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Regional wall motion abnormality (RWMA) can be absent during stress echocardiography (SE) in patients with chronic coronary syndromes (CCS) and angiographically significant coronary artery disease (CAD) despite a reduction of coronary flow velocity reserve (CFVR).

Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies.

Coronary flow velocity reserve (CFVR) measured in the left anterior descending artery during high-dose vasodilator stress echocardiography interrogates both epicardial and microcirculatory coronary function and has been inversely associated with chronic inflammation and microvascular dysfunction, as well as with the presence of obstructive coronary artery disease. Microvascular dysfunction and chronic inflammation are common mechanisms of disease in cardiovascular (CV) and non-CV conditions. We aimed to assess whether CFVR is associated with all-cause death, but more specifically with CV, cancer, and non-CV and noncancer (NCVNC) mortality, independently and increasingly over other demographic, clinical, and echocardiography variables.

Risk prediction of future atherothrombotic cardiovascular events is currently based on conventional risk factor assessment and the use of validated algorithms, such as the Framingham Risk Score, the Pooled Cohort Equations, and the European SCORE Risk Charts. However, the identification of subclinical organ damage has emerged as a potentially more accurate predictor of individual risk. Several imaging modalities have been proposed for identification of preclinical atherosclerosis. Coronary artery calcification scanning performed using cardiac computed tomography and calculation of the Agatston score is the most commonly used technique in clinical practice for detection of subclinical disease, prognostic stratification of asymptomatic individuals and implementation of preventive strategies. Furthermore, conventional echocardiographic examination may offer an assessment of cardiac calcifications at different sites, such as the mitral apparatus (including annulus, leaflets and papillary muscles), aortic valve and ascending aorta, that are associated with the clinical manifestation of atherosclerotic disease and are predictive of future cardiovascular events. The aim of this paper is to summarize available evidence on the clinical use of cardiac calcification, review the pathogenetic mechanisms involved, including similarities with atherosclerosis, and evaluate its potential for risk stratification and prevention of clinical events in the primary prevention setting.

Regional wall motion abnormality is considered a sensitive and specific marker of ischemia during stress echocardiography (SE). However, ischemia is a multifaceted entity associated with either coronary artery disease (CAD) or angina with normal coronary arteries, a distinction difficult to make using a single sign. The aim of this study was to evaluate the diagnostic potential of the five-step ABCDE SE protocol for CAD detection.

We compared the long-term outcome of subjects without prior cardiac disease who underwent either vasodilator single-photon emission computed tomography (SPECT) or contrast stress-echocardiography (cSE) for suspected coronary artery disease (CAD).

A fully automatic machine learning–based analysis of late gadolinium enhancement cardiac MRI quantified myocardial scar and improved prediction of major adverse cardiac events compared with current guidelines.

Real-time contrast stress echocardiography (RTCSE) permits the simultaneous analysis of myocardial perfusion and wall motion during stress echocardiography, which has resulted in improved coronary artery disease detection. Although several studies have confirmed a protective effect of obesity in coronary artery disease, it is unclear whether this benefit is dependent on the functional significance of the disease. The objective of this study was to compare outcomes in obese versus nonobese subjects referred for pharmacologic RTCSE.

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown.

Myocardial bridging (MB) correlation with ischemia remains a diagnostic challenge. There is a lack of studies that have assessed MB using contrast stress echo and compared the findings with those in patients demonstrating a normal coronary course, with or without obstructive coronary artery disease (CAD).

Background:Quantitative volumetric assessment of the right ventricle (RV) can significantly enhance risk stratification in heart failure (HF), especially with the increasing availability of cardiac MRI (CMR). The prognostic value of RV dilation measured by RV end diastolic volume indexed to body surface area (RVEDVi) is not yet well established. In this analysis, we investigate the prognostic significance of RVEDVi measured by CMR in a stable HF cohort.Methods:We conducted a retrospective analysis on the DERIVATE registry, a large cohort of stable HF patients who underwent baseline CMR and echocardiography assessment. We used the cut-off value 90ml/m2as the upper limit of normal for CMR-derived RVEDVi. The primary outcome was all-cause mortality (ACM), while the secondary outcome was a composite of ACM and/or heart failure hospitalization (HFH). A Cox proportional hazard model was used to evaluate the association with outcomes.Results:2,447 patients with HF and reduced ejection fraction (HFrEF) were included, with a median follow-up time of 959 days (IQR: 560-1590). Mean LVEF was 34.0 ± 10.8, mean age was 59.8 ± 14.0 years and 42% were females. Mean RVEDVi was 75.0 ± 29.4 ml/m2and 23.2% had an RVEDVi >90 ml/m2. Elevated RVEDVi (>90 ml/m2) was significantly associated with an increased risk for ACM (aHR= 1.40, 95% CI [1.17-1.67] p=0.01) and the composite of ACM/HFH (aHR= 1.40, 95% CI [1.03-1.90] p= 0.03).Conclusion:In a large cohort of HFrEF undergoing baseline CMR, elevated RVEDVi was associated with an increased risk of ACM and ACM and/or HFH, independent of LV systolic function.

Cardiovascular risk prediction is deemed fundamental and the assessment of organ damage is emerging as a potentially ‘downstream’ picture of individual risk. Our aim was to assess the feasibility and value of prediction of coronaropathy coronary artery disease (CAD) of integrated cardiovascular ultrasound examination.

Myocardium subtended by obstructive coronary artery disease (CAD) may show reduced left ventricle (LV) global longitudinal strain (GLS), as well as early systolic lengthening (ESL) before shortening; these can be measured at rest and may predict obstructive CAD. This study investigated whether baseline resting LV longitudinal strain measurements may be able to detect significant CAD in patients undergoing stress echocardiography (SE) and coronary angiography, who have normal resting wall motion. We selected patients with a clinical indication of coronary angiography who were previously referred for SE. Patients with known CAD, rest wall-motion (WM) abnormalities, or rhythm/conduction abnormalities were excluded. Speckle tracking strain analyses were retrospectively performed on digitally archived 2D video-loops, using vendor independent software. Peak GLS and duration of ESL were recorded. Diagnostic accuracy of each parameter to predict obstructive (≥50%) CAD was assessed and multivariate logistic regression models fitted and compared. Eighty-two patients were enrolled and 49 had significant CAD by quantitative angiography. Patients with CAD were more often male (P=0.01) and more frequently presented with typical angina (P<0.01). Among rest and stress variables, GLS showed a Youden index of 0.665, while SE WM assessment showed a Youden index of 0.599. These were the only two parameters that remained predictive in multivariate analyses. In conclusion, rest GLS demonstrated comparable accuracy with stress-echo data for prediction of angiographically obstructive CAD; it also added significant CAD prediction when combined with clinical data, similar to SE WM assessment.

A 52-year-old man presented after one episode of effort angina, normal treadmill electrocardiogram (ECG), and clearly positive adenosine cardiac magnetic resonance (aCMR) for reversible perfusion defects in the left anterior descending (LAD) coronary artery territory. Contrast high-dose dipyridamole (0.84 mg/kg per 6 min) stress echocardiography (cSE) demonstrated normal myocardial perfusion (MP) and wall motion at rest, while perfusion defects were shown in the lateral and apical segments after dipyridamole. Wall motion at stress was completely normal and stress/rest Doppler diastolic velocity ratio on the LAD demonstrated reduced flow reserve. In this case, cSE was the provocative test detecting both the LAD and circumflex obstructive lesions, thanks to MP analysis, while wall motion assessment was negative, not different from treadmill ECG, and aCMR highlighted only the LAD disease.

The addition of myocardial perfusion (MP) imaging during dipyridamole real-time contrast echocardiography improves the sensitivity to detect coronary artery disease, but its prognostic value to predict hard cardiac events in large numbers of patients with known or suspected coronary artery disease remains unknown.

An important goal of noninvasive stress testing is the identification of patients with left main coronary artery or three-vessel disease, because coronary artery disease extension and severity are major prognostic factors in ischemic heart disease. Wall motion abnormalities during vasodilator stress echocardiography become apparent in more than one coronary territory only in a small number of patients with multivessel disease. The aim of this study was to assess the value of change in left ventricular ejection fraction change (ΔLVEF) to identify patients with multivessel obstructive coronary artery disease during dipyridamole stress echocardiography.

No large study has demonstrated that any stress test can risk-stratify future hard cardiac events (cardiac death or myocardial infarction) in patients with suspected acute coronary syndromes (ACS), nondiagnostic electrocardiographic (ECG) findings, and normal troponin levels. The aim of this study was to test the hypothesis that combined contrast wall motion and myocardial perfusion echocardiographic assessment (cMCE) during stress echocardiography can predict long-term hard cardiac events in patients with suspected ACS, nondiagnostic ECG findings, and normal troponin.

Wall motion (WM), Doppler-derived measurement of the coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD), and myocardial perfusion imaging (MPI) can be sequentially assessed during dipyridamole stress echocardiography. Data regarding the relative diagnostic value of each of these parameters when assessed during the same examination in patients with suspected coronary artery disease (CAD) are lacking.

Objectives: The aims of this study were to investigate the clinical agreement between myocardial performance index (MPI) measured conventionally and by pulsed-wave tissue Doppler (PW-TD) of the mitral annulus, and to test whether PW-TD MPI can accurately differentiate between healthy subjects and patients affected by congestive heart failure (CHF) with mild to moderate reduction of systolic function. Background: Calculation of MPI using PW-TD may have advantages over conventional left ventricle inflow/outflow tract pulsed-wave Doppler (PWD) method; for example, all of the data needed for PW-TD MPI calculation can be derived from one single cardiac cycle, whereas with PWD at least two different cycles are needed. Thus, heart rate variability does not interfere with PW-TD MPI. Methods and Results: In group A, we included 70 healthy adults with normal left ventricular ejection fraction and normal diastole, whereas for group B we studied 50 patients with CHF and left ventricular ejection fraction between 35% and 45%. MPI measured with PWD was statistically different (P < .0001) from MPI measured with PW-TD both in group A (0.33 +/- 0.09 vs 0.42 +/- 0.09) and group B (0.69 +/- 0.15 vs 0.79 +/- 0.12). Nonetheless, clinical agreement existed between the two methods in the single subject. Receiver operating characteristic curves showed very high accuracy for both methods to discriminate patients with CHF from healthy subjects; the optimal cutoff point was different and specific to each method: 0.50 for the conventional method and 0.60 for the PW-TD method. Conclusion: We found clinical agreement between MPI measured in the same subject with the conventional PWD method and with PW-TD. Both methods had similarly high diagnostic accuracy for CHF, but this study supports the use of a higher MPI cut-point for best diagnostic accuracy when using the new PW-TD method. Summary: We performed a study in healthy adults and in patients with congestive heart failure to investigate the clinical agreement between MPI measured conventionally and by PW-TD of the mitral annulus. We found mild agreement between MPI measured by the conventional method and by PW-TD. Both methods had high diagnostic accuracy for CHF. PW-TD method requires a higher MPI cut-point for best diagnostic accuracy.

Reduced GLS of the left ventricle is associated with adverse prognosis in healthy subjects and in different cardiovascular conditions. Rest GLS may enable risk assessment independently from stress-echocardiography (SE). We assessed whether there is an association of global longitudinal strain (GLS) measured at rest before SE with long-term outcome, independent of clinical parameters or inducible wall motion abnormalities (RWMA) and Doppler coronary flow velocity reserve (CFVR).

Acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality worldwide, placing a major economic and resource burden on public health systems. During hospitalization, all AMI patients should be evaluated with transthoracic echocardiography, a noninvasive, low-cost, and easily available bedside imaging tool that allows the detection of myocardial walls involved in the ischemic process, damage extent, functional consequences, and mechanical complications. Moreover, and more importantly, transthoracic echocardiography can provide information on short- and long-term outcomes after AMI. The purpose of this review is to clarify the role of standard and advanced echocardiographic parameters for an early identification of patients at high risk for developing adverse events and mortality after AMI. Standard echocardiography (in particular left ventricular ejection fraction, wall motion score index, and diastolic measurements including E velocity deceleration time and E/e′ ratio) proposes powerful parameters for risk stratification after AMI. Advanced echocardiographic technologies, in particular speckle-tracking–derived longitudinal strain, coronary flow velocity reserve, and myocardial contrast echocardiography (contrast defect index), can provide additional prognostic value beyond standard techniques. Therefore, echocardiography plays a fundamental role in predicting short- and long-term prognosis, and a more accurate risk stratification of patients may be useful to drive therapy and follow-up after AMI. Accordingly, a comprehensive echocardiography-based algorithm would be welcome for an early stratification of cardiovascular risk in patients experiencing AMI.

Aims According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima–media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk. Methods and results In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10–20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination. Conclusions Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.