ABC | Volume 113, Nº1, July 2019

Statement Position Statement on Indications of Echocardiography in Adults – 2019 Arq Bras Cardiol. 2019; 113(1):135-181 Table 37 – Recommendations of stress echocardiography in patients with known or suspected chronic coronary disease Recommendation Class of recommendation Level of evidence As an initial method in the investigation of chronic coronary disease in patients with intermediate or high pre-test probability I B As an initial method in the investigation of chronic coronary disease in patients with low pretest probability, but unable to perform an exercise test or with electrocardiogram not interpretable I B As a sequential method in the investigation of patients submitted to an ergometric test with intermediate or non-diagnostic result I B As a sequential method in the investigation of patients submitted to coronary tomography with a calcium score (Agatston) > 400 I B As a sequential method in the investigation of patients submitted to coronary angiography with identified lesions of uncertain functional significance I B In the preoperative evaluation of non-cardiac vascular surgery in a patient with one or more risk factors for chronic coronary disease I B In the assessment of viability in patients with ventricular dysfunction and chronic coronary disease and eligible for revascularization I B In the preoperative assessment of non-cardiac intermediate risk surgery in a patient with one or more risk factors for chronic coronary disease with functional class < 4 METs or indeterminate IIa B In the sequential investigation of patients with moderate to high pre-test risk with previous testing for ischemia for more than two years IIa B In the assessment of asymptomatic patients after incomplete revascularization IIa C In the evaluation of symptomatic patients after revascularization IIa B Routine reassessment (every five years) in asymptomatic patients after revascularization IIb C As an initial method in the assessment of patients with low pre-test probability and with clinical conditions and interpretable electrocardiogram to perform an ergometric test III C In the preoperative assessment of non-cardiac intermediate-risk surgery in patients with functional class ≥ 4 METS III B Routine ergometric test substitution in patients with physical capacity and interpretable electrocardiogram for the performance of the test III C MET: metabolic equivalent of risk. weapon for adequate visualization of the endocardium of all LV segments. 185,190 Thus, in the presence of two or more contiguous segments with limited technical quality, the use of any of these agents is indicated (Table 38). 191,192 The use of contrast agents for myocardial perfusion, although it is part of the same procedure, only with modifications in the acquisition and analysis of the images, remains considered off-label by the US and European health agencies. Guidelines on stable coronary disease already recognize the use of contrast agents to delineate endocardial borders, but they are still not based on myocardial perfusion evaluation. 175 However, robust evidence supports the use of these agents for assessing myocardial perfusion both in the diagnosis of coronary disease in acute and chronic coronary syndromes, 193 even showing its superiority over conventional stress echocardiography in predicting cardiovascular events. 194 The accuracy of contrast agents has been compared with other methods such as myocardial scintigraphy and, in contrast, showed similarity, with greater sensitivity, mainly in the detection of uni-coronary lesions. 195 However, the use of contrast agents for perfusion analysis is facilitated when stress is performed with dipyridamole; and the low use of dipyridamole in most Brazilian and worldwide echocardiography laboratories 192 may be a barrier to the implementation of myocardial perfusion analysis. Coronary flow reserve can also be assessed by contrast echocardiography under stress. Reduced values of coronary flow reserve are indicative of functional repercussion in lesions that anatomically have dubious expression. In addition, some studies have shown the role of this index in assessing viability and in predicting myocardial functional recovery in patients with stable coronary artery disease. 196 6. Evaluation of Emboligenic Sources and Cardioembolic Diseases Stroke is the major cause of disability and the second leading cause of death in the world. 197 Brazil is the Latin American country with the highest mortality rates due to stroke, being the main cause of female death. 198,199 Although the death rate from stroke has declined in recent decades, the values ​remain very high. 200 It is estimated that cardioembolic disease is responsible for 15% to 40% of all causes of ischemic stroke, 201 whereas indeterminate (cryptogenic) causes account for 30 to 40% of these ischemic neurological events. 202-204 Other causes of ischemic 164