Stress echocardiography: Need to optimize its appropriate use in suspected angina and a review of available additional tools for its clinical application in 2018: First do no harm! second do it at the highest possible accuracy

Abstract

There is a need to reassess the most appropriate indications for stress echocardiography in the current era, in patients with suspect or known coronary artery disease (CAD), and also the most helpful additional parameters that can be easily calculated in clinical practice to increase the known suboptimal sensitivity for obstructive CAD of this test. The current review tries to clarify what is and what should be the proper role for functional testing in general, but specifically regarding modern stress echocardiography in the current practice, for suspected CAD and/or atypical chest pain. Few candidate additional parameters beyond wall motion assessment are here suggested to improve diagnostic accuracy of stress echocardiography, and pertinent literature is briefly reviewed, together with a more personal view of the author regarding the characteristics of each parameter, as far as ease of acquisition, cost, and true diagnostic or prognostic clinical usefulness are concerned. The reviewed additional parameters, which can be acquired during stress echocardiography, are Doppler coronary flow reserve in the left anterior descending artery, cardiac calcium score, global longitudinal strain, ventricular elastance, and contrast myocardial perfusion. Each of them finds a potential place in the current practice or may find a place in the future practice of stress echocardiography.

Evolution of Stress Echocardiogram in the Era of CT Angiography

“…One of the fundamental flaws in our cardiology community is our view on revascularization [ 20 ]. Coronary revascularization is usually considered the primary treatment approach for CAD.…”

“…There is a substantial disregard for medical therapy [ 21 ]. This doctrine has a domino effect on imaging and may partially be responsible for the rise of coronary CTA and the fall of stress testing [ 20 ]. Coronary CTA is frequently used as a screening tool to identify obstructive disease in asymptomatic and mildly symptomatic patients [ 20 ].…”

“…This doctrine has a domino effect on imaging and may partially be responsible for the rise of coronary CTA and the fall of stress testing [ 20 ]. Coronary CTA is frequently used as a screening tool to identify obstructive disease in asymptomatic and mildly symptomatic patients [ 20 ]. The mere presence of blockage in these patients automatically leads to revascularization.…”

“…The European Society of Cardiology (ESC) strongly opposes stress testing in CAD patients with less than a 15% pre-test probability [ 26 ]. If a patient has a low pre-test probability, no diagnostic testing is recommended [ 20 ]. This aids in the conservation of medical resources.…”

Mitochondrial mutations associated with cardiac angina

“…One of the main risk factors for cardiac angina is a atherosclerosis of coronary arteries [2][3][4][5][6] . Other risk factors for cardiac angina include hypertension, diabetes mellitus, obesity, smoking; stress, hypodynamia, infectious diseases, allergic lesions and genetic mutations [7][8][9][10][11][12] .…”