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.

The hibernating myocardium: current concepts, diagnostic dilemmas, and clinical challenges in the post-STICH era.

A very large body of evidence--predominantly retrospective--suggests that revascularization is superior to optimal medical therapy in patients with a significant amount of 'hibernating' myocardium. Contemporary cardiological practice has embraced this standard of practice, as many centres worldwide place great emphasis upon the results of viability testing by non-invasive imaging techniques in determining the need for coronary revascularization. This practice has been challenged by the recent results of the Surgical Treatment for Ischaemic Heart Failure (STICH) trial, which suggested both lack of mortality benefit from revascularization and also from viability testing. In this review article, we have summarized the pathophysiology of hibernating myocardium, briefly discussed each of the non-invasive imaging modalities used in contemporary practice for detecting myocardial hibernation before critically appraising the prospective studies in this field, most importantly the main STICH trial and viability sub-study. STICH was clearly a complex trial but has not ended the question over the benefit of revascularization in ischaemic heart failure. Finally, we have suggested a possible methodology for an 'ideal trial' designed to evaluate the role of revascularization in such patients and also explored how viability testing should be used in clinical practice in the post-STICH era.