Skip to main content
Download PDF

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

Echo Research & Practice volume 3, pages 105–113 (2016)Cite this article

Abstract

Introduction: In 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.

Methods: We 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.

Results: In 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.

Conclusion: SE 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.

References

  1. Montalescot G, Sechtem U, Achenbach S, Andreotti F, Arden C, Budaj A, Bugiardini R, Crea F, Cuisset T, Di Mario C, et al. 2013 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. European Heart Journal 34 2949–3003. (doi:10.1093/eurheartj/eht296)

    Article  Google Scholar 

  2. Wijns W, Kolh P, Danchin N, Di Mario C, Falk V, Folliguet T, Garg S, Huber K, James S, Knuuti J, et al. 2010 Guidelines on myocardial revascularization. European Heart Journal 31 2501–2555. (doi:10.1093/eurheartj/ehq277)

    Article  Google Scholar 

  3. Garbi M, Chambers J, Vannan MA, Lancellotti P 2015 Valve stress echocardiography. JACC: Cardiovascular Imaging 8 724–736. (doi:10.1016/j.jcmg.2015.02.010)

    PubMed  Google Scholar 

  4. Kristensen SD, Knuuti J, Saraste A, Anker S, Botker HE, De Hert S, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, et al. 2014 Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesth. European Heart Journal 35 2383–2431. (doi:10.1093/eurheartj/ehu282)

    Article  Google Scholar 

  5. Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, Voigt JU, Zamorano JL 2008 Stress echocardiography expert consensus statement. European Journal of Echocardiography 9 415–437. (doi:10.1093/ejechocard/jen175)

    Article  Google Scholar 

  6. Geleijnse ML, Krenning BJ, Nemes A, Van Dalen BM, Soliman OII, Ten Cate FJ, Schinkel AFL, Boersma E, Simoons ML 2010 Incidence, pathophysiology, and treatment of complications during dobutamine-atropine stress echocardiography. Circulation 121 1756–1767. (doi:10.1161/CIRCULATIONAHA.109.859264)

    Article  Google Scholar 

  7. Marcovitz P, Armstrong WF 1992 Accuracy of dobutamine stress echocardiography in detecting coronary artery disease. American Journal of Cardiology 69 1269–1273. (doi:10.1016/0002-9149(92)91219-T)

    Article  CAS  Google Scholar 

  8. Ryan T, Vasey C, Presti C, O’Donnell J, Feigenbaum H, Armstrong W 1988 Exercise echocardiography: detection of coronary artery disease in patients with normal left ventricular wall motion at rest. Journal of the American College of Cardiology 11 993–999. (doi:10.1016/S0735-1097(98)90056-0)

    Article  CAS  Google Scholar 

  9. Segar DS, Brown SE, Sawada SG, Ryan T, Feigenbaum H 1992 Dobutamine stress echocardiography: correlation with coronary lesion severity as determined by quantitative angiography. Journal of the American College of Cardiology 19 1197–1202. (doi:10.1016/0735-1097(92)90324-G)

    Article  CAS  Google Scholar 

  10. Sicari R, Pasanisi E, Venneri L, Landi P, Cortigiani L, Picano E 2003 Stress echo results predict mortality: a large-scale multicenter prospective international study. Journal of the American College of Cardiology 41 589–595. (doi:10.1016/S0735-1097(02)02863-2)

    Article  Google Scholar 

  11. Marwick TH, Case C, Sawada S, Rimmerman C, Brenneman P, Kovacs R, Short L, Lauer M 2001 Prediction of mortality using dobutamine echocardiography. Journal of the American College of Cardiology 37 754–760. (doi:10.1016/S0735-1097(00)01191-8)

    Article  CAS  Google Scholar 

  12. Poldermans D, Fioretti PM, Boersma E, Bax JJ, Thomson IR, Roelandt JR, Simoons ML 1999 Long-term prognostic value of dobutamine-atropine stress echocardiography in 1737 patients with known or suspected coronary artery disease: a single-center experience. Circulation 99 757–762. (doi:10.1161/01.CIR.99.6.757)

    Article  CAS  Google Scholar 

  13. Lucas FL, DeLorenzo MA, Siewers AE, Wennberg DE 2006 Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001. Circulation 113 374–379. (doi:10.1161/CIRCULATIONAHA.105.560433)

    Article  CAS  Google Scholar 

  14. Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, Gutgesell H, Reichek N, Sahn D, Schnittger I, et al. 1989 Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. Journal of the American Society of Echocardiography 2 358–367. (doi:10.1016/S0894-7317(89)80026-4)

    Article  CAS  Google Scholar 

  15. Velazquez EJ, Lee KL, Deja MA, Jain A, Sopko G, Marchenko A, Ali IS, Pohost G, Gradinac S, Abraham WT, et al. 2011 Coronary-artery bypass surgery in patients with left ventricular dysfunction. New England Journal of Medicine 364 1607–1616. (doi:10.1056/NEJMoa1100356)

    Article  CAS  Google Scholar 

  16. Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, Knudtson M, Dada M, Casperson P, Harris CL, et al. 2007 Optimal medical therapy with or without PCI for stable coronary disease. New England Journal of Medicine 356 1503–1516. (doi:10.1056/NEJMoa070829)

    Article  CAS  Google Scholar 

  17. De Bruyne B, Pijls NH, Kalesan B, Barbato E, Tonino PA, Piroth Z, Jagic N, Mobius-Winkler S, Rioufol G, Witt N, et al. 2012 Fractional flow reserve-guided PCI vs medical therapy in stable coronary disease. New England Journal of Medicine 367 991–1001. (doi:10.1056/NEJMoa1205361)

    Article  Google Scholar 

  18. Cortigiani L, Borelli L, Raciti M, Bovenzi F, Picano E, Molinaro S, Sicari R 2015 Prediction of mortality by stress echocardiography in 2835 diabetic and 11 305 nondiabetic patients. Circulation Cardiovascular Imaging 8 e002757–e002757. (doi:10.1161/CIRCIMAGING.114.002757)

    Article  Google Scholar 

  19. Bugiardini R, Manfrini O, De Ferrari GM 2006 Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography. Archives of Internal Medicine 166 1391–1395. (doi:10.1001/archinte.166.13.1391)

    Article  Google Scholar 

  20. Panza JA, Laurienzo JM, Curiel RV, Unger EF, Quyyumi AA, Dilsizian V, Cannon RO 1997 Investigation of the mechanism of chest pain in patients with angiographically normal coronary arteries using transesophageal dobutamine stress echocardiography. Journal of the American College of Cardiology 29 293–301. (doi:10.1016/S0735-1097(96)00481-0)

    Article  CAS  Google Scholar 

  21. Kannel WB, Wolf PA, Verter J 1983 Manifestations of coronary disease predisposing to stroke. The Framingham study. JAMA 250 2942–2946. (doi:10.1001/jama.1983.03340210040022)

    Article  CAS  Google Scholar 

  22. Dichgans M, Malik R, König IR, Rosand J, Clarke R, Gretarsdottir S, Thorleifsson G, Mitchell BD, Assimes TL, Levi C, et al. 2013 Shared genetic susceptibility to ischemic stroke and coronary artery disease: a genome-wide analysis of common variants. Stroke 45 24–36. (doi:10.1161/STROKEAHA.113.002707)

    Article  Google Scholar 

  23. Camici PG, Crea F 2007 Coronary microvascular dysfunction. New England Journal of Medicine 356 830–840. (doi:10.1056/NEJMra061889)

    Article  CAS  Google Scholar 

  24. Cortigiani L, Rigo F, Gherardi S, Galderisi M, Bovenzi F, Sicari R 2014 Prognostic meaning of coronary microvascular disease in type 2 diabetes mellitus: a transthoracic Doppler echocardiographic study. Journal of the American Society of Echocardiography 27 742–748. (doi:10.1016/j.echo.2014.02.010)

    Article  Google Scholar 

  25. Rinkevich D, Belcik T, Gupta NC, Cannard E, Alkayed NJ, Kaul S 2013 Coronary autoregulation is abnormal in syndrome X: insights using myocardial contrast echocardiography. Journal of the American Society of Echocardiography 26 290–296. (doi:10.1016/j.echo.2012.12.008)

    Article  Google Scholar 

Download references

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Cardiology, King’s College Hospital NHS Foundation Trust, London, UK

    Alexandros Papachristidis MD, Damian Roper MBChB, Daniela Cassar Demarco MD, Ioannis Tsironis MD, Michael Papitsas MD, Jonathan Byrne PhD, Khaled Alfakih MD & Mark J. Monaghan PhD

  2. Lewisham Healthcare NHS Trust, London, UK

    Khaled Alfakih MD

Authors
  1. Alexandros Papachristidis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Damian Roper MBChB
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniela Cassar Demarco MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ioannis Tsironis MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael Papitsas MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jonathan Byrne PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Khaled Alfakih MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mark J. Monaghan PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alexandros Papachristidis MD.

Rights and permissions

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Papachristidis, A., Roper, D., Cassar Demarco, D. et al. The prognostic role of stress echocardiography in a contemporary population and the clinical significance of limited apical ischaemia. Echo Res Pract 3, 105–113 (2016). https://doi.org/10.1530/ERP-16-0033

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-16-0033

Key Words

Echo Research & Practice

ISSN: 2055-0464

Contact us