title: Exercise stress echocardiography with tissue Doppler imaging in risk stratification of mild to moderate aortic stenosis.
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.
  
  
  METHODS
  Observational prospective single-centre study.
  
  
  OBJECTIVE
  To determine the prognostic role of exercise stress echocardiography (ESE) in patients with mild and moderate asymptomatic AS.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.affiliation: Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy. sonaglioniandrea@gmail.com.
authors.forename: Andrea
authors.initials: A
authors.lastname: Sonaglioni
authors.affiliation: Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Lombardo
authors.affiliation: Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Baravelli
authors.affiliation: Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy.
authors.forename: Graziana
authors.initials: G
authors.lastname: Trotta
authors.affiliation: Multimedica Holding S.p.A., Milan, Italy.
authors.forename: Carmen
authors.initials: C
authors.lastname: Sommese
authors.affiliation: Department of Cardiology, Ospedale San Giuseppe Multimedica, Via San Vittore 12, 20123, Milan, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Anzà
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D018572:Disease-Free Survival; D015150:Echocardiography, Doppler; D025401:Echocardiography, Stress / Q000379:methods*; D005080:Exercise Test; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006439:Hemodynamics; D006760:Hospitalization; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic stenosis; Exercise stress echocardiography; Tissue Doppler imaging