Heart Rate Lowering Significantly Increases Feasibility in Doppler Recording Blood Flow Velocity in Coronaries during Transthoracic Doppler Echocardiography

Background: Coronary blood flow Doppler recording by Transthoracic Doppler in convergent mode (E-Doppler TTE) might be further improved by lowering heart rate (HRL) down to <60 bpm, since low HR < 60 b/m causes a disproportional lengthening of the diastole, so the coronaries are still for a longer time, very much improving the Doppler signal/noise ratio. Methods: A group of 26 patients underwent E-Doppler TTE before and after HR lowering in four branches of the coronary tree, namely, the left main (LMCA); left anterior descending (LAD), subdivided into three segments: proximal, mid and distal; proximal left circumflex (LCx); and obtuse marginal (OM). Color and PW coronary Doppler signal was judged by two expert observers as undetectable (SCORE 1), weak or with clutter artifacts (SCORE 2), or well delineated (SCORE 3). In addition, local accelerated stenotic flow (AsF) was measured in the LAD before and after HRL. Results: Beta-blockers significantly decreased the mean HR from 76 ± 5 to 57 ± 6 bpm (p < 0.001). Before HRL, the Doppler quality was very poor in the proximal and mid-LAD segments (median score value = 1 in both), while in the distal LAD, it was significantly better but still suboptimal (median score value = 1.5, p = 0.009 vs. proximal and mid-LAD score). After HRL, blood flow Doppler recording in the three LAD segments was strikingly improved (median score value = 3, 3 and 3, p = ns), so the effect of HRL was more efficacious in the two more proximal LAD segments. In 10 patients undergoing coronary angiography (CA), no AsF as expression of transtenotic velocity was detected at baseline. After HRL, thanks to the better quality and length of color flow, ASF was detected in five patients while in five others, it was not in perfect agreement with CA (Spearman correlation coefficient = 1, p < 0.01). The color flow in the proximal LCx and OM was extremely poor at baseline (color flow length 0 and 0, median (interquartile range) mm, respectively) and improved considerably after HRL (color flow length 23 [13.5] and 25 [12.0] mm, respectively, p < 0.001). Conclusions: HRL greatly improved the success rate of blood flow Doppler recording in coronaries, not only in the LAD, but also in the LCx. Therefore, AsF for stenosis detection and coronary flow reserve assessment can have wider clinical applications. However, further studies with larger samples are needed to confirm these results.