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The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol.
Cardiovasc Ultrasound. 2018 Oct 02; 16(1):22.CU

Abstract

BACKGROUND

The detection of regional wall motion abnormalities is the cornerstone of stress echocardiography. Today, stress echo shows increasing trends of utilization due to growing concerns for radiation risk, higher cost and stronger environmental impact of competing techniques. However, it has also limitations: underused ability to identify factors of clinical vulnerability outside coronary artery stenosis; operator-dependence; low positivity rate in contemporary populations; intermediate risk associated with a negative test; limited value of wall motion beyond coronary artery disease. Nevertheless, stress echo has potential to adapt to a changing environment and overcome its current limitations.

INTEGRATED-QUADRUPLE STRESS-ECHO

Four parameters now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-stress echo. They are: 1- regional wall motion abnormalities; 2-B-lines measured by lung ultrasound; 3-left ventricular contractile reserve assessed as the stress/rest ratio of force (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D); 4- coronary flow velocity reserve on left anterior descending coronary artery (with color-Doppler guided pulsed wave Doppler). IQ-Stress echo allows a synoptic functional assessment of epicardial coronary artery stenosis (wall motion), lung water (B-lines), myocardial function (left ventricular contractile reserve) and coronary small vessels (coronary flow velocity reserve in mid or distal left anterior descending artery). In "ABCD" protocol, A stands for Asynergy (ischemic vs non-ischemic heart); B for B-lines (wet vs dry lung); C for Contractile reserve (weak vs strong heart); D for Doppler flowmetry (warm vs cold heart, since the hyperemic blood flow increases the local temperature of the myocardium). From the technical (acquisition/analysis) viewpoint and required training, B-lines are the kindergarten, left ventricular contractile reserve the primary (for acquisition) and secondary (for analysis) school, wall motion the university, and coronary flow velocity reserve the PhD program of stress echo.

CONCLUSION

Stress echo is changing. As an old landline telephone with only one function, yesterday stress echo used one sign (regional wall motion abnormalities) for one patient with coronary artery disease. As a versatile smart-phone with multiple applications, stress echo today uses many signs for different pathophysiological and clinical targets. Large scale effectiveness studies are now in progress in the Stress Echo2020 project with the omnivorous "ABCD" protocol.

Authors+Show Affiliations

Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124, Pisa, Italy. picano@ifc.cnr.it.Fatebenefratelli Hospital of Benevento, Viale Principe di Napoli, 12, 82100, Benevento, Italy.Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Ul Kniaziewicza 1/5, 91-347, Lodz, Poland.CVASIC Research Center Sibiu, "Lucian Blaga" University of Sibiu, Sibiu, Romania.Cardiothoracic department, Cisanello Hospital, University of Pisa, Pisa, Italy.Institute of Clinical Physiology, National Council Research, Via Giuseppe Moruzzi 1, 56124, Pisa, Italy.

Pub Type(s)

Journal Article
Review

Language

eng

PubMed ID

30285774

Citation

Picano, Eugenio, et al. "The New Clinical Standard of Integrated Quadruple Stress Echocardiography With ABCD Protocol." Cardiovascular Ultrasound, vol. 16, no. 1, 2018, p. 22.
Picano E, Ciampi Q, Wierzbowska-Drabik K, et al. The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. Cardiovasc Ultrasound. 2018;16(1):22.
Picano, E., Ciampi, Q., Wierzbowska-Drabik, K., Urluescu, M. L., Morrone, D., & Carpeggiani, C. (2018). The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. Cardiovascular Ultrasound, 16(1), 22. https://doi.org/10.1186/s12947-018-0141-z
Picano E, et al. The New Clinical Standard of Integrated Quadruple Stress Echocardiography With ABCD Protocol. Cardiovasc Ultrasound. 2018 Oct 2;16(1):22. PubMed PMID: 30285774.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The new clinical standard of integrated quadruple stress echocardiography with ABCD protocol. AU - Picano,Eugenio, AU - Ciampi,Quirino, AU - Wierzbowska-Drabik,Karina, AU - Urluescu,Mădălina-Loredana, AU - Morrone,Doralisa, AU - Carpeggiani,Clara, Y1 - 2018/10/02/ PY - 2018/06/29/received PY - 2018/08/24/accepted PY - 2018/10/5/entrez PY - 2018/10/5/pubmed PY - 2019/4/4/medline KW - B-lines KW - Coronary flow reserve KW - Echocardiography KW - Force KW - Left ventricular contractility KW - Lung water KW - Stress echocardiography KW - Wall motion abnormalities SP - 22 EP - 22 JF - Cardiovascular ultrasound JO - Cardiovasc Ultrasound VL - 16 IS - 1 N2 - BACKGROUND: The detection of regional wall motion abnormalities is the cornerstone of stress echocardiography. Today, stress echo shows increasing trends of utilization due to growing concerns for radiation risk, higher cost and stronger environmental impact of competing techniques. However, it has also limitations: underused ability to identify factors of clinical vulnerability outside coronary artery stenosis; operator-dependence; low positivity rate in contemporary populations; intermediate risk associated with a negative test; limited value of wall motion beyond coronary artery disease. Nevertheless, stress echo has potential to adapt to a changing environment and overcome its current limitations. INTEGRATED-QUADRUPLE STRESS-ECHO: Four parameters now converge conceptually, logistically, and methodologically in the Integrated Quadruple (IQ)-stress echo. They are: 1- regional wall motion abnormalities; 2-B-lines measured by lung ultrasound; 3-left ventricular contractile reserve assessed as the stress/rest ratio of force (systolic arterial pressure by cuff sphygmomanometer/end-systolic volume from 2D); 4- coronary flow velocity reserve on left anterior descending coronary artery (with color-Doppler guided pulsed wave Doppler). IQ-Stress echo allows a synoptic functional assessment of epicardial coronary artery stenosis (wall motion), lung water (B-lines), myocardial function (left ventricular contractile reserve) and coronary small vessels (coronary flow velocity reserve in mid or distal left anterior descending artery). In "ABCD" protocol, A stands for Asynergy (ischemic vs non-ischemic heart); B for B-lines (wet vs dry lung); C for Contractile reserve (weak vs strong heart); D for Doppler flowmetry (warm vs cold heart, since the hyperemic blood flow increases the local temperature of the myocardium). From the technical (acquisition/analysis) viewpoint and required training, B-lines are the kindergarten, left ventricular contractile reserve the primary (for acquisition) and secondary (for analysis) school, wall motion the university, and coronary flow velocity reserve the PhD program of stress echo. CONCLUSION: Stress echo is changing. As an old landline telephone with only one function, yesterday stress echo used one sign (regional wall motion abnormalities) for one patient with coronary artery disease. As a versatile smart-phone with multiple applications, stress echo today uses many signs for different pathophysiological and clinical targets. Large scale effectiveness studies are now in progress in the Stress Echo2020 project with the omnivorous "ABCD" protocol. SN - 1476-7120 UR - https://www.unboundmedicine.com/medline/citation/30285774/The_new_clinical_standard_of_integrated_quadruple_stress_echocardiography_with_ABCD_protocol L2 - https://cardiovascularultrasound.biomedcentral.com/articles/10.1186/s12947-018-0141-z DB - PRIME DP - Unbound Medicine ER -