Stress echocardiography, or stress echocardiography, is an ultrasound examination of the heart before and after stress. Exercise may be provided in the form of movement (eg, walking on a treadmill), medication, or electrical stimulation. The purpose of this effect is to speed up the contractions of the heart and identify areas of the myocardium that arise in this case, experiencing a lack of oxygen.
Indications
The reasons and need for stress echocardiography are determined by a cardiologist. The purpose of stress echocardiography is to identify latent coronary insufficiency. In the process of stress echocardiography, the earliest lesions of the coronary arteries are recognized, since impaired myocardial contractility precedes subsequent signs of ischemia - chest pain, ECG abnormalities. Stress echocardiography is indicated for ECG signs of left ventricular hypertrophy, changes in intraventricular conduction, electrolyte imbalances, etc., as well as in the case of false-positive or unreliable results of stress tests.
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Using stress echocardiography, a prognostic assessment of a stable form of angina is made: the absence of initiated ischemia indicates a low, and detection - a high risk of cardiovascular complications. Stress echocardiography is used to dynamically monitor the effectiveness of rehabilitation and treatment tactics after myocardial infarction or CABG surgery. Stress echocardiography with pharmacological tests can be performed in cases where it is impossible to perform a treadmill test or VEM, as well as when the patient cannot achieve the required power load. Stress echocardiography can be useful not only for identifying coronary artery disease, but also for assessing the reserves of myocardial contractility in various heart defects - aortic stenosis, mitral insufficiency and stenosis.
Indications for the study are as follows:
- Surgery on the heart;
- The need to evaluate its performance during the recovery period after a heart attack;
- ECG indicators, swelling and shortness of breath;
- Unsatisfactory results of load application;
- Ischemic disease in the chronic stage;
- Analysis of the effectiveness of therapy;
- Forecast for the development of pathology;
- Suspected angina;
- Work ability analysis;
- Routine examination of professional athletes.
Contraindications
Factors limiting the use of stress echocardiography are the reduced ability to image cardiac structures in obesity, gigantomastia, hyperventilation, and subjectivity in the interpretation of results. The limited use of stress ECHO-CG with physical testing is caused by the fact that in a third of patients the required load cannot be achieved due to pathology of the lungs, peripheral vessels, joints, and poor training. Stress echocardiography is contraindicated in acute myocardial infarction, a history of thromboembolism, congestive heart failure, aortic aneurysm dissection, severe renal, respiratory, and liver failure.
Preparing for the examination
Before undergoing the procedure, the doctor or laboratory assistant instructs the patient how
should be prepared.
Generally, the following is recommended:
- the day before the test, exclude coffee, some carbonated drinks (for example, Coca-Cola, etc.), tea, and chocolates from the diet;
- 4 hours before the test you must stop eating and drinking;
- continue taking medications prescribed by your doctor, be sure to take a list of these medications with you;
- you need to add to the list of documents a copy of the latest ECG, echocardiogram (if available) and a referral from the attending physician for this examination;
- clothes and shoes should not restrict movement.
Be sure to inform the doctor performing the ultrasound examination:
- about medications that are taken, food supplements;
- pregnancy;
- presence of a pacemaker;
as well as about such diseases (if any) as:
- aortic aneurysm;
- hypertonic disease;
- heart valve pathologies;
- severe heart failure;
- recent myocardial infarction, pericarditis;
- severe anemia (low red blood cell count);
- chronic lung disease.
Based on the patient's condition, the doctor may recommend other “special” preparation.
Methodology
Stress echocardiography involves 2 doctors (a diagnostician skilled in echocardiography and a specialist in stress tests) and a nurse assistant. All personnel involved in performing stress echocardiography must have the skills to provide emergency cardiac resuscitation measures, and the office must have the necessary equipment for this (defibrillator) and medications. At the initial stage of stress echocardiography, a resting echocardiogram is standardly recorded in four sections - parasternal, transverse, longitudinal and apical, with the image saved in video loop format. At the same time, the initial indicators of a 12-channel ECG, heart rate, and blood pressure are recorded.
The next stage of stress echocardiography includes provoking ischemia in the chosen way (using dynamic physical activity, pharmacological test, emergency pacemaker, etc.). During the test, all changes in ECG, heart rate and blood pressure are monitored and recorded. When using a horizontal bicycle ergometer test, pharmacological tests, and transesophageal electrical stimulation during stress echocardiography at the stage of ischemia provocation, echocardiographic data is monitored and stored.
Reasons for stopping stress testing during stress echocardiography may include the patient’s refusal to continue the load, the occurrence of unacceptable side effects (headache, nausea, a critical increase in blood pressure, etc.), as well as the registration of ischemic markers. Markers of ischemia include clinical (chest pain, decreased blood pressure, signs of peripheral or cerebral hypoperfusion), electrocardiographic (ST segment elevation or depression without an altered Q wave, the development of dangerous arrhythmias) and echocardiographic (determination of disturbances in regional contractility of the LV) manifestations.
In the post-exertion period, stress echocardiography again records an echocardiogram in standard sections with preservation of video loops. At the final stage of stress echocardiography, all sequentially obtained video images are reproduced on one screen, cardiac cycles are synchronized, and the nature of the mobility of myocardial areas is compared.
Stress echocardiography: the essence of the procedure
An inexpensive and accessible type of non-invasive examination is a type of cardiac ultrasound, supplemented with artificial stimulation of myocardial contractility. Increased rhythm is provoked by certain types of loads. The appearance of foci in the myocardium with a disturbed contraction rhythm is considered to be the first sign of ischemic heart disease, the signals of which are not always recorded by the cardiogram. As a result of oxygen starvation of the organ, ischemic pathology progresses, gradually manifesting itself with the following symptoms:
- deterioration in motor activity in the affected area, which is reflected in ultrasound results;
- detection of changes in ECG graphs obtained under the influence of stress tests;
- subsequent development in the patient of painful compression syndrome behind the sternum.
The essence of diagnosis is to obtain comprehensive information about the work of the heart at the peak of contractions of the maximum frequency. An increase in pulsation is ensured by the action of the load. At this time, the organ requires more oxygen than at rest.
Please note: The main advantage of a stress test is associated with its high information content, in contrast to an ECG with stress tests such as bicycle ergometry and treadmill tests. In cardiology, research is usually carried out to identify early signs of coronary heart disease (CHD).
Patients who do not know what stress echocardiography is are often interested in the question: “why the examination should be carried out under stress.” Thanks to the provoking effect on the organ, the diagnostician receives a visual picture on the monitor showing the areas affected by the disease. During stress tests, various types of loads are used, as well as stress echocardiography modes. Their choice depends on the diagnostic purposes, and the reliability of the results depends on the experience of the doctor performing the procedure.
Interpretation of results
The normal reaction of the myocardium in response to stress during stress echocardiography is characterized by hyperkinesis of the LV walls, an increase in the ejection fraction, the absence of disturbances in the kinetics of the walls, thickening of the walls during systole, and a decrease in end-systolic volume. With a pathological response (positive stress echocardiography test), areas with impaired kinetics (akinesia, hypokinesia, dyskinesia), an increase in the end-systolic volume of the LV, a decrease in wall thickening in systole, a decrease in EF to 35% and below, an increase in the RV, etc. can be determined. The severity of ischemic changes detected during stress echocardiography is judged by the number of affected areas of the LV, the type of asynergic changes, the time of development and disappearance of disorders.
Evaluation of the results of stress diagnostics
The main purpose of stress testing is to compare (local) left ventricular contractility before and after the stress test. Immediately after the procedure, the cardiologist has the opportunity to preliminary analyze the test results. For a more in-depth study of the functioning parameters of a vital organ, a review of the video recording of the process in slow motion mode will be required.
Local contractility of the left ventricle is assessed taking into account the movement of the myocardium and the degree of its thickening in the areas of individual segments. For this purpose, the myocardium of the left ventricle is conventionally divided into sections; it is customary to adhere to the 17-segment model. The criterion for a positive test is a deterioration in the contractility of at least two sections of the ventricle (left), the numerical interpretation is expressed by an index. To calculate it, the degree of contractility of each segment is indicated by points:
- 1 – corresponds to normal motor activity;
- 2 – manifestations of hypokinesia with a reduced level of contractility;
- 3 – signs of loss of normal motor function (akinesia);
- 4 – symptoms of dyskinesia, accompanied by bulging of the wall (aneurysm).
The index of impaired contractility (local) is calculated by dividing the sum of points by the total number of segments participating in the examination.
The painless procedure of stress echocardiography can be prescribed regardless of the patient’s age category; the test is not contraindicated even for pregnant women. The key to absolute safety of the study will be heart testing in a certified clinic staffed by experienced, highly qualified personnel.
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Ivan Grekhov
Graduated from the Ural State Medical University with a degree in General Medicine. General practitioner
Complications
During stress echocardiography, undesirable effects may develop, which will be grounds for stopping the study: headache, muscle tremors, nausea, ventricular and supraventricular extrasystole. Minor complications of stress echocardiography include short episodes of paroxysms (up to 2 minutes) and hemodynamically insignificant tachycardia. Threatening complications of stress echocardiography that require urgent cardiac resuscitation are acute coronary syndrome, ventricular fibrillation, and asystole.
Cost of stress echocardiography in Moscow
The cost of the study varies depending on the type of stress tests. When pricing, the duration and complexity of the test for a specialist are taken into account, as well as the need for additional costs (for example, when conducting tests with drugs). In addition, the price of stress echocardiography in Moscow is determined by the type of diagnostic and treatment institution (public or private), the urgency of the diagnostic procedure and the level of specialist training. If the patient wishes to undergo Stress Echo-CG without a queue, when the procedure is performed by a doctor of the highest category, a candidate or doctor of medical sciences, the cost of the technique may increase.
How to prepare for the procedure
During stress echocardiography, dynamic indicators are measured, which can change depending on external conditions. In this regard, there are rules, the observance of which will help to obtain the most informative and reliable results.
First of all, you need to agree with your doctor about taking medications. Nitrates, beta blockers and other substances that affect preload or vascular tone can significantly distort the results. On the day of the study, it is preferable to stop taking all medications. If angina attacks occur, it is allowed to use fast-acting nitrates.
The day before stress echocardiography, foods containing caffeine or tannin (strong tea, coffee) are excluded. These substances affect blood pressure and myocardial contractility, which can lead to distorted results.
Special attention is paid to nicotine. Due to the spasmodic effect, the perfusion of all tissues, including the myocardium, is reduced. Therefore, one day before the expected stress echocardiography, you should stop smoking cigarettes.
Research Modes
To obtain an informative image, the following modes can be used: a simple M-mode displays a sketch view of the heart, visualizes the thickness of the walls, the size of the ventricles and atria, Doppler echocardiography assesses the work of blood vessels and blood circulation speed, on the screen - a black and white image, or Doppler mapping in color, 2D and 3D echocardiography – a two-dimensional or three-dimensional picture of the heart. The choice of mode depends on the cardiologist and the degree to which the hospital is equipped with the necessary equipment and equipment.
How is it carried out?
Although stress echocardiography does not require special preparation, it is still better to follow several rules before the procedure:
- dress lightly and comfortably, in loose clothing;
- a couple of hours before the test, have a small snack and drink water;
- refrain from coffee during the day before stress echocardiography;
- do not smoke an hour before the procedure;
- at least 3 hours before the procedure, eliminate all physical activity;
- If you are taking any medications, talk to your doctor about it - perhaps the specialist will temporarily stop them in order to obtain more reliable data on the condition of your heart.
The room for carrying out this diagnostic method must be equipped with equipment for carrying out resuscitation measures in case something goes wrong. Also in the office there is a special exercise machine - a bicycle ergometer, on which a person will receive the necessary physical activity.
In practice, doctors most often use medicinal “stress” - drugs are injected into the patient’s veins, which cause an increase in heart rate - usually dobutamine or dipyridamole. The duration of the procedure in general is about an hour.
Stress echocardiography itself is carried out in several stages:
- First, the specialist will take readings of a regular electrocardiogram, measure your pulse and blood pressure, and record an echocardiogram while standing at rest.
- The next stage is to apply stress to the body in the form of physical activity or pharmaceuticals to “provoke” an ischemic attack.
- An echocardiogram is taken again.
- Next, the doctor analyzes the data obtained, comparing the images obtained on the monitor screen.
In case of pain in the heart area, increased blood pressure, or nausea, stress echocardiography can be terminated prematurely.
