Contrast Stress Echocardiography (Stress Echo with Contrast)

Overview

Stress echocardiography is a non-invasive imaging technique that plays a vital role in evaluating and managing patients with suspected coronary artery disease (CAD). Multiple large-scale studies across diverse populations, including men and women, have demonstrated its accuracy and prognostic value. By providing real-time imaging of the heart’s functional response to stress, stress echocardiography enables the assessment of global and regional ventricular function, helping to detect ischemic areas that may otherwise go undiagnosed.

It is estimated that up to 20% of resting transthoracic echocardiograms (TTE) have suboptimal left ventricular endocardial visualization, defined as two or more segments not being adequately visualized. This limitation highlights the importance of enhanced imaging for accurate diagnosis. Contrast Echocardiography, using Definity as a contrast agent, significantly improves the sensitivity of standard TTE by enhancing the visualization of cardiac structures and blood flow, particularly in patients with suboptimal baseline images.

Clinical Indications for Contrast Stress Echocardiography

  • Chest pain evaluation.

  • Evaluating hypertrophic cardiomyopathy.

  • Suboptimal left ventricular endocardial visualization.

  • Identifying regional wall motion abnormalities in technically challenging patients.

  • LV ejection fraction assessment.

  • Detecting microvascular dysfunction in diabetic patients.

  • LV thrombus and intracardiac mass evaluation.

  • LV aneurysm versus pseudoaneurysm

  • LV noncompaction.

  • Other less common apical abnormalities.

  • Intracardiac abnormalities.

Procedure

During the test, the patient exercises on a treadmill. Definity, a perflutren lipid microsphere contrast agent, is administered intravenously to enhance echocardiographic images. The microbubbles within Definity reflect ultrasound waves, improving contrast between the blood pool and surrounding tissues. This results in clearer visualization of:

  • Left ventricular endocardial borders.

  • Valvular anatomy.

  • Blood flow dynamics.

This enhanced clarity facilitates more accurate assessment of ischemia, wall motion abnormalities, and overall cardiac function.

Possible Side Effects

While generally well-tolerated, potential side effects of Definity include:

  • Mild Reactions: Headache, dizziness, nausea, flushing, back pain, or mild chest discomfort.

  • Injection Site Reactions: Minor bruising or infection at the IV site.

Serious Reactions: Rare but potentially serious hypersensitivity, respiratory distress, or arrhythmias occur in fewer than 0.01% of cases, typically within 30 minutes of administration.

Contraindications

Definity is contraindicated in patients with:

  • Hypersensitivity to perflutren or albumin.

  • Acute coronary syndrome or unstable heart failure.

Patient Considerations

Please notify the sonographer if the patient has any of the following conditions:

  • Acute myocardial infarction or acute coronary syndrome.

  • Unstable or worsening congestive heart failure.

  • Serious ventricular arrhythmias.

  • Respiratory failure.

  • Pregnancy or breastfeeding.

Patients with pre-existing conditions will be monitored for approximately 30 minutes following the administration of Definity. 

Report Processing

Following the procedure, the echocardiographic images are meticulously analyzed by a cardiologist. A detailed report, including conclusions and clinical recommendations, is sent directly to the referring physician to ensure timely and accurate follow-up care.

Next Steps

To refer a patient for Contrast Stress Echocardiography or other diagnostic modalities, please download the Requisition Form and fax it to our Requisition Processing Centre at 647-351-6648.

References

Cheitlin, M.D. (2003). Stress echocardiography: A valuable tool in the diagnosis of coronary artery disease. Journal of the American College of Cardiology.

CorHealth Ontario. (2021). Standards for Provision of Echocardiography in Ontario.

Lanza, G.A., et al. (2007). Stress echocardiography in the diagnosis and prognosis of coronary artery disease: A review of the literature. Journal of the American Society of Echocardiography, 20(9), 1101-1111.

Marwick, T.H., et al. (2009). Stress echocardiography: Role in the diagnosis of coronary artery disease. European Heart Journal.

Medical Advisory Secretariat. (2010). Use of contrast agents with echocardiography in patients with suboptimal images: An evidence-based analysis. Ontario Health Technology Assessment Series, 10(9), 1–44.

Senior, R., Monaghan, M., Becher, H., & Nihoyannopoulos, P. (2005). Contrast echocardiography: Evidence-based recommendations by European Association of Echocardiography. European Journal of Echocardiography, 6(1), 3-15.