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1.
Eur Heart J Open ; 3(3): oead053, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-37305342

RESUMO

Aims: There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD. Methods and results: Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. Conclusion: In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.

2.
Open Heart ; 7(1)2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32587105

RESUMO

OBJECTIVE: Due to the low prevalence of obstructive coronary artery disease (CAD) in women, stress testing has a relatively low predictive value for this. Additionally, conventional cardiovascular risk scores underestimate risk in women. This study sought to evaluate the role of atherosclerosis assessment using carotid ultrasound (CU) in women attending for stress echocardiography (SE). METHODS: This was a prospective study in which consecutive women with recent-onset suspected angina, who were referred for clinically indicated SE, underwent CU. RESULTS: 415 women (mean age 61±10 years, 29% diabetes mellitus, mean body mass index 28) attending for SE underwent CU. 47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (carotid plaque in 41%, carotid intima-media thickness >75th percentile in 15%). Women with CD were older (65 vs 58 years, p<0.001), and more likely to have diabetes (41% vs 21%, p=0.001), hypertension (67% vs 36%, p<0.01) and a higher pretest probability of CAD (59% vs 41%, p<0.001). 40% of women classified as low Framingham risk were found to have evidence of CD.The positive predictive value of SE for flow-limiting CAD was 51%, but with the presence of carotid plaque, this was 71% (p<0.01). Carotid plaque (p=0.004) and ischaemia (p=0.01) were the only independent predictors of >70% angiographic stenosis. In women with ischaemia on SE and no carotid plaque, the negative predictive value for flow-limiting disease was 88%.During a follow-up of 1058±234 days, there were 15 events (defined as all-cause mortality, non-fatal myocardial infarction, heart failure admissions and late coronary revascularisation). Age (HR 1.07 (1.00-1.15), p=0.04), carotid plaque burden (HR 1.65 (1.36-2.00), p<0.001) and ischaemic burden (HR 1.41 (1.18-1.68), p<0.001) were associated with outcome. There was a stepwise increase in events/year from 0.3% when there were no ischaemia and atherosclerosis, 1.1% when there was atherosclerosis and no ischaemia, 2.2% when there was ischaemia and no atherosclerosis and 10% when there were both ischaemia and atherosclerosis (p<0.001). CONCLUSION: CU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography, and improves risk stratification in women attending for SE, as well identifying a subset of women who may benefit from primary preventative measures.


Assuntos
Angina Pectoris/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Espessura Intima-Media Carotídea , Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse , Agonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Idoso , Angina Pectoris/etiologia , Angina Pectoris/mortalidade , Doenças das Artérias Carótidas/complicações , Doenças das Artérias Carótidas/mortalidade , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Dobutamina/administração & dosagem , Teste de Esforço , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Tempo
3.
4.
Echo Res Pract ; 5(3): K59-K62, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30115627

RESUMO

SummaryWe present the case of a 32-year-old man who presented with a remote history of chest pain and was diagnosed with non-compaction cardiomyopathy on echocardiography. On presentation, he was relatively asymptomatic with normal cardiac function. Unfortunately, he presented 1 year later with a catastrophic embolic stroke. LEARNING POINTS: Left ventricular non-compaction (LVNC) is a myocardial disorder characterised by prominent left ventricular (LV) trabeculae, a thin compacted layer and deep intertrabecular recesses.Two-dimensional echocardiography with colour Doppler is the study of choice for diagnosis and follow-up of LVNC. CMR serves an important role where adequate echocardiographic imaging cannot be obtained.LVNC is associated with high rates of mortality and morbidity in adults, including heart failure, thromboembolic events and tachyarrhythmias.

5.
J Am Soc Echocardiogr ; 31(8): 860-869, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29861279

RESUMO

BACKGROUND: Single-photon emission computed tomography (SPECT) is a well-established method to evaluate patients with coronary artery disease. Myocardial contrast echocardiography (MCE) is an imaging technique that allows the assessment of myocardial perfusion in real time. Previous research has shown that vasodilator MCE is superior to SPECT for the prediction of hard events. The aim of this study was to investigate the long-term association of SPECT and MCE with clinical outcomes in patients with known or suspected coronary artery disease. METHODS: Accordingly, 258 patients who underwent MCE and SPECT as part of multicenter studies performed prospectively were followed up for hard events (all-cause mortality and nonfatal myocardial infarction). The mean age was 63.4 ± 5.5 years, 186 (72.1%) were men, and 32 (12.4%) had left ventricular systolic dysfunction. We calculated the ratio of the number of abnormal segments (at rest and/or stress) to the total number of segments expressed as MCE and SPECT indices. RESULTS: Over a mean follow-up period of 80.4 ± 6.1 months, 46 patients had hard events. MCE and SPECT indices were associated with all-cause mortality on univariate analysis (P = .008 and P = .035, respectively) but only MCE index was independently associated with hard events (hazard ratio, 4.24; 95% CI, 1.27-14.15; P = .019), beyond clinical data and left ventricular function, and independently associated with hard cardiac events (hazard ratio, 4.78; 95% CI, 1.06-21.59; P = .042). CONCLUSIONS: MCE but not SPECT showed a long-term association with outcome. These results thus favor the routine use of MCE in the long-term assessment of patients with known or suspected coronary artery disease.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse , Tomografia Computadorizada de Emissão de Fóton Único , Causas de Morte , Meios de Contraste , Doença da Artéria Coronariana/mortalidade , Dipiridamol , Feminino , Compostos Férricos , Humanos , Ferro , Masculino , Pessoa de Meia-Idade , Óxidos , Compostos Radiofarmacêuticos , Sensibilidade e Especificidade , Tecnécio Tc 99m Sestamibi
6.
Int J Cardiol ; 259: 1-7, 2018 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-29579580

RESUMO

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.


Assuntos
Angina Pectoris/diagnóstico por imagem , Angina Pectoris/economia , Análise Custo-Benefício/métodos , Ecocardiografia sob Estresse/economia , Eletrocardiografia/economia , Teste de Esforço/economia , Adulto , Idoso , Angina Pectoris/fisiopatologia , Gerenciamento Clínico , Ecocardiografia sob Estresse/métodos , Eletrocardiografia/métodos , Teste de Esforço/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade
7.
J Am Soc Echocardiogr ; 31(2): 180-186, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29246509

RESUMO

BACKGROUND: The ischemic consequences of coronary artery stenosis can be assessed by invasive fractional flow reserve (FFR) or by noninvasive imaging. We sought to determine (1) the concordance between wall thickening assessment during clinically indicated stress echocardiography (SE) and FFR measurements and (2) the factors associated with hard events in these patients. METHODS: Two hundred twenty-three consecutive patients who underwent SE and invasive FFR measurements in close succession were analyzed retrospectively for diagnostic concordance and clinical outcomes. RESULTS: At the vessel level, the sensitivity, specificity, positive predictive value, and negative predictive value of SE for identifying significant disease as assessed by FFR was 68%, 75%, 43%, and 89%, respectively. The greatest discordance was seen in patients with wall thickening abnormalities (WTAs) and negative FFR. During a follow-up of 3.6 ± 2.2 years, there were 23 cardiovascular (CV) events (death and nonfatal myocardial infarction). The number of wall segments with inducible WTAs emerged as the strongest factor associated with CV events (hazard ratio, 1.18 [1.05-1.34]; P = .008). FFR was not associated with outcome. There was a significant increase in event rate in patients with WTA/negative FFR versus no WTA/negative FFR (P = .01), but no significant difference versus WTA/positive FFR (P = .85). CONCLUSIONS: In a patient population with significant CV risk factors, a normal SE had a high negative predictive value for excluding abnormal FFR. WTAs were associated with outcomes regardless of FFR value, suggesting that this is a superior marker of ischemia to FFR.


Assuntos
Estenose Coronária/diagnóstico , Vasos Coronários/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Reserva Fracionada de Fluxo Miocárdico/fisiologia , Idoso , Angiografia Coronária , Estenose Coronária/fisiopatologia , Vasos Coronários/fisiopatologia , Feminino , Seguimentos , Humanos , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença
8.
Curr Cardiol Rep ; 19(12): 121, 2017 10 18.
Artigo em Inglês | MEDLINE | ID: mdl-29046974

RESUMO

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.


Assuntos
Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Ecocardiografia sob Estresse/métodos , Doenças das Artérias Carótidas/complicações , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/complicações , Estenose Coronária/diagnóstico , Dipiridamol , Dobutamina , Ecocardiografia Tridimensional/métodos , Teste de Esforço , Humanos , Imagem de Perfusão do Miocárdio/métodos , Simpatomiméticos , Ultrassonografia , Vasodilatadores
10.
Eur Heart J Cardiovasc Imaging ; 18(2): 195-202, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27013248

RESUMO

AIMS: Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test. METHODS AND RESULTS: Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively (P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG (P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups. CONCLUSION: In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.


Assuntos
Angina Estável/diagnóstico , Estenose Coronária/diagnóstico por imagem , Ecocardiografia sob Estresse/economia , Eletrocardiografia , Teste de Esforço/economia , Adulto , Idoso , Doença da Artéria Coronariana/diagnóstico , Estenose Coronária/fisiopatologia , Análise Custo-Benefício , Diagnóstico Diferencial , Ecocardiografia sob Estresse/métodos , Teste de Esforço/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade
11.
Eur Heart J Cardiovasc Imaging ; 18(4): 415-421, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28013281

RESUMO

AIMS: Patients with symptomatic left bundle branch block (LBBB) may have myocardial ischaemia due to both coronary artery disease and/or cardiomyopathy (microcirculatory abnormalities) and may have concomitant left ventricular (LV) dysfunction. We aimed to assess the feasibility and prognostic value of contemporary stress echocardiography (SE), which can uncover both pathophysiologies in LBBB patients in routine clinical practice, and also aimed to assess the additive value of contrast SE. METHODS AND RESULTS: Accordingly, 190 consecutive patients (age 70.5 ± 11.3 years, LV ejection fraction = 50.1 ± 10%) with symptomatic LBBB who underwent SE over 6 years were assessed, of which 142 (75%) underwent contrast SE and 176 (92.6%) had diagnostic SE. Inducible ischaemia was present in 25 (14.2%) patients. During follow-up (35.4 ± 20.2 months) there were 32 deaths (18%) and 18 (10.2%) first cardiovascular (CV) events (acute myocardial infarction/mortality) in the 176 patients with diagnostic studies. Wall thickening score index at peak stress (WTSIpeak), which measures combined LV function and inducible ischaemia, was an independent predictor of mortality (HR = 3.78, 95% CI = 1.39-10.31, P = 0.01) and CV events (HR = 3.96, 95% CI = 1.1-14.3, P = 0.036). An abnormal SE (myocardial ischaemia and/or abnormal LV function) predicted an almost three-fold increase in all-cause mortality and CV events compared with normal SE. Amongst the confounders affecting assessment of wall thickening in LBBB and conventional prognostic variables, use of contrast was an independent predictor (P = 0.034) of WTSI1.16 (optimal predictor of mortality/CV outcome). CONCLUSION: SE in patients with LBBB demonstrated high feasibility and the combination of LV systolic function and myocardial ischaemia provided important prognostic information. Contrast-enhanced SE improved the prediction of outcome.


Assuntos
Bloqueio de Ramo/diagnóstico por imagem , Meios de Contraste , Ecocardiografia sob Estresse/métodos , Eletrocardiografia/métodos , Infarto do Miocárdio/diagnóstico por imagem , Volume Sistólico/fisiologia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Bloqueio de Ramo/mortalidade , Bloqueio de Ramo/fisiopatologia , Estudos de Coortes , Angiografia Coronária/métodos , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Reino Unido
12.
Heart ; 103(7): 517-523, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-27694111

RESUMO

INTRODUCTION: Although stress echocardiography (SE) is invaluable in younger populations, its prognostic value may be attenuated in the elderly due to shorter life expectancy and the frequent presence of severe comorbidities. This study sought to evaluate the clinical effectiveness of SE in octogenarians, particularly its prognostic value over clinical variables, in predicting hard events. METHODS: A total of 374 consecutive octogenarians who underwent SE for evaluation of coronary artery disease (CAD) were assessed for feasibility, diagnostic accuracy and safety of the test, and followed up for hard outcomes (all-cause mortality, cardiovascular (CV) deaths and non-fatal myocardial infarction (NFMI)). Cox regression analysis was performed to identify predictors of outcome. RESULTS: Of the 374 tests, 360 (96.3%) were diagnostic. Of the 50 patients with inducible ischaemia, 33 patients (66%) proceeded to angiography of which 27 (82%) patients had significant CAD. During long-term follow-up of 4.0±2.0 years, there were 127 deaths and 36 NFMIs. The annualised mortality, NFMI and combined mortality /NFMI rates were 8.1%, 1.8% and 9.4% for patients with a normal SE and 12.1%, 5.5% and 14.1% for those with an abnormal SE, respectively. Predictors of NFMI on multivariate analysis were prior CAD (HR 2.89, CI 1.03 to 8.15, p=0.045), peripheral vascular disease (HR 3.33, CI 1.18 to 9.45, p=0.02), and inducible ischaemia (HR 3.97, CI 1.49 to 10.55, p=0.006). In patients without prior history of CAD, inducible ischaemia was the only independent predictor of NFMI (HR 8.72, CI 1.46 to 52.2, p=0.018). The larger the extent of ischaemia, the greater the incidence of NFMI. The independent predictors of CV events (NFMI or CV mortality) were PAD (HR 2.81, CI 1.21 to 6.52, p=0.016) and peak wall motion score index (HR 5.71, CI 1.67 to 19.6, p=0.006). Although inducible ischaemia predicted all-cause mortality on unadjusted analysis, it did not on multivariate analysis. CONCLUSIONS: In octogenarians, SE demonstrated excellent feasibility, safety and diagnostic accuracy. SE parameters were independent predictors of NFMI and CV events, and the presence of inducible ischaemia was associated with a 50% increase in all-cause mortality.


Assuntos
Agonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Doenças Cardiovasculares/diagnóstico por imagem , Dobutamina/administração & dosagem , Ecocardiografia sob Estresse/métodos , Teste de Esforço , Fatores Etários , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/terapia , Distribuição de Qui-Quadrado , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Humanos , Masculino , Análise Multivariada , Infarto do Miocárdio/diagnóstico por imagem , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
13.
Curr Opin Cardiol ; 31(5): 459-68, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27271926

RESUMO

PURPOSE OF REVIEW: Left ventricular ejection fraction (LVEF) is a powerful prognostic marker in heart failure and plays a pivotal role in the allocation of many treatments that reduce morbidity and mortality. Although unenhanced two-dimensional echocardiography (2DE) is the most ubiquitous tool for the assessment of left ventricular (LV) size and systolic function, it does not provide reliable, reproducible and accurate measures. The purpose of this review is to critically appraise contrast echocardiography and three-dimensional echocardiography (3DE) for the assessment of LVEF and LV volumes. RECENT FINDINGS: Contrast echocardiography results in more accurate assessment of LVEF and LV volumes than unenhanced 2DE, significantly improving correlation with cardiac magnetic resonance, with comparable reproducibility. Contrast echocardiography reduces downstream testing, frequently alters patient management, and results in substantial cost savings. 3DE shows higher levels of agreement with cardiac magnetic resonance over unenhanced 2DE for LVEF and LV volumes, but requires adequate image quality, and consistently underestimates LV volumes due to limited spatial resolution. SUMMARY: The advent of contrast 2DE and 3DE has marked the dawn of significant improvements in the precision and reproducibility of echocardiography. Contrast 3DE improves LV assessment in patients with suboptimal images, but further work is needed to demonstrate incremental benefit over contrast echocardiography.


Assuntos
Ecocardiografia Tridimensional/métodos , Ecocardiografia/normas , Insuficiência Cardíaca/diagnóstico por imagem , Interpretação de Imagem Assistida por Computador/métodos , Imageamento Tridimensional/métodos , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico , Humanos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade
14.
Heart ; 102(5): 370-5, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26740479

RESUMO

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.


Assuntos
Angina Pectoris/diagnóstico por imagem , Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia sob Estresse , Obesidade Mórbida/complicações , Idoso , Angina Pectoris/etiologia , Angina Pectoris/terapia , Índice de Massa Corporal , Distribuição de Qui-Quadrado , Meios de Contraste , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/terapia , Intervalo Livre de Doença , Estudos de Viabilidade , Feminino , Hospitais de Distrito , Humanos , Estimativa de Kaplan-Meier , Londres , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/mortalidade , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Prospectivos , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo
17.
Expert Rev Cardiovasc Ther ; 14(4): 477-94, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26686698

RESUMO

Stress echocardiography (SE) is an established tool not only for the assessment of coronary artery disease (CAD), but also for the evaluation of valvular disease and cardiomyopathy. New techniques, namely contrast echocardiography for function and perfusion including assessment of coronary flow reserve, strain imaging, 3-dimensional echocardiography, Doppler-derived coronary flow reserve and multimodality echocardiography, have been incorporated into stress protocols for improving assessment of cardiac disease. In this review, the advantages and disadvantages of these novel SE techniques are examined in terms of feasibility, accuracy, reproducibility and applications.


Assuntos
Cardiomiopatias/diagnóstico , Doença da Artéria Coronariana/diagnóstico , Ecocardiografia sob Estresse , Doenças das Valvas Cardíacas/diagnóstico , Cardiomiopatias/fisiopatologia , Doença da Artéria Coronariana/fisiopatologia , Precisão da Medição Dimensional , Ecocardiografia sob Estresse/métodos , Ecocardiografia sob Estresse/tendências , Reserva Fracionada de Fluxo Miocárdico , Doenças das Valvas Cardíacas/fisiopatologia , Humanos , Reprodutibilidade dos Testes
19.
Curr Heart Fail Rep ; 12(2): 112-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25500783

RESUMO

Recent efforts have reduced the mortality from coronary artery disease (CAD), with the consequent increase in heart failure with reduced left ventricular function, referred to as ischaemic cardiomyopathy (ICM). As ischemic left ventricular (LV) dysfunction may be partially or completely reversible by revascularization in the presence of viable myocardium, the assessment of myocardial viability is central to the management of ICM. Decades of observational analyses have provided positive evidence for the role of revascularization in hibernating myocardium in improving survival. However, recently the Surgical Treatment for Ischaemic Heart Failure (STICH) trial has challenged this notion, highlighting the noninferiority of optimal medical therapy (OMT) over revascularization and OMT. In this review, we discuss noninvasive imaging modalities to assess myocardial viability and the impact of myocardial viability on revascularization. We critically appraise the STICH trial and suggest an algorithm for viability testing before revascularization in patients with ICM and significant LV dysfunction.


Assuntos
Insuficiência Cardíaca/terapia , Revascularização Miocárdica/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Cintilografia , Ultrassonografia
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