Stress echocardiography in heart failure
© Agricola et al; licensee BioMed Central Ltd. 2004
Received: 12 July 2004
Accepted: 30 July 2004
Published: 30 July 2004
Echocardiography has the ability to noninvasively explore hemodynamic variables during pharmacologic or exercise stress test in patients with heart failure. In this review, we detail some important potential applications of stress echocardiography in patients with heart failure. In patients with coronary artery disease and chronic LV dysfunction, dobutamine stress echocardiography is able to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Exercise testing, in combination with echocardiographic monitoring, is a method of obtaining accurate information in the assessment of functional capacity and prognosis. Functional mitral regurgitation is a common finding in patients with dilated and ischaemic cardiomyopathy and stress echocardiography in the form of exercise or pharmacologic protocols can be useful to evaluate the behaviour of mitral regurgitation. It is clinical useful to search the presence of contractile reserve in non ischemic dilated cardiomyopathy such as to screen or monitor the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents. Moreover, in patients with suspected diastolic heart failure and normal systolic function, exercise echocardiography could be able to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Finally, in the aortic stenosis dobutamine echocardiography can distinguish severe from non-severe stenosis in patients with low transvalvular gradients and depressed left ventricular function.
Keywordsstress echocardiography heart failure diastolic dysfunction mitral regurgitation
Therefore, the present review will detail some important potential applications of stress echocardiography in patients with heart failure in the evaluation of the different clinical and physiopathologic aspects of heart failure syndrome.
Systolic heart failure
Searching the myocardial viability
The most common cause of heart failure in the Western world is coronary artery disease, accounting for up to 60% of cases . In patients with coronary artery disease and chronic LV dysfunction, it is crucial to distinguish between viable and fibrotic tissue to make adequate clinical decisions. Noncontractile but viable myocardium may correspond to different states that are important but difficult to distinguish, i.e., ischemia, stunning, nontransmural infarction, or hibernation and in individual patients these pictures may coexist .
After brief episodes of coronary occlusion and reflow a reversible global LV dysfunction can occur. This phenomenon was called myocardial stunning . It is characterized as prolonged mechanical dysfunction after coronary reflow despite resumption of normal perfusion and lack of permanent tissue damage. Stunning seems to result from alterations in contractile proteins in response to sublethal ischemic insults. This phenomenon can occur in several settings, including after acute reperfused myocardial infarction and after CABG. In humans, the return of functional recovery may require days to weeks . Hence, diagnostic methods to distinguish stunning from necrosis are particularly relevant for clinical investigation and management in patients with acute, severe LV dysfunction or cardiogenic shock after revascularization. Persistent wall motion abnormalities can be observed by echocardiography at a time when chest pain, ST segment deviation, and regional perfusion had recovered. The presence of contractile reserve during dobutamine infusion identifies the stunning but viable myocardium from myocardial necrosis.
The term "Hibernating myocardium" was first termed by Rahimtoola to indicate the state of reversible dysfunctional myocardium, which was considered to be the result of a state of persistently impaired myocardial function at rest, caused by reduced coronary blood flow, and which could be partially or completely restored to normal either by improving blood flow or reducing oxygen demand .
Echocardiography can detect viable myocardium during infusion of drugs which have ability to elicit an enhanced contractile response by recruiting contractile proteins. At least two drugs have these proprieties: the dobutamine, a synthetic β1 agonist with additional α1- and β2-stimulating properties and the enoximone that inhibits cyclic adenosine monophosphate-specific phosphosdiesterase [6, 7]. Routinely, the dobutamine is the most common stressor used, whereas the enoximone is particularly useful in patients on beta-blocker therapy [7, 8]. The mechanism by which dobutamine stimulation elicits a contractile response in hypoperfused dysfunctional segments without precipitating ischemia has been demonstrated by Sun et al. . By using positron emission tomography and echocardiography, they demonstrated that the improvement in contractile function during dobutamine infusion was associated with a concomitant increase in myocardial blood flow. The increase in myocardial blood flow occurs because there is persistent, albeit reduced, coronary flow reserve distal to a stenosis which dobutamine may exploit. Another mechanism whereby contractile response may be elicited during dobutamine infusion is through its peripheral vasodilator effect, which causes reduction in LV end-systolic wall stress by reducing afterload . Moreover, dipyridamole echocardiography (up to 0.84 mg/kg over 10 minutes) can identify regions with myocardial viability . Dipyridamole leads to transiently increased coronary flow, which leads to improved contractility in viable myocardium . A small study comparing dipyridamole with dobutamine revealed 93% concordance . Combined dipyridamole-dobutamine (low-dose dipyridamole followed by low-dose dobutamine) has also been proposed and found to recruit a contractile reserve in some asynergic segments that were nonresponders after dobutamine or dipyridamole alone .
An initial evaluation of end diastolic wall thickness of akinetic segments with resting echocardiography can be used as an initial screening technique for assessment of viability. Indeed, akinetic regions with an end diastolic wall thickness <6 mm do not contain viable myocardium and do not improve in function after revascularization . However, in segments with a thickness ≥ 6 mm, additional testing is needed because approximately 40% of these regions do not contain viable myocardium and will not improve after revascularization . Therefore, myocardial thinning should not be equated with the lack of myocardial viability, and in some patients, these regions can improve in contractile function after revascularization . The detection of subendocardial infarcts became clinically relevant because the quantification of non-viable myocardium in addition to viable myocardium in that region of LV is important in predicting contractile improvement following revascularization. Thus, the ratio of viable to total myocardium (viable plus non-viable) in the dysfunctional region was more accurate that absolute amount of viable myocardium alone in predicting functional improvement . Unfortunately, currently available techniques, such as single photon emission computed tomography, dobutamine stress echocardiography and positron emission tomography are still insufficient to provide a comprehensive assessment including the evaluation of subendocardial infraction with respect to magnetic resonance imaging .
During stress echocardiography is possible to observe four response patterns based on regional wall function: normal, ischemic, viable and necrotic. In the normal response, a segment is normokinetic at rest and normal or hyperkinetic during stress. In the ischemic response, a segment worsens its function during stress from normokinesis to dyssynergy. In the necrotic response, a segment akinesia remains akinetic during stress. In the viability response, a segment with resting dysfunction improves during stress. During pharmacologic stress, a viable response at low dose can be followed by ischemic response at high dose (biphasic response). This biphasic response is suggestive of viability and ischemia, with jeopardized myocardium fed by a critically stenosed coronary artery . A resting akinesia which becomes dyskinesia during stress reflects a purely passive mechanical phenomenon and should not be considered a true active ischemia.
The overall sensitivity and specificity of dobutamine echocardiography for predicting recovery of regional function after revascularization was 84% and 81% respectively . In a study by Afridi et al., the best predictive value for recovery of function after revascularization was most often noted in patients demonstrating an ischemic response during low and high doses of dobutamine infusion . On the other hand, sustained improvement of regional function during dobutamine infusion was a poor marker of recovery function.
Sensitivity of dobutamine echocardiography may be affected by several factors such as the severe reduction of myocardial blood flow that can preclude the contractile response, the premature interruption of dobutamine infusion, resting tachycardia that may renders the myocardium ischemic and dobutamine can only augment ischemia . On the contrary, the specificity may be affected by the tethering effect, the injured subendocardial portion of myocardium that does not respond to dobutamine when the infarction is confined to subendocardium, and also specificity may be reduced in myocardial regions that do not develop an ischemic response .
Assessing the functional capacity
In most patients with chronic heart failure, symptoms are not present at rest but become limiting with exercise. Despite this, the major measures used to characterise the symptoms, the severity, the mechanisms and the prognosis of heart failure are obtained at rest. Exercise testing, in combination with echocardiographic monitoring, may be an attractive and practical method of obtaining accurate information which can aid in the diagnosis of heart failure as well as the assessment of functional limitation and prognosis. Exercise rather than dobutamine is the stressor of choice to evaluate functional capacity due to the possibility to combine echocardiographic variables with common parameters available during physiologic exercise.
Symptom limited exercise testing can be undertaken using either treadmill or bicycle exercise protocols. Available data about the safety of exercise testing in patients with significant heart failure suggest a very low incidence of serious adverse events such as arrythmias or hypothension.
Potential parameters obtainable during exercise echocardiography.
Common variables during exercise test
Additional echocardiographic variables during exercise test
Duration of exercise
Mitral valve function
Pulmonary systolic pressure
Right ventricular function
VO2 workload ratio
Additive prognostic value of stress echo in patients with intermediate values of VO2max (10–14 ml/Kg/min).
Low (5–10% year)
High (≥ 25–30% year)
≥ 8–10 min
Right ventricular dysfunction
↓ or =
Looking at the behaviour of mitral valve
MR is a common finding in heart failure patients. In patients with dilated and ischaemic cardiomyopathy, the MR is typically functional and reflects geometric distortions of LV chamber, which displaces the normal valve and subvalvar closing mechanisms. This functional MR is a consequence of adverse LV remodelling and increased sphericity of the chamber. It is typically dynamic and a marker of adverse prognosis. The 5-year survival of heart failure patients with functional MR ranges from 39.9% to 48.7% depending on the degree of MR .
Stress echocardiography in the form of exercise or pharmacologic protocols can be useful in the assessment of MR. Exercise echocardiography is usually preferred due to the possibility to reproduce physiological setting. Even though supine bike protocol allows to obtain good image acquisition, upright bicycle or treadmill protocols are more frequently utilized in the practical setting. Treadmill exercises can be performed using the standard protocols such as Bruce or modified Bruce, while gradual increase in the bike workload of 20–25 W every 2–3 minutes is often applied until the patients achieves either the target heart rate or develops symptoms of fatigue or shortness of breath. Sometimes, pharmacologic stress is used with dobutamine protocol at low or intermediate doses infusion. In the collection of echocardiographic data should be included: the MR jet to evaluate the MR jet area and the vena contracta width, the velocity time integrals (mitral and aortic) to calculate the regugitant volume and the effective regurgitant orifice area (EROA), the LV volumes to assess the myocardial contractility and the tricuspid regurgitant jet velocity to measure the sPAP that is an useful index of the haemodynamic burden of MR.
Evaluating the contractile reserve beyond hibernating myocardium
It is commonly believed that the assessment of contractile reserve is only confined and clinically useful to search the myocardial viability in patients with LV dysfunction and coronary artery disease. Growing published data suggest the utility in searching the presence of contractile reserve in non ischemic dilated cardiomyopathy (DCM). While in the ischemic cardiomyopathy the search of myocardial viability is focused to find the presence of reversible segmental myocardial dysfunction and its possible effect on global systolic LV recovery after revascularization, in DCM the primary end point is to evaluate the presence of residual global contractile reserve. Both dobutamine and exercise testing have been used in the study patients with DCM, but there is a clear predominance for the use of dobutamine test. The doses of dobutamine utilized vary from investigators, but safety in its use in this population has been documented in doses as high as 40 μg/kg per minute. In the interpretation of results both wall motion score index and the LV volume to derive LVEF must be calculated.
LV systolic function at the time of diagnosis has been proposed to be the strongest predictor of survival in DCM, but now the presence of contractile reserve recognised by dobutamine echocardiography seems to be the best marker of good prognosis in patients with severe LV dysfunction at rest [37, 38]. Patients with significant improvement in their wall motion score index and LVEF during dobutamine infusion have a better survival rate and increase in the LVEF during follow-up period . The data extracted from dobutamine study can be used as an adjunct or alternative to predict VO2max and exercise capacity of patients with heart failure, especially when the patients fall into the gray zone of VO2max (10–14 ml/kg/min) or when there is limitation to ambulation . Moreover, the response to dobutamine infusion predicts the improvement in LVEF with beta-blocker therapy in patients with advanced heart failure. Patients with contractile reserve experienced a greater improvement in LVEF with beta-blocker by biologically augmenting myocyte a chamber contractility . Whereas, in the absence of contractile reserve (when myocytes have been replaced by fibrosis), ventricular function cannot improve by this biological mechanism because there are not enough contractile units and the sympatholytic effects of beta-blocker prevail . However, the clinical use of dobutamine stress echocardiography in patients with chronic heart failure may be limited by a substantial proportion of patients already receiving beta-blocker therapy at time of evaluation. In these patients enoximone echocardiography might be a valid alternative to low-dose dobutamine for evaluating contractile reserve showing a more potent and a better safety profile than dobutamine .
Stress echocardiography may also help in the identification of patients in the initial phase of cardiomyopathy overt normal resting echocardiographic parameters. Both dobutamine and exercise have to be used to screen for the presence of latent myocardial dysfunction in patients who had exposure to cardiotoxic agents .
Diastolic heart failure
The prevalence of diastolic heart failure in the community is now to be at least as high as that reported in previous studies of hospitalised patients; almost half of all patients with heart failure have diastolic heart failure . The term asymptomatic diastolic dysfunction is used to refer to an asymptomatic patient with a normal LVEF and abnormal echo-Doppler pattern of LV filling; this is often seen, for example, in patients with hypertensive heart disease. If such patients exhibit symptoms of effort intolerance and dyspnoea, especially if there are evidence of venous congestion and edema, the term diastolic heart failure can be used .
Resting echocardiography is most useful in the assessment of LV size, LVEF and the use of Doppler-derived indices of diastolic function has impact on the identification of diastolic dysfunction. However, to determine whether an abnormality of diastolic function is the cause of the patient's symptoms, we need to demonstrate the existence of such dysfunction and determine that it is sufficient to limit exercise tolerance. Therefore, the stress echocardiography, in particular exercise echocardiography could be useful in dyspnoeic patients with apparently normal LV function to unmask the presence of diastolic dysfunction (signs of elevated LV filling pressure) during exercise as cause of symptoms.
Patients with diastolic heart failure, as well as those with diastolic dysfunction and little or no congestion, exhibit exercise intolerance for several reasons. First, an elevated LV diastolic and pulmonary venous pressure during exercise causes reduction in lung compliance, which increases work of breathing and evokes the symptom of dyspnoea . Second, a substantial number of patients who have LV hypertrophy, high relative wall thickness and small end diastolic volume exhibit a low stroke volume and a depressed cardiac output . These hearts exhibit a limited ability to utilize the Frank-Starling mechanism during exercise. Such limited preload reserve, specially if coupled with the chronotropic incompetence limits the cardiac output during exercise . Third, elevated LV diastolic and pulmonary venous pressures in patients with normal LVEF are directly related to abnormalities in the diastolic proprieties of the ventricle. This is not to say contractile function is entirely normal, but subtle and latent abnormalities of contractile function could be present in many patients, in whom, however, diastolic dysfunction is the dominant feature .
Useful echocardiographic parameters to evaluate diastolic function during exercise test in patients with suspected diastolic heart failure.
Transmitral Doppler indices
Pulmonary systolic artery pressure
Aortic stenosis with left ventricular dysfunction
Stress echocardiography with dobutamine infusion is particularly useful in clinical decision making in patients with aortic stenosis with LV dysfunction and low transvalvular gradients. In this group of patients, an important clinical question rises: is the low gradient a consequence of low cardiac output due to a severe aortic stenosis which has led to LV dysfunction or is the low gradient a consequence of LV dysfunction is unrelated to aortic stenosis and the aortic stenosis is an incidental finding?
It is well known that the transvalvular gradients are flow-depentent parameters so that they are influenced by LV function. The aortic valve area can be accurately determined by Doppler echocardiography with continuity equation and that correlate well with Gorlin formula . However, it has been shown that valve areas calculated by the Gorlin formula is flow-dependent and usually increase with flow, probably due to the flow dependence of the empirical constant C of the Gorlin formula, which represents the ratio of effective to anatomical orifice area. Burwash et al., with dobutamine stress-echocardiography, demonstrate a flow-dependent increase in actual orifice aortic valvular area calculated with continuity equation .
When interpreting the results of a dobutamine study in these patients to rule out or confirm definitively the presence of a severe fixed aortic stenosis, it is advisable to use an absolute cut-off value of the aortic valve area at peak of dobutamine >1 cm2 rather than an increase of ≥ 0.3 cm2 from baseline alone [49, 50].
Beyond the identification of viable hibernating myocardium, stress echocardiography is particular useful in patients with systolic and diastolic heart failure to assess the different physiopathologic component of heart failure syndrome and can aid to an appropriate clinical decision making.
Concerning the authorship, the listed authors have contributed as follows to the manuscript:
EA and MP: 1) conception, design, analysis and interpretation of data, 2) drafting of the manuscript and 3) final approval of the manuscript
MO and AM: 1) critical revision of the manuscript for important intellectual content, and 3) final approval of the manuscript.
List of abbreviations
- LV :
- MR :
- LVEF :
left ventricular ejection fraction
- DCM :
- TAPSE :
Tricuspid annular plane systolic excursion
- sPAP :
Systolic pulmonary artery pressure
- Teerlink JR, Goldhaber SZ, Pfeffer MA: An overview of contemporary etiologies of congestive heart failure. Am Heart J 1991,121(6 Pt 1):1852-1853. 10.1016/0002-8703(91)90072-PView ArticlePubMedGoogle Scholar
- Shulz R, Heusch G: Characterization of hibernating and stunned myocardium. Eur Heart J 1995,16(Suppl J):19-25.View ArticleGoogle Scholar
- Braunwald E, Kloner RA: The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982, 66: 1146-1149.View ArticlePubMedGoogle Scholar
- Kloner RA, Bolli R, Marban E, Reinlib L, Braunwald E: Medical and cellular implications of stunning, hibernation, and preconditioning: an NHLBI workshop. Circulation 1998, 97: 1848-1867.View ArticlePubMedGoogle Scholar
- Rahimtoola SH: The hibernating myocardium. Am Heart J 1989, 117: 211-221. 10.1016/0002-8703(89)90685-6View ArticlePubMedGoogle Scholar
- Sun KT, Czernin J, Krivokapich J, Lau YK, Bottcher M, Maurer G, Phelps ME, Schelbert HR: Effects of dobutamine stimulation on myocardial blood flow, glucose metabolism, and wall motion in normal and dysfunctional myocardium. Circulation 1996, 94: 3146-3154.View ArticlePubMedGoogle Scholar
- Lu C, Carlino M, Fragasso G, Maisano F, Margonato A, Cappelletti A, Chierchia SL: Enoximone echocardiography for predicting recovery of left ventricular dysfunction after revascularization: a novel test for detecting myocardial viability. Circulation 2000, 101: 1255-1260.View ArticlePubMedGoogle Scholar
- Ghio S, Constantin C, Raineri C, Fontana A, Klersy C, Campana C, Tavazzi L: Enoximone echocardiography: a novel test to evaluate left ventricular contractile reserve in patients with heart failure on chronic beta-blocker therapy. Cardiovasc Ultrasound 2003, 1: 13. 10.1186/1476-7120-1-13View ArticlePubMedPubMed CentralGoogle Scholar
- Picano E, Marzullo P, Gigli G, Reisenhofer B, Parodi O, Distante A, L'Abbate : Identification of viable myocardium by dipyridamole-induced improvement in regional left ventricular function assessed by echocardiography in myocardial infarction and comparison with thallium scintigraphy at rest. Am J Cardiol 1992, 70: 703-710. 10.1016/0002-9149(92)90545-AView ArticlePubMedGoogle Scholar
- Varga A, Ostojic M, Djordjevic-Dikic A, Sicari R, Pingitore A, Nedeljkovic I, Picano E: Infra-low dose dipyridamole test. A novel dose regimen for selective assessment of myocardial viability by vasodilator stress echocardiography. Eur Heart J 1996, 17: 629-634.View ArticlePubMedGoogle Scholar
- Picano E, Ostojic M, Varga A, Sicari R, Djordjevic-Dikic A, Nedeljkovic I, Torres M: Combined low dose dipyridamole-dobutamine stress echocardiography to identify myocardial viability. J Am Coll Cardiol 1996, 27: 1422-1428. 10.1016/0735-1097(95)00621-4View ArticlePubMedGoogle Scholar
- Schinkel AF, Bax JJ, Boersma E, Elhendy A, Vourvouri EC, Roelandt JR, Poldermans D: Assessment of residual myocardial viability in regions with chronic electrocardiographic Q-wave infarction. Am Heart J 2002, 144: 865-869. 10.1067/mhj.2002.125627View ArticlePubMedGoogle Scholar
- Kim RJ, Shah DJ: Fundamental concepts in myocardial viability assessment revisited: when knowing how much is "alive" is not enough. Heart 2004, 90: 137-140. 10.1136/hrt.2003.023101View ArticlePubMedPubMed CentralGoogle Scholar
- Klein C, Nekolla SG, Bengel FM, Momose M, Sammer A, Haas F, Schnackenburg B, Delius W, Mudra H, Wolfram D, Schwaiger M: Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Circulation 2002, 105: 162-167. 10.1161/hc0202.102123View ArticlePubMedGoogle Scholar
- Picano E: Stress echocardiography. From pathophysiological toy to diagnostic tool. Circulation 1992, 85: 1604-1612.View ArticlePubMedGoogle Scholar
- Senior R, Lahiri A: Role of dobutamine echocardiography in detection of myocardial viability for predicting outcome after revascularization in ischemic cardiomyopathy. J Am Soc Echocardiogr 2001, 14: 240-248. 10.1067/mje.2001.107636View ArticlePubMedGoogle Scholar
- Afridi I, Kleiman NS, Raizner AE, Zoghbi WA: Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995, 91: 663-670.View ArticlePubMedGoogle Scholar
- Picano E, Sicari R, Landi P, Cortigiani L, Coletta C, Galati A, Heyman J, Mattioli R, Previtali M, Mathias W Jr, Dodi C, Minardi G, Lowenstein J, Seveso G, Pingitore A, Salustri A, Raciti M: Prognostic value of myocardial viability in medically treated patients with global left ventricular dysfunction early after an acute uncomplicated myocardial infarction: a dobutamine stress echocardiographic study. Circulation 1998, 98: 1078-1084.View ArticlePubMedGoogle Scholar
- Nesto RW, Cohn LH, Collins JJ Jr, Wynne J, Holman L, Cohn PF: Inotropic contractile reserve: a useful predictor of increased 5 year survival and improved postoperative left ventricular function in patients with coronary artery disease and reduced ejection fraction. Am J Cardiol 1982, 50: 39-44. 10.1016/0002-9149(82)90006-6View ArticlePubMedGoogle Scholar
- Bax JJ, Poldermans D, Elhendy A, Cornel JH, Boersma E, Rambaldi R, Roelandt JR, Fioretti PM: Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol 1999, 34: 163-169. 10.1016/S0735-1097(99)00157-6View ArticlePubMedGoogle Scholar
- Schinkel AF, Poldermans D, Rizzello V, Vanoverschelde JL, Elhendy A, Boersma E, Roelandt JR, Bax JJ: Why do patients with ischemic cardiomyopathy and a substantial amount of viable myocardium not always recover in function after revascularization? J Thorac Cardiovasc Surg 2004, 127: 385-390. 10.1016/j.jtcvs.2003.08.005View ArticlePubMedGoogle Scholar
- Werner GS, Schaefer C, Dirks R, Figulla HR, Kreuzer H: Prognostic value of Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy. Am J Cardiol 1994, 73: 792-798. 10.1016/0002-9149(94)90883-4View ArticlePubMedGoogle Scholar
- Yock PG, Popp RL: Noninvasive estimation of right ventricular systolic pressure by Doppler ultrasound in patients with tricuspid regurgitation. Circulation 1984, 70: 657-662.View ArticlePubMedGoogle Scholar
- Himelman RB, Stulbarg M, Kircher B, Lee E, Kee L, Dean NC, Golden J, Wolfe CL, Schiller NB: Noninvasive evaluation of pulmonary artery pressure during exercise by saline-enhanced Doppler echocardiography in chronic pulmonary disease. Circulation 1989, 79: 863-871.View ArticlePubMedGoogle Scholar
- Gorcsan J 3rd, Murali S, Counihan PJ, Mandarino WA, Kormos RL: Right ventricular performance and contractile reserve in patients with severe heart failure. Assessment by pressure-area relations and association with outcome. Circulation 1996, 94: 3190-3197.View ArticlePubMedGoogle Scholar
- Ghio S, Recusani F, Klersy C, Sebastiani R, Laudisa ML, Campana C, Gavazzi A, Tavazzi L: Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestive heart failure secondary to idiopathic or ischemic dilated cardiomyopathy. Am J Cardiol 2000, 85: 837-842. 10.1016/S0002-9149(99)00877-2View ArticlePubMedGoogle Scholar
- Meluzin J, Spinarova L, Dusek L, Toman J, Hude P, Krejci J: Prognostic importance of the right ventricular function assessed by Doppler tissue imaging. Eur J Echocardiogr 2003, 4: 262-271. 10.1016/S1525-2167(02)00171-3View ArticlePubMedGoogle Scholar
- Nagaoka H, Isobe N, Kubota S, Iizuka T, Imai S, Suzuki T, Nagai R: Myocardial contractile reserve as prognostic determinant in patients with idiopathic dilated cardiomyopathy without overt heart failure. Chest 1997, 111: 344-350.View ArticlePubMedGoogle Scholar
- Paraskevaidis IA, Adamopoulos S, Kremastinos DT: Dobutamine echocardiographic study in patients with nonischemic dilated cardiomyopathy and prognostically borderline values of peak exercise oxygen consumption: 18-month follow-up study. J Am Coll Cardiol 2001, 37: 1685-1691. 10.1016/S0735-1097(01)01194-9View ArticlePubMedGoogle Scholar
- Trichon BH, Felker GM, Shaw LK, Cabell CH, O'Connor CM: Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol 2003, 91: 538-543. 10.1016/S0002-9149(02)03301-5View ArticlePubMedGoogle Scholar
- Tunick PA, Freedberg RS, Gargiulo A, Kronzon I: Exercise Doppler echocardiography as an aid to clinical decision making in mitral valve disease. J Am Soc Echocardiogr 1992, 5: 225-230.View ArticlePubMedGoogle Scholar
- Lancellotti P, Lebrun F, Pierard LA: Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2003, 42: 1921-1928. 10.1016/j.jacc.2003.04.002View ArticlePubMedGoogle Scholar
- Keren G, Laniado S, Sonnenblick EH, Lejemtel TH: Dynamics of functional mitral regurgitation during dobutamine therapy in patients with severe congestive heart failure: a Doppler echocardiographic study. Am Heart J 1989, 118: 748-754. 10.1016/0002-8703(89)90588-7View ArticlePubMedGoogle Scholar
- Lancellotti P, Troisfontaines P, Toussaint AC, Pierard LA: Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation 2003, 108: 1713-1717. 10.1161/01.CIR.0000087599.49332.05View ArticlePubMedGoogle Scholar
- Keren G, Katz S, Strom J, Sonnenblick EH, LeJemtel TH: Dynamic mitral regurgitation. An important determinant of the hemodynamic response to load alterations and inotropic therapy in severe heart failure. Circulation 1989, 80: 306-313.View ArticlePubMedGoogle Scholar
- Heinle SK, Tice FD, Kisslo J: Effect of dobutamine stress echocardiography on mitral regurgitation. J Am Coll Cardiol 1995, 25: 122-127. 10.1016/0735-1097(94)00358-WView ArticlePubMedGoogle Scholar
- Pratali L, Picano E, Otasevic P, Vigna C, Palinkas A, Cortigiani L, Dodi C, Bojic D, Varga A, Csanady M, Landi P: Prognostic significance of the dobutamine echocardiography test in idiopathic dilated cardiomyopathy. Am J Cardiol 2001, 88: 1374-1378. 10.1016/S0002-9149(01)02116-6View ArticlePubMedGoogle Scholar
- Drozdz J, Krzeminska-Pakula M, Plewka M, Ciesielczyk M, Kasprzak JD: Prognostic value of low-dose dobutamine echocardiography in patients with idiopathic dilated cardiomyopathy. Chest 2002, 121: 1216-1222. 10.1378/chest.121.4.1216View ArticlePubMedGoogle Scholar
- Eichhorn EJ, Grayburn PA, Mayer SA, St John Sutton M, Appleton C, Plehn J, Oh J, Greenberg B, DeMaria A, Frantz R, Krause-Steinrauf H: Myocardial contractile reserve by dobutamine stress echocardiography predicts improvement in ejection fraction with beta-blockade in patients with heart failure: the Beta-Blocker Evaluation of Survival Trial (BEST). Circulation 2003, 108: 2336-2341. 10.1161/01.CIR.0000097111.00170.7BView ArticlePubMedGoogle Scholar
- Bountioukos M, Doorduijn JK, Roelandt JR, Vourvouri EC, Bax JJ, Schinkel AF, Kertai MD, Sonneveld P, Poldermans D: Repetitive dobutamine stress echocardiography for the prediction of anthracycline cardiotoxicity. Eur J Echocardiogr 2003, 4: 300-305. 10.1016/S1525-2167(03)00017-9View ArticlePubMedGoogle Scholar
- Senni M, Tribouilloy CM, Rodeheffer RJ, Jacobsen SJ, Evans JM, Bailey KR, Redfield MM: Congestive heart failure in the community: a study of all incident cases in Olmsted County, Minnesota, in 1991. Circulation 1998, 98: 2282-2289.View ArticlePubMedGoogle Scholar
- Gaasch WH, Zile MR: Left ventricular diastolic dysfunction and diastolic heart failure. Annu Rev Med 2004, 55: 373-394. 10.1146/annurev.med.55.091902.104417View ArticlePubMedGoogle Scholar
- Aurigemma GP, Gaasch WH, McLaughlin M, McGinn R, Sweeney A, Meyer TE: Reduced left ventricular systolic pump performance and depressed myocardial contractile function in patients > 65 years of age with normal ejection fraction and a high relative wall thickness. Am J Cardiol 1995, 76: 702-705. 10.1016/S0002-9149(99)80201-XView ArticlePubMedGoogle Scholar
- Cuocolo A, Sax FL, Brush JE, Maron BJ, Bacharach SL, Bonow RO: Left ventricular hypertrophy and impaired diastolic filling in essential hypertension. Diastolic mechanisms for systolic dysfunction during exercise. Circulation 1990, 81: 978-986.View ArticlePubMedGoogle Scholar
- Ha JW, Lulic F, Bailey KR, Pellikka PA, Seward JB, Tajik AJ, Oh JK: Effects of treadmill exercise on mitral inflow and annular velocities in healthy adults. Am J Cardiol 2003, 91: 114-115. 10.1016/S0002-9149(02)03016-3View ArticlePubMedGoogle Scholar
- Ommen SR, Nishimura RA, Appleton CP, Miller FA, Oh JK, Redfield MM, Tajik AJ: Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study. Circulation 2000, 102: 1788-1794.View ArticlePubMedGoogle Scholar
- Oh JK, Taliercio CP, Holmes DR Jr, Reeder GS, Bailey KR, Seward JB, Tajik AJ: Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. J Am Coll Cardiol 1988, 11: 1227-1234.View ArticlePubMedGoogle Scholar
- Burwash IG, Pearlman AS, Kraft CD, Miyake-Hull C, Healy NL, Otto CM: Flow dependence of measures of aortic stenosis severity during exercise. J Am Coll Cardiol 1994, 24: 1342-1350.View ArticlePubMedGoogle Scholar
- deFilippi CR, Willett DL, Brickner ME, Appleton CP, Yancy CW, Eichhorn EJ, Grayburn PA: Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol 1995, 75: 191-194. 10.1016/S0002-9149(00)80078-8View ArticlePubMedGoogle Scholar
- Schwammenthal E, Vered Z, Rabinowitz B, Kaplinsky E, Feinberg MS: Stress echocardiography beyond coronary artery disease. Eur Heart J 1997,18(Suppl D):D130-137.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.