop shop the core "ABCD" (Asynergy+B-lines+Contractile reserve+Doppler flowmetry) protocol. It allows a synoptic assess- ment of parameters mirroring the epicardial artery stenosis (RWMA), interstitial lung water (B- lines), myocardial function (LVCR) and small coronary vessels (CFVR). Each variable has a clear clinical correlate, different and complementary to all others: RWMA identify an ischemic vs non- ischemic heart; B-lines a wet vs dry lung; LVCR a strong vs weak heart; CFVR a warm vs cold heart. IQ-SE is highly feasible, with minimal increase in the imaging and analysis time, and obvi- ous diagnostic and prognostic impact also beyond coronary artery disease - especially in heart fail- ure. Large scale effectiveness studies with IQ-SE are now under way with the Stress Echo 2020 study, and will provide the necessary evidence base prior to large scale acceptance of the tech- nique.


KEY WORDS: B-lines - Coronary flow - Velocity reserve - Left ventricular force - Regional wall motion abnormalities

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Publication History

Article first published online: April 11, 2018
Manuscript accepted: April 4, 2018
Manuscript received: March 28, 2018

Per citare questo articolo

Picano E, Morrone D, Scali MC, Huqi A, Coviello K, Ciampi Q. Integrated quadruple stress echocardiography. Minerva Cardioangiol 2018 Apr 11. DOI: 10.23736/S0026-4725.18.04691-1

Corresponding author e-mail

picano@ifc.cnr.it