Abstract
BackgroundRelationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear. The aim of the study is to evaluate whether carotid disease is associated with CAD in patients submitted to exercise echocardiography (EE) and if it improves the EE ability to predict CAD.MethodsWe retrospectively studied 156 subjects without previous vascular disease who underwent EE, carotid ultrasonography and coronary angiography between 2002 and 2013. Positive EE was defined as exercise induced wall motion abnormalities, carotid disease according to Manheim and American Society of Echocardiography Consensus and significant CAD as stenosis ≥50%.ResultsEighty-nine (57.1%) subjects had significant CAD. Factors associated with CAD in multivariate analysis were fasting plasma glucose (odds ratio [OR] 1.02, p = 0.031), pre-test probability of CAD > 65% (OR 3.71, p < 0.001), positive EE (OR 10.51, p < 0.001) and carotid plaque (CP) presence (OR 2.95, p = 0.013). There was neither statistical significant difference in area under the curve after addition of CP to EE results (0.77 versus 0.81, p = 0.525) nor sensitivity, specificity, predictive values or efficiency. CP presence reclassified as very high-risk according to Systematic COronary Risk Evaluation 13 patients (34.2%) with negative EE and 22 (33.3%) without CAD.ConclusionCP is associated with CAD in patients undergoing EE, however its addition to EE does not improve CAD prediction, probably due to insufficient statistical power. CP reclassified one third of patients to very high-risk category despite negative EE or CAD absence, these subjects benefit from aggressive primary prevention interventions.
Highlights
Relationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear
It is necessary to highlight the fact that nearly one third of patients with negative exercise echocardiography (EE) and without CAD are reclassified to high-risk group according to carotid ultrasonography findings
Akosah et al [13] found an association between carotid (CP or maximal carotid intima-media thickness (CIMT) ≥1 mm) and CAD in 236 patients referred for elective coronary angiography with a high negative predictive values (NPV) in case of both negative tests
Summary
Relationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear. Stress echocardiography is a well-validated tool for diagnosis and risk stratification in patients with new onset chest pain, but it has some limitations that can impair its diagnostic capacity such as the dependence of pre-test probabilities (PTP) of coronary artery disease (CAD), the need to achieve submaximal heart rate, the presence of suboptimal echocardiographic windows, the inability to detect non limiting flow coronary stenosis or pathologies that can produce wall motion abnormalities during exercise [2,3,4]. Franco-Gutiérrez et al Cardiovascular Ultrasound (2018) 16:26 investigators to evaluate the possibility of using carotid disease in the diagnosis of CAD of patients undergoing invasive and non-invasive tests, the studies published so far have shown inconsistent results [9,10,11,12,13,14,15,16,17,18,19]. In that sense a meta-analysis of 34 studies focused on the relation of CIMT with coronary atherosclerosis, 30 showed a positive but modest relationship with correlation positive coefficients between 0.12 and 0.51 with only one study being above 0.5 and some studies showed no relationship at all [19]
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