Prognostic Value Of Stress Echocardiography Research Articles

Long-term prognostic value of stress echocardiography in patients with suspected coronary artery disease - Systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Objective To evaluate the association between results of stress echocardiography and outcomes for patients with suspected coronary artery disease. Design Systematic review and meta-analysis. Data Sources Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, and Clinicaltrials. Eligibility criteria for selecting studies Randomised controlled trials (RCT) evaluating long term outcome of SE in patients suspected of coronary artery disease. Data Synthesis A meta-analysis utilising the fixed effects model to evaluate evidence from recent RCT trials on SE or comparing SE to other non-invasive diagnostic modalities. The primary outcome was the composite of all-cause mortality, or cardiovascular death and non-fatal myocardial infarction. Positive SE result was defined as inducible ischaemia in at least 1 of the 16 left ventricular segments. Results Six trials fulfilled the search criteria. A total of 19477 subjects who underwent either pharmacological (Dobutamine or Dipyridamole) or treadmill SE were recruited in the meta-analysis with a median follow-up of 31 months (range 21–101). The mean age was 59 years, and 55% were male. Fifty six percent had hypertension, 48% dyslipidaemia, 33% history of smoking, 21% diabetes mellitus and 26% history of myocardial infarction. The overall annual event rate was 1.79% for the composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction and for death 1.82%. Positive SE result was associated with an increased risk of the composite outcome and death with an annual event rate of 1.98% vs 1.26%, Odds Ratio 1.99 (CI 1.75–2.26) and 3.59% vs. 0.93, Odds Ratio 2.06 (CI 1.80–2.35) for the composite outcome and death, respectively Figure A,B. Heterogeneity and inconsistency (Chi2 1.7 P= 0.89) were low. Imprecision was low in the composite outcomes, and the optimal information size was achieved across the studies. Conclusions In this meta -analysis positive SE results were associated with poorer long-term composite outcome of all-cause or cardiovascular mortality and non-fatal myocardial infarction as well as for death only. Figure. Composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction. (Abstract picture 1) All-cause or cardiovascular death. (Abstract picture 2)

Enhancing the Prognostic Value of Stress Echocardiography

Can the prognostic value of stress echocardiography (SE) be enhanced by looking at parameters beyond development of regional wall motion abnormality

Prognostic value of stress echocardiography assessed by the ABCDE protocol.

AimThe aim of this study was to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicentre, international, effectiveness study. Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, electrocardiogram-based heart rate reserve.Methods and resultsFrom July 2016 to November 2020, we enrolled 3574 all-comers (age 65 ± 11 years, 2070 males, 58%; ejection fraction 60 ± 10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent clinically indicated ABCDE-SE. The employed stress modality was exercise (n = 952, with semi-supine bike, n = 887, or treadmill, n = 65 with adenosine for step D) or pharmacological stress (n = 2622, with vasodilator, n = 2151; or dobutamine, n = 471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only endpoint. Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D, and 37% for E steps. During a median follow-up of 21 months (interquartile range: 13–36), 73 deaths occurred. Global X 2 was 49.5 considering clinical variables, 50.7 after step A only (P = NS (not significant)) and 80.6 after B–E steps (P < 0.001 vs. step A). Annual mortality rate ranged from 0.4% person-year for score 0 up to 2.7% person-year for score 5.ConclusionABCDE-SE allows an effective prediction of survival in patients with chronic coronary syndromes.

Comparison of coronary flow reserve feasibility in different stress echocardiography protocols: dobutamine, dipyridamole, exercise, and rapid pacing.

The assessment of coronary flow velocity reserve (CFVR) may improve the diagnostic and prognostic value of stress echocardiography (SE). The aim of the study was to compare the feasibility of CFVR assessment in the left anterior descending artery (LAD) in 4 modalities of SE: dobutamine, dipyridamole, rapid cardiac pacing, and exercise using cycle ergometer. We performed SE in 369 patients (mean [SD] age, 67 [11] years) with dobutamine (n = 230), dipyridamole (n = 73), rapid cardiac pacing (n = 22), or exercise (n = 44) between June 2017 and June 2020. We measured CFVR as the ratio of peak diastolic coronary flow velocity during exercise, pharmacological stress, or pacing to peak diastolic coronary flow velocity at rest in the distal or mid LAD. The feasibility of CFVR was excellent during rapid cardiac pacing (100%), dobutamine (95%), and dipyridamole (95%) and was lower during exercise (73%; P <⁠0.01 vs other groups). In multivariable analysis, the exercise protocol was a predictor of the loss of blood flow in the LAD during SE (odds ratio, 7.89; 95% CI, 2.17–31.33; P = 0.002). The median (interquartile range) CFVR was lower with rapid cardiac pacing (1.7 [1.4–2.0]) as compared with dobutamine (2.1 [1.7–2.5]), dipyridamole (2.1 [1.8–2.5]), and exercise (2.0 [1.7–2.3]) (P <⁠0.05 for all). CFVR in the LAD can be obtained during all forms of SE, but the feasibility is significantly higher with rapid cardiac pacing and pharmacological tests as compared with exercise, which was identified in our study as an independent predictor of the loss of blood flow during a blood flow recording in the LAD at the peak of stress test.

Prognostic impact of stress echocardiography with discordant stress electrocardiography in patients with suspected coronary artery disease.

During stress echocardiography, the echocardiologist routinely collects both echocardiographic images and stress electrocardiogram (ECG) concurrently. The managing physician faces a dilemma when the stress ECG and stress echocardiography results are discordant; for example, when a patient has negative stress echocardiography but positive stress ECG. We therefore sought to evaluate the prognostic value of stress echocardiography in relation to concordant or discordant stress ECG findings in our local Singapore setting, which has a well-defined Southeast Asian population. This was a retrospective observational study of all patients who underwent stress echocardiography in 2012 at Changi General Hospital, Singapore. All study patients were followed up for 18 months via electronic medical records. There was no difference in the major adverse cardiovascular events (MACE) outcome of patients with normal stress echocardiography and normal stress ECG (reference group) as compared with patients with normal stress echocardiography but positive (discordant) stress ECG (odds ratio 2.02, 95% confidence interval 0.82‒4.98; p = 0.125). This study will help to reassure cardiologists that discordant results (negative stress echocardiography but positive stress ECG) do not portend a higher risk of MACE when compared to concordant results (i.e. both stress echocardiography and stress ECG are negative).

P1788 Prognostic value of stress echocardiography in preoperative risk stratification and management

Abstract Introduction The prognostic value of pharmacologic stress echocardiography has been extensively demonstrated in patients undergoing noncardiac surgery since 42% of the perioperative complications are cardiac. Coronary artery stenoses can became flow-limiting due to hemodynamic fluctuations in this period leading to myocardial ischemia. Purpose Evaluation of prognostic value of pharmacologic stress echocardiography in preoperative risk stratification. Methods Single center retrospective analysis of patients’ data referred to perform a preoperative risk stratification through pharmacological stress echocardiography between January 2014- December 2018. Data was collected regarding clinical and echocardiographic parameters to predict perioperative cardiac complications (myocardial infarction and development of arrythmias) and evaluate the impact of the result of DSE in patients´ clinical management. Results Of 910 pharmacological stress echocardiograms, 106 were performed to evaluate preoperative risk. Patients´ mean age was 66 ± 11 years, 85% males. 64% had hypertension, 45% dyslipidaemia, 38% current smokers and 18% diabetes. 189% had previously myocardial infarction and 9% stroke. All patients were proposed to intermediate-high risk surgeries: 73% to vascular surgery, 14% to kidney transplant and 13% to other type of surgery (especially abdominal surgery). Most of the stress tests (64%) were performed with dobutamine and the others 34% with dipyridamole. 91% of stress echocardiography were negative, 6% positive and 4% inconclusive. The patients with a positive stress test was submitted to coronary angiography to treat relevant lesions and cardiovascular risk factors were optimized. 72% of the patients has already been submitted to the proposed surgery; in this population, there was a 5% rate of cardiac complications following the surgery, all in patients with previous negative stress echocardiography. Complications were non-ST elevation myocardial infarction in 1% and de novo atrial fibrillation in 4%. Half of the patients with a positive stress echocardiography were operated with no cardiac perioperative complications, possibly related to patient´s optimization before the surgery; in the other half it was decided not to perform the surgery due to the potential cardiac risk. Predictor factors for perioperative cardiac complications, evaluated through univariate and multivariate analysis, were age (odds ratios (OR) 1.232, confidence interval (CI) 1.043-1.456, p 0.007) and stroke (OR 0.057, CI 0.947-44.592, p 0.033). Conclusion In our study, patients with a positive stress echocardiography were optimized before the surgery leading to none cardiac perioperative complications, emphasizing the importance of this test in preoperative patients´ management.

P1511Promising prognostic value of negative stress echocardiography in patients with incomplete revascularization after successful primary PCI

Abstract Background The specific role of non-invasive functional testing in a risk stratification of patients with incomplete revascularization after primary percutaneous coronary intervention (pPCI) still needs to be evaluated. The aim of our study was to assess negative prognostic value of stress echocardiography (SECHO) after successful pPCI and incomplete revascularization of non-culprit lesions. Methods Our study consisted of 202 patients (mean age 59±10 years, male 142) successfully treated with pPCI, who performed SECHO according to Bruce protocol in order to assess residual ischemia in coronary artery with non-culprit lesion. Duke treadmill score, functional capacity (Metabolic Equivalents - METs), achieved target heart rate (THR), heart rate recovery (HRR), wall motion score index (WMSI) and ejection fraction were interrogated in all patients. Slow HRR was defined as ≤18 beats/min. Median follow-up of the patients was 70 months (IQR 55–83 months) for the occurrence of cardiovascular death and non-fatal myocardial infarction. We also assessed the independent predictors for the occurrence of the adverse events. Results Out of 202 patients, 42 (20.8%) had positive SECHO test, 4 patients (1.98%) had died due to non-cardiac causes and 7 patients (3.5%) were lost to follow-up. From the remaining 149 patients with negative SECHO, 13 (8.7%) had an adverse event (7 cardiovascular deaths and 6 non-fatal MI). Negative predictive value of SECHO test was 91.3%. Univariate predictors of adverse events were slow HRR (HR 4.343 [95% CI 1.473–14.011], p=0.008), and not achieved THR (HR 0.322 [95% CI 0.105–0.985], p=0.047). By multivariate analysis, only slow HRR remained independent predictor of adverse events (HR 3.324 [95% CI 1.013–10.906], p=0.048). Conclusion SECHO test has excellent negative prognostic value in patients with incomplete revascularization of non-culprit lesions after successful pPCI. Still, particular care should be taken to the patients with slow HRR and negative SECHO due to increased risk for the occurrence of adverse events. Acknowledgement/Funding Ministry of Education and Science of the Republic of Serbia (Grant No III41022)

Incremental Prognostic Value of Stress Echocardiography With Carotid Ultrasound for Suspected CAD

ObjectivesThis study hypothesized that ischemia and atherosclerosis assessment by ultrasound (US) may provide incremental prognostic information in patients with new-onset chest pain who do not have coronary artery disease (CAD). BackgroundThe clinical significance of atherosclerosis assessment by carotid US in patients undergoing stress echocardiography (SE) in such patients is unknown. MethodsConsecutive patients with suspected angina but no history of CAD underwent simultaneous SE and US prospectively to assess myocardial ischemia and carotid plaque burden (CPB), respectively. Patients were followed up for major adverse events (MAEs)—all-cause mortality, nonfatal myocardial infarction, and unplanned coronary revascularization. ResultsOf 591 recruited patients, 580 (men, 46%; mean age 59 ± 11 years) patients were available for follow-up. SE demonstrated myocardial ischemia in 12%, but prevalence of carotid plaques was 59%. During a mean follow-up of 1,117 ± 361 days, 40 first MAEs occurred. In the multivariable regression model, pre-test probability (PTP) of CAD (p = 0.001), abnormal SE (p < 0.0001), and CPB (p < 0.0001) predicted MAEs. MAE rates per year increased from 0.9% versus 1.97% versus 4.3% versus 9.7% in patients with no carotid plaque and normal SE versus patients who had plaque and normal SE versus those with no plaque and abnormal SE versus patients with plaque and abnormal SE, respectively (p < 0.0001). In hierarchical analysis, plaque burden provided incremental prognostic value over PTP of CAD and SE; likewise, SE was incremental to PTP-CAD and CPB (p < 0.0001 for both). ConclusionsIn patients with suspected stable angina without known CAD, simultaneous SE (for ischemia) and US (for atherosclerosis) provided incremental prognostic value.

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

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 clinical efficacy and long-term prognostic value of stress echocardiography in octogenarians

IntroductionAlthough stress echocardiography (SE) is invaluable in younger populations, its prognostic value may be attenuated in the elderly due to shorter life expectancy and the frequent presence of severe comorbidities....

Utilization of stress echocardiography in patients with multivessel coronary artery disease.

The purpose of this study was to evaluate the role of stress echocardiography in the risk stratification and prognosis of patients with multivessel coronary artery disease (CAD). Stress echocardiography is an established technique for diagnosis, risk stratification, and prognosis of patients with known or suspected CAD. We evaluated 409 patients (65 ± 10 years; 63% men) referred for stress echocardiography (45% treadmill, 55% dobutamine), who underwent stress echocardiography and coronary angiography within 3 months. All patients had multivessel CAD as defined by coronary stenosis (≥50% left main or ≥70% in two or more major epicardial vessels or branches). The left ventricle was divided into 16 segments and was scored on a five-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). Follow-up (3.1 ± 1.3 years) for nonfatal myocardial infarction (n = 35) and cardiac death (n = 25) was obtained. In patients with multivessel CAD, stress echocardiography effectively risk-stratified normal (no ischemia, n = 83) vs. abnormal (ischemia, n = 326) groups for cardiac events (event rate 1.9 vs. 5.4%/year; P < 0.01). Multivariable Cox proportional-hazards regression model identified stress-induced ischemia (hazard ratio 5.5, 95% confidence interval 1.9-15.9, P = 0.002) as the most significant predictor of adverse cardiac events. A stepwise Cox proportional-hazards model demonstrated significant incremental prognostic value of stress echocardiography over clinical variables, stress electrocardiography and resting left ventricular function (P < 0.0001), with the highest global chi-square value. In patients with angiographically significant multivessel CAD, despite normal-stress echocardiography, there was an intermediate cardiac event rate (1.9%/year); abnormal-stress echocardiography identified a high-risk group (5.4%/year); and stress echocardiography provided incremental prognostic value for risk stratification and prediction of cardiac events.

Prognostic Value of Stress Echocardiography in Patients With Low-Intermediate or High Short-Term (10 Years) Versus Low (

This study evaluates the prognostic value of stress echocardiography (Secho) in short-term (10 years) and lifetime atherosclerotic cardiovascular disease risk-defined groups according to the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator. The ideal risk assessment and management of patients with low-to-intermediate or high short-term versus low (<39%) or high (≥39%) lifetime CV risk is unclear. The purpose of this study was to evaluate the prognostic value of Secho in short-term and lifetime CV risk-defined groups. We evaluated 4,566 patients (60 ± 13years; 46% men) who underwent Secho (41% treadmill and 59% dobutamine) with low-intermediate short-term (<20%) risk divided into low (<39%, n= 368) or high (≥39%, n= 661) lifetime CV risk and third group with high short-term risk (≥20%, n= 3,537). Follow-up (3.2 ± 1.5years) for nonfatal myocardial infarction (n= 102) and cardiac death (n= 140) were obtained. By univariate analysis, age (p <0.001) and ≥3 new ischemic wall motion abnormalities (WMAs, p<0.001) were significant predictors of cardiac events. Cumulative survival in patients was significantly worse in patients with ≥3 WMA versus <3 WMA in low-intermediate short-term and low (3.3% vs 0.3% per year, p <0.001) or high (2.0% vs 0% per year, p <0.001) lifetime risk and also in those with high short-term CV risk group (3.5% vs 1.0% per year, p <0.001). Multivariate Cox proportional hazards analysis identified ≥3 new ischemic WMAs as the strongest predictor of cardiac events (hazard ratio 3.0, 95% confidence interval 2.3 to 3.9, p<0.001). In conclusion, Secho results (absence or presence of ≥3 new ischemic segments) can further refine risk assessment in patients with low-intermediate or high short-term versus low or high lifetime cardiovascular risk. Event rate with normal Secho is low (≤1% per year) but higher in patients with high short-term CV risk by the American College of Cardiology/American Heart Association 2013 cardiovascular risk calculator.

Prognostic Value of Stress Echocardiography in Patients Presenting with Syncope.

Evaluation for ischemia is appropriate in patients at risk for or with a history of coronary artery disease presenting with syncope. The aim of this study is to determine the prognostic value of stress echocardiography in patients presenting with syncope. We examined our database of all patients undergoing stress echocardiography at our institution. Patients referred due to syncope were grouped as high risk based on any of the following: (1) known history of coronary artery disease, (2) left ventricular ejection fraction <50%, (3) moderate or severe mitral or aortic valve regurgitation, and (4) moderate mitral or aortic valve stenosis. The main outcomes were the presence of ischemia on stress imaging and all-cause mortality using the social security death index. A total of 225 patients were identified; mean age was 64.3 ± 14.5 years, the mean follow-up duration was 29.2 ± 13.8 months. There were 163 patients in the low-risk group and 62 patients in the high-risk group. On imaging, 7% of the overall cohort had ischemia. The low-risk group had 5 (3%) patients with ischemia and the high-risk group had 10 patients (16%) with ischemia (P < 0.01). The mortality rate was significantly higher in the high-risk group (3.99%/year vs. 1.02%/year; P = 0.02); this difference was not affected by the presence of ischemia. High-risk patients with syncope as defined by appropriateness criteria and existing evidence carry a higher risk of ischemia and all-cause mortality. The presence of ischemia may not be predictive of long-term outcome in this group.

Abstract 9440: Prognostic Value of Stress Echocardiography in Patients With Low (&lt;10%)-Intermediate (10-20%) Framingham Risk Score (Short-Term) versus Low (&lt;39%) or High (≥39%) Lifetime Predicted Risk of Cardiovascular Disease

Background: The ideal risk assessment and management of patients with low-intermediate or high Framingham risk score (FRS, short-term) versus low or high lifetime cardiovascular (CV) risk is unclear. The purpose of this study was to evaluate the prognostic value of stress echocardiography (SE) in defined FRS and lifetime risk groups. Methods: We evaluated 4566 patients (60±13 years; 46% male) undergoing SE (41% treadmill, 59% dobutamine) with low-intermediate FRS (&lt;20%) divided into: low (&lt;39%, n=368) or high lifetime (≥39%, n=661) CV risk and third group with high FRS (≥20%, n=3537). Follow-up (3.2±1.5 years) for non-fatal myocardial infarction (n=102) and cardiac death (n=140) were obtained. Results: By univariate analysis, age (p&lt;0.001), ejection fraction (p&lt;0.001) and ≥3 ischemic wall motion abnormalities (WMA) (p&lt;0.001) were significant predictors of cardiac events. Cumulative survival in patients with low or intermediate short term risk groups were significantly worse in patients with ≥3 WMA vs. &lt;3 WMA in low-intermediate FRS and low (3.3%/year vs. 0.3%/year, p&lt;0.001) or high lifetime CV risk (2.0%/year vs. 0%/year, p&lt;0.001) and high FRS group (3.5%/year vs. 1.0%/year, p&lt;0.001). Multivariate Cox proportional hazards analysis identified ≥3 new ischemic wall motion abnormalities as the strongest predictor of cardiac events (HR 3.2, 95% CI 2.2-4.6, p &lt;0.001). Conclusion: Stress echocardiography results (absence or presence of ≥3 ischemic segments) can equally and effectively risk stratify low-intermediate or high FRS versus low or high lifetime cardiovascular risk patients. Event rate with normal SE is highest in patients with high FRS.

Prevalence and Long‐Term Prognosis of Patients with Complete Bundle Branch Block (Right or Left Bundle Branch) with Normal Left Ventricular Ejection Fraction Referred for Stress Echocardiography

The prognostic value of stress echocardiography (SE) in patients with complete bundle branch blocks (BBB) with normal left ventricular ejection fraction (LVEF) has not been well described. We sought to determine the prognostic value of SE in patients with BBB and normal LVEF. We analyzed 7214 patients (58 ± 14 years; 57% female) with a mean follow-up time of 9 ± 4 years. Dobutamine SE was performed in 51% of patients and exercise SE was performed in 49%. All-cause mortality data were obtained from the Social Security Death Index. There were 222 (3%) patients with right bundle branch block (RBBB) and 50 (0.7%) patients with left bundle branch block (LBBB). Patients with LBBB were 3 times more likely to have an abnormal stress test after adjusting for age, gender, mode of stress test, and coronary artery disease risk factors (OR = 3.3; 95% CI: 1.86-5.92; P < 0.001). The mortality rates were 4.5%/year for patients with LBBB, 2.5%/year for patients with RBBB, and 1.9%/year for patients without BBB (P < 0.001). Among patients with a normal SE, those with LBBB had similar mortality to those without LBBB (HR = 0.9; 95% CI: 0.4-2.2; P = 0.8). Patients with LBBB and abnormal SE had more than 2 times greater risk of all-cause mortality (HR = 2.4; 95% CI: 1.4-4.2; P = 0.002). A normal stress echocardiogram in LBBB is associated with benign prognosis while those with LBBB and abnormal SE have the worst outcomes.

Long-term prognostic value of stress echocardiography in patients presenting to the ED with spontaneous chest pain

PurposeThe aims of this study were to evaluate the long-term prognostic value of stress echocardiography (SE) in patients evaluated in emergency department (ED) and to determine SE parameters that best predicted outcome. MethodsBetween June 2008 and July 2012, 626 patients with an episode of spontaneous chest pain underwent SE (exercise stress echocardiography or dobutamine stress echocardiography [DSE]). Between December 2012 and January 2013, all patients were contacted to verify the occurrence of cardiac events. Patients were divided in 3 subgroups according to peak stress Wall Motion Score Index (pWMSI): normal peak wall motion (pWMSI, 1; group A1), mild to moderate peak asynergy (pWMSI, 1.1-1.7; group A2), and severe peak asynergy (pWMSI, >1.7; group A3). ResultsStress echocardiography showed inducible ischemia in 159 patients (25%); it was negative in 425 (68%) and inconclusive in 42 (7%). Patients with cardiac events more frequently showed inducible ischemia (50% vs 26%; P = .015) compared with patients with good prognosis; a normal SE (14% vs 61%) was significantly less common. At a multivariate regression analysis, an increased pWMSI (relative risk: 9.816, 95% confidence interval: 3.665-26.290; P < .0001) was independently associated with a bad outcome. Cumulative event-free survival was significantly worse with an increasing degree of peak wall motion asynergy (99% in group A1; 96%, group A2; and 88% in group A3; P = .011 between A1 and A2 groups, P = .012 between A2 and A3 groups, and P < .0001 between A1 and A3 groups). ConclusionsStress echocardiography showed an optimal prognostic value among ED patients evaluated for chest pain. The presence of an extensive asynergic area at peak stress was associated with an adverse prognosis.

Feasibility and Prognostic Value of Stress Echocardiography in Obese, Morbidly Obese, and Super Obese Patients Referred for Bariatric Surgery

Stress echocardiography (SE) is clinically used in the risk stratification and prognosis of patients with coronary artery disease. Due to multiple comorbidities, obese patients have increased risk of adverse cardiovascular events perioperatively in noncardiac surgery. The aim of this study was to investigate the feasibility of SE in morbidly obese patients undergoing bariatric surgery. Consecutive patients referred for SE for preoperative evaluation prior to bariatric surgery from January 2002 to July 2011 formed the study cohort. Contrast was used to define the endocardial border in patients with poor acoustic windows. All-cause mortality data were obtained from Social Security Death Index. Six hundred fifty-two patients (47 ± 10 years, 84% females) with the mean follow-up of 3.0 ± 2.7 years and mean body mass index (BMI) of 47 ± 9 kg/m² were included in this analysis. Dobutamine SE was performed in 65% of patients compared to exercise SE in 35%. Patients with higher BMI were more likely to undergo dobutamine SE (P < 0.0001). Similarly, incidence of poor acoustic windows and contrast use was higher in those with increased BMI (P < 0.001). Contrast use was higher in patients undergoing dobutamine SE (39%) versus exercise (25%), (P = 0.002). 19 patients (3%) had an abnormal SE and 8 patients (1.2%) died during the follow-up period. Stress echocardiography is feasible in the morbidly obese patients. Patients with higher BMI were more likely to undergo dobutamine SE and have higher incidence of poor acoustic windows and contrast use.

Abstract 9333: Prognostic Value of Stress Echocardiography In Patients Achieving a High Exercise Workload (=10 Metabolic Equivalents) and Submaximal Heart Rate Response

Background: High exercise capacity (≥10 metabolic equivalents, METS) is a predictor of favorable prognosis. Submaximal studies (&lt;85% maximum predicted heart rate, MPHR) may lead to non-diagnostic results and indeterminate outcomes. The purpose of this study was to examine the prognostic value of stress echocardiography (SEcho) in patients achieving high exercise capacity and submaximal heart rate response. Methods: We evaluated 81 patients (50 ± 13 years; 62% male) achieving nine minutes (≥10 METS) and &lt;85% MPHR with treadmill SEcho. Resting left ventricular ejection fraction and regional wall motion were assessed. The left ventricle was divided into 16 segments and scored on 5-point scale of wall motion. Abnormal SEcho was defined as stress-induced ischemia (wall-motion score of ≥1 grade). Followup (3.4 ± 1.5 years) for non-fatal myocardial infarction and cardiac death (n = 2) were obtained. Results: By univariate analysis, the number of new ischemic wall motion abnormalities (hazard ratio = 2.5, confidence interval 1.2 - 5.3, p = 0.02) was the most significant predictor of cardiac events. Cumulative survival in patients achieving nine minutes (≥10 METS) and &lt;85% MPHR was significantly worse in patients with abnormal (ischemic) vs. normal (nonischemic) SEcho (1.1%/year vs. 0.2%/year, p = 0.02)[Graph]. Conclusions: The ability to achieve nine minutes (≥10 METS), despite &lt;85% MPHR by treadmill SEcho was associated with a benign prognosis (~1.0%/year). In the setting of high achieved exercise capacity and &lt;85% MPHR, SEcho results (presence or absence of ischemia) were further able to sub-stratify this low risk group.

Abstract 9888: Is There Additional Prognostic Value of Stress Echocardiography in Patients Achieving a High Exercise Capacity (≥10 Metabolic Equivalents)?

Background: High exercise capacity is a predictor of favorable prognosis in patients with known or suspected coronary artery disease. The purpose of this study was to examine the prognostic value of stress echocardiography (SEcho) in patients achieving high exercise workload. Methods: We evaluated 970 patients (51 ± 11 years; 62% male) achieving nine minutes (≥10 metabolic equivalents) on a Bruce protocol by treadmill SEcho. Resting left ventricular ejection fraction and regional wall motion were assessed. The left ventricle was divided into 16 segments and scored on 5-point scale of wall motion. Abnormal SEcho was defined as stress-induced ischemia (wall-motion score of ≥1 grade). Followup (3.4 ± 1.5 years) for non-fatal myocardial infarction (n = 11) and cardiac death (n = 3) were obtained. Results: By univariate analysis, both peak wall motion score index (p=0.002) and number of new ischemic wall motion abnormalities (p&lt;0.0001) were significant predictors of cardiac events. Cumulative survival in patients achieving nine minutes (≥10 metabolic equivalents) was signficantly worse in patients with abnormal (ischemic) vs. normal (nonischemic) SEcho (1.1%/year vs. 0.2%/year, p=0.001)(Graph). Multivariate logistic regression analysis identified number of new ischemic wall motion abnormalities as the strongest predictor of cardiac events (RR 1.27, 95% CI 1.0-1.6, p=0.01). Conclusions: The ability to achieve nine minutes (≥10 metabolic equivalents) by treadmill stress echocardiography confers a benign prognosis (~1.0%/year). In the setting of high achieved exercise capacity, stress echocardiography (absence or presence of ischemia) is further able to effectively risk stratify a low risk group.

Prognostic Value of Stress Echocardiogram in Patients With Angiographically Significant Coronary Artery Disease

The purpose of this study was to evaluate the prognostic value of stress echocardiography in patients with angiographically significant coronary artery disease (CAD). Two hundred sixty patients (mean age 63 ± 10 years, 58% men) who underwent stress echocardiography (41% treadmill, 59% dobutamine) and coronary angiography within 3 months and without intervening coronary revascularization were evaluated. All patients had significant CAD as defined by coronary stenosis ≥70% in major epicardial vessels or branches (45% had single-vessel disease, and 55% had multivessel disease). The left ventricle was divided into 16 segments and scored on a 5-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). Follow-up (3.1 ± 1.2 years) for nonfatal myocardial infarction (n = 23) and cardiac death (n = 6) was obtained. In patients with angiographically significant CAD, stress echocardiography effectively risk stratified normal (no ischemia, n = 91) in contrast to abnormal (ischemia, n = 169) groups for cardiac events (event rate 1.0%/year vs 4.9%/year, p = 0.01). Multivariate logistic regression analysis identified multivessel CAD (hazard ratio 2.53, 95% confidence interval 1.16 to 5.51, p = 0.02) and number of segments in which ischemia was present (hazard ratio 4.31, 95% confidence interval 1.29 to 14.38, p = 0.01) as predictors of cardiac events. A Cox proportional-hazards model for cardiac events showed small, significant incremental value of stress echocardiography over coronary angiography (p = 0.02) and the highest global chi-square value for both (p = 0.004). In conclusion, in patients with angiographically significant CAD, (1) normal results on stress echocardiography conferred a benign prognosis (event rate 1.0%/year), and (2) stress echocardiographic results (no ischemia vs ischemia) added incremental prognostic value to coronary angiographic results, and (3) stress echocardiography and coronary angiography together provided additive prognostic value, with the highest global chi-square value.