The clinical impact of contemporary stress echocardiography in morbid obesity for the assessment of coronary artery disease.

OBJECTIVE: Non-invasive cardiac imaging may suffer from poor image quality in morbidly obese individuals. This study aimed to determine the clinical value of contemporary stress echocardiography (SE) in morbidly obese patients referred for assessment of suspected coronary artery disease (CAD). METHODS: This prospective, multicentre observational study was conducted in two district hospitals and one tertiary centre in London, UK. Individuals with body mass index ≥35 kg/m(2) referred for SE were evaluated. The percentage of patients with obstructive CAD on coronary angiography, following abnormal SE, was assessed. Patient outcomes were determined with follow-up for the composite end-point of all-cause mortality, myocardial infarction and late revascularisation. RESULTS: Over a 13-month period, 209 morbidly obese patients underwent SE, and contrast agent was used in 96% of patients. A diagnostic result was obtained in 200/209 (96%) patients. Of 32 (15%) patients with inducible ischaemia, 25 underwent angiography, 22 (88%) had corresponding significant CAD and, of these, 16 (77%) underwent revascularisation. Conversely, only 2/157 patients (1.3%) with normal SE underwent angiography, and none underwent revascularisation. Over a mean follow-up period of 17.8±5.4 months, there were nine events. The annualised cardiac event rate after a normal SE was 0.95%. Events were more frequent in patients with inducible ischaemia versus those without ischaemia (5/32 (15.6%) vs 4/153 (2.6%); p=0.002). Ejection fraction <50% (HR 9.5; 95% CI 2.4 to 38.0; p=0.002) and inducible ischaemia (HR 9.4; 95% CI 2.5 to 35.8; p=0.001) were predictors of outcome on univariable Cox regression analysis. CONCLUSIONS: Contemporary SE has excellent feasibility and positive predictive value and resulted in appropriate risk stratification of symptomatic patients with significant obesity. A normal SE portends an excellent outcome over the short-intermediate term in this high-risk patient population.

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.

Independent and incremental value of stress echocardiography over clinical and stress electrocardiographic parameters for the prediction of hard cardiac events in new-onset suspected angina with no history of coronary artery disease.

AIMS: Recent data have shown that exercise electrocardiogram (ECG) has no incremental prognostic value over clinical and rest ECG parameters in chest pain patients without a history of coronary artery disease (CAD). The incremental prognostic value of stress echocardiography (SE) in this population is unknown. METHODS AND RESULTS: Accordingly, 547 consecutive patients (68 ± 4.9 years) with chest pain but no previous history of CAD, referred for SE (exercise and dobutamine), were identified. Patients were followed up for death and acute myocardial infarction (AMI). At a median follow-up period of 28 months, there were a total of 35 hard cardiac events (5 deaths and 30 non-fatal AMI). Among the prognostic clinical, resting/stress ECG, and SE data, univariate predictors were the Framingham risk score (P = 0.025), diabetes (P = 0.06), hypercholesterolaemia (P = 0.06), stress ECG ischaemia (P = 0.044), stress heart rate (P = 0.019), and SE-determined ischaemic burden (stress-rest wall thickening score index; P < 0.001). In a multivariate model, ischaemic burden was the only independent predictor of events (P < 0.001). SE also showed incremental prognostic value over and above clinical (Framingham's risk score) and stress ECG changes in a global χ(2) model. This was true also for patients undergoing only exercise SE (n = 347). CONCLUSION: SE provides both independent and incremental prognostic value for the prediction of hard cardiac events in chest pain patients without a previous history of CAD-over and above clinical, ECG, and stress ECG data.