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

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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.

Original languageEnglish
Pages (from-to)1519-1527
Number of pages9
JournalInternational Journal of Cardiovascular Imaging
Issue number8
Publication statusPublished - Dec 1 2015


  • Aortic stenosis
  • Exercise stress echocardiography
  • Tissue Doppler imaging

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine


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