Abstracts
Background:
Studies have demonstrated the diagnostic accuracy and prognostic value of physical stress echocardiography in coronary artery disease. However, the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia is limited.
Objective:
To evaluate the effectiveness of physical stress echocardiography in the prediction of mortality and major cardiac events in patients with exercise test positive for myocardial ischemia.
Methods:
This is a retrospective cohort in which 866 consecutive patients with exercise test positive for myocardial ischemia, and who underwent physical stress echocardiography were studied. Patients were divided into two groups: with physical stress echocardiography negative (G1) or positive (G2) for myocardial ischemia. The endpoints analyzed were all-cause mortality and major cardiac events, defined as cardiac death and non-fatal acute myocardial infarction.
Results:
G2 comprised 205 patients (23.7%). During the mean 85.6 ± 15.0-month follow-up, there were 26 deaths, of which six were cardiac deaths, and 25 non-fatal myocardial infarction cases. The independent predictors of mortality were: age, diabetes mellitus, and positive physical stress echocardiography (hazard ratio: 2.69; 95% confidence interval: 1.20 - 6.01; p = 0.016). The independent predictors of major cardiac events were: age, previous coronary artery disease, positive physical stress echocardiography (hazard ratio: 2.75; 95% confidence interval: 1.15 - 6.53; p = 0.022) and absence of a 10% increase in ejection fraction. All-cause mortality and the incidence of major cardiac events were significantly higher in G2 (p < 0. 001 and p = 0.001, respectively).
Conclusion:
Physical stress echocardiography provides additional prognostic information in patients with exercise test positive for myocardial ischemia.
Echocardiography,Stress/mortality; Exercise Test; Physical Exertion; Coronary Artery Disease; Myocardial Ischemia
Fundamento:
Estudos têm demonstrado a acurácia diagnóstica e o valor prognóstico da ecocardiografia com estresse físico na doença arterial coronária, mas a predição de mortalidade e de eventos cardíacos maiores, em pacientes com teste ergométrico positivo para isquemia miocárdica, é limitada.
Objetivo:
Avaliar a predição de mortalidade e de eventos cardíacos maiores pela ecocardiografia com estresse físico em pacientes com teste ergométrico positivo para isquemia miocárdica.
Métodos:
Trata-se de uma coorte retrospectiva em que foram estudados 866 pacientes consecutivos, com teste ergométrico positivo para isquemia miocárdica, submetidos à ecocardiografia com estresse físico. Os pacientes foram divididos em dois grupos: ecocardiografia com estresse físico negativa (G1) ou positiva (G2) para isquemia miocárdica. Os desfechos avaliados foram mortalidade por qualquer causa e eventos cardíacos maiores, definidos como óbito cardíaco e infarto agudo do miocárdio não fatal.
Resultados:
O G2 constituiu-se de 205 (23,7%) pacientes. Durante o seguimento médio de 85,6 ± 15,0 meses, ocorreram 26 óbitos, sendo seis por causa cardíaca, e 25 casos de infarto agudo do miocárdio não fatais. Os preditores independentes de mortalidade foram idade, diabetes melito e a ecocardiografia com estresse físico + (hazard ratio: 2,69; intervalo de confiança de 95%: 1,20 - 6,01; p = 0,016), com os seguintes eventos cardíacos maiores: idade, doença arterial coronária prévia, ecocardiografia com estresse físico + (hazard ratio: 2,75; intervalo de confiança de 95%: 1,15 - 6,53; p = 0,022) e ausência do incremento de 10% na fração de ejeção. A mortalidade por qualquer causa e os eventos cardíacos maiores foram significativamente superiores no G2 (p < 0, 001 e p = 0,001, respectivamente).
Conclusão:
A ecocardiografia com estresse físico oferece informações prognósticas adicionais em pacientes com teste ergométrico positivo para isquemia miocárdica.
Ecocardiografia sob Estresse/mortalidade; Teste de Esforço; Esforço Físico; Doença da Artéria Coronariana; Isquemia Miocárdica
Introduction
Coronary artery disease (CAD) is the major cause of morbidity and mortality in Western
countries11 Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K,
et al; American Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Heart disease and stroke statistics - 2009 update: a report from the
American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
Circulation. 2009;119(3):480-6. Circulation. 2009;119(3):e182.. In Brazil, cardiovascular diseases
account for more than 30% of deaths22 Ministério da Saúde. Datasus : informações sobre mortalidade e
informações demográficas. [citado 2005 ago 10]. Disponível em:
http://tabnet.datasus.gov.br/cgi/tabcgi.
http://tabnet.datasus.gov.br/cgi/tabcgi...
. Since new
effective therapeutic options are now available, the identification of patients at a
higher risk for cardiovascular events is mandatory33 Jahnke C, Nagel E, Gebker R, Kokocinski T, Kelle S, Manka R, et al.
Prognostic value of cardiac magnetic resonance stress tests: adenosine stress
perfusion and dobutamine stress wall motion imaging. Circulation. 2007;115(13):
1769-76.. Although coronary angiography remains the gold-standard for the diagnosis
of CAD44 Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, et al.
ACC/AHA guidelines for coronary angiography. A report of the American College of
Cardiology/American Heart Association Task Force on practice guidelines (Committee on
Coronary Angiography). Developed in collaboration with the Society for Cardiac
Angiography and Interventions. J Am Coll Cardiol.
1999;33(6):1756-824., non-invasive techniques play a key role
in the diagnosis and in the indication of invasive procedures.
Myocardial ischemia and infarction occur as a result of sequential changes known as "ischemic cascade". Perfusion abnormalities are followed by metabolic changes, left ventricular (LV) diastolic dysfunction, regional contraction deficit, electrocardiographic abnormalities and chest pain55 Heyndrickx GR, Baig H, Nellens P, Leusen I, Fishbein MC, Vatner SF. Depression of regional blood flow and wall thickening after brief coronary occlusions. Am J Physiol. 1978;234(6):H653-9.. The ischemic cascade may be understood as a spectrum throughout which different markers of myocardial ischemia may show different sensitivity66 Geft MC, Fishbein K, Ninomiya J, Hashida E, Chaux J, Yano J, et al. Intermittent brief periods of ischemia have a cumulative effect and may cause myocardial necrosis. Circulation. 1982;66(6):1150-3.,77 Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med. 1986;314(19):1214-9..
Exercise test (ET) is the noninvasive test initially recommended for the diagnosis and
risk stratification of patients with suspected CAD88 Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey KR, Gersh BJ.
Prognostic value of treadmill exercise testing: a population-based study in Olmsted
County, Minnesota. Circulation. 1998;98(25):2836-41.
9 Goraya TY, Jacobsen SJ, Pellikka PA, Miller TD, Khan A, Weston SA, et
al. Prognostic value of treadmill exercise testing in elderly persons. Ann Intern
Med. 2000;132(11):862-70.-1010 Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher
VF, et al; American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines.
ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll
Cardiol. 2002;40(8):1531-40. Erratum in J Am Coll Cardiol.
2006;48(8):1731.. However, the use of
ET is limited in several situations such as in the presence of left bundle branch block
(LBBB) or of ST-segment abnormalities in resting electrocardiogram (ECG)1010 Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher
VF, et al; American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines.
ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll
Cardiol. 2002;40(8):1531-40. Erratum in J Am Coll Cardiol.
2006;48(8):1731., thus requiring the association of imaging
methods to improve the diagnostic accuracy1111 DePuey EG, Guertler-Krawczynska E, Perkins JV, Robbins WL, Whelchel JD,
Clements SD. Alterations in myocardial thallium-201 distribution in patients with
chronic systemic hypertension undergoing single photon emission computed tomography".
Am J Cardiol. 1988;62(4):234-8..
Physical stress echocardiography (PSE) has high sensitivity and specificity, and is more accurate than ECG, ET and resting echocardiography in the detection of CAD1212 Kowatsch I. Acurácia diagnóstica da ecocardiografia sob estresse associada ao estudo da perfusão miocárdica com contraste na avaliação da isquemia miocárdica: estudo comparativo entre adenosina e dobutamina. [Tese]. São Paulo (SP): Faculdade de Medicina . Universidade de São Paulo ; 2005.,1313 Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Soc Echocardiogr. 2003;16(10):1091-110.. LV wall motion abnormalities (WMA) detected by PSE occur earlier than angina or ST-segment abnormalities1414 Picano E; American College of Cadiology; American Heart Association. Stress echocardiography for the diagnosis of coronary artery disease. Indian Heart J. 2003;55(3):223-7.. Additionally, PSE also has an additional value in the location and quantification of myocardial ischemia as well as in the prediction of adverse events in patients with established CAD1515 Barbosa MM, Nunes MCP, Campos Filho O, Camarozano A, Rabischoffsky A, Maciel BC, et al. Sociedade Brasileira de Cardiologia. Diretrizes das indicações da ecocardiografia. Arq Bras Cardiol. 2009;93(6 supl.3):e265-e302..
The objective of this study was to analyze the effectiveness of PSE in predicting mortality and major cardiac events (MCE) in patients with ET showing ischemia.
Methods
Patients
A total of 866 consecutive patients referred for PSE in the Laboratory of Echocardiography of São Lucas Hospital, Aracaju (SE), after their respective physicians had detected electrocardiographic signs of myocardial ischemia on ET, were included between January 2001 and June 2010. The exclusion criteria were: ET negative for myocardial ischemia; presence of LBBB; failure to confirm ischemia by ET (repeated as PSE protocol); patient refusal to participate in the study; and failure to establish phone contact during the follow-up period.
The protocol consisted of complete clinical assessment with investigation of previous symptoms such as chest pain or shortness of breath, as well as risk factors for CAD, followed by ECG and resting echocardiography. Then, the patients underwent physical exertion on a treadmill and new echocardiographic images were acquired. Clinical and demographic data, as well as the results of the stress tests were recorded in the database. The individuals were divided into two groups according to the absence (G1) or presence (G2) of myocardial ischemia on PSE.
Exercise test
After a light meal, the patients were examined and advised not to practice any excessive physical activity on the day the test was performed. The study was performed with the individuals breathing spontaneously in room air, at a constant temperature (20 to 24ºC). The Bruce protocol was used to perform ET. During the test, the individuals were continuously monitored by three-lead ECG, and were encouraged to reach their peak physical exertion. ET was considered as positive for myocardial ischemia whenever ST-segment elevation or horizontal or downsloping ST-segment depression ≥ 1 mm was detected for at least 60 to 80 ms of J point1010 Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531-40. Erratum in J Am Coll Cardiol. 2006;48(8):1731..
Physical stress echocardiography
Echocardiographic studies were performed using Packard/Phillips Hewlett SONOS 5500 equipment according to the technical specifications described by Schiller et al1616 Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989;2(5):358-67.. Two-dimensional echocardiographic images were obtained with the patient in the left lateral position, in the parasternal and apical acoustic windows, at rest and immediately after exercise, with simultaneous electrocardiographic recording in videocassette or digital video, and assessed by an experienced echocardiographer (level III), as recommended by the American Society of Echocardiography1717 Picard MH, Adams D, Bierig SM, Dent JM, Douglas PS, Gillam LD, et al; American Society of Echocardiography. American Society of Echocardiography Recommendations for quality echocardiography laboratory operations. J Am Soc Echocardiogr. 2011;24(1):1-10.. In cases of doubt, the images were analyzed by a second, equally experienced, examiner.
Wall motion was scored from 1 to 4 (1 if normal, 2 if hypokinesia, 3 if akinesia, and 4 if dyskinesia), according to a 16-segment model. The wall motion index (WMI) was determined at rest and at peak exercise as the sum of segmental scores divided by the number of segments visualized. Left ventricular systolic function was quantified, based on WMI, as: 1 if normal; 1.1 to 1.6 if mild ventricular dysfunction; 1.61 to 2 if moderate ventricular dysfunction; and > 2 if severe ventricular dysfunction1616 Schiller NB, Shah PM, Crawford M, DeMaria A, Devereux R, Feigenbaum H, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms. J Am Soc Echocardiogr. 1989;2(5):358-67.. The difference between exercise and resting WMI was named ΔWMI; it was considered normal when equal to zero, and abnormal when different from zero. Any result showing the development of new motion abnormalities induced by exercise or worsening of a preexisting contractile deficit, that is, every ΔWMI different from zero was considered as myocardial ischemia on PSE; absence of myocardial ischemia was defined as the absence of the criteria described above, that is, ΔWMI equal to zero.
Follow-up and endpoints
Patients were followed-up by means of telephone interviews, contact with the assisting physician, or medical record review. All-cause death and MCE were considered as study endpoints; MCE were defined as cardiac death and non-fatal acute myocardial infarction (AMI).
Statistical analysis
Categorical variables were described as percentages and compared between groups using the chi-square or Fisher's exact test. Continuous variables were described as mean and standard deviation (SD), and the differences between groups were analyzed using the Student's t test or Mann-Whitney test, as appropriate. The cumulative events curves were estimated using the Kaplan-Meier method and compared using the log-rank test. To evaluate the risk factors for MCE and death, Cox regression was used, considering univariate and multivariate analyses. The variables included in the multivariate model were those with p < 0.1 in the univariate analysis. Differences were considered significant when p < 0.05. The statistical analyses were carried out using the Statistical Package for the Social Sciences (SPSS) program, version 17.0 (Chicago, IL).
The study was carried out in compliance with the ethical principles for human experimentation and the patients gave written informed consent. The study was approved by the Research and Ethics Committee of Federal University of Sergipe (CAAE 1818.0.000.107-06).
Results
Clinical characteristics of the study population
The population comprised 866 patients with ST-segment abnormalities during ET, and who underwent PSE. The patients were divided into two groups, one with 661 (76.3%) patients without ischemia on PSE (ΔWMI = 0) (G1), and the other with 205 (23.7%) patients with ischemia (ΔWMI ≠ 0) (G2). In G1, the mean age of patients was 55.97 ± 11 years, and 298 (45.1%) were men; in G2, the mean age was 58.96 ± 9.83 years, and 87 (42.4%) were men. G2 patients had significantly higher BMI (p = 0.002), age (p < 0.001), and presence of suggestive chest pain (p < 0.001) in relation to G1; non-suggestive chest pain was more frequent in G1 (p = 0.004). Additionally, there were significantly more patients with hypertension (p = 0.004), diabetes mellitus (p = 0.001), dyslipidemia (p = 0.01), and family history of CAD (p = 0.008) in G2. No other significant differences were observed between the groups regarding their clinical characteristics (Table 1).
Clinical characteristics of patients with and without myocardial ischemia on physical stress echocardiography
Three out of four positive ET did not show ischemia on PSE, i.e., approximately 75% of the study patients were better analyzed.
Hemodynamic and echocardiographic measurements
G2 showed a significantly lower peak heart rate (HR) (p < 0.001), higher resting WMA (p = 0.036), higher exercise WMI and higher ΔWMI (p < 0.001). In relation to the other hemodynamic and echocardiographic parameters, there were no significant differences between G1 and G2 (Table 2).
Hemodynamic and echocardiographic findings In patients without (G1) and with ischemia (G2) on physical stress echocardiography
Follow-up and endpoints
During the mean 85.6 ± 15.0-month follow-up, there were 26 all-cause death, of which seven in G1 (sudden death, sepsis, stroke, airway obstruction and neoplasia), and 19 in G2 (kidney failure, sepsis, pancreatitis and neoplasia); additionally, there were 31 MCE (one cardiac death and five AMI in G1, and five cardiac deaths and 20 AMI in G2). As regards overall mortality, in the univariate analysis the significant variables were: age ≥ 60 years (p < 0.001), diabetes mellitus (p = 0.001), resting WMA (p = 0.003), positive PSE (p = 0.001) and left ventricular mass index (LVMI; p < 0.001).
As regards MCE, the significant variables in univariate analysis were: male gender (p = 0.044), age ≥ 60 years (p < 0.001), typical chest pain (p = 0.030), atypical chest pain (p = 0.017), diabetes mellitus (p = 0.005), dyslipidemia (p = 0.019), previous CAD (p < 0.001), resting WMA (p < 0.001), positive PSE (p < 0.001), LV ejection fraction (LVEF; p < 0.001), LVMI (p = 0.006) and ΔWMI (p = 0.042). (Table 3). In the multivariate analysis, the independent predictors of mortality were age ≥ 60 years, and positive PSE. The independent predictors of MCE were age ≥ 60 years, previous CAD, positive PSE, and absence of a 10% increase in EF (Tables 4 and 5).
For MCE, there was a significant difference between groups G1 vs. G2, with p = 0.022. For overall mortality, there was also a significant difference between groups G1 vs. G2, with p = 0.016.
Mortality and MCE curves are shown in Figures 1 and 2, respectively.
Discussion
This study has demonstrated that PSE is an independent predictor of death and MCE in
patients with ET showing ischemia. The independent predictors of mortality after
multivariate analysis were: age ≥ 60 years, diabetes mellitus, and positive PSE.
Predictors of MCE were age ≥ 60 years and previous CAD. Several studies have
demonstrated the clinical characteristics described above as well-established risk
factors for CAD1818 Sartorelli DS, Franco LJ. Tendências do diabetes mellitus no Brasil: o
papel da transição nutricional. Cad Saúde Pública.
2003;19(1):S29-36.
19 Mota E, Moriguchi E. Dislipidemia em idosos: devemos tratar?
Dislipidemia Today. 2001;1:3-10.
20 Wilhelmesen L, Rosengren A, Eriksson H, Lappas G. Heart failure in the
general population of men: morbidity, risk factors and prognosis. J Intern Med.
2001;249(3):253-61.-2121 Zanchetti A. The hipertensive patients with multiple risk factors. Is
treatment really so difficult? Am J Hypertens. 1997;10(10 Pt
2):223S-9S. and as predictors of adverse events in patients
with stable or suspected angina or established CAD2222 Phillips AN, Shaper AG, Pocock SJ, Walker M, Macfarlane PW. The role of
risk factors in heart attacks occurring in men with pre-existing ischaemic heart
disease. Br Heart J. 1988;60(5):404-10.
23 Brewer HB Jr. Hypertriglyceridemia: changes in the plasma lipoproteins
associated with an increased risk of cardiovascular disease. Am J Cardiol.
1999;83(9B):3F-12F.-2424 Anderson JL, Muhlestein JB, Horne BD, Carlquist JF, Bair TL, Madsen TE,
et al. Plasma homocysteine predicts mortality independently of traditional risk
factors and C-reactive protein in patients with angiographically defined coronary
artery disease. Circulation. 2000;102(11):1227-32.. Our results
corroborate these previous findings.
Echocardiographic findings have the ability to demonstrate pathophysiological changes resulting from myocardial ischemia in earlier phases and are, therefore, more sensitive than clinical results and ECG changes2525 Lewis WR. Echocardiography in the evaluation of patients in chest pain units. Cardiol Clin. 2005;23(4):531-9.. In this study, we found an important association of suggestive pain in patients with myocardial ischemia on PSE and on MCE.
As regards the echocardiographic findings, a significant presence of resting WMA, greater stress WMI and high ΔWMI were observed in G2. The results associated with overall mortality were resting WMA, positive PSE, and high LVMI. Those associated with endpoints were resting WMA, positive PSE, low EF, high LVMI and ΔWMI. After multivariate analysis, positive PSE remained as an independent predictor of mortality; and positive PSE and low EF, as predictive of MCE. Even patients showing WMA only at rest had an increased risk of MCE and death in this study. This finding is also described in a recent study with 333 patients in which Schlett et al2626 Schlett CL, Banerji D, Siegel E, Bamberg F, Lehman SJ, Ferencik M, et al. Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year outcomes of the ROMICAT trial. JACC Cardiovasc Imaging. 2011;4(5):481-91. observed that the 2-year cumulative probability of MCE increased in patients with resting WMA with coronary stenosis (relative risk - RR = 62.4%; log-rank p < 0.0001), as well as in those with resting WMA without stenosis (RR = 15%; log-rank p < 0.0001).
LVMI was also relevant in patients with myocardial ischemia on PSE and multivariate analysis. The risk of MCE was represented by ΔWMI. Our results are consistent with those of a cohort of 5798 patients with known or suspected CAD, which demonstrated that ΔWMI had a significant prognostic value for MCE2727 Arruda-Olson AM, Juracan EM, Mahoney DW, McCully RB, Roger VL, Pellikka PA. Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference? J Am Coll Cardiol. 2002;39(4):625-31.. ΔWMI is known to be associated not only with a higher risk of adverse events, but also with mortality2727 Arruda-Olson AM, Juracan EM, Mahoney DW, McCully RB, Roger VL, Pellikka PA. Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference? J Am Coll Cardiol. 2002;39(4):625-31..
In a Spanish cohort of 4004 patients, 16.7% had myocardial ischemia on PSE, and ΔWMI was an independent predictor of mortality and MCE2828 Elhendy A, Mahoney DW, Burger KN, McCully RB, Pellikka PA. Prognostic value of exercise echocardiography in patients with classic angina pectoris. Am J Cardiol. 2004;94(5):559-63.. However, this was not observed in relation to mortality, in our study. This can be explained by the adequate use of medical treatment with drugs that decrease mortality.
Additionally, the univariate analysis demonstrated that a positive PSE was associated
with risk of death and MCE, and remained an independent predictor of both after
multivariate analysis. Several studies have analyzed the value of PSE as predictive of
mortality and MCE2828 Elhendy A, Mahoney DW, Burger KN, McCully RB, Pellikka PA. Prognostic
value of exercise echocardiography in patients with classic angina pectoris. Am J
Cardiol. 2004;94(5):559-63.
29 Arruda AM, Das MK, Roger VL, Klarich KW, Mahoney DW, Pellikka PA.
Prognostic value of exercise echocardiography in 2,632 patients > or = 65 years of
age. J Am Coll Cardiol. 2001;37(4):1036-41.
30 Oliveira JL, Barreto-Filho JA, Oliveira CR, Santana TA, Anjos-Andrade
FD, Alves EO, et al. Prognostic value of exercise echocardiography in diabetic
patients. Cardiovasc Ultrasound. 2009;7:24.-3131 Yao S, Bangalore S, Ahuja A, Chaudhry FA. Stress echocardiography: risk
stratification, prognosis, patient outcomes and cost-effectiveness. Minerva
Cardioangiol. 2009;57(3):315-31.. This study corroborates the prognostic
importance of PSE, already established in the literature.
The use of tests for prognostic purposes is based on the premise that patients identified as having a high risk for adverse events may undergo more invasive interventions aimed at changing the natural history of the disease, thus reducing the risk of events3232 Bouzas-Mosquera A, Peteiro J, Alvarez-Garcia N, Broullon FJ, Mosquera VX, Garcia-Bueno L, et al. Prediction of mortality and major cardiac events by exercise echocardiography in patients with normal exercise electrocardiographic testing. J Am Coll Cardiol. 2009;53(21):1981-90.,3333 Elhendy A, Mahoney DW, Khandheria BK, Paterick TE, Burger KN, Pellikka PA. Prognostic significance of the location of wall motion abnormalities during exercise echocardiography. J Am Coll Cardiol. 2002;40(9):1623-9.. Randomized clinical studies have demonstrated that drug therapies and coronary revascularization may reduce mortality in certain groups of patients3434 Alderman EL, Bourassa MG, Cohen LS, Davis KB, Kaiser GG, Killip T, et al. Ten-year follow-up of survival and myocardial infarction in the randomized Coronary Artery Surgery Study. Circulation. 1990;82(5):1629-46.. Clinical studies using drug therapy have shown a reduction in the rates of cardiac death and of fatal and non-fatal myocardial infarction3535 Jong P, Yusuf S, Rousseau MF, Ahn SA, Bangdiwala SI. Effect of enalapril on 12-year survival and life expectancy in patients with left ventricular systolic dysfunction: a follow-up study. Lancet. 2003;361(9372):1843-8. During the study, we observed that a significant proportion of patients with ET positive for myocardial ischemia did not show ischemia on PSE. Three in every four patients with positive ET did not show ischemia on PSE, i.e., approximately 75% of the study patients were better analyzed. Additionally, the 25% with a positive PSE were those who were actually at an increased risk of adverse cardiac events, thus confirming the importance of the prognostic assessment of PSE.
The limitation of this study was the failure to compare the results found in the population with those of the population with an ET negative for myocardial ischemia.
The sample size, follow-up period (approximately 9 years), and the fact that the study was carried out in only one study center are considered favorable factors. The most important contribution of this study was to show that in every four positive ET, only one showed PSE positive for myocardial ischemia, which, in fact, provides a better stratification of this population at a low and intermediate risk for CAD, thus preventing the unnecessary use of invasive tests.
Conclusion
Physical stress echocardiography allows for a more accurate identification of patients at a higher risk of developing adverse cardiac events during the progression of coronary artery disease, thus providing important prognostic information for the clinical practice.
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Sources of FundingThere were no external funding sources for this study.
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Study AssociationThis study is not associated with any thesis or dissertation work.
References
-
1Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119(3):480-6. Circulation. 2009;119(3):e182.
-
2Ministério da Saúde. Datasus : informações sobre mortalidade e informações demográficas. [citado 2005 ago 10]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.
» http://tabnet.datasus.gov.br/cgi/tabcgi -
3Jahnke C, Nagel E, Gebker R, Kokocinski T, Kelle S, Manka R, et al. Prognostic value of cardiac magnetic resonance stress tests: adenosine stress perfusion and dobutamine stress wall motion imaging. Circulation. 2007;115(13): 1769-76.
-
4Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, et al. ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol. 1999;33(6):1756-824.
-
5Heyndrickx GR, Baig H, Nellens P, Leusen I, Fishbein MC, Vatner SF. Depression of regional blood flow and wall thickening after brief coronary occlusions. Am J Physiol. 1978;234(6):H653-9.
-
6Geft MC, Fishbein K, Ninomiya J, Hashida E, Chaux J, Yano J, et al. Intermittent brief periods of ischemia have a cumulative effect and may cause myocardial necrosis. Circulation. 1982;66(6):1150-3.
-
7Gottlieb SO, Weisfeldt ML, Ouyang P, Mellits ED, Gerstenblith G. Silent ischemia as a marker for early unfavorable outcomes in patients with unstable angina. N Engl J Med. 1986;314(19):1214-9.
-
8Roger VL, Jacobsen SJ, Pellikka PA, Miller TD, Bailey KR, Gersh BJ. Prognostic value of treadmill exercise testing: a population-based study in Olmsted County, Minnesota. Circulation. 1998;98(25):2836-41.
-
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Publication Dates
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Publication in this collection
28 Oct 2014 -
Date of issue
Nov 2014
History
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Received
03 Nov 2013 -
Reviewed
25 Mar 2014 -
Accepted
02 June 2014