Sex-based impact of carotid plaque in patients with chest pain undergoing stress echocardiography

OBJECTIVE

Women with suspected angina without history of coronary artery disease (CAD) less frequently have flow-limiting stenosis (FL-CAD) and more often have microvascular disease, affecting predictive accuracy of stress echocardiography (SE) for detection of FL-CAD. We postulated that carotid plaque burden (CPB) assessment would improve detection of FL-CAD and risk stratification.

METHODS

Consecutive consenting patients assessed by SE on clinical grounds for new-onset chest pain also underwent simultaneous carotid ultrasound. Patients were followed for major adverse events (MAE): all-cause mortality, non-fatal myocardial infarction and unplanned revascularisation. Carotid plaque presence and burden (CPB) were assessed.

RESULTS

After a mean of 2617±469 days (range 17-3740), of 591 recruited patients, 573 (97%) outcome data (314 females) were obtainable. Despite lower pretest probability of CAD in females versus males (14.9±0.8 vs 20.5±1.3, respectively, p<0.0001), prevalence of myocardial ischaemia was similar (p=0.08). Females also had lower prevalence of both carotid plaque (p<0.0001) and FL-CAD (p<0.05). CPB improved the positive predictive value of SE for detection of FL-CAD (from 34.5% to 60%) in females but not in males. Absence of CPB in females with myocardial ischaemia ruled out FL-CAD in 93% versus 57% in males. CPB was the only independent predictor of MAE (p=0.012) in females, whereas in males both SE (p<0.0001) and CPB (p=0.003) remained significant.

CONCLUSION

In females with new-onset stable angina without a history of cardiovascular disease, CPB improved the predictive accuracy of myocardial ischaemia for flow-limiting CAD. However, CPB provided incremental risk stratification in both sexes.

P1467Long-term prognostic value of simultaneous assessment of atherosclerosis and ischemia in patients with suspected angina: implications for routine use of carotid ultrasound during stress echocardiograp

Background

The long-term clinical impact of carotid plaque burden (CPB) in patients with new onset suspected stable angina beyond stress echocardiography (SE) with no history of coronary artery disease (CAD) is not known.

Methods

Consecutive patients referred for SE, underwent simultaneous carotid ultrasonography to assess CPB. Patients were prospectively followed up for major adverse events (MAE).

Results

Of the 592 patients, 573 (age 59±11, 45% male) had follow-up data. During a mean of 7±1.2 years, 85 patients had first MAE (all-cause mortality and acute myocardial infarction: 67 (hard events) and 18 unplanned revascularisation). On multivariate Cox regression analysis, pre-test probability of CAD, peak wall thickness scoring index and CPB predicted MAE (p<0.0001 for all); however, only CPB retained significance for both hard events and hard cardiac events (p=0.008 and 0.001, respectively). MAE and hard events were least in patients with normal SE and absent carotid plaque (annualised event rate: 1.1% and 1.01%respectively) with significant increase in normal SE with plaque disease (2.4% and 2.05%, p=0.004 and 0.01 respectively). Presence of plaque did not impact on these outcomes in abnormal SE.

Conclusions

In patients with suspected stable angina, carotid atherosclerosis and myocardial ischemia in combination provided synergistic MAE information long term but atherosclerosis predicted hard events particularly in patients with normal SE but not in ischemic patients. This implies routine use of simultaneous carotid ultrasound following a normal SE for optimum prognostication

Relative diagnostic, prognostic and economic value of stress echocardiography versus exercise electrocardiography as initial investigation for the detection of coronary artery disease in patients with new onset suspected angina

Objectives

We hypothesised that stress echocardiography (SE), may be superior to exercise ECG (ExECG), for predicting CAD and outcome, and cost-beneficial, when performed as initial investigation in newly suspected angina.

Methods

All patients seen in 2011, with suspected angina, no history of CAD, pre-test likelihood of CAD of > 10% and who underwent SE or ExECG as first line were identified retrospectively. Cost to diagnosis was calculated by adding the cost of all tests, up to and including coronary angiography (CA), on an intention-to-treat basis. Follow-up data on cardiac death and myocardial infarction (MI) were collected, 26 months after the presentation of the last study patient.

Results

A total of 456 patients underwent ExECG (224 (49%) negative, 93 (20%) positive, 139 (31%) inconclusive) and 241 underwent SE (200 (83%) negative, 35 (15%) positive, 6 (2%) inconclusive) as first line. In patients subsequently undergoing CA, CAD was present in 46% (37/80) of patients with positive ExECG vs. 72% (23/32) patients with positive SE (p = 0.01). Mean cost to diagnosis was £456 for the ExECG vs. £360 for the SE group (p = 0.002). Over a mean follow-up period of 31 ± 5 months, cardiac events were 2% each in negative SE vs. negative ExECG (p = 0.9).

Conclusions

SE is superior to ExECG for prediction of CAD and is cost-beneficial when used as initial test in patients with no history of CAD presenting with suspected angina.

Role of simultaneous carotid ultrasound in patients undergoing stress echocardiography for assessment of chest pain with no previous history of coronary artery disease

BACKGROUND

We prospectively explored prevalence of carotid disease (CD), its independent association with coronary artery disease (CAD) and outcome as well as potential impact on management, in patients undergoing stress echocardiography (SE) for new onset chest pain without known CAD.

METHODS

Accordingly, 591 consecutive patients referred for SE underwent carotid ultrasound. Carotid disease was defined as carotid intima-media thickness (C-IMT) >75th percentile for age and sex and/or presence of plaque.

RESULTS

Myocardial ischemia was demonstrated in only a minority (11%), but there was a high prevalence of CD (70%). Incidence of CD was similar in patients with and without ischemia (76% versus 69%, P = .26). Carotid data led to reclassification of Framingham risk score categories in 65% of patients as well as more than a third of negative SE patients potentially benefitting from primary prevention therapy. Of the 83 patients undergoing coronary arteriography, 59 (71%) demonstrated coronary atherosclerosis (any atheroma) and 33 (40%) CAD. Positive predictive value of SE for CAD was 56%, but presence of carotid plaque improved it to 70%. Although both CD and plaque showed association with CAD and revascularization, after adjustment for conventional risk factors, only carotid plaque maintained significant association (P = .024 and P = .023, respectively).

CONCLUSIONS

There is significantly higher prevalence of CD compared with myocardial ischemia in patients undergoing SE and carotid ultrasound for suspected CAD. This can lead to significant Framingham risk score reclassification with important primary prevention implications. Carotid plaque is superior to clinical assessment for the prediction of CAD and improves positive predictive value of SE for CAD in these patients.

Incremental diagnostic and prognostic value of contemporary stress echocardiography in a chest pain unit: mortality and morbidity outcomes from a real-world setting

BACKGROUND

Clinical assessment often cannot reliably or rapidly risk stratify patients hospitalized with suspected acute coronary syndrome. The real-world clinical value of stress echocardiography (SE) in these patients is unknown. Thus, we undertook this study to assess the feasibility, safety, ability for early triaging, and prediction of hard events of SE incorporated into a chest pain unit for patients admitted with acute chest pain, nondiagnostic ECG, and negative 12-hour troponin.

METHODS AND RESULTS

Accordingly, 839 consecutive patients who underwent clinical, ECG, and SE assessments within 24 hours of admission were assessed for feasibility, safety, impact on triaging and discharge, and 30-day readmission rate and were followed up for hard events (all-cause mortality and acute myocardial infarction). Of the 839 patients, 811 (96.7%) had diagnostic SE results. Median time to SE and median length of stay for normal SE patients (77%) were both 1 day. The 30-day readmission rate was 0.5%. During long-term follow-up of 27±11 months, 39 hard events (30 deaths and 9 acute myocardial infarctions) occurred. Kaplan-Meier estimates of hard events were 0.5% versus 6.6% in the normal versus abnormal SE groups, respectively, in the first year of follow-up (15 events in the first year). Among all prognostic variables, only abnormal SE (hazard ratio, 4.08; 95% confidence interval, 2.15-7.72; P<0.001) and advancing age (hazard ratio, 1.78; 95% confidence interval, 1.39-2.37; P<0.001) predicted hard events in multivariable regression analysis.

CONCLUSIONS

SE incorporated into a chest pain unit has excellent feasibility and provides rapid assessment and discharge with accurate risk stratification of patients with suspected acute coronary syndrome but nondiagnostic ECG and negative 12-hour troponin.