Abnormal Exercise Echocardiography Research Articles

P358 Prevalence of suicide in a cohort of subjects submitted to exercise echocardiography: clinical characteristics and exercise echocardiography results

Abstract Patients with clinical symptoms and morbidities might be more prone to commit suicide. Suicidal rate reaches up to 25-30/100.000 subjects in the countries most affected by this problem. We aimed to establish the rate of suicides among a large cohort of patients submitted to Exercise echocardiography (ExE), and also to study their clinical and ExE results, to better understand possible explanations. Methods Retrospective analysis of prospectively collected data on 12,615 patients (age 62 ± 12 years, 63% men) with a first treadmill ExE performed in our center for known/suspected coronary artery disease. Exclusion criteria were significant valve disease, cardiomyopathy, congenital heart disease, and age <18 year-old. Ischemia was defined as the development of new wall motion abnormalities (WMAs) with exercise; abnormal ExE as ischemia or resting WMAs. Results During a follow-up of 4.7± 4.8 years (interquartil range 0.1-8.0 years) there were 2,578 deaths, including 21 due to suicide (rate 166/100.000 subjects). We compare clinical characteristics and ExE results between patients that committed suicide (S), patients that died of other causes (OC), and patients that survived (Surv). The worst clinical and ExE characteristics were found in patients that died of non-suicidal causes, whereas patients that committed suicide were in an intermediate risk position (Table). In conclusion, suicidal rate seems to be very high among patients with a clinically indicated ExE. Clinical characteristics and ExE results of suicidal subjects are worse than in survivor patients and could in part explain this event. Surv S OC P value Age, y 61 ± 12 65 ± 11 69 ± 9 <0.001 Male 60% 86% 72% <0.001 Diabetes Mellitus 17.5% 24% 31% <0.001 Achieved METS 9.7 ± 3.2 8.3 ± 3.6 7.6 ± 2.9 <0.001 Good functional capacity (≥10 METs) 55% 52% 29% <0.001 Symptoms during ExE 16% 14% 19% 0.01 Maximal double product 25.0 ± 5.9 22.5 ± 6.4 22.9 ± 6.0 <0.001 Submaximal test 20% 31% 32% <0.001 Ischemia 27% 38% 44% <0.001 ExE abnormal 37% 50% 63% <0.001 LVEF at rest 59 ± 7 53 ± 13 54 ± 11 <0.001 LVEF at peak 64 ± 11 60 ± 16 55 ± 15 <0.001

Abnormal exercise echocardiography plus abnormal E/e′ ratio at exercise portends worse outcome in patients with dyspnea

BackgroundThe role of exercise echocardiography (ExE) for the assessment of patients with dyspnea is promising. We aimed to analyze the clinical characteristics and outcome of patients with this condition referred for ExE. MethodsA total of 505 patients (66 ± 11 years, 57% women) referred for evaluation of dyspnea were considered. Mitral regurgitation, ratio of early left ventricular inflow wave to early diastolic annulus wave (E/e′), and wall motion abnormalities (WMAs) were measured at rest and at exercise. Considered events were overall mortality, non-fatal myocardial infarction, late revascularization, and admission for heart failure. ResultsIschemia was observed in 102 patients (20%), whereas WMAs were already present at rest in 55 patients (11%). A percent achieved of predicted metabolic equivalents >100% was found for most of the patients (70%). During a median follow-up of 3.50 years, 66 patients had events (annualized event rate 3.5%). An E/e′ value of 13 at post-exercise was the best cut-off value to predict events. After adjustment by clinical and ExE variables, the combination of an abnormal ExE and E/e′ values at post-exercise ≥13 was an independent predictor of events (hazard ratio = 3.67, 95% confidence interval = 2.11–6.38, p < 0.001). The worse outcome corresponded to patients with abnormal ExE and raised E/e′ values at post-exercise (annualized event rate 17.2%). Patients with normal E/e′ values at post-exercise had better outcome irrespective of the ExE results (annualized event rate 2.2% with normal ExE and 2.9% with abnormal ExE), whereas patients with high E/e′ values at post-exercise but normal ExE results were at intermediate risk (annualized event rate 5.0%). ConclusionsDespite favorable ExE results, event rate remains high among patients with dyspnea referred for ExE, which may have a role to predict outcome in this setting. Patients with both raised E/e′ values at post-exercise and abnormal ExE results are at the highest event risk.

Prognostic Value of Exercise-Stress Echocardiography in Asymptomatic Patients With Aortic Valve Stenosis

ObjectivesThis study sought to evaluate the prognostic value of mean pressure gradient (MPG) increase and peak systolic pulmonary artery pressure (SPAP) measured during exercise stress echocardiography in asymptomatic patients with aortic stenosis (AS). BackgroundExercise testing is recommended in asymptomatic AS patients, but the additional value of exercise-stress echocardiography, especially the prognostic value of MPG increase and peak SPAP, is still debated. MethodsWe enrolled all consecutive patients with pure, isolated, asymptomatic AS and preserved ejection fraction ≥50% and normal SPAP (<50 mm Hg) who underwent symptom-limited exercise echocardiography at our institution. Occurrence of AS-related events (symptoms or congestive heart failure) or occurrence of aortic valve replacement was recorded. ResultsWe enrolled 148 patients (66 ± 15 years of age; 74% males; MPG: 47 ± 13 mm Hg; SPAP: 34 ± 6 mm Hg). No complications were observed. Thirty-six patients (24%) had an abnormal exercise test result (occurrence of symptoms, fall in blood pressure, and/or ST-segment depression) and were referred for surgery. Among the 112 patients with a normal exercise test result, 38 patients (34%) had abnormal exercise echocardiography scores (MPG increase >20 mm Hg and/or SPAP at peak exercise >60 mm Hg). These 112 patients were managed conservatively. During a mean follow-up of 14 ± 8 months, an AS-related event occurred in 30 patients, and 25 patients underwent surgery. Neither MPG increase >20 mm Hg nor peak SPAP >60 mm Hg was predictive of occurrence of AS-related events or aortic valve replacement (all p > 0.20). In contrast, baseline AS severity was an important prognostic factor (all p < 0.01). ConclusionsIn this observational study including 148 patients with asymptomatic AS, we confirmed and extended the importance of exercise testing for unveiling functional limitation. More importantly, neither the increase in MPG nor in SPAP at peak exercise was predictive of outcome. Our results do not support the use of these parameters in risk-stratification and clinical management of asymptomatic AS patients.

What is the real practice of exercise echocardiographic testing in asymptomatic patients with severe aortic stenosis?

Background Although exercise testing has been suggested to help predict clinical outcome, limited data are available to guide how exercise Doppler echocardiography (ECG) can be used clinically in asymptomatic patients with aortic stenosis (AS). The aim of this study was to assess the clinical value of exercise echocardiographic testing in asymptomatic patients with severe AS. Methods Symptom-limited treadmill exercise testing using the modified Bruce protocol was performed in 31 asymptomatic patients (mean age (62±11) years) with severe AS (aortic valve area &lt;1 cm2, peak aortic velocity (AV Vmax) &gt;4 m/sec, or a mean transaortic pressure gradient (AV mean PG) &gt;40 mmHg (1 mmHg=0.133 kPa)) with normal left ventricular (LV) systolic function (LV ejection fraction (EF) &gt;50%). Clinical symptoms, vital signs, ECG, and Doppler hemodynamics were obtained during and/or immediately after exercise. Results Aortic valve replacement (AVR) was performed in 18 patients during follow-up. The patients who had AVR exhibited higher baseline AV mean PG (51 (35-84) vs. 44 (25.2-57.0) mmHg; P=0.031). There were no significant differences between the AVR group and non-AVR group including exercise duration (7.47 (2.32-11.59) vs. 7.25 (4.06-10.52) minutes, P=0.917), exercise capacity (10.1 (4.6-12.8) vs. 10.1 (7.0-12.8) metabolic equivalents, P=0.675), and an increment in AV mean PG by exercise (18.5 (3.2-48.0) vs. 12.6 (4.4-32.1) mmHg, P=0.366). Univariate regression analysis revealed that independent determinant of AVR was the baseline AV mean PG (P=0.031). Conclusions Although additional value of exercise ECG was demonstrated, baseline transaortic mean pressure gradient is the major determinant of AVR. Further large-scale prospective studies are required to determine whether surgery should be recommended in the presence of an abnormal exercise ECG in asymptomatic severe AS.

Assessment of Diastolic Function During Exercise Echocardiography: Annulus Mitral Velocity or Transmitral Flow Pattern?

We hypothesize that the change in the left ventricular (LV) diastolic pattern (DP) may be measured with high reproducibility and correlates with exercise echocardiography (EE) better than the ratio of early LV inflow velocity to early diastolic annulus velocity (E/e' index). The E/e' index has been related to LV filling pressures but has not been compared with DP. We selected 179 consecutive patients who were referred for EE. Early (E) and late (A) LV inflow velocities by conventional pulsed Doppler, and septal annulus e' velocity by pulsed Doppler myocardial imaging were measured at rest (R) and post-exercise (PE). Four LV-DPs were found: abnormal relaxation (AR) at R and PE (E < A) in 110 patients; AR at PE (E > A at R; E < A at PE) in 22 patients; restrictive pattern (RP) at R and PE (E > A) in 18 patients; and RP at PE (E < A at R; E > A at PE) in 29 patients. The more accurate PE cutoff E/e' values to predict abnormal EE, ischemic response, poor functional capacity (< 8 Mets in men; < 6 Mets in women), and lack of increase in left ventricular ejection fraction (LVEF) were 12, 12, 11, and 11 (areas under the curve were 0.53, 0.53, 0.63, and 0.57, respectively). Corresponding areas under the curve for an RP at R + PE or only at PE were 0.57, 0.55, 0.54, and 0.56 (P = not significant). The sensitivity of an RP at R + PE or only at PE was lower and the specificity was higher than those of the different E/e' cutoff values for predicting abnormal EE, functional capacity, ischemic response, and lack of increase in LVEF. Achieved Mets were lower in patients with an RP at R + PE or only at PE irrespectively of the E/e' values, whereas achieved Mets in patients with AR at R + PE or only at PE were lower if the E/e' was > or = 11 (8.2 +/- 2.9 vs. 9.8 +/- 3.1, P = .01). Interobserver and intraobserver concordance were 95% (kappa = 0.86) and 100% (kappa = 1.0) for an RP, and 86% (kappa = 0.73) and 92% (kappa = 0.78) for a PE-E/e' value of > or = 11. E/e' does not allow further stratification in patients with exercise RP. We propose both measurement of E/e' and determination of the LV-DP (a quickly assessable variable) for the assessment of diastolic function during EE. However, when an RP persists or develops with exercise, further assessment may not be more informative.

Risk Stratification by Treadmill Exercise Echocardiography in Patients with Excellent Exercise Capacity

The incremental value of exercise echocardiography (EE) has been demonstrated to be maximal in patients with moderate pretest probability for coronary artery disease, but there is a lack of data in patients with low pretest probability or patients with good functional capacity. To investigate whether such incremental value is maintained in patients with excellent exercise capacity, we studied 1,433 patients who had excellent exercise capacity (>or=8 METs for women, >or=10 METs for men). During a follow-up of 2.3 +/- 1.5 years, 42 hard events occurred (cardiac death or nonfatal myocardial infarction). Variables independently associated to hard events were male gender (P = 0.04), % of the age-predicted maximum heart rate (P = 0.02), chronotropic reserve (P = 0.002), and abnormal EE (P = 0.03; incremental P value of EE = 0.03). EE has incremental value over clinical variables, resting echocardiography, and exercise testing variables in patients with excellent exercise capacity. EE may be preferable to ECG exercise testing even in patients expected to have good exercise capacity.

Value of Resting and Exercise Mitral Regurgitation During Exercise Echocardiography to Predict Outcome in Patients With Left Ventricular Dysfunction

The relative value of exercise echocardiography (EE) over resting echocardiography when this last incorporates information on mitral regurgitation (MR) is unknown. Furthermore, limited data exists regarding to the value of MR worsening during exercise in patients with LV dysfunction. We investigated whether: a) EE has incremental value over a resting echo-Doppler study; and b) post-exercise MR increments the value of EE for predicting outcome in patients with LV dysfunction. 388 consecutive patients with LV dysfunction (LV ejection fraction <50%) were followed for 2.1 (1.5) years. There were 46 hard events (myocardial infarction in 10 and cardiac death in 36). There were 43 events in 319 patients with abnormal EE vs 3 events in 69 patients with normal EE (13% vs 4%, P=.04), whereas there were 20 events in the 103 patients with at least moderate resting MR vs 26 events in the 288 with no/mild MR (19% vs 9%, P=.006). Resting MR, peak heart rate x blood pressure, and n masculine of diseased territories on EE were independently associated to hard events. The same variables and MR worsening were independently associated to cardiac death. EE maintains its higher prognostic value over resting echocardiography even when this last incorporates information on MR. MR worsening increments the value of EE for predicting cardiac death in patients with LV dysfunction.

Preoperative Exercise Echocardiography and Perioperative Cardiovascular Outcomes in Elderly Patients Undergoing Cancer Surgery

Limited information is available on the value of exercise echocardiography (EE) for identifying operative risk in elderly patients undergoing noncardiac surgery. The authors investigated the outcome in 221 consecutive patients 75 years and older who had EE before intermediate- or high-risk cancer surgery. Baseline clinical data, postoperative adverse cardiovascular events (PACE), and 30-day mortality were collected from the medical records and the Social Security Death Index. The mean age +/- SD of the group was 78.9+/-3.5 years; 57% were men. Significant cardiovascular abnormalities (by echocardiography) were present in 71.5%. Mean metabolic equivalents +/- SD achieved during exercise was 4.9+/-1.9. EE identified 50 (22.6%) patients with ischemia and/or infarction. Perioperative beta-blockers were used in 80% of patients with coronary artery disease vs 48.5% without coronary artery disease (P<.0001). There were 31 PACE in 26 (11.8%) patients. Atrial fibrillation was the most common PACE, seen in 18 (8.1%) patients, followed by congestive heart failure in 8 (3.6%), acute coronary syndrome in 2 (0.9%), and cardiac arrest in 1 (0.5%). Thirty-day mortality was only 0.9%. Hospital lengths of stay for patients with and without PACE were 16.8+/-14.9 and 8.5+/-4.8 days (P< or =.0001), respectively. An abnormal EE predicted PACE (22% vs 8.8%; P< .025). Perioperative beta-blockers reduced the incidence of postoperative atrial fibrillation (4.9% vs 12.2%; P=.052). In conclusion, EE is feasible in very elderly patients. There is a high prevalence of cardiac abnormalities in the elderly. An abnormal EE predicts PACE, which, in turn, is associated with increased length of stay.

Prognostic Value of Mitral Regurgitation Assessment During Exercise Echocardiography in Patients with Known or Suspected Coronary Artery Disease

Although mitral regurgitation (MR) may be assessed during exercise echocardiography (EE) there are no data regarding its value for predicting outcome in large series of patients. We sought to determine whether the predictive value of EE is maintained over clinical variables and resting echocardiography when the latter included information on MR, and to verify whether postexercise MR may improve the value of EE for predicting outcome. In all, 1916 patients (mean age +/- 1SD = 62 +/- 11 years; mean left ventricular ejection fraction +/- 1SD = 56 +/- 11) referred for EE were followed up for 1.9 +/- 1.4 years. There were 87 cardiac events before revascularization: 67 events occurred in 948 patients with abnormal EE and 20 events occurred in 968 patients with normal EE (P < .0001), whereas there were 24 events in the 218 patients with moderate or higher resting MR and 63 events in the 1698 patients with no or mild MR (P < .0001). Previous myocardial infarction, resting MR, peak double product, and peak left ventricular ejection fraction were independently associated to hard events (chi2 model = 144, P < .0001). The same variables were associated to cardiac death (chi2 model = 141, P < .0001). Predictors of cardiac events in patients with abnormal EE were resting MR, resting wall-motion score index, metabolic equivalents, peak double product, and MR worsening (incremental P value of MR worsening = .03). Predictors of cardiac death were resting MR, peak double product, peak left ventricular ejection fraction, and MR worsening (incremental P value of MR worsening = .03). EE maintains its higher prognostic value over resting echocardiography even when the latter incorporates information on resting MR. MR worsening provides significant incremental prognostic information in patients with abnormal EE.

Comparison of exercise echocardiography and the Duke treadmill score for risk stratification in patients with known or suspected coronary artery disease and normal resting electrocardiogram

Although exercise echocardiography (EE) is not clearly indicated in patients with normal electrocardiogram (ECG) as the first evaluation, there is a lack of data regarding its superiority over the Duke score for prognosis. We investigate whether EE has incremental value over the Duke score for predicting outcome in patients with normal ECG. One thousand six hundred forty-seven patients with interpretable ECG referred for EE were followed up for 2.5 +/- 1.4 years. There were 58 hard events (myocardial infarction or cardiovascular death). There were 38 events in 735 patients with abnormal EE versus 20 events in 912 with normal EE (P < .0001). The Duke score, resting wall motion score index, and ischemia were independently associated to events (incremental P value of EE = .03). The Duke score allowed stratification of patients with abnormal EE (P = .001) or ischemia (P = .01) into different risk categories but did not stratify patients without these characteristics. Exercise echocardiography variables stratified patients with the low Duke score (left anterior descending artery territory P = .04, left anterior descending artery ischemia P = .03) and with the intermediate Duke score (abnormal EE P = .005, necrosis P = .0009, ischemia P = .004, resting ejection fraction P < .00001, resting wall motion score index P < .00001, peak ejection fraction P < .00001, peak wall motion score index P < .0001, number of territories P = .002, left anterior descending artery territory P = .001, and left anterior descending artery ischemia P = .002) but did not with the high Duke score. Exercise echocardiography has incremental value over clinical variables, the Duke score, and resting echocardiography for the prediction of hard cardiovascular events in patients with normal resting ECG.

Screening for coronary artery disease in patients with diabetes: A Bayesian strategy of clinical risk evaluation and exercise echocardiography

Screening for coronary artery disease is constrained by its low prevalence in unselected patients. We compared the ability of clinical scores to identify a high-risk group with diabetes mellitus and investigated a Bayesian strategy by combination with exercise echocardiography (ExE). The Framingham risk score (FRS), a score based on the American Diabetes Association (ADA) screening guidelines, the United Kingdom Prospective Diabetes Study (UKPDS) risk engine, and a disease-specific diabetic cardiac risk score (DCRS) were calculated in 199 asymptomatic patients with type 2 diabetes mellitus undergoing ExE. The frequency of abnormal ExE and the proportion of these with coronary stenoses were sought in groups designated as high risk on the basis of optimal cutoffs for each score. All patients were followed up for 1 year. High risk was identified in fewer patients with the DCRS (27%) than FRS (38%, P = .02), ADA (41%, P = .004), and UKPDS (43%, P = .001). Exercise echocardiography was positive in 27 (14%); 11 of 23 proceeding to angiography showed significant stenoses. Areas under the receiver operator characteristic curves for prediction of a positive ExE were similar for DCRS, UKPDS, and FRS but less for ADA (P = .04). Positive ExE was uncommon in low-risk patients (8%-11%) and most were false positives (58%-80%). Cardiovascular events (n = 9) were more likely in the high-risk compared with the low-risk UKPDS (9% vs 2%, P = .03) and DCRS (12% vs 2%, P = .01). Combination of the UKPDS or DCRS with ExE may optimize detection of coronary artery disease and cardiac events in asymptomatic patients, while minimizing the numbers of ExE and false-positive rate.

Prognosis of Patients with Good Exercise Capacity and Mildly Abnormal Exercise Echocardiography Results: Identification of an At-risk Subgroup

Patients with good exercise capacity and mildly abnormal exercise echocardiography results have a favorable overall prognosis. We sought to define subgroups that might be at higher risk. We examined outcomes of 868 patients (women, > or = 5 metabolic equivalents; men, > or = 7 metabolic equivalents) with mild rest- or exercise-induced wall-motion abnormalities and evaluated potential predictors of time to cardiac death or nonfatal myocardial infarction (MI). Mean age was 64 +/- 10 years; 477 patients (55%) were men. Mean follow-up was 3.1 +/- 1.5 years; cardiac event rate was 1.2% per person-year. A history of MI was the only significant predictor (risk ratio, 3.9; 95% confidence interval, 1.9-7.8; P = .0001), with 1-, 3-, and 5-year event-free survival of 98.5% +/- 1.1%, 92.6% +/- 2.6%, and 83.3% +/- 5.1%, respectively (event rate, 3.4%). Patients with a history of MI have a higher annual cardiac event rate and may benefit from reevaluation, whereas no history of MI connotes a favorable prognosis.

Prediction of mortality in patients with left ventricular hypertrophy by clinical, exercise stress, and echocardiographic data

ObjectivesThis study evaluated the clinical, exercise stress test, and echocardiographic predictors of mortality and cardiac events in patients with left ventricular hypertrophy (LVH). BackgroundLeft ventricular hypertrophy is associated with an increased risk of cardiovascular morbidity and mortality. MethodsSymptom-limited treadmill exercise echocardiography was performed for evaluation of coronary artery disease in 483 patients (age, 66 ± 11 years; 281 men) with LVH. End points during follow-up were all-cause mortality and hard cardiac events (cardiac death and nonfatal myocardial infarction [MI]). ResultsForty-six patients died and 14 had nonfatal MI. The cumulative mortality rate was higher in patients with abnormal exercise echocardiography (3% vs. 0.4% at one year, 11.7% vs. 3.7% at three years, and 18.3% vs. 9.5% at five years, p < 0.001). In a sequential multivariate analysis model of clinical, exercise test, and rest and exercise echocardiographic data, incremental predictors of mortality were workload (hazard ratio [HR], 0.5; 95% confidence interval [CI], 0.3 to 0.9), rate pressure product (HR, 0.7; 95% CI, 0.5 to 0.9), left ventricular (LV) mass index (HR, 1.4; 95% CI, 1.1 to 1.8), and failure to increase ejection fraction (EF) with exercise (HR, 2.1; 95% CI, 1.1 to 3.8). Predictors of cardiac events were history of coronary artery bypass grafting (HR, 2.6; 95% CI, 1.2 to 5.4), lower exercise rate-pressure product (HR, 0.6; 95% CI, 0.5 to 0.8), resting wall motion score index (HR, 1.4; 95% CI, 1.1 to 1.8), and failure to increase EF with exercise (HR, 3.3; 95% CI, 1.6 to 6.9). ConclusionsIn patients with LVH, LV mass index and EF response to exercise are independent predictors of mortality, incremental to clinical and exercise test data and resting LV function. A normal exercise echocardiogram predicts a relatively low mortality rate during the following three years.

Outcome after abnormal exercise echocardiography for patients with good exercise capacity. prognostic importance of the extent and severity of exercise-related left ventricular dysfunction

Outcome after abnormal exercise echocardiography for patients with good exercise capacity. prognostic importance of the extent and severity of exercise-related left ventricular dysfunction

Patients with Good Exercise Capacity but Abnormal Exercise Echocardiography

Exercise echocardiography commonly is used for diagnostic and prognostic purposes in patients with known or suspected coronary-artery disease. Because

Outcome after abnormal exercise echocardiography for patients with good exercise capacity: Prognostic importance of the extent and severity of exercise-related left ventricular dysfunction

ObjectivesWe sought to define the prognostic implications of the extent and severity of exercise echocardiographic abnormalities in patients with good exercise capacity. BackgroundThe exercise capacity of patients with known or suspected coronary artery disease (CAD) is of prognostic importance, as is the extent of exercise-related left ventricular (LV) hypoperfusion or dysfunction. MethodsWe examined the outcomes of 1,874 patients with known or suspected CAD (mean age 64 ± 10 years, 64% men) who had good exercise capacity (≥5 metabolic equivalents [METs] for women, ≥7 METs for men) but abnormal exercise echocardiograms and analyzed the potential association between clinical, exercise and echocardiographic variables and subsequent cardiac events. ResultsMultivariate predictors of time to cardiac death or nonfatal myocardial infarction (MI) were diabetes mellitus (risk ratio [RR] 1.88; 95% confidence interval [CI] 1.2 to 3.0), history of MI (RR 2.44; 95% CI 1.6 to 3.6) and an increase or no change in LV end-systolic size in response to exercise (RR 1.61; 95% CI 1.1 to 2.5). Using echocardiographic variables that were of incremental prognostic value, we were able to stratify the cardiac risk of the study population; cardiac death or nonfatal MI rate per person-year of follow-up was 1.6% for patients who had a decrease in LV end-systolic size in response to exercise (n = 1,330) and 1.2% for patients who did not have any severely abnormal LV segments immediately after exercise (n = 868). ConclusionsIn patients with good exercise capacity, echocardiographic descriptors of the extent and severity of exercise-related LV dysfunction were of independent and incremental prognostic value. Stratification of patients into low- and higher risk subgroups was possible using these exercise echocardiographic characteristics.

Prognostic stratification of diabetic patients by exercise echocardiography

OBJECTIVESThe aim of this study was to assess the incremental value of exercise echocardiography for the risk stratification of diabetic patients.BACKGROUNDThere are currently insufficient outcome data in diabetic patients to define the role of stress echocardiography as a prognostic tool.METHODSWe studied the prognostic value of exercise echocardiography in 563 patients with diabetes mellitus (mean age 64 ± 11 years, 336 men) and known or suspected ischemic heart disease (IHD).RESULTSCardiac events occurred in 50 patients (cardiac death in 23 and nonfatal myocardial infarction [MI] in 27) during a median follow-up period of three years. Event rate was lower in patients with normal as compared to those with abnormal exercise echocardiography at one year (0% vs. 1.9%), three years (1.8% vs. 11.9%), and five years (7.6% vs. 23.3%), respectively (p = 0.0001). Patients with multivessel distribution of echocardiographic abnormalities had the highest event rate (2.9% at one year, 15.2% at three years, and 32.8% at five years). In an incremental multivariate analysis model, exercise echocardiography increased the chi-square of the clinical and exercise ECG model from 29 to 44.8 (p = 0.0001).CONCLUSIONSExercise echocardiography provides incremental data for risk stratification of diabetic patients with known or suspected IHD. Patients with a normal exercise echocardiogram have a low event rate. Patients with multivessel distribution of exercise echocardiographic abnormalities are at the highest risk of cardiac events, as one-third of these patients experience cardiac death or nonfatal MI during the five years following exercise echocardiography.