Eugenio Picano Institute of Clinical Physiology, CNR Pisa, Italy

1. Gramado, Brazil , 19 May 2016,h 10 am Stress echo 2020: above and beyond coronary artery disease Eugenio Picano Institute of Clinical Physiology, CNR Pisa, Italy

2. Stress echo lab 1.0:One patient, one technology, one sign Rest Stress Adapted from Picano E. Am J Med 2003

3. (Picano E, Pellikka P, Eur Heart J 2014) Stress echo lab 2.0: versatility Ischemia Viability CFVR Mitral Insufficiency 200 LV elastance Extravascular lung water Secondarypulmonary hypertension (SScl, PPH) CAD CMD Valvular HD Congenital HD Athletes, divers, climbers HeartTransplantpts

4. Stressecho beyond CAD • Started as early as stress echo in CAD (in the eighties, mainly on mitral stenosis and valves) • Small part (<1/10 ) of stress echo guidelines (ASE 2007 Pellikka et al; EACVI 2008 Sicari et al) • Special Focus in EHJ clinical review 2014 (Picano E, Pellikka P, EHJ 2014) • Targeted by joint ASE-EACVI recommendation (Lancellotti P., Pellikka P, Tsutsui J, Picano E et al, EHJ-CV imaging 2016) • Now it is multicenter trial time: SE 2020

5. Stress echo 2020 pedigree: si parva licet componere magnis … SE 2020 a step-child of GISSI: 1 - Sponsored by a respected, independent, not-for-profit national professional society (it was ANMCO; it is SIEC) 2 - Scientific coordination from a distinguished research institute (it was Mario Negri in Milan, it is CNR-IFC Pisa) 3 - Inclusivity (it was all CCU’s, it is all SE labs of the nation) 4 – Emphasis on clinical relevant outcomes changing patient care (it was thrombolytic therapy in acute myocardial infarction, it is cardiac imaging within and beyond CAD) Braunwald E, Am Heart J, 2004: The GISSI twentieth birthday

6. EPIC, the father of Stress echo 2020 1 - simple protocols without economic induction can change guidelines (it was in CAD, it is also beyond CAD for SE 2020) 2 - Italians do it (SE) better, we have cultural and technological infrastructure (it was analogic dip and dob, it is digital and also semi-supine exercise) 3 - Echo people like to do extra-work that make their practice better if clinically worthwhile (it was RWMA , it is also CFVR, B-lines, SPAP, LV elastance index, etc) 4 – We need the fruit of effectiveness (real world data), not the seed of efficacy (virtual reality of journals written by enthousiastic fellows and presented by gray-haired opinion leaders paid by industry) to feed our patients 30 EPIC-EDIC papers with over 75 authors of 4 continents and 12 countries on top-ranked journals over a 20 years span (1992- 2012) changing clinical practice

7. STRESSECHO 2020 The 10 protocols, 100 centers and 10,000 patients Running title : Italians still do it better? (10-100-10,000)

8. Contractile reserve and CRT response (Ciampi Q et al, 2016, ESC abstract)

9. Stress B- lines in Heart Failure Scali MC,Marzilli M et al, ESC 2016 (abstract)

10. Stress echo in HCM : coronary flow reserve makes the difference Ciampi Q et al, ESC meeting 2016

11. HFrEF: EDV reserve matters (diastolic pressure-volume better than pressure only!) HFpEF HFrEF Controls (Shimiaie et al, JACC heart fail 2015)

12. Beneficial effects of TAVI on MR Costantino F et al, CardioUltra 2015

13. Stress echo Outdoor • 18 subjects (10 males) • mean age 45±10 years Gokyo m s.l. 5130 Namche Bazaar 4790 * Gorak Shep 3440 * Kathmandu * 1350 Kathmandu 1350 days Cardiac and chest echo Pratali L. et al Critical Care Medicine 2010

14. SE in adult repaired ToF RV FAC decreases at exercise RV FAC increases at exercise RESPONDERS (74 pts) NON RESPONDERS (49 pts) RV FAC at Rest RV FAC at Exercise RV FAC at Rest RV FAC at Exercise L. Ait Ali et al, J Am Soc Echocardiogr. 2014

15. SE in patients at risk for pulmonary arterial hypertension Figure 2. Changes in PASP values from rest to peak exercise for each individual patient. Luna Gargani, Alberto Pignone, Gergely Agoston, Antonella Moreo, Eugenia Capati, Luigi P. Badano, Marica Doveri, Laura Bazzichi, Marco Fabio Costantino, Andrea Pavellini, Francesco Pieri, Francesco Musca, Denisa Muraru, Oscar Epis, Eleonora Bruschi, Benedetta De Chiara, Federico Perfetto, Fabio Mori, Oberdan Parodi, Rosa Sicari, Stefano Bombardieri, Albert Varga, Marco Matucci Cerinic, Eduardo Bossone, Eugenio Picano American Heart Journal, Volume 165, Issue 2, 2013, 200–207 http://dx.doi.org/10.1016/j.ahj.2012.10.020

16. Incrementalvalueof CFR overwallmotiontopredictmortality n = 4,313 p < 0.0001 Cortigiani. JACC Cardiovasc Imaging 2012;5:1079

17. Genetic stress echo in HCM, PPH and DCM

18. Stress Echo Computerized Software 2.0

20. Conclusions • Stress-echo 2020 will help the Italian SE community in tailoring the right stress to the right patient with the right technology, used by the right (properly trained and certified) cardiologist. • SE has today an unprecedented advantage of economic sustainability, lack of radiation, portability and versatility making it potentially dominant in the current era of societal pressures on cardiac imaging costs and risks. • Stressecho 2020 will recruit 10,000 patients by 2020 spread over 10 subprojects and should create a SE lab without walls

21. Marco Antonio, Liz, Monica, Pedro, Adriana, Patricia, Leticia, Wilson, Lucas, and many others: EPIC EDIC and Brazil, 20 years after here we go again Nunca procures saber por quem os sinos dobram; eles dobram por ti