Does the prognostic value of dobutamine stress echocardiography differ among different age groups?

Prognostic Role of Cardiac Power in a Large Cohort of Patients with Normal Ejection Fraction Referred for Dobutamine Stress Echocardiography

BACKGROUND

Cardiac power reflects cardiac performance in terms of energy transferred by the left ventricle (LV) to the aorta per unit time. Peak stress cardiac power has been shown to predict outcome in patients with reduced LV ejection fraction (EF), and more recently, in patients with normal EF referred for exercise stress echocardiography. We sought to evaluate the prognostic significance of cardiac power in patients with normal EF referred for dobutamine stress test (DSE).

METHODS

We studied data from 15,576 patients with EF ≥50% and no significant valvular or right ventricular dysfunction, undergoing DSE. Cardiac power at rest and peak stress and power reserve (peak stress minus rest power) were calculated and normalized to LV mass. Outcome endpoints were all-cause mortality and new-onset heart failure (HF).

RESULTS

The mean age was 66±13 years and 49% patients were females. Resting and peak stress power/mass were 0.7±0.2 and 1.6±0.6 W/100 g of LV myocardium, respectively. During follow-up [median 3.3 (IQR 0.7-7.3) years], 2,278 patients died and 2,137 developed HF. After adjusting for age, sex, comorbidities, and stress test results, lower peak stress power/mass was independently associated with mortality [adjusted hazard ratio (HR), highest vs. lowest quartile, 0.84, 95% confidence intervals (CI) 0.74-0.95, P=0.004] and HF at follow-up [adjusted HR 0.67, 95% CI 0.59-0.76, P<0.0001]. Power reserve showed similar associations with outcomes.

CONCLUSION

Assessment of cardiac power during DSE in patients with normal EF provides valuable prognostic information regarding risk of mortality and future HF, in addition to stress test results. It is an important research tool to study cardiac performance and development of risk scores incorporating this novel index could be considered after further validation in prospective studies.

Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study

Aims

Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography.

Methods and results

Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57–74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals.

Conclusion

Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

Utility and safety of three-dimensional contrast low-dose dobutamine echocardiography in the evaluation of myocardial viability early after an acute myocardial infarction

INTRODUCTION

The aim of the study was to determine the utility and safety of three-dimensional contrast low-dose dobutamine echocardiography (3DCLDDE) in the evaluation of myocardial viability early after ST-elevation myocardial infarction (STEMI).

MATERIAL AND METHODS

We prospectively evaluated a group of 100 consecutive patients. Myocardial viability was assessed using dobutamine echocardiography in 76 patients with segmental wall motion abnormalities, including 37 patients evaluated using 3DCLDDE and 39 patients evaluated using a standard low-dose dobutamine echocardiography protocol (LDDE), alternately.

RESULTS

Single ventricular ectopic beats were observed during the test in 1 (2.5%, 1, p = 1) patient in the 3DCLDDE group, while pain (1, p = 1) dyspnea (1, p = 1), single ventricular beats (2, p = 1), and complex ventricular arrhythmia (2, p = 0.49) were noted in 4 (10%) patients in the LDDE group. Five-year survival was 89% in the 3DCLDDE group and 87% in the LDDE group.

CONCLUSIONS

3DCLDDE and LDDE are equally safe and useful in patients after STEMI.

The prognostic value of dobutamine stress echocardiography amongst British Indian Asian and Afro-Caribbean patients: a comparison with European white patients

Background

The incidence of cardiovascular disease is considerably disparate among different racial and ethnic populations. While dobutamine stress echocardiography (DSE) has been shown to be useful in Caucasian patients, its role among ethnic minority groups remains unclear. This study aimed to investigate the prognostic importance of DSE in three ethnic groups in the UK.

Methods

DSE was performed on 6231 consecutive patients. After exclusions, 5329 patients formed the study (2676 [50.2 %] Indian Asian, 2219 [41.6 %] European white and 434 [8.1 %] Afro-Caribbean). Study outcome measures were non-fatal cardiac events (NFCE) and all-cause mortality.

Results

There were 849 (15.9 %) NFCE and 1365 (25.6 %) deaths over a median follow-up period of 4.6 years. In total 1174 (22 %) patients had inducible myocardial ischaemia during DSE, 859 (16.1 %) had fixed wall motion abnormalities and 3645 (68.4 %) patients had a normal study. Ethnicity did not predict events. Among the three ethnic groups, ischaemia on DSE was associated with 2 to 2.5 times the risk of non-fatal cardiac events and 1.2 to 1.4 times the risk of all-cause mortality. Peak wall motion score index was the strongest independent predictor of non-fatal cardiac events and all-cause mortality in all groups. The C statistic for the prediction of NFCE and all-cause mortality were significantly higher when DSE parameters were added to the standard risk factors for all ethnic groups.

Conclusions

DSE is a strong predictor of NFCE and all-cause mortality and provides predictive information beyond that provided by standard risk factors in three major racial and ethnic groups. No major differences among racial and ethnic groups in the predictive value of DSE was detected.

Electronic supplementary material

The online version of this article (doi:10.1186/s12947-015-0028-1) contains supplementary material, which is available to authorized users.

Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging

The lack of standardized reporting of the magnitude of ischemia on noninvasive imaging contributes to variability in translating the severity of ischemia across stress imaging modalities. We identified the risk of coronary artery disease (CAD) death or myocardial infarction (MI) associated with ≥10% ischemic myocardium on stress nuclear imaging as the risk threshold for stress echocardiography and cardiac magnetic resonance. A narrative review revealed that ≥10% ischemic myocardium on stress nuclear imaging was associated with a median rate of CAD death or MI of 4.9%/year (interquartile range: 3.75% to 5.3%). For stress echocardiography, ≥3 newly dysfunctional segments portend a median rate of CAD death or MI of 4.5%/year (interquartile range: 3.8% to 5.9%). Although imprecisely delineated, moderate-severe ischemia on cardiac magnetic resonance may be indicated by ≥4 of 32 stress perfusion defects or ≥3 dobutamine-induced dysfunctional segments. Risk-based thresholds can define equivalent amounts of ischemia across the stress imaging modalities, which will help to translate a common understanding of patient risk on which to guide subsequent management decisions.

Prognostic value of Doppler echocardiographic-derived coronary flow velocity reserve of left anterior descending artery in octogenarians with stress echocardiography negative for wall motion criteria

AIMS

Doppler-derived coronary flow velocity reserve (CFVR) of left anterior descending (LAD) artery is an effective tool to predict overall mortality. The aim was to investigate the capability of CFVR to predict outcome in an unselected cohort of patients older than 80 years having stress echo negative by wall motion criteria.

METHODS AND RESULTS

The study group refers to 369 patients aged > 80 years (156 men; mean age 83 ± 2 years) who had undergone dipyridamole stress echocardiography with CFVR assessment of LAD artery of known (n = 144) or suspected (n = 225) coronary artery disease. Stress echocardiography was negative for wall motion criteria in all cases. Mean CFVR was 2.07 ± 0.53. During a median follow-up of 21 months, there were 62 major adverse cardiac events (MACEs; 45 deaths and 17 non-fatal myocardial infarctions). With a receiver operating characteristic analysis, a CFVR of ≤ 1.93 was the best cut-off for predicting mortality and MACE. At individual patient analysis, 152 (41%) subjects had a CFVR of < 1.93. Annual mortality was 9.8% in patients with CFVR <1.93 and 3.7% in those with CFVR > 1.93 (P = 0.001); an annual MACE rate was 14.8% in the former and 4.5% in the latter (P < 0.0001). Of 15 clinical and echocardiographic parameters analysed, CFVR ≤ 1.93 [hazard ratio (HR) = 2.17, 95% CI 1.14-4.10] and resting wall motion abnormality (RWMA; HR = 2.60; 95% CI 1.35-5.00) were multivariable indicators of mortality. Moreover, CFVR ≤ 1.93 (HR = 2.69, 95% CI 1.56-4.67), and RWMA (HR = 2.38; 95% CI 1.31-4.33) were also strong independent predictors of MACEs. At incremental analysis, CFR ≤ 1.93 added prognostic information over clinical evaluation and RWMA when both mortality and MACE were taken as clinical end points.

CONCLUSIONS

A reduced CFVR of LAD artery is a strong and independent indicator of both mortality and MACE, adding prognostic information over clinical evaluation and RWMA. Conversely, a preserved CFVR predicts a favourable outcome particularly in subjects with no RWMA.