Elsevier

International Journal of Cardiology

Volume 296, 1 December 2019, Pages 157-163
International Journal of Cardiology

False-positive stress echocardiograms: Predictors and prognostic relevance

https://doi.org/10.1016/j.ijcard.2019.08.037Get rights and content

Highlights

  • •

    Predictors of false-positive findings on stress echocardiography could limit the use of unnecessary cardiac catheterization.

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    Patients with false-positive results had similar outcomes to those with true-positive results.

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    Patients with false-positive results could benefit from aggressive risk factor control and careful clinical follow-up.

Abstract

Background

Recent studies indicate that the pretest likelihood of significant coronary artery disease (CAD) (≥50% luminal stenosis) is over-estimated and that the frequency and severity of positive stress tests have been decreasing. This suggests an increased prevalence of false-positive (FP) stress tests. The aims of this retrospective study were to investigate the predictors of FP stress echocardiography (SE) and to compare the outcomes of patients with FP results to those with true-positive (TP) results.

Methods

Patients who underwent SE between 2013 and 2017 in a tertiary-care center were reviewed. Included were patients aged ≥40 years who had cardiac catheterization (CC) within 1 year of the index stress test. SE was considered FP if a new or worsening wall motion abnormality was present in the absence of significant corresponding CAD.

Results

Of the 5100 patients with SE, 1069 satisfied inclusion criteria. A total of 305 patients had positive SE results; of which 162 (53%) were FP. Logistic regression revealed that female gender (p = 0.009), the absence of diabetes (p = 0.03), the absence of a personal history of CAD (p = 0.004), and lower stress WMSI (p = 0.03) were independently associated with FP results. Patients with FP results on SE had similar all-cause mortality to those with TP results.

Conclusions

Accounting for predictors of FP findings on SE could improve the interpretation of SE results and limit the use of unnecessary CC. Furthermore, patients with FP results on SE could benefit from aggressive risk factor control and careful clinical follow-up.

Section snippets

Background

Stress echocardiography (SE) is a validated non-invasive diagnostic modality for the detection and risk-stratification of patients with coronary artery disease (CAD). The sensitivity and specificity of SE for the detection of significant CAD (defined as coronary artery stenosis ≥50%) have been reported to be of 85% and 75% when used with exercise, and 80% and 86% when used with dobutamine, respectively [[1], [2], [3]]. As with any diagnostic test, SE has its limitations. These include

Patient selection

The records of 5100 patients aged ≥40 years who underwent SE between January 1, 2013, and December 31, 2017, at Indiana University Health Methodist Hospital (Indianapolis, IN) were reviewed. Patients who had a CC within 1 year after the index stress test were included. In the event a patient had more than one stress test during the study period, only the first stress test was selected for analysis. A total of 1069 patients satisfied the inclusion criteria and constituted our study population.

Clinical characteristics of the study population

Patient clinical characteristics are summarized in Table 1. Common clinical indications for SE included: preoperative evaluation (603 patients, all pre-solid organ transplant candidates including 588 liver transplant candidates, 57%), chest pain (227 patients, 21%) and dyspnea (100 patients, 10%). Among patients with a positive stress test, the most common reasons for the test were similarly preoperative evaluation (79 patients, 26%), chest pain (100 patients, 33%) and dyspnea (61 patients,

Discussion

SE is an important tool for evaluating patients with suspected CAD. However, FP results often lead to unnecessary invasive procedures. In our study, of 1069 patients who underwent CC, we identified 162 patients (15%) who had a FP result. This percentage was similar to those previously reported for dobutamine (11%) and exercise SE (13%) [6,7]. Among the 305 patients who had positive stress echocardiograms and subsequent angiography, 162 patients (53%) had a FP result. Similar results were

Conclusion

Current practice guidelines recommend analyzing stress testing results in the context of pretest probability, test performance characteristics, and posttest probability. Our study identified female gender, the absence of diabetes, the absence of a personal history of CAD, and lower stress WMSI as independent predictors of FP SE findings. Accounting for these factors could improve the interpretation of SE results and potentially avoid unnecessary CC. Additionally, patients with FP results had

Funding sources

None.

Declaration of competing interest

None declared. All the authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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