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Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease. [ABSTRACT FROM AUTHOR]

Obesity is a modifiable cardiovascular risk factor, but adipose tissue (AT) depots in humans are anatomically, histologically, and functionally heterogeneous. For example, visceral AT is a pro-atherogenic secretory AT depot, while subcutaneous AT represents a more classical energy storage depot. Perivascular adipose tissue (PVAT) regulates vascular biology via paracrine cross-talk signals. In this position paper, the state-of-the-art knowledge of various AT depots is reviewed providing a consensus definition of PVAT around the coronary arteries, as the AT surrounding the artery up to a distance from its outer wall equal to the luminal diameter of the artery. Special focus is given to the interactions between PVAT and the vascular wall that render PVAT a potential therapeutic target in cardiovascular diseases. This Clinical Consensus Statement also discusses the role of PVAT as a clinically relevant source of diagnostic and prognostic biomarkers of vascular function, which may guide precision medicine in atherosclerosis, hypertension, heart failure, and other cardiovascular diseases. In this article, its role as a 'biosensor' of vascular inflammation is highlighted with description of recent imaging technologies that visualize PVAT in clinical practice, allowing non-invasive quantification of coronary inflammation and the related residual cardiovascular inflammatory risk, guiding deployment of therapeutic interventions. Finally, the current and future clinical applicability of artificial intelligence and machine learning technologies is reviewed that integrate PVAT information into prognostic models to provide clinically meaningful information in primary and secondary prevention. [ABSTRACT FROM AUTHOR]

The human gut microbiota is the microbial ecosystem in the small and large intestines of humans. It has been naturally preserved and evolved to play an important role in the function of the gastrointestinal tract and the physiology of its host, protecting from pathogen colonization, and participating in vitamin synthesis, the functions of the immune system, as well as glucose homeostasis and lipid metabolism, among others. Mounting evidence from animal and human studies indicates that the composition and metabolic profiles of the gut microbiota are linked to the pathogenesis of cardiovascular disease, particularly arterial hypertension, atherosclerosis, and heart failure. In this review article, we provide an overview of the function of the human gut microbiota, summarize, and critically address the evidence linking compositional and functional alterations of the gut microbiota with atherosclerosis and coronary artery disease and discuss the potential of strategies for therapeutically targeting the gut microbiota through various interventions. [ABSTRACT FROM AUTHOR]

Aim The aim of this study was to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicentre, international, effectiveness study. Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, electrocardiogram-based heart rate reserve. Methods and results From July 2016 to November 2020, we enrolled 3574 all-comers (age 65 ± 11 years, 2070 males, 58%; ejection fraction 60 ± 10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent clinically indicated ABCDE-SE. The employed stress modality was exercise (n  = 952, with semi-supine bike, n  = 887, or treadmill, n  = 65 with adenosine for step D) or pharmacological stress (n  = 2622, with vasodilator, n  = 2151; or dobutamine, n  = 471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only endpoint. Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D, and 37% for E steps. During a median follow-up of 21 months (interquartile range: 13–36), 73 deaths occurred. Global X 2 was 49.5 considering clinical variables, 50.7 after step A only (P  = NS (not significant)) and 80.6 after B–E steps (P  < 0.001 vs. step A). Annual mortality rate ranged from 0.4% person-year for score 0 up to 2.7% person-year for score 5. Conclusion ABCDE-SE allows an effective prediction of survival in patients with chronic coronary syndromes. [ABSTRACT FROM AUTHOR]

Aims The aim of the study was to assess the value of coronary flow reserve (CFR) for predicting improvement of left ventricular function after cardiac resynchronization therapy (CRT). Methods and results Study population included 40 patients (mean age 58 ± 9 years) with heart failure (ejection fraction 25, 7 ± 5,4%) and QRS duration of 158 ± 22 ms, planned for CRT. Before and after CRT implantation, CFR was measured non-invasively during hyperaemia induced with adenosine. Responders were defined by decrease in end-systolic volume ≥ 15%. Follow-up echocardiography and CFR measurements were obtained after 6 months. At baseline there was no significant difference in left ventricular ejection fraction (LVEF), QRS duration, 6 min walk test distance and coronary flow velocity at rest between responder (n = 26) vs. non-responder group (n = 14, P = ns). Before CRT implantation, responders compared with non-responders, showed a greater increase in coronary flow velocity during hyperaemia, and consequently higher CFR: 2.41 ± 0.60 vs. 1.61 ± 0.45 (P = 0.001). There was significant correlation between CFR before CRT implantation and LVEF after 6 months (r = 0.545, P = 0.001). End-diastolic, end-systolic left ventricular diameter, and CFR before CRT were predictors of LV functional improvement. By multivariate analysis, only CFR before CRT was independent predictor of left ventricular recovery in the follow-up period (P = 0.001). Conclusion Our results demonstrate that preserved CFR in patients with dilated cardiomyopathy is predictive of left ventricular improvement after CRT implantation. [ABSTRACT FROM AUTHOR]

Aims The aim of this study was to assess the relationship between exercise-induced changes in mitral regurgitation (MR) and echocardiographic characteristics of mitral deformation, global left ventricular (LV) function and shape at rest and after exercise. [ABSTRACT FROM PUBLISHER]

Aims The aim of this study was to assess the prognostic value of myocardial viability recognized as a contractile response to vasodilator stimulation in patients with left ventricular dysfunction in a large scale, prospective, multicentre, observational study.Methods and Results Three hundred and seven patients (mean age 60±10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction and severe left ventricular dysfunction (ejection fraction <35%; mean ejection fraction: 28±7%) were enrolled in the study. Each patient underwent low dose dipyridamole echo (0·28mg.kg−1in 4min). Myocardial viability was identified as an improvement of ≥0·20 in the wall motion score index. By selection, all patients were followed up for a median of 36 months. One-hundred and twenty-four were revascularized either by coronary artery bypass grafting (n=83) or coronary angioplasty (n=41). The only end-point analysed was cardiac death. In the revascularized group, cardiac death occurred in one of the 41 patients with and in 16 of the 83 patients without a viable myocardium (2·4% vs 19·3%,P <0·01). Outcome, as estimated by Kaplan–Meier survival, was better for patients with, compared to patients without, a viable myocardium, who underwent coronary revascularization (97·6 vs 77·4%,P =0·01). Using a Cox proportional hazards model, the presence of myocardial viability was shown to exert a protective effect on survival (chi-square 4·6, hazard ratio 0·1, 95% CI 0·01–0·8,P <0·03). The survival rate in medically treated patients was lower than in revascularized patients irrespective of the presence of a viable myocardium (79·7% vs 86·2,P =ns).Conclusion In severe left ventricular ischaemic dysfunction, myocardial viability, as assessed by low dose dipyridamole echo, is associated with improved survival in revascularized patients. [ABSTRACT FROM PUBLISHER]

Aim The aim of this study was to evaluate simultaneously echocardiographic, haemodynamic and angiographic changes that occur during adenosine and dipyridamole infusion, in patients with one-vessel coronary artery stenosis. This would assess whether deterioration in left ventricular haemodynamics during vasodilator agent infusion is influenced by vasodilation per se, or the development of myocardial ischaemia. Methods and results We performed adenosine (140 μg.kg−1.min−1 over 4 min) and dipyridamole (up to 0·84 mg.kg−1 over 10 min) stress echocardiography tests, together with angiographic and haemodynamic assessment, in 26 patients undergoing elective coronary angioplasty. In 12 of 26 patients, adenosine and dipyridamole tests were repeated 24 h after angioplasty. The criterion for echocardiography test positivity was the appearance of a new transient regional wall motion abnormality. Coronary angiograms were analysed with quantitative coronary arteriography. Adenosine and dipyridamole induced regional dysfunction in 18/26 (69%) and 14/26 (54%) patients before angioplasty, respectively (P=ns). In the echocardiography-positive patients, the percent diameter stenosis was significantly (P<0·05) tighter stenosis than in the echocardiography-negative patients (adenosine, 66·6±8·3% vs 58·0±8·9%; dipyridamole, 69·2±7·1% vs 57·±7·6%). During both tests, left ventricular end-diastolic pressure significantly increased (P<0·05) in echocardiography-positive patients (adenosine, 9·8±2·7 mmHg to 13·5±4·1 mmHg; dipyridamole, 10·1±2·8 mmHg to 14·1±4·3 mmHg), but not in echocardiography-negative patients. In the patients who had undergone successful angioplasty (reduction to <50% diameter stenosis), both adenosine and dipyridamole confirmed the arteriographic success of the procedure (echocardiography negative in all patients). In this group of patients, no significant change was observed in left ventricular end-diastolic pressure during adenosine or dipyridamole infusion. Conclusions Intravenous infusion of either adenosine or dipyridamole was accompanied by an obvious increase in left ventricular end-diastolic pressure only in patients with induced wall motion abnormalities. Coronary vasodilation per se has no significant effect on left ventricular end-diastolic pressure when no ischaemia is induced, disproving any clinically significant ‘erectile’ and adverse effects of coronary vasodilation per se. [ABSTRACT FROM PUBLISHER]

Low (0·56 mg.kg−1 over 4 min) and high (0·48 mg.kg−1 over 10 min) doses of dipyridamole can identify viable myocardium through the contractile recovery of basally dyssynergic regions; however, it also induces ischaemia in susceptible patients. The aim of this study was to assess the potential of an ‘infra-low’ dose of dipyridamole to selectively identify myocardial viability, independently evaluated by low dose dobutamine. Forty patients with resting dyssynergy and angiographically assessed coronary artery disease (1-vessel in 18, 2-vessel in 12, and 3-vessel in 10 patients) separately underwent a low dose dobutamine (5–10μg. kg−1 min for 3 min) echo test and an infra low dose (0·28 mg.kg−1 over 4 min) dipyridamole echo test. Systolic blood pressure (rest: 131±19 mmHg) changed slightly after dobutamine (137±21, P<0·05 vs rest) and remained stable after dipyridamole (130± 17, p=ns vs rest). Heart rate (rest: 68±13 beats. min−1) was also unchanged after dipyridamole (69±12, P=ns vs rest) and increased slightly after dobutamine (71±15, P<0·05 vs rest and vs dipyridamole). No patient developed echocar diographic or electrocardiographic signs of ischaemia after either dipyridamole or dobutamine. Of the 243 segments with baseline dyssynergy, 70 were responders (i.e. they showed an improvement of I grade or more, from I normalIhyperkinetic to 4=dyskinetic in a 16-segment model of the left ventricle) by both dipyndamole and dobutamine, 157 were non-responders (i.e. they showed no change) by both dipyridamole and dobutamine, and 16 showed discordant results (five responders by dipyridamole only; 11 by dobutamine only). The overall concordance of dipyridamole and dobutamine was 93%. An echocardio graphic follow-up could be obtained >6 weeks after suc cessful revascularization (achieved with angioplasty in 17, with by pass surgery in 3) in 19 patients and showed an improvement of one grade or more in 50 segments (viable) and no improvement in 50 segments (necrotic). The sensi tivity of dobutamine and dipyridamole for predicting recov ery was 76 and 78% respectively (p=ns); the specificity of both tests was 94%.In conclusion, infra-low dose dipyridamole is a haemody namically neutral stress test which does not affect either heart rate or systolic blood pressure; it allows myocardial viability to be explored selectively, without eliciting ischae mia; it shows excellent overall concordance with low dose dobutamine and has good sensitivity and excellent specifi city for predicting functional recovery following successful revascularization. [ABSTRACT FROM PUBLISHER]

Stress echocardiography has become an accepted and cost-effective method for diagnosing coronary artery disease. However, as exercise stress echocardiography is a demanding technique, difficult to reproduce, pharmacological stress echocardiography has become very popular in recent years. The two most popular tests from the pharmacological stress echocardiography arena are dipyridamole and dobutamine. They have enabled the technical limitations inherent in exercise echocardiography to be overcome, and have provided the opportunity to obtain, during stress, images of unchanged quality in comparison to baseline. However, the sensitivity of both pharmacological stresses applied separately is less than ideal in patients with milder forms of coronary artery disease and in patients under therapy. To overcome this, a new generation of pharmacological stress tests, the combined dipyridamole-dobutamine tests were introduced. A combined dipyridamole-dobutamine echocardiography stress test should suggest that the agents are natural allies rather than competitors but in some instances they are applicable only in selected patients, and each pharmacological agent may be clinically contraindicated for administration. This is the message from a large scale study of recent years. [ABSTRACT FROM PUBLISHER]

An abstract of the article "Comparison of transthoracic Doppler echocardiography to intracoronary Doppler guide wire measurments for assessment of coronary flow velocity reserve in patients with previous myocardial infarction," by A. Djordjevic-Dikic and colleagues is presented.

An abstract of the article "The prognostic value of coronary flow reserve in patients with single vessel disease and intermediate stenosis severity: a stress echo study," by F. Rigo and colleagues is presented.

An abstract of the article "The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stess echo," by R. Sicari and colleagues is presented.

An abstract of the article "The additional prognostic value of coronary flow reserve on anterior descending artery in patients with positive stress echo by wall motion criteria. A transthoracic vasodilator stress echo study," by F. Rigo and colleagues is presented.

An abstract of the article "Noninvasive assessment of coronary flow reserve after elective stenting in patients with previous myocardial infarction: Relation to left ventricular recovery," by B. Beleslin and colleagues is presented.

An abstract of the article "Can we predict acute coronary events by myocardial jeopardy score in patients with natural progression of coronary artery disease,' by I. Nedeljkovic and colleagues is presented.

An abstract of the article "Chronotropic incompetence vs. echocardiographic ischemia as a predictor of repeat revascularization after the first coronary intervention on left anterior descending coronary artery," by D. Orlic and colleagues is presented.

An abstract of the article "Influence of Beta-Blockade on Results of Low-Dose Dipyridamole Echocardiography Tests for Myocardial Viability" by A. Djordjevic-Dikic and colleagues is presented.

An abstract of the article "Assessment of Myocardial Viability in Patients With Myocardial Infarction: Comparison of Low Dose Dipyridamole Radionuclide Ventriculography With Dipyridamole Stress Echocardiography" by Z. Petrasinovic and colleagues is presented.

An abstract of the article "Cultural Evolution of Digital Description of Coronary Artery Disease Severity Potential of Inducing Myocardial Ischemia During Exercise Stress Echocardiography" by I.P. Nedeljkovic and colleagues is presented.

An abstract of the article "Mental Stress and Myocardial Ischemia: Hemodynamic and Echocardiographic Parameters" by J. Stepanovic and colleagues is presented.

An abstract of the article "Functional mitral regurgitation in patients with prior myocardial infarction - Quantitative exercise-echocardiographic study" by V. Giga and colleagues is presented.

An abstract of the article "Prediction of mortality by modified myocardial jeopardy score: a strategy for combination with stress echocardiography," by I.P. Nedeljkovic and colleagues is presented.