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Exercise stress echocardiography with tissue Doppler imaging in risk stratification of mild to moderate aortic stenosis

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Abstract

Background Patients with mild to moderate aortic stenosis (AS) seem to have a worse outcome than commonly expected. Early identification of subjects who may develop a rapid disease progression or cardiovascular events is critical in order to apply adequate risk management. Study design Observational prospective single-centre study. Objective To determine the prognostic role of exercise stress echocardiography (ESE) in patients with mild and moderate asymptomatic AS. Patients Ninety consecutive patients (mean age 74 ± 12 years) with isolated mild and moderate AS were enrolled into the study protocol over a 20 months period. Follow-up time was 12 months. Methods A complete echocardiographic study with tissue Doppler imaging (TDI) was performed at baseline and during semi-supine symptom-limited exercise test to evaluate: (1) the occurrence of symptoms, (2) ST segment changes, (3) transaortic pressure gradient, (4) the E/A ratio, (5) the E/e′ ratio and (6) the systolic pulmonary artery pressure. Main outcome measures During the 1 year follow-up time, we evaluated the occurrence of adverse cardiac events, defined as any of the following: (1) cardio-vascular hospitalization; (2) requirement for aortic valve replacement; (3) cardiac death. Results During follow-up, three patients died, 11 underwent aortic valve replacement and 26 had cardiovascular hospitalizations. On univariate analysis, patients who exhibited symptoms during exercise (HR 2.93, p = 0.003); the occurrence of a ≥2 mm exercise-induced ST segment depression (HR 3.12, p = 0.001); a ≥15 mmHg increase in mean transaortic pressure gradient during exercise (HR 2.77, p = 0.001); a ≥50 mmHg exercise-induced increase in systolic pulmonary artery pressure (HR 2.90, p = 0.009); an exercise-induced pseudo-normalization of the E/A ratio (E/A ≥ 1) (HR 7.50, p = 0.0001) and, particularly, a ≥15 exercise-induced increase in the E/e′ ratio (HR 7.69, p = 0.0001) had a significantly higher risk of cardiac events during the follow-up time. On multivariate analysis, only the latter covariate (HR 6.04, p = 0.009) was independently associated with adverse cardiac events. Conclusions A ≥15 stress-induced increase in E/e′ ratio is highly predictive of cardiac events in patients with mild to moderate AS. Assessment of diastolic function using TDI during ESE provides additional prognostic information in such patients.

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Authors and Affiliations

  1. Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy

    Andrea Sonaglioni, Michele Lombardo, Massimo Baravelli, Graziana Trotta & Claudio Anzà

  2. Multimedica Holding S.p.A., Milan, Italy

    Carmen Sommese

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  1. Andrea Sonaglioni
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  2. Michele Lombardo
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  3. Massimo Baravelli
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Correspondence to Andrea Sonaglioni.

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Conflict of interest

We wish to confirm that there are no conflicts of interest associated with this publication. Andrea Sonaglioni declares that he has no conflict of interest. Michele Lombardo declares that he has no conflict of interest. Massimo Baravelli declares that he has no conflict of interest. Graziana Trotta declares that she has no conflict of interest. Claudio Anzà declares that he has no conflict of interest.

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All procedures performed in the present study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Sonaglioni, A., Lombardo, M., Baravelli, M. et al. Exercise stress echocardiography with tissue Doppler imaging in risk stratification of mild to moderate aortic stenosis. Int J Cardiovasc Imaging 31, 1519–1527 (2015). https://doi.org/10.1007/s10554-015-0724-9

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  • DOI: https://doi.org/10.1007/s10554-015-0724-9

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