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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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Yang SY, Hwang HJ. Does diabetes increase the risk of cardiovascular events in patients with negative treadmill stress echocardiography? Endocr J 2022; 69:785-796. [PMID: 35125378 DOI: 10.1507/endocrj.ej21-0693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cardiovascular morbidity and mortality rates are considered to be high in patients with diabetes despite negative stress test results; however, little data are available to support this supposition. We compared the long-term cardiovascular events between patients with diabetes and those without diabetes with negative treadmill stress echocardiography and evaluated the predictors for cardiovascular events in patients with diabetes. A total of 1,243 consecutive patients (mean age, 56 ± 10 years; non-diabetics: diabetics, 975:268; mean follow-up of 5 years) with negative treadmill stress echocardiography were evaluated. Clinical data were examined, and major adverse cardiovascular events (MACEs, a composite of coronary revascularization, acute myocardial infarction, and cardiovascular death) were compared between the non-diabetic and diabetic groups. In the population matched by clinical characteristics, the diabetic and non-diabetic groups had similar occurrence of MACEs (non-diabetics vs. diabetics = 5% versus 7%; p = 0.329) and event-free survival. MACEs in the diabetic group were associated with elevated early diastolic velocity of the mitral inflow/mitral annulus (E/e') ratio, indicative of diastolic dysfunction. The absence of statin and dipeptidyl peptidase-4 inhibitor use and use of sulfonylureas were also predictors of more MACEs. In conclusion, long-term cardiovascular events in patients with diabetes and negative stress echocardiography were comparable to those in patients without diabetes. However, appropriate monitoring of diastolic dysfunction, statin use, and individualized antidiabetic drug selection are required to reduce the cardiovascular risk in patients with diabetes.
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Affiliation(s)
- So Young Yang
- Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Hui-Jeong Hwang
- Department of Cardiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Republic of Korea
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Cardiovasc Comput Tomogr 2022; 16:54-122. [PMID: 34955448 DOI: 10.1016/j.jcct.2021.11.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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4
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78:e187-e285. [PMID: 34756653 DOI: 10.1016/j.jacc.2021.07.053] [Citation(s) in RCA: 310] [Impact Index Per Article: 103.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. STRUCTURE Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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5
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Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP, Conejo T, Diercks DB, Gentile F, Greenwood JP, Hess EP, Hollenberg SM, Jaber WA, Jneid H, Joglar JA, Morrow DA, O'Connor RE, Ross MA, Shaw LJ. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 144:e368-e454. [PMID: 34709879 DOI: 10.1161/cir.0000000000001029] [Citation(s) in RCA: 141] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. METHODS A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
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Bailly M, Ribeiro MJ, Angoulvant D. Combining flow and reserve measurement during myocardial perfusion imaging: A new era for myocardial perfusion scintigraphy? Arch Cardiovasc Dis 2021; 114:818-827. [PMID: 34801410 DOI: 10.1016/j.acvd.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022]
Abstract
Myocardial flow reserve represents the ratio of myocardial blood flow between stress and rest, giving functional information about both macrocirculation and microcirculation; it has been reported extensively in positron emission tomography, with an increase in diagnostic performance, providing important prognostic information and being a powerful tool to guide therapy. Advances in single photon emission computed tomography, with the widespread availability of "cadmium zinc telluride" single photon emission computed tomography cameras, raise the question of myocardial flow reserve use in daily clinical practice. In this article, we review the pathophysiology of myocardial blood flow and myocardial flow reserve, and the initial data available from single photon emission computed tomography myocardial blood flow and myocardial flow reserve evaluation; we also discuss potential limitations to the wider implementation of flow evaluation in single photon emission computed tomography.
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Affiliation(s)
- Matthieu Bailly
- Nuclear Medicine Department, CHR Orleans, 14, Avenue de l'Hôpital, 45100 Orleans, France; UMR 1253, iBrain, Université de Tours, Inserm, 37000 Tours, France.
| | - Maria Joao Ribeiro
- UMR 1253, iBrain, Université de Tours, Inserm, 37000 Tours, France; Nuclear Medicine Department, CHRU Tours, 37000 Tours, France
| | - Denis Angoulvant
- Cardiology Department, CHRU Tours, 37000 Tours, France; EA4245, T2i, Tours University, 37000 Tours, France
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Loh J, Amanullah MR, See CK, Tang HC, Gunasegaran K, Hamid N, Lau J, Lee CY, Ewe SH, Ding ZP, Sahlén A. Predicting premature termination of exercise during Bruce protocol stress echocardiography. Echocardiography 2021; 38:1612-1617. [PMID: 34505312 DOI: 10.1111/echo.15186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/18/2021] [Accepted: 08/15/2021] [Indexed: 11/28/2022] Open
Abstract
AIMS Clinical guidelines recommend that the exercise protocol of a stress echocardiogram is selected to induce volitional exhaustion after a target duration of at least 8 minutes. While the Bruce protocol is very commonly used for clinical stress tests, it is known to be "steep", and many patients therefore fail to reach 8 minutes. We studied predictors of failure and developed a method for identifying patients not suitable for Bruce protocol which was accurate and yet simple enough to be used as a point-of-care decision support tool. METHODS AND RESULTS We studied data out-patients undergoing Bruce protocol stress echocardiograms (n = 11 086) and analyzed predictors of inappropriate early termination (defined as test duration < 8 min as per current practice guidelines) using logistic regression. A prediction model was constructed as follows: .5 points were given for each of hypertension, diabetes, smoking, and E/e' > 7.9 in the resting echocardiogram; .1 point was added for each 1-unit increment in body mass index; 1 point was added for patient age by decade; 2.0 points were subtracted for male sex (p for all < 0.001). In tests on held-out validation data, the model was well calibrated (in plots of predicted vs actual risk) and discriminated failure versus non-failure well (C-statistic .86 for a score of 6.0 points; p < 0.001). CONCLUSION These data may help to standardize protocol selection in stress echocardiography, by identifying patients pre-hoc where Bruce protocol will be inappropriately steep.
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Affiliation(s)
- Julian Loh
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | | | - Chai Keat See
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - Hak Chiaw Tang
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | | | - Nadira Hamid
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - Jeffrey Lau
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - Chung Yin Lee
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - See Hooi Ewe
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - Zee Pin Ding
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore
| | - Anders Sahlén
- National Heart Centre Singapore, 5 Hospital Drive, Singapore, Singapore.,Karolinska Institutet, Stockholm, Sweden
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Yamagishi M, Tamaki N, Akasaka T, Ikeda T, Ueshima K, Uemura S, Otsuji Y, Kihara Y, Kimura K, Kimura T, Kusama Y, Kumita S, Sakuma H, Jinzaki M, Daida H, Takeishi Y, Tada H, Chikamori T, Tsujita K, Teraoka K, Nakajima K, Nakata T, Nakatani S, Nogami A, Node K, Nohara A, Hirayama A, Funabashi N, Miura M, Mochizuki T, Yokoi H, Yoshioka K, Watanabe M, Asanuma T, Ishikawa Y, Ohara T, Kaikita K, Kasai T, Kato E, Kamiyama H, Kawashiri M, Kiso K, Kitagawa K, Kido T, Kinoshita T, Kiriyama T, Kume T, Kurata A, Kurisu S, Kosuge M, Kodani E, Sato A, Shiono Y, Shiomi H, Taki J, Takeuchi M, Tanaka A, Tanaka N, Tanaka R, Nakahashi T, Nakahara T, Nomura A, Hashimoto A, Hayashi K, Higashi M, Hiro T, Fukamachi D, Matsuo H, Matsumoto N, Miyauchi K, Miyagawa M, Yamada Y, Yoshinaga K, Wada H, Watanabe T, Ozaki Y, Kohsaka S, Shimizu W, Yasuda S, Yoshino H. JCS 2018 Guideline on Diagnosis of Chronic Coronary Heart Diseases. Circ J 2021; 85:402-572. [PMID: 33597320 DOI: 10.1253/circj.cj-19-1131] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Nagara Tamaki
- Department of Radiology, Kyoto Prefectural University of Medicine Graduate School
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School
| | - Kenji Ueshima
- Center for Accessing Early Promising Treatment, Kyoto University Hospital
| | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | - Yutaka Otsuji
- Second Department of Internal Medicine, University of Occupational and Environmental Health, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | | | | | - Hajime Sakuma
- Department of Radiology, Mie University Graduate School
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, University of Fukui
| | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | | | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa Universtiy
| | | | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Atsushi Nohara
- Division of Clinical Genetics, Ishikawa Prefectural Central Hospital
| | | | | | - Masaru Miura
- Department of Cardiology, Tokyo Metropolitan Children's Medical Center
| | | | | | | | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Toshihiko Asanuma
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Kinen Hospital
| | - Eri Kato
- Department of Cardiovascular Medicine, Department of Clinical Laboratory, Kyoto University Hospital
| | | | - Masaaki Kawashiri
- Department of Cardiovascular and Internal Medicine, Kanazawa University
| | - Keisuke Kiso
- Department of Diagnostic Radiology, Tohoku University Hospital
| | - Kakuya Kitagawa
- Department of Advanced Diagnostic Imaging, Mie University Graduate School
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School
| | | | | | | | - Akira Kurata
- Department of Radiology, Ehime University Graduate School
| | - Satoshi Kurisu
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital
| | - Akira Sato
- Department of Cardiology, University of Tsukuba
| | - Yasutsugu Shiono
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School
| | - Junichi Taki
- Department of Nuclear Medicine, Kanazawa University
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of the University of Occupational and Environmental Health, Japan
| | | | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Ryoichi Tanaka
- Department of Reconstructive Oral and Maxillofacial Surgery, Iwate Medical University
| | | | | | - Akihiro Nomura
- Innovative Clinical Research Center, Kanazawa University Hospital
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Hospital
| | - Masahiro Higashi
- Department of Radiology, National Hospital Organization Osaka National Hospital
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University
| | | | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center
| | - Naoya Matsumoto
- Division of Cardiology, Department of Medicine, Nihon University
| | | | | | | | - Keiichiro Yoshinaga
- Department of Diagnostic and Therapeutic Nuclear Medicine, Molecular Imaging at the National Institute of Radiological Sciences
| | - Hideki Wada
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University
| | - Yukio Ozaki
- Department of Cardiology, Fujita Medical University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
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Vyas H, Shah M, More N. Stress Echocardiography Audit: Experience of a Tertiary Care Center. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_63_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Khan JN, Griffiths T, Kanagala P, Kwok CS, Sandhu K, Cabezon S, Baig S, Naneishvili T, Kay Lee VC, Pasricha A, Robins E, Fatima T, Mihai A, Rai K, Booth S, Lee D, Bennett S, Butler R, Duckett S, Heatlie G. Accuracy and Prognostic Value of Physiologist-Led Stress Echocardiography for Coronary Disease. Heart Lung Circ 2020; 30:721-729. [PMID: 33191138 DOI: 10.1016/j.hlc.2020.09.933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 08/24/2020] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We demonstrated that physiologist-led stress echocardiography (PLSE) is feasible for coronary artery disease (CAD) assessment. We sought to extend our work by assessing its accuracy and prognostic value. METHODS Retrospective study of 898 subjects undergoing PLSE (n=393) or cardiologist-led stress echocardiography (CLSE) (n=505) for CAD assessment using exercise or dobutamine. For accuracy assessment, the primary outcome was the ability of stress echocardiography to identify significant CAD on invasive coronary angiography (ICA). Incidence of 24-month non-fatal MI, total and cardiac mortality, revascularisation and combined major adverse cardiac events (MACE) were assessed. RESULTS Demographics, comorbidities, CAD predictors, CAD pre-test probability and cardiac medications were matched between the PLSE and CLSE groups. PLSE had high sensitivity, specificity, positive and negative predictive value and accuracy (85%, 74%, 69%, 88%, 78% respectively). PLSE accuracy measures were similar and non-inferior to CLSE. There was a similar incidence of individual and combined outcomes in PLSE and CLSE subjects. Negative stress echocardiography conferred a comparably low incidence of non-fatal MI (PLSE 1.4% vs. CLSE 0.9%, p=0.464), cardiac mortality (0.6% vs. 0.0%, p=0.277) and MACE (6.8% vs. 3.1%, p=0.404). CONCLUSION This is the first study of the accuracy compared with gold standard of ICA, and prognostic value of PLSE CAD assessment. PLSE demonstrates high and non-inferior accuracy compared with CLSE for CAD assessment. Negative PLSE and CLSE confer a similarly very low incidence of cardiac outcomes, confirming for the first time the important prognostic value of PLSE.
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Affiliation(s)
- Jamal Nasir Khan
- Department of Cardiology, University Hospital of Coventry & Warwickshire, Coventry, England, UK; University of Warwick, Coventry, England, UK.
| | - Timothy Griffiths
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Prathap Kanagala
- Department of Cardiology, Aintree Hospital, Liverpool, England, UK
| | - Chun Shing Kwok
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Kully Sandhu
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Sinead Cabezon
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Shanat Baig
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Tamara Naneishvili
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Vetton Chee Kay Lee
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Arron Pasricha
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Emily Robins
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Tamseel Fatima
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Andreea Mihai
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
| | - Kam Rai
- Department of Cardiology, University Hospital of Coventry & Warwickshire, Coventry, England, UK
| | - Samantha Booth
- Department of Cardiology, University Hospital of Coventry & Warwickshire, Coventry, England, UK
| | - Doug Lee
- Department of Cardiology, University Hospital of Coventry & Warwickshire, Coventry, England, UK
| | - Sadie Bennett
- Department of Cardiology, University Hospital of North Midlands, Stoke-on-Trent, England, UK
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11
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Rachwan RJ, Mshelbwala FS, Bou Chaaya RG, El-Am EA, Sabra M, Dardari Z, Jaradat ZA, Batal O. Long-term prognosis and predictors of outcomes after negative stress echocardiography. Int J Cardiovasc Imaging 2020; 36:1953-1962. [PMID: 32757119 DOI: 10.1007/s10554-020-01913-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
Negative stress echocardiography (NSE) is associated with low cardiovascular morbidity and overall mortality. We aimed to determine the clinical and echocardiographic predictors of overall and cardiovascular outcomes following NSE. Patients who underwent SE between 2013 and 2017 were reviewed. Patients with a history of solid organ transplant or being evaluated for transplant, history of end-stage renal or liver disease, and positive SE were excluded. NSE results were divided into negative diagnostic if patient reached target heart rate (THR) and had no wall motion abnormality (WMA) at rest or stress; negative non-diagnostic if patient had no WMA but did not reach THR or if image quality was non-diagnostic; and abnormal non-ischemic if patient had a resting WMA not worsened at stress along with a personal history of coronary artery disease (CAD). New CAD lesion at 1 year was defined as ≥ 50% stenosis on cardiac catheterization. Of 4119 patients with SE, 2575 were included. All-cause mortality rate was 1.1%/year and CAD rate was 3.1%/year. Predictors of all-cause mortality were age, male gender, history of smoking and being selected for dobutamine SE. Predictors of a new CAD lesion at 1 year were male gender, diabetes, personal history of CAD and abnormal non-ischemic SE. We identified clinical and echocardiographic characteristics in a subset of NSE patients who are at higher risk for subsequent adverse events. These characteristics should be accounted for during the clinical interpretation of SE, and patients found at increased risk for morbidity and mortality warrant continued follow-up.
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Affiliation(s)
- Rayan Jo Rachwan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Rody G Bou Chaaya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Edward A El-Am
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Sabra
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ziad A Jaradat
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, 1801 North Senate Boulevard, Indianapolis, IN, USA
| | - Omar Batal
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, 1801 North Senate Boulevard, Indianapolis, IN, USA.
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12
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“Sound” Advice—Let's “Stress” the Importance of Prevention: Combining Carotid Ultrasound and Stress Echocardiography for Cardiovascular Risk Assessment. J Am Soc Echocardiogr 2020; 33:570-572. [DOI: 10.1016/j.echo.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/05/2020] [Accepted: 03/05/2020] [Indexed: 02/03/2023]
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Daubert MA, Sivak J, Dunning A, Douglas PS, Coyne B, Wang TY, Mark DB, Velazquez EJ. Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography. JAMA Intern Med 2020; 180:494-502. [PMID: 31985749 PMCID: PMC6990669 DOI: 10.1001/jamainternmed.2019.6958] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Patients with abnormal (positive) exercise electrocardiography, but normal stress echocardiography (+ECG/-Echo) are commonly encountered in clinical practice; however, the prognostic significance of this discordant result is unclear. OBJECTIVE To determine whether patients with +ECG/-Echo have a higher rate of adverse clinical events and a poorer prognosis than patients with negative exercise ECG and normal stress Echo imaging (-ECG/-Echo). DESIGN, SETTING, AND PARTICIPANTS Between January 1, 2000, and February 28, 2014, a total of 47 944 consecutive patients without known coronary artery disease who underwent exercise stress Echo at Duke University Medical Center were evaluated for inclusion in this observational cohort study. Data analysis was conducted from January 1, 2000, to December 31, 2016. INTERVENTIONS/EXPOSURES Patients were categorized as having -ECG/-Echo, +ECG/-Echo, or +Echo (-ECG/+Echo and +ECG/+Echo). MAIN OUTCOMES AND MEASURES The primary outcome was a composite end point of death, myocardial infarction, hospitalization for unstable angina, and coronary revascularization. Secondary outcomes included individual adverse events and downstream testing. RESULTS After excluding submaximal tests and nondiagnostic ECG or stress imaging results, 15 077 patients (mean [SD] age, 52 [13] years; 6228 [41.3%] men) were classified by stress test results. Of these, 12 893 patients (85.5%) had -ECG/-Echo, 1286 patients (8.5%) had +ECG/-Echo, and 898 patients (6.0%) had +Echo. Through a median follow-up of 7.3 (interquartile range, 4.4-10.0) years, the composite end point occurred in 794 patients with -ECG/-Echo (8.5%), 142 patients with +ECG/-Echo (14.6%), and 297 patients with +Echo (37.4%). Death occurred in 425 patients with -ECG/-Echo (4.8%), 50 patients with +ECG/-Echo (5.9%), and 70 patients with +Echo (11.2%). Myocardial infarction occurred in 195 patients with -ECG/-Echo (2.2%), 31 patients with +ECG/-Echo (3.6%), and 59 patients with +Echo (8.7%). The addition of stress ECG findings to clinical and exercise data yielded incremental prognostic value. Patients with -ECG/-Echo imaging results had the least downstream testing (2.3%), followed by +ECG/-Echo (12.8%), and +Echo (33.6%) (P < .001). CONCLUSIONS AND RELEVANCE The presence of +ECG results with normal stress Echo imaging may identify a population of patients who are at slightly increased risk for adverse cardiac events, which was not previously recognized. Further study is needed to determine whether these patients will benefit from intensification of medical management.
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Affiliation(s)
- Melissa A Daubert
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Joseph Sivak
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill
| | - Allison Dunning
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Pamela S Douglas
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Brian Coyne
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Tracy Y Wang
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel B Mark
- Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Eric J Velazquez
- Department of Medicine, Division of Cardiology, Yale School of Medicine, New Haven, Connecticut
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14
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Chai SC, Teo HK, Lee PS, Kam CJW, Tong KL. Prognostic impact of stress echocardiography with discordant stress electrocardiography in patients with suspected coronary artery disease. Singapore Med J 2020; 61:142-148. [PMID: 32488267 PMCID: PMC7905114 DOI: 10.11622/smedj.2019105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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). CONCLUSION 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).
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Affiliation(s)
- Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore
| | - Hooi Khee Teo
- Department of Cardiology, Changi General Hospital, Singapore
| | - Pei Shan Lee
- Department of Renal Medicine, Changi General Hospital, Singapore
| | | | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore
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15
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Beri N, Dang P, Bhat A, Venugopal S, Amsterdam EA. Usefulness of Excellent Functional Capacity in Men and Women With Ischemic Exercise Electrocardiography to Predict a Negative Stress Imaging Test and Very Low Late Mortality. Am J Cardiol 2019; 124:661-665. [PMID: 31300200 DOI: 10.1016/j.amjcard.2019.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.
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17
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Shaw LJ, Blankstein R, Brown DL, Dhruva SS, Douglas PS, Genders TS, Gibbons RJ, Greenwood JP, Kwong R, Leipsic J, Mahmarian JJ, Maron D, Nagel E, Nicol E, Nieman K, Pellikka PA, Redberg RF, Weir-McCall J, Williams MC, Chandrasekhar Y. Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes. JACC Cardiovasc Imaging 2019; 12:1254-1278. [DOI: 10.1016/j.jcmg.2019.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/21/2022]
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18
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Samiei N, Parsaee M, Pourafkari L, Tajlil A, Pasbani Y, Rafati A, Nader ND. The value of negative stress echocardiography in predicting cardiovascular events among adults with no known coronary disease. J Cardiovasc Thorac Res 2019; 11:85-94. [PMID: 31384401 PMCID: PMC6669423 DOI: 10.15171/jcvtr.2019.16] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 05/19/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction: Stress echocardiography is a safe and cost-effective method of evaluating the patients with suspected coronary artery disease (CAD). However, the risk factors of an adverse cardiovascular event after a normal exercise (ESE) or dobutamine (DSE) stress echocardiography are not well established.
Methods: A cohort of 705 patients without previous history of CAD and a negative ESE/DSE was studied. All studies were performed in a high-volume echocardiologic laboratory and interpreted by two experienced echocardiography-trained cardiologists. Patients with inconclusive studies and those with an evidence of myocardial ischemia were excluded. Demographic, echocardiographic and hemodynamic findings were recorded. Patients were followed for at least 2 years. Independent predictors of major adverse cardiovascular events (MACE) were determined by regression analysis.
Results: During a period of 55.7±17.5 months, MACE occurred in 35 (5.0%) of patients. Negative predictive value (NPV) of DSE was 89.2%, which was significantly less than 96.5% for ESE in predicting the occurrence of MACE (P = 0.001). MACE occurred more frequently among older (≥65 years) men with preexisting diabetes, hypertension, and/or hyperlipidemia. During ESE, a higher maximum blood pressure*heart rate product for the achieved level of metabolic equivalent (METS) of tasks was also an independent predictor of MACE.
Conclusion: Inability of patients to undergo traditional ESE that led to the choice of using DSE alternative reduces the NPV of the stress echocardiography among patients without previous history of CAD. A modest rise of heart rate and blood pressure in response to increased level of activity serves as favorable prognostic value and improves the NPV of stress echocardiography.
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Affiliation(s)
- Niloufar Samiei
- Heart Valve Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
| | - Mozhgan Parsaee
- Echocardiography Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
| | - Leili Pourafkari
- Echocardiography Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran.,Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY, USA
| | - Arezou Tajlil
- Echocardiography Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
| | - Yeganeh Pasbani
- Heart Valve Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
| | - Ali Rafati
- Heart Valve Research Center, Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
| | - Nader D Nader
- Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY, USA
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19
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Pettemerides V, Turner T, Steele C, Macnab A. Does stress echocardiography still have a role in the rapid access chest pain clinic post NICE CG95? Echo Res Pract 2019; 6:17-23. [PMID: 30893640 PMCID: PMC6477652 DOI: 10.1530/erp-18-0082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction The 2016 NICE clinical guideline 95 (CG95) demoted functional imaging to a second-line test following computed tomography coronary angiography (CTCA). Many cardiac CT services in the UK require substantial investment and growth to implement this. Chest pain services like ours are likely to continue to use stress testing for the foreseeable future. We share service evaluation data from our department to show that a negative stress echocardiogram can continue to be used for chest pain assessment. Methods 1815 patients were referred to rapid access chest pain clinic (RACPC) between June 2013 and March 2015. 802 patients had stress echocardiography as the initial investigation. 446 patients had normal resting left ventricular (LV) systolic function and a negative stress echocardiogram. At least 24 months after discharge, a survey was carried out to detect major adverse cardiovascular events (MACE) (cardiac death, myocardial infarction, admission to hospital for heart failure or angina, coronary artery disease at angiography, revascularisation by angioplasty or coronary artery bypass grafting) within 2 years. Results Overall, 351 patients were successfully followed up. The mean Diamond-Forrester (D-F) score and QRISK2 suggested a high pre-test probability (PTP) of coronary artery disease (CAD). There were nine deaths (eight non-cardiac deaths and one cardiac death). MACE occurred in four patients with a mean time of 17.5 months (11.6–23.7 months). The annual event rate was 0.6%. Conclusion A negative stress echocardiogram can reliably reassure patients and clinicians even in high PTP populations with suspected stable angina. It can continue to be used to assess stable chest pain post CG95.
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Affiliation(s)
- Victoria Pettemerides
- Manchester University Foundation Trust, North West Heart Centre, Wythenshawe Hospital, Manchester, UK
| | - Thomas Turner
- University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Conor Steele
- University of Manchester Faculty of Biology, Medicine and Health, Manchester, UK
| | - Anita Macnab
- Manchester University Foundation Trust, North West Heart Centre, Wythenshawe Hospital, Manchester, UK
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20
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Steeds RP, Wheeler R, Bhattacharyya S, Reiken J, Nihoyannopoulos P, Senior R, Monaghan MJ, Sharma V. Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography. Echo Res Pract 2019; 6:G17-G33. [PMID: 30921767 PMCID: PMC6477657 DOI: 10.1530/erp-18-0068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022] Open
Abstract
Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, Institute of Cardiovascular Science, University Hospital Birmingham, Birmingham, UK
| | - Richard Wheeler
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | | | - Joseph Reiken
- Department of Cardiology, Kings College Hospital, London, UK
| | - Petros Nihoyannopoulos
- Department of Cardiology, National Heart Lung Institute, Hammersmith Hospital, London, UK
| | - Roxy Senior
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Mark J Monaghan
- Department of Cardiology, Kings College Hospital, London, UK
| | - Vishal Sharma
- Department of Cardiology, Royal Liverpool and Broadgreen University Hospital, Liverpool, UK
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21
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Xian Quah J, Greaves K, Thomas L, Stanton T. The Clinical Utility and Enduring Versatility of Stress Echocardiography. Heart Lung Circ 2019; 28:1376-1383. [PMID: 31078426 DOI: 10.1016/j.hlc.2019.02.188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/08/2019] [Accepted: 02/01/2019] [Indexed: 01/06/2023]
Abstract
Stress echocardiography is an established cardiac imaging modality for the detection and quantification of severity of coronary artery disease. In recent years, there has also been an increasing use of stress echocardiography in the assessment of non-ischaemic cardiac disease given its ability to assess functional capacity and haemodynamic changes with exercise which can help guide therapy and inform prognosis. The emerging use of strain, myocardial contrast and three-dimensional (3D) echocardiography further assists in improving diagnostic accuracy particularly in patients with coronary artery disease. This paper summarises the protocols, indications and clinical applications of stress echocardiography in both ischaemic and non-ischaemic cardiac disease.
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Affiliation(s)
- Jing Xian Quah
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia
| | - Kim Greaves
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia
| | - Liza Thomas
- Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tony Stanton
- Department of Cardiology, Sunshine Coast University Hospital, Brisbane, Qld, Australia; University of the Sunshine Coast, Brisbane, Qld, Australia; School of Medicine, Griffith University, Sunshine Coast University Hospital, Brisbane, Qld, Australia.
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22
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Gurunathan S, Zacharias K, Akhtar M, Ahmed A, Mehta V, Karogiannis N, Vamvakidou A, Khattar R, Senior R. Cost-effectiveness of a management strategy based on exercise echocardiography versus exercise electrocardiography in patients presenting with suspected angina during long term follow up: A randomized study. Int J Cardiol 2018; 259:1-7. [PMID: 29579580 DOI: 10.1016/j.ijcard.2018.01.112] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/14/2017] [Accepted: 01/23/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Exercise ECG (Ex-ECG) is advocated by guidelines for patients with low - intermediate probability of coronary artery disease (CAD). However, there are no randomized studies comparing Ex-ECG with exercise stress echocardiography (ESE) evaluating long term cost-effectiveness of each management strategy. METHODS Accordingly, 385 patients with no prior CAD and low-intermediate probability of CAD (mean pre-test probability 34%), were randomized to undergo either Ex-ECG (194 patients) or ESE (191 patients). The primary endpoint was clinical effectiveness defined as the positive predictive value (PPV) for the detection of CAD of each test. Cost-effectiveness was derived using the cumulative costs incurred by each diagnostic strategy during a mean of follow up of 3.0 years. RESULTS The PPV of ESE and Ex-ECG were 100% and 64% (p = 0.04) respectively for the detection of CAD. There were fewer clinic (31 vs 59, p < 0.01) and emergency visits (14 vs 30, p = 0.01) and lower number of hospital bed days (8 vs 29, p < 0.01) in the ESE arm, with fewer patients undergoing coronary angiography (13.4% vs 6.3%, p = 0.02). The overall cumulative mean costs per patient were £796 for Ex-ECG and £631 for ESE respectively (p = 0.04) equating to a >20% reduction in cost with an ESE strategy with no difference in the combined end-point of death, myocardial infarction, unplanned revascularization and hospitalization for chest pain between ESE and Ex-ECG (3.2% vs 3.7%, p = 0.38). CONCLUSION In patients with low to intermediate pretest probability of CAD and suspected angina, an ESE management strategy is cost-effective when compared with Ex-ECG during long term follow up.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Kostas Zacharias
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom
| | - Mohammed Akhtar
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom
| | - Asrar Ahmed
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom
| | - Vishal Mehta
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom
| | - Nikos Karogiannis
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom
| | - Anastasia Vamvakidou
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Raj Khattar
- Department of Cardiology, Royal Brompton Hospital, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Roxy Senior
- Department of Cardiology, Northwick park Hospital, Harrow, United Kingdom; Department of Cardiology, Royal Brompton Hospital, United Kingdom; Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, United Kingdom.
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23
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Adigun RO, Boler AN, Mankad R. Disparities in Cardiac Care of Women: Current Data and Possible Solutions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:87. [PMID: 30242773 DOI: 10.1007/s11936-018-0688-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease remains the leading cause of death in women. The goal of this review is to address known disparities in cardiovascular care with regard to diagnosis and treatment of heart disease in women. RECENT FINDINGS Gender-specific differences in regard to the incidence, treatment, and outcomes of common cardiovascular pathology are increasingly recognized. Particular attention to ischemic heart disease, arrhythmia, congestive heart failure, and structural heart disease are reviewed in this article. There is a clear racial and ethnic discrepancy among women which is particularly concerning with a progressively diverse patient population. Medical and surgical treatment differences between men and women must be addressed by providers in order to optimize long-term outcomes among all patients. Understanding the unique cardiovascular risk profile and barriers to optimal treatment outcomes in women is imperative to eliminate the current disparities in cardiovascular disease.
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Affiliation(s)
- Rosalyn O Adigun
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Amber N Boler
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA
| | - Rekha Mankad
- Department of Cardiovascular Disease, 200 1st street SW, Rochester, MN, 55901, USA.
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24
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Verardi R, Fioravanti F, Barbero U, Conrotto F, Omedè P, Montefusco A, Moretti C, D'Amico M, Rinaldi M, Escaned J, D'Ascenzo F. Network meta-analysis comparing iFR versus FFR versus coronary angiography to drive coronary revascularization. J Interv Cardiol 2018; 31:725-730. [PMID: 30136420 DOI: 10.1111/joic.12551] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS Instantaneous free-wave ratio (iFR) has been recently demonstrated non-inferior to fractional flow reserve (FFR) to drive coronary revascularization; however, no study has compared iFR versus coronary angiography (CA). We performed a network meta-analysis to evaluate efficacy and safety of iFR- versus CA-guided strategy. METHODS AND RESULTS We searched for randomized trials and studies with propensity score matching in The Cochrane Collaboration Central Register of Controlled Trials, EMBASE, and MEDLINE/Pubmed. CA, FFR, and iFR were the three competitive arms, MACE (a composite endpoint of death, myocardial infarction [MI], and target vessel revascularization [TVR]) was the primary endpoint, while its single components the secondary ones. Subgroup analysis was performed for patients presenting with stable coronary artery disease. Eight studies were selected: 4126 patients were evaluated with FFR, 2160 with iFR, and 2214 with CA, acute coronary syndrome (ACS) was the most frequent admission diagnosis. After 12 months, rates of MACE and all-cause death did not differ between groups (respectively OR 1.04 and OR 0.86 for iFR vs FFR). Both FFR and iFR reduced TVR compared to CA (respectively OR 0.68 and OR 0.70). In patients with stable CAD both FFR and iFR reduced risk of subsequent MI compared to CA (respectively OR 0.66 and OR 0.79). CONCLUSION Compared to CA alone, both FFR and iFR are safe and effective in guiding coronary revascularization at 12 months. In patients with stable CAD, both FFR and iFR-guided revascularization reduce the risk of subsequent MI at 12 months.
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Affiliation(s)
- Roberto Verardi
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Francesco Fioravanti
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Umberto Barbero
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Claudio Moretti
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Maurizio D'Amico
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Mauro Rinaldi
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.,Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Torino, Torino, Italy
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25
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Pour-Ghaz I, Bob-Manuel T, Marella HK, Kelly J, Nanda A, Skelton WP, Khouzam RN. Incidence and predictors of acute coronary syndrome within a year following a negative stress test-a false sense of security: is routine screening any useful? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:13. [PMID: 29404359 DOI: 10.21037/atm.2017.11.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
One of the major issues in management of the acute coronary syndrome (ACS) is classification of patients with atypical presentation who have low risk of having a coronary episode at presentation. There have been multiple studies on the stratification of high risk patients and medical management of such cases, however, there is a sub-class of patients who do not fit any category. In this paper, we have looked at the current literature on stratification of patients based on the study tools available and the risk of having a coronary episode during the following year. In our overview, we have found that the current methods in place namely, cardiac stress test and stress echocardiogram have a good prognostic factor in terms of mortality in the next one year and can safely stratify the patients at low risk when correlated with clinical presentation and laboratory studies. However, such data are limited for computerized tomography or magnetic resonant imaging and their application might be limited due to accessibility and cost of studies. Current guidelines for classification of high risk patient do an excellent job and we believe that proper application of stress tests together with other imaging modalities together with laboratory, clinical judgment, and proper use of medical management can help with safe discharge of patients from the emergency department (ED) and reduction of burden from healthcare.
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Affiliation(s)
- Issa Pour-Ghaz
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Tamunoinemi Bob-Manuel
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Hemnishil K Marella
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Jayna Kelly
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Amit Nanda
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - William Paul Skelton
- Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Coronary Atherosclerosis Assessment by Coronary CT Angiography in Asymptomatic Diabetic Population: A Critical Systematic Review of the Literature and Future Perspectives. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8927281. [PMID: 29511691 PMCID: PMC5820580 DOI: 10.1155/2018/8927281] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 12/02/2017] [Indexed: 12/29/2022]
Abstract
The prognostic impact of diabetes mellitus (DM) on cardiovascular outcomes is well known. As a consequence of previous studies showing the high incidence of coronary artery disease (CAD) in diabetic patients and the relatively poor outcome compared to nondiabetic populations, DM is considered as CAD equivalent which means that diabetic patients are labeled as asymptomatic individuals at high cardiovascular risk. Lessons learned from the analysis of prognostic studies over the past decade have challenged this dogma and now support the idea that diabetic population is not uniformly distributed in the highest risk box. Detecting CAD in asymptomatic high risk individuals is controversial and, what is more, in patients with diabetes is challenging, and that is why the reliability of traditional cardiac stress tests for detecting myocardial ischemia is limited. Cardiac computed tomography angiography (CCTA) represents an emerging noninvasive technique able to explore the atherosclerotic involvement of the coronary arteries and, thus, to distinguish different risk categories tailoring this evaluation on each patient. The aim of the review is to provide a wide overview on the clinical meaning of CCTA in this field and to integrate the anatomical information with a reliable therapeutic approach.
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Peteiro J, Bouzas-Mosquera A, Broullón J, Martínez D, Vázquez-Rodríguez JM. Diagnostic and Prognostic Findings in Patients With Positive Clinical or ECG Exercise Tests in the Absence of Echocardiographic Abnormalities. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2018; 71:55-56. [PMID: 28416290 DOI: 10.1016/j.rec.2017.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 01/25/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Jesús Peteiro
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC) y Universidad de A Coruña, A Coruña, Spain.
| | - Alberto Bouzas-Mosquera
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC) y Universidad de A Coruña, A Coruña, Spain
| | - Javier Broullón
- Servicio de Informática, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC) y Universidad de A Coruña, A Coruña, Spain
| | - Dolores Martínez
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC) y Universidad de A Coruña, A Coruña, Spain
| | - José M Vázquez-Rodríguez
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC) y Universidad de A Coruña, A Coruña, Spain
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Peteiro J, Bouzas-Mosquera A, Broullón J, Martínez D, Vázquez-Rodríguez JM. Hallazgos diagnósticos y pronósticos en pacientes con prueba de esfuerzo clínica o ECG positivos pero ecocardiografía negativa. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Mordi IR, Badar AA, Irving RJ, Weir-McCall JR, Houston JG, Lang CC. Efficacy of noninvasive cardiac imaging tests in diagnosis and management of stable coronary artery disease. Vasc Health Risk Manag 2017; 13:427-437. [PMID: 29200864 PMCID: PMC5701553 DOI: 10.2147/vhrm.s106838] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The aim of this review was to discuss the current literature regarding the utility of noninvasive imaging in diagnosis and management of stable coronary artery disease (CAD) including recent data from large randomized trials assessing diagnosis and prognosis. Current guidelines recommend revascularization in patients with refractory angina and in those with potential prognostic benefit. Appropriate risk stratification through noninvasive assessment is important in ensuring patients are not exposed to unnecessary invasive coronary angiograms. The past 20 years have seen an unprecedented expansion in noninvasive imaging modalities for the assessment of stable CAD, with cardiovascular magnetic resonance and computed tomography complementing established techniques such as myocardial perfusion imaging, echocardiography and exercise electrocardiogram. In this review, we examine the current state-of-the-art in noninvasive imaging to provide an up-to-date analysis of current investigation and management options.
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Affiliation(s)
- Ify R Mordi
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.,Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | - Athar A Badar
- Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | - R John Irving
- Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
| | | | - J Graeme Houston
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.,Department of Cardiology, Ninewells Hospital and Medical School, Dundee, UK
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Low Adverse Event Rates But High Emergency Department Utilization in Chest Pain Patients Treated in an Emergency Department Observation Unit. Crit Pathw Cardiol 2017; 16:15-21. [PMID: 28195938 DOI: 10.1097/hpc.0000000000000099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Nearly 40% of all previously admitted chest pain patients re-present to the emergency department (ED) within 1 year regardless of stress testing, and nearly 5% of patients return with a major adverse cardiac event (MACE). The primary objective of this study was to determine the prevalence of return visits to the ED among patients previously admitted to an ED chest pain observation unit (CPU). We also identified the patient characteristics and health risk factors associated with these return ED visits. METHODS This was a prospective cohort study of patients admitted to a CPU in a large-volume academic urban ED who were subsequently followed over a period of 1 year. Inclusion criteria were age ≥18 years old, American Heart Association low-to-intermediate assessed risk, electrocardiogram nondiagnostic for acute coronary syndrome (ACS), and a negative initial troponin I. Excluded patients were those age >75 years with a history of coronary artery disease. Patients were followed throughout their observation unit stay and then subsequently for 1 year. On all repeat ED evaluations, standardized chart abstractions forms were used, charts were reviewed by 2 trained abstractors blinded to the study hypothesis, and a random sample of charts was examined for interrater reliability. Return visits were categorized as MACE, cardiac non-MACE, or noncardiac based on a priori criteria. Social security death index searches were performed on all patients. Univariate and multivariate ordinal logistic regressions were conducted to determine demographics, medical procedures, and comorbid conditions that predicted return visits to the ED. RESULTS A total of 2139 patients were enrolled over 17 months. The median age was 52 years, 55% were female. Forty-four patients (2.1%) had ACS on index visit. A total of 36.2% of CPU patients returned to the ED within 1 year vs. 5.4% of all ED patients (P < 0.01). However, the overall incidence of MACE at 1 year in all patients and in those without an index visit diagnosis of ACS was 0.5% (95% confidence interval [CI], 0.4%-06%) and 0.4% (95% CI, 0.2%-0.7%), respectively. Patients who received a stress test on index visit were less likely to return (adjusted odds ratio [AOR] = 0.64 [95% CI, 0.51-0.80]) but patients who smoked (AOR = 1.51 [95% CI, 1.16-1.96]) or had diabetes (AOR = 1.36 [95% CI, 1.07-1.87]) were more likely to return. Hispanic and African-American patients had increased odds of multiple return ED visits (AOR=1.23 [95% CI, 1.04-1.46] and AOR =1.74 [95% CI, 1.45-2.13], respectively). CONCLUSION Patients treated in an ED CPU have a very low rate of MACE at 1 year. However, these same patients have very high rates of subsequent ED utilization. The associations between certain comparative demographics and ED utilization suggest the need for further research to identify and address the needs of these patient populations that precipitate the higher than expected return rate.
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Abstract
PURPOSE OF REVIEW Stress echocardiography (SE) is a well-established technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). This review article summarizes the status of SE in CAD, including testing protocols, clinical efficacy and current use of newer technologies: myocardial perfusion, strain imaging, three-dimensional echocardiography and adjunctive carotid ultrasonography. RECENT FINDINGS Recent major findings in SE include the clinical value of myocardial perfusion imaging in multicentre studies, as well as when added to left ventricular (LV) wall motion assessment in clinical service. Additionally, SE has been shown to be more cost-effective than exercise ECG in patients with low-intermediate pre-test probability of CAD. Adjunctive atherosclerosis imaging by carotid ultrasonography (CU) to ischaemia testing by SE provides synergistic prognostic value, equivalent to hybrid imaging by PET-CT. Despite the development of newer and more expensive imaging modalities, SE remains the cornerstone for the assessment of CAD and has excellent clinical efficacy, is safe and is cost-effective.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK
| | - Roxy Senior
- Department of Cardiology, Northwick Park Hospital, Harrow, UK.
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK.
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Velasco del Castillo S, Antón Ladislao A, Gómez Sánchez V, Onaindia Gandarias JJ, Cacicedo Fernández de Bobadilla Á, Rodríguez Sánchez I, Laraudogoitia Zaldumbide E. Influencia del riesgo cardiovascular en la predicción y el momento de aparición de eventos cardiacos tras ecocardiograma de esfuerzo sin isquemia. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Velasco Del Castillo S, Antón Ladislao A, Gómez Sánchez V, Onaindia Gandarias JJ, Cacicedo Fernández de Bobadilla Á, Rodríguez Sánchez I, Laraudogoitia Zaldumbide E. Influence of Cardiovascular Risk in the Prediction and Timing of Cardiac Events After Exercise Echocardiogram Testing Without Ischemia. ACTA ACUST UNITED AC 2017; 70:736-743. [PMID: 28416165 DOI: 10.1016/j.rec.2016.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES There have been no analyses of the influence of cardiovascular risk as a predictor of events in patients with exercise echocardiography (EE) without ischemia. Our objective was to determine the predictors of cardiac events, paying special attention to cardiovascular risk. METHODS This study included 1640 patients with EE without ischemia. Of these, there were 1206 with no previously known coronary artery disease (CAD), whose risk of a fatal cardiovascular disease event was estimated according to the European SCORE (Systematic COronary Risk Evaluation) risk assessment system, and 434 with known CAD. The primary endpoint was cardiac event-free survival (EFS) (cardiac death, nonfatal acute coronary syndrome, and coronary revascularization). RESULTS After a median follow-up of 35 [23-54] months, no differences were found in cardiac EFS between patients with a SCORE ≥ 10 or diabetes and patients with previous CAD (89.8% vs 87.1%). In the first year, cardiac EFS was high in all groups (99.4% if SCORE < 5; 100% if 5-9; 98% if ≥ 10 or diabetes and 97% in patients with CAD). In the third year, cardiac EFS was similar in the group with SCORE ≥ 10 or diabetes (94.5%) and patients with CAD (91.1%, P = NS). In these patients, the annualized event rate was 2.8% and 2.55%, respectively, and was significantly higher than in groups with SCORE < 5 (0.6%) and SCORE 5-9 (0.12%). The most frequent events were non-ST-segment elevation acute coronary syndrome and late revascularization. Predictors of cardiac events were previous CAD, SCORE ≥ 10 or diabetes mellitus, creatinine clearance, left ventricular ejection fraction, and chest pain during EE. CONCLUSIONS Initial outcome after an EE without ischemia is favorable but is subsequently modulated by cardiovascular risk.
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Abstract
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
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Padang R, Pellikka PA. The role of stress echocardiography in the evaluation of coronary artery disease and myocardial ischemia in women. J Nucl Cardiol 2016; 23:1023-1035. [PMID: 27457525 DOI: 10.1007/s12350-016-0592-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/08/2016] [Indexed: 01/06/2023]
Abstract
Considering the unfavorable prognosis of women with ischemic heart disease, an aggressive but safe approach to evaluate women presenting with chest pain is warranted so that coronary artery disease (CAD) can be identified and treated early. Stress echocardiography (SE) has matured into an invaluable technique for the noninvasive detection of obstructive epicardial CAD. Its versatility, accuracy, safety, noninvasiveness, and lack of radiation exposure make SE an attractive technique to apply to the assessment of women with known or suspected heart disease. This article focuses on the current evidence supporting the role of SE in the assessment of CAD and myocardial ischemia in women.
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Affiliation(s)
- Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Brewer LC, Svatikova A, Mulvagh SL. The Challenges of Prevention, Diagnosis and Treatment of Ischemic Heart Disease in Women. Cardiovasc Drugs Ther 2016. [PMID: 26210899 DOI: 10.1007/s10557-015-6607-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Increasing evidence suggests that there are significant differences in the presentation, diagnosis and treatment of ischemic heart disease in women compared to men. Women often present with atypical symptoms, and this, in association with a consistent underestimation of their risk for ischemic heart disease, leads to underdiagnosis and undertreatment in women. Cardiovascular risk factors unique to women have only recently been recognized, and moreover, traditional risk factors have recently been shown to have greater impacts on women. Consequently, women suffer more disability and poorer clinical outcomes, with higher cardiovascular morbidity and mortality. These discrepancies may in part be secondary to the higher prevalence of nonobstructive coronary artery disease in women with persistent chest pain symptoms as compared to men when evaluated invasively. Focused diagnostic and therapeutic strategies unique to women are thus needed, but unfortunately, such sex-specific guidelines do not yet exist, largely due to lack of awareness, both on the part of providers and patients, as well as a paucity of evidence-based research specific to women. Although underutilized in women, diagnostic modalities, including functional and anatomic cardiac tests as well as physiologic assessments of endothelial and microvascular function, are useful for establishing the diagnosis and prognosis of suspected ischemic heart disease in women. This review discusses the current challenges of prevention, diagnosis and treatment of ischemic heart disease in women.
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Zacharias K, Ahmed A, Shah BN, Gurunathan S, Young G, Acosta D, Senior R. Relative clinical and economic impact of exercise echocardiography vs. exercise electrocardiography, as first line investigation in patients without known coronary artery disease and new stable angina: a randomized prospective study. Eur Heart J Cardiovasc Imaging 2016; 18:195-202. [DOI: 10.1093/ehjci/jew049] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 02/21/2016] [Indexed: 11/14/2022] Open
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O’Driscoll JM, Rossato C, Gargallo-Fernandez P, Araco M, Giannoglou D, Sharma S, Sharma R. The prognostic value of dobutamine stress echocardiography amongst British Indian Asian and Afro-Caribbean patients: a comparison with European white patients. Cardiovasc Ultrasound 2015; 13:36. [PMID: 26245751 PMCID: PMC4527129 DOI: 10.1186/s12947-015-0028-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/20/2015] [Indexed: 01/20/2023] Open
Abstract
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.
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The Incremental Prognostic Value of the Incorporation of Myocardial Perfusion Assessment into Clinical Testing with Stress Echocardiography Study. J Am Soc Echocardiogr 2015; 28:1358-65. [DOI: 10.1016/j.echo.2015.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Indexed: 01/08/2023]
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Echocardiographic Evaluation of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Trends in noninvasive testing for coronary artery disease: less exercise, less information. Am J Med 2015; 128:5-7. [PMID: 25195187 DOI: 10.1016/j.amjmed.2014.08.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 08/12/2014] [Accepted: 08/12/2014] [Indexed: 11/22/2022]
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Prognostic Value of Normal Exercise Echocardiography in a One-Year Follow-up. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2014. [DOI: 10.5812/rijm.22075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Mieres JH, Gulati M, Bairey Merz N, Berman DS, Gerber TC, Hayes SN, Kramer CM, Min JK, Newby LK, Nixon JVI, Srichai MB, Pellikka PA, Redberg RF, Wenger NK, Shaw LJ. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350-79. [PMID: 25047587 DOI: 10.1161/cir.0000000000000061] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Barbieri A, Mantovani F, Bursi F, Ruggerini S, Lugli R, Abdelmoneim SS, Modena MG. Prognostic value of a negative peak supine bicycle stress echocardiography with or without concomitant ischaemic stress electrocardiographic changes: a cohort study. Eur J Prev Cardiol 2014; 22:636-44. [PMID: 24821732 DOI: 10.1177/2047487314535115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/19/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND a negative peak supine bicycle exercise stress echocardiography (ESE) was shown to have a long-term favourable prognostic value. Data on the long-term prognosis of ischaemic electrocardiographic (ISECG) changes in the setting of a negative peak supine bicycle ESE are lacking. DESIGN we evaluated the prognostic value of negative peak supine bicycle ESE with or without concomitant ISECG changes in a referral population evaluated for chest pain after an inconclusive first-line work-up including clinical evaluation and exercise ECG stress. METHODS from 2003 to 2010, patients who underwent a peak supine bicycle ESE and were deemed to be negative were evaluated. Two groups based on concomitant stress ECG tracing were analysed - those with normal stress ECG and those with ISECG changes. The primary endpoint was cumulative incidence of cardiovascular death, hospitalizations for acute coronary syndrome and coronary revascularizations. RESULTS a total of 371 patients (mean age 59.1 ± 12.1 years, 49.9% women) were studied. Of those, 141 (38.0%) had concomitant ISECG changes. Mean follow-up was 3.46 ± 1.76 years. The primary endpoint occurred in 3.0% of patients, (2.2% in those with normal stress ECG, and in 4.3% with ISECG changes, p = 0.251); with unadjusted hazard ratio for primary endpoint of 2.04 (95%CI 0.62-6.69, p = 0.239) in patients with ISECG changes compared to those with normal stress ECG. CONCLUSIONS in an outpatient population without known CAD evaluated for chest pain after inconclusive first-line work-up, a negative peak supine bicycle ESE confers an excellent prognosis regardless of the nature of concomitant stress ECG abnormalities.
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Affiliation(s)
- Andrea Barbieri
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Francesca Mantovani
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Francesca Bursi
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Sara Ruggerini
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Roberta Lugli
- Department of Cardiology, Policlinico Hospital, Modena and Reggio Emilia University, Modena, Italy
| | - Sahar S Abdelmoneim
- Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Mayo Clinic, Rochester, MN, USA Division of Cardiovascular Diseases, Assiut University, Egypt
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Earls JP, Woodard PK, Abbara S, Akers SR, Araoz PA, Cummings K, Cury RC, Dorbala S, Hoffmann U, Hsu JY, Jacobs JE, Min JK. ACR Appropriateness Criteria Asymptomatic Patient at Risk for Coronary Artery Disease. J Am Coll Radiol 2014; 11:12-9. [DOI: 10.1016/j.jacr.2013.09.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/25/2013] [Indexed: 01/07/2023]
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Murphy M, Krothapalli S, Cuellar J, Kanjanauthai S, Heeke B, Gomadam PS, Guha A, Barnes VA, Litwin SE, Sharma GK. Prognostic value of normal stress echocardiography in obese patients. J Obes 2014; 2014:419724. [PMID: 25258682 PMCID: PMC4167457 DOI: 10.1155/2014/419724] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 07/15/2014] [Accepted: 08/02/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Chest pain is a common problem in obese patients. Because of the body habitus, the results of noninvasive evaluation for CAD may be limited in this group. METHODS We reviewed the records of 1446 consecutive patients who had undergone clinically indicated stress echocardiography (SE). We compared major adverse cardiac events (MACE; myocardial infarction, cardiac intervention, cardiac death, subsequent hospitalization for cardiac events, and emergency department visits) at 1 year in normal weight, overweight, and obese subjects with normal SE. RESULTS Excluding patients with an abnormal and indeterminate SE and those who were lost to follow-up, a retrospective analysis of 704 patients was performed. There were 366 obese patients (BMI ≥ 30), 196 overweight patients (BMI 25-29.9), and 142 patients with normal BMI (18.5-24.9). There was no MACE in the groups at 1-year follow-up after a normal SE. CONCLUSIONS In obese patients including those with multiple risk factors and symptoms concerning for cardiac ischemia, stress echocardiography is an effective and reliable noninvasive tool for identifying those with a low 1-year risk of cardiac events.
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Affiliation(s)
- Michele Murphy
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Siva Krothapalli
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Jose Cuellar
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Somsupha Kanjanauthai
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Brian Heeke
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Pallavi S. Gomadam
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Avirup Guha
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Vernon A. Barnes
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Sheldon E. Litwin
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
| | - Gyanendra K. Sharma
- Division of Cardiology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, BBR 6518, Augusta, GA 30912-3105, USA
- *Gyanendra K. Sharma:
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Fine NM, Pellikka PA, Scott CG, Gharacholou SM, McCully RB. Characteristics and outcomes of patients who achieve high workload (≥10 metabolic equivalents) during treadmill exercise echocardiography. Mayo Clin Proc 2013; 88:1408-19. [PMID: 24290114 DOI: 10.1016/j.mayocp.2013.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine the frequency and prognostic significance of abnormal exercise echocardiographic results for patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise echocardiography. PATIENTS AND METHODS Patients who underwent treadmill exercise echocardiography from November 1, 2003, through December 31, 2008, and exercised for 9 or more minutes using the Bruce protocol (N=7236) were included. Clinical and exercise echocardiographic characteristics and outcomes were evaluated. Variables associated with abnormal exercise echocardiographic results and mortality were identified. RESULTS Exercise echocardiographic results were positive for ischemia in 862 patients (12%). Extensive ischemia developed in 265 patients (4%). For patients with normal exercise echocardiographic results, all-cause and cardiovascular mortality rates were 0.30% and 0.05% per person-year of follow-up, respectively. For patients who had extensive ischemia, all-cause and cardiovascular mortality rates were 0.84% and 0.25% per person-year of follow-up, respectively. Patients at highest risk were those who had extensive and severe regional wall motion abnormalities at rest (n=58), and their all-cause and cardiovascular mortality rates were 2.65% and 0.76% per person-year of follow-up. Exercise echocardiographic variables did not identify sizable patient subgroups at risk for death and did not provide incremental prognostic information (C statistic was 0.74 compared with 0.73 for the clinical plus exercise electrocardiography model). CONCLUSION Patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise testing do not often have extensive ischemic abnormalities on exercise echocardiography. Although exercise echocardiographic results provide some prognostic information, it is not of incremental value for these patients, whose short-term and medium-term prognosis is excellent.
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Affiliation(s)
- Nowell M Fine
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN
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Zagatina A, Krylova L, Vareldzhan Y, Tyurina TV, Clitsenko O, Zhuravskaya N. Comparison of 5-Year Outcomes for Patients With Coronary Artery Disease in Groups With and Without Revascularization With Different Results of Stress Echocardiography. Cardiol Res 2013; 4:152-158. [PMID: 28352438 PMCID: PMC5358200 DOI: 10.4021/cr294e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2013] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND There is conflicting data in contemporary literature concerning the best way to treat patients with stable coronary artery disease; specifically, whether medical treatment alone or invasive strategies combined with medical treatment are better. The purpose of this study was to evaluate the clinical outcomes of patients with and without revascularization after stress echocardiography and to create formulas for detecting patients with a very high risk of cardiac death/major adverse cardiac event (MACE) in their present conditions. METHODS We assessed 323 patients (53.9 ± 8.4 years, 247 men), undergoing upright bicycle stress echocardiography in 2006 - 2007. During a median follow-up of 5.2 ± 0.2 years, 21 cardiovascular and 5 confirmed non-cardiac deaths occurred. Eighty-three patients underwent revascularization. RESULTS Stress echocardiography was normal in 32% and abnormal in 68%. All the patients with CAD were prescribed acetylsalicylic acid, statins, beta-blockers and ACE inhibitors. Eighty-seven percents of the patients took medication regularly. The percentage taking medication didn't significantly differ in the subgroups. Two formulas were created for detecting a very high risk of cardiac death (25%) or MACE (68%) within 5 years. All the patients with abnormal stress tests were divided into two subgroups: 80 patients with revascularization and 138 subjects without revascularization. There was a significant difference in 5 year cardiac mortality if the patients had an index of wall motion abnormality (IWMA) after exercise greater than or equal to 1.3. CONCLUSION It is possible to identify during stress echocardiography subjects with a very high risk for cardiac death/MACE. Patients with IWMA ≥ 1.3 had improved outcomes following revascularization.
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Affiliation(s)
| | - Ludmila Krylova
- Leningrad Regional Cardiologic Dispensary, St. Petersburg, Russian Federation
| | | | - Tatyana V Tyurina
- Leningrad Regional Cardiologic Dispensary, St. Petersburg, Russian Federation
| | - Olga Clitsenko
- Northwestern Medical University n.a. I.I. Mechnikov, St. Petersburg, Russian Federation
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49
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Thavendiranathan P, Dickerson JA, Scandling D, Balasubramanian V, Pennell ML, Hinton A, Raman SV, Simonetti OP. Comparison of treadmill exercise stress cardiac MRI to stress echocardiography in healthy volunteers for adequacy of left ventricular endocardial wall visualization: A pilot study. J Magn Reson Imaging 2013; 39:1146-52. [PMID: 24123562 DOI: 10.1002/jmri.24263] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 05/16/2013] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To compare exercise stress cardiac magnetic resonance (cardiac MR) to echocardiography in healthy volunteers with respect to adequacy of endocardial visualization and confidence of stress study interpretation. MATERIALS AND METHODS Twenty-eight healthy volunteers (age 28 ± 11 years, 15 males) underwent exercise stress echo and cardiac MR one week apart assigned randomly to one test first. Stress cardiac MR was performed using an MRI-compatible treadmill; stress echo was performed as per routine protocol. Cardiac MR and echo images were independently reviewed and scored for adequacy of endocardial visualization and confidence in interpretation of the stress study. RESULTS Heart rate at the time of imaging was similar between the studies. Average time from cessation of exercise to start of imaging (21 vs. 31 s, P < 0.001) and time to acquire stress images (20 vs. 51 s, P < 0.001) was shorter for cardiac MR. The number of myocardial segments adequately visualized was significantly higher by cardiac MR at rest (99.8% vs. 96.4%, P = 0.002) and stress (99.8% vs. 94.1%, P = 0.001). The proportion of subjects in whom there was high confidence in the interpretation was higher for cardiac MR than echo (96% vs. 60%, P = 0.005). CONCLUSION Exercise stress cardiac MR to assess peak exercise wall motion is feasible and can be performed at least as rapidly as stress echo.
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Affiliation(s)
- Paaladinesh Thavendiranathan
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ohio State University, Columbus, Ohio, USA; Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario, Canada
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50
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Shaw LJ, Tandon S, Rosen S, Mieres JH. Evaluation of suspected ischemic heart disease in symptomatic women. Can J Cardiol 2013; 30:729-37. [PMID: 24582723 DOI: 10.1016/j.cjca.2013.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/20/2013] [Accepted: 09/22/2013] [Indexed: 01/22/2023] Open
Abstract
There is a wealth of evidence about the role of a variety of diagnostic testing modalities to define coronary artery disease (CAD) risk in women presenting for evaluation of suspected myocardial ischemia. The exercise electrocardiogram (ECG) is the core index procedure, which can define risk in women capable of performing maximal exercise. Stress imaging, using echocardiography or myocardial perfusion single-photon emission computed tomography/positron emission tomography, is useful for symptomatic women with an abnormal resting ECG or for those who are functionally disabled. For women with low-risk stress imaging findings, there is a very low risk of CAD events, usually < 1%. There is a gradient relationship between the extent and severity of inducible abnormalities and CAD event risk. Women at high risk are those defined as having moderate to severely abnormal wall motion or abnormal perfusion imaging findings. In addition to stress imaging, the evidence of the relationship between CAD extent and severity and prognosis has been clearly defined with coronary computed tomographic angiography. In women, prognosis for those with mild but nonobstructive CAD is higher when compared with those without any CAD. The current evidence base clearly supports that women presenting with chest pain can benefit from one of the commonly applied diagnostic testing modalities.
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Affiliation(s)
- Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia, USA.
| | | | - Stacey Rosen
- North Shore Long Island Jewish Hospital, Manhasset, New York, USA
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