The prognostic role of stress echocardiography in a contemporary population and the clinical significance of limited apical ischaemia

Abstract

IntroductionIn this study, we aim to reassess the prognostic value of stress echocardiography (SE) in a contemporary population and to evaluate the clinical significance of limited apical ischaemia, which has not been previously studied.MethodsWe included 880 patients who underwent SE. Follow-up data with regards to MACCE (cardiac death, myocardial infarction, any repeat revascularisation and cerebrovascular accident) were collected over 12 months after the SE. Mortality data were recorded over 27.02 ± 4.6 months (5.5–34.2 months). We sought to investigate the predictors of MACCE and all-cause mortality.ResultsIn a multivariable analysis, only the positive result of SE was predictive of MACCE (HR, 3.71; P = 0.012). The positive SE group was divided into 2 subgroups: (a) inducible ischaemia limited to the apical segments (‘apical ischaemia’) and (b) ischaemia in any other segments with or without apical involvement (‘other positive’). The subgroup of patients with apical ischaemia had a significantly worse outcome compared to the patients with a negative SE (HR, 3.68; P = 0.041) but a similar outcome to the ‘other positive’ subgroup. However, when investigated with invasive coronary angiography, the prevalence of coronary artery disease (CAD) and their rate of revascularisation was considerably lower. Only age (HR, 1.07; P < 0.001) was correlated with all-cause mortality.ConclusionSE remains a strong predictor of patients’ outcome in a contemporary population. A positive SE result was the only predictor of 12-month MACCE. The subgroup of patients with limited apical ischaemia have similar outcome to patients with ischaemia in other segments despite a lower prevalence of CAD and a lower revascularisation rate.

The safety, efficacy and cost-effectiveness of stress echocardiography in patients with high pretest probability of coronary artery disease

“…Interestingly, 16 of these patients had only apical ischaemia on SE, a finding that may be related to microvascular disease. 6 The ICA findings of the remaining seven patients were (1) significant right coronary artery (RCA) disease which was a small vessel, (2) moderate disease on proximal and distal left anterior descending artery (LAD), (3) moderate ostial LAD disease, (4) moderate RCA disease, (5) moderate to severe very distal LAD lesion, (6) diffuse atheroma and mild to moderate disease in the distal LAD and (7) proximal LAD disease, not suitable for PCI and turned down for coronary artery bypass graft due to comorbidities. In the above cases (1–6), the angiographic findings and clinical symptoms were not considered severe enough to warrant revascularisation.…”

Does stress echocardiography still have a role in the rapid access chest pain clinic post NICE CG95?

“…Even with this broader MACE definition, our data show a low annual event rate, despite a high PTP cohort. The role of stress echo in assessing prognosis has been demonstrated in a similar contemporary audit where MACE was defined by cardiac death, myocardial infarction, revascularisation and cerebrovascular accident (20). They demonstrated a 1% annual event rate, which may in part be explained by the inclusion of cerebrovascular accident as a primary endpoint.…”

Comparison of NICE and ESC proposed strategies on new onset chest pain and the contemporary clinical utility of pretest probability risk score

“…The echocardiography department's recommended policy is for ischaemia limited to apical segments only to be considered as suggestive of microvascular disease requiring no further investigation. 5 Patients with two or more segments of non-apical ischaemia were considered to have a positive stress test and based on clinician's discretion they were further referred for ICA.…”