Improving stress echocardiography-based decision pathways for coronary intervention patients: where can current and previous trials improve real-world practice?

Abstract

Introduction: Stress echocardiography (SE) is a widely used noninvasive imaging method to detect myocardial ischemia and assess prognosis in patients with suspected or established coronary artery disease (CAD). However, its results may challenge clinical interpretation and individualized management when technical performance is inadequate.

Areas covered: This review summarizes key diagnostic issues regarding SE that affect interpretation and clinical decision pathways for coronary intervention, including: discordance between SE and coronary angiography findings (positive studies with non-obstructive coronaries and negative studies with anatomically significant stenoses), limited myocardial ischemia, and normal wall-motion response with ischemic ECG changes or chest pain. In addition to that, this review discusses issues in specific patient groups like those with small LV cavity/LV hypertrophy, left bundle branch block, extensive baseline wall-motion abnormalities, and atrial fibrillation/arrhythmias. Moreover, we have mentioned recent technological advances like three-dimesion SE and speckle tracking analysis, which have shown promising preliminary results. An extensive literature search was performed in Pubmed and Embase platforms using the appropriate keywords. Unfortunately, the available data are limited and clinical practice is based on operators' experience.

Expert opinion: SE remains an operator-dependent technique. In order to improve the objectivity of each study, several steps have been proposed like stress workload adequacy, use of contrast agents, coronary microvascular evaluation commitment, and advocacy of adjunctive methods (atropine infusion, hand-grip).