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Cameron Dockerill, William Woodward, Annabelle McCourt, Cristiana Monteiro, Elena Benedetto, Maria Paton, David Oxborough, Shaun Robinson, Keith Pearce, Mark J Monaghan, Daniel X Augustine, and Paul Leeson


Healthcare delivery is being transformed by COVID-19 to reduce transmission risk but continued delivery of routine clinical tests is essential. Stress echocardiography is one of the most widely used cardiac tests in the NHS. We assessed the impact of the first (W1) and second (W2) waves of the pandemic on the ability to deliver stress echocardiography.


Clinical echocardiography teams in 31 NHS hospitals participating in the EVAREST study were asked to complete a survey on the structure and delivery of stress echocardiography as well as its impact on patients and staff in July and November 2020. Results were compared to stress echocardiography activity in the same centre during January 2020.


24 completed the survey in July, and 19 NHS hospitals completed the survey in November. A 55% reduction in the number of studies performed was reported in W1, recovering to exceed pre-COVID rates in W2. The major change was in the mode of stress delivery. 70% of sites stopped their exercise stress service in W1, compared to 19% in W2. In those still using exercise during W1, 50% were wearing FFP3/N95 masks, falling to 38% in W2. There was also significant variability in patient screening practices with 7 different pre-screening questionnaires used in W1 and 6 in W2.


Stress echocardiography delivery restarted effectively after COVID-19 with adaptations to reduce transmission that means activity has been able to continue, and exceed, pre-COVID-19 levels during the second wave. Further standardization of protocols for patient screening and PPE may help further improve consistency of practice within the United Kingdom.

Open access

Ying X Gue, Sanjay S Bhandari, and Mubarak Ahamed

76-year-old female presented following an episode of collapse. She was hypotensive with the paramedics and remained refractory despite fluid resuscitation. Her initial baseline tests revealed an elevated troponin; she subsequently underwent a coronary angiogram that showed mild coronary artery disease. Left ventriculogram was performed, which showed abnormal mid-wall ballooning and severely impaired systolic function, characteristic of Takotsubo syndrome. Echocardiogram confirmed the presence of diagnosis and presence of left ventricular outflow tract obstruction with high gradient. She was initiated on medical heart failure therapy and improved. Follow-up investigations after 2 months showed complete resolution of systolic dysfunction and symptoms.

Learning points:

  • Takotsubo syndrome can present similarly to ACS.

  • Early use of echocardiography in the acute setting can provide vital information.

  • Takotsubo syndrome can result in hemodynamic instability requiring urgent interventions.

  • Other investigative modalities can be used in conjunction with echocardiography to confirm the diagnosis of Takotsubo syndrome.

  • Prognosis is generally good in patients with Takotsubo syndrome.

Open access

Alice Cowley, Laura Dobson, John Kurian, and Christopher Saunderson

Isolated myocardial involvement in tuberculosis is exceedingly rare but there are reports it can present with sudden cardiac death, atrioventricular block, ventricular arrhythmias or congestive cardiac failure. We report the case of a 33-year-old male, of South Asian descent, who presented with chest pain, shortness of breath and an abnormal ECG. The patient had no significant past medical history and coronary angiogram showed no evidence of coronary artery disease. Of note, the patient had recently been discharged from a local district hospital with an episode of myocarditis. The patient was found to be severely hypoxic with evidence of severe biventricular failure on echocardiography. Computed tomography of the chest demonstrated hilar lymphadenopathy, and the differential diagnosis was thought to be tuberculosis or sarcoidosis. A TB Quantiferon gold test performed at the district hospital was positive; however, fine needle aspiration was negative for acid-fast bacilli. Despite aggressive diuresis, the patient became increasingly hypoxic and suffered a cardiac arrest. Post-mortem confirmed a diagnosis of myocardial tuberculosis – a rare case of acute decompensated heart failure.

Learning points:

  • Tuberculosis myocarditis is a rare diagnosis but should be considered in at risk individuals presenting with acute fulminant myocarditis.

  • Cardiac failure can occur even in the absence of disseminated tubercular disease.

  • TB myocarditis is not just a disease of the immunocompromised.

  • Definitive diagnosis of cardiac tuberculosis during life requires a myocardial biopsy.

  • Echocardiography is a vital tool for the assessment of cardiac function, filling pressures and fluid status in the critically unwell patient.

Open access

Thomas R Porter

Dobutamine stress echocardiography (DSE) has been utilized extensively in the detection of coronary artery disease (CAD) and prediction of patient outcome ( 1 , 2 , 3 , 4 ). Its safety has also been thoroughly investigated in the contemporary

Open access

Keith Pearce and John Chambers

negative studies returned with significant complications due to multivessel coronary artery disease. In fact, there were eight patients with negative stress echocardiograms who subsequently had coronary angiography showing coronary disease. However, there

Open access

Martin R Cowie

age at first diagnosis was around 76 years, and the incidence was always higher in men than that in women, presumably related to the earlier onset of coronary artery disease in men ( 4 ). The risk increases steeply with age in both sexes and reaches as

Open access

Shreya Ohri, Ankush Sachdeva, Mona Bhatia, and Sameer Shrivastava

period of 6 months, administered in cycles for of 3 weeks followed by 1 week of respite (in order to avoid toxicity), along with other drugs for coronary artery disease management. The patient was advised for timely follow-up to look for any reoccurrences

Open access

Ying X Gue, Sanjay S Bhandari, and Damian J Kelly

. Paramedic ECG ( Fig. 1 ) showed inferior STEMI with voltage criteria for left ventricular hypertrophy (LVH). Past medical history included hypertension and benign prostatic hyperplasia (BPH). The patient’s risk factors for coronary artery disease (CAD

Open access

Stephan Stoebe, Dietrich Pfeiffer, and Andreas Hagendorff

-coded Doppler echocardiography is established in clinical practice for the detection of coronary artery disease by determining the coronary flow reserve (CFR) during adenosine or dipyridamole stress ( 4 , 5 , 11 , 15 , 16 , 17 , 18 ). However, the

Open access

Carolyn M Larsen and Sharon L Mulvagh

therapy can put patients at risk for a variety of cardiovascular complications including heart failure, coronary artery disease, peripheral vascular disease, thromboembolism, pericardial disease and valvular heart disease. Cancer patients receiving therapy