CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Lauro Cortigiani, MD* and
Rosa Sicari, MD, PhD, FESC
* Division of Cardiology, Campo di Marte Hospital, Lucca, Italy (Email: lacortig{at}tin.it).
We thank Dr. Nemes for the interest in our paper (1). We fully agree that coronary flow reserve cannot be considered the sole prognostic parameter in this subset of patients and that other reliable parameters, along with established and more conventional ones, should be identified to better characterize these patients. We do not have data on aortic elasticity because none of our patients underwent Doppler echocardiography coronary flow reserve during transesophageal scanning. It is conceivable that this parameter may add more prognostic information and become clinically useful when added to coronary flow reserve. However, preliminary data showed that aortic distensibility did not offer any added value in predicting cardiovascular survival in patients with coronary artery disease (2). Moreover, its main limitation is the transesophageal approach, which makes it less appealing for both patients and physicians. The clinical use of vasodilatory stress echocardiography stems from a 20-year-old clinical experience. Its sensitivity and specificity with simple regional wall motion analysis is high and comparable to other stress imaging modalities, such as exercise or dobutamine (3). On top of this extensively validated information on wall motion, coronary flow reserve adds an extra benefit in diagnostic and prognostic terms without any increase in imaging time (4). Newer parameters able to identify those at higher risk of experiencing events, such as diastolic function force-frequency relationship as an index of left ventricular contractility (5), are critical and would compose a powerful armamentarium for the cardiologist-echocardiographist, but only after a careful and through validation. The new parameters will certainly broaden risk stratification capability of stress echo in the challenging subset of diabetic patients in the near future. It is, however, important that the technique, with all its new advances, remains simple, feasible, and non-time-consuming (6).
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References
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- Cortigiani L, Rigo F, Gherardi S, et al. Additional prognostic value of coronary flow reserve in diabetic and nondiabetic patients with negative dipyridamole stress echocardiography by wall motion criteria J Am Coll Cardiol 2007;5:1354-1361.
- Nemes A, Forster T, Geleijnse ML, et al. Prognostic value of coronary flow reserve and aortic distensibility indices in patients with suspected coronary artery disease Heart Vessels 2008In press.
- Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography J Am Soc Echocardiogr 2007;20:1021-1024.[CrossRef][ISI][Medline]
- Rigo F, Sicari R, Gherardi S, Djordjevic-Dikic A, Cortigiani L, Picano E. The additive prognostic value of wall motion abnormalities and coronary flow reserve during dipyridamole stress echo Eur Heart J 2008In press.
- Bombardini T, Galderisi M, Agricola E, Coppola V, Mottola G, Picano E. Negative stress echo: further prognostic stratification with assessment of pressure-volume relation Int J Cardiol 2007May 15; [Epub ahead of print].
- Picano E. Stress echocardiography: a historical perspective Am J Med 2003;114:126-130.[CrossRef][ISI][Medline]
Related Article
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Relationship Between Coronary Microcirculatory Function and Aortic Stiffness in Diabetes
- Attila Nemes
J. Am. Coll. Cardiol. 2008 51: 597-598.
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