Clinical Investigation
Exercise Echocardiography
The Prognostic Value of Exercise Echocardiography After Percutaneous Coronary Intervention

https://doi.org/10.1016/j.echo.2020.09.001Get rights and content

Highlights

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    The prognostic value of exercise echocardiography after PCI remains poorly validated.

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    Patients with a negative stress test result were at low risk for hard events.

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    An inconclusive result conferred higher risk for cardiac events than a negative result.

Background

Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of a negative EE test is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) test results.

Methods

A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates.

Results

The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16–3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21–3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51–2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42–7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative EE test results. Focusing on those patients with nonpositive results, cardiac event–free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03–2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75–2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38–4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10–3.91; P = .025) were significantly associated with the occurrence of cardiac events.

Conclusion

Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

Section snippets

Methods

A retrospective single-center study was performed at a tertiary general hospital.

All consecutive patients who underwent exercise echocardiography at our institution between January 2008 and December 2017 were considered for inclusion. We enrolled those patients with known coronary artery disease who had at least one percutaneous coronary intervention performed. We excluded those who had surgical myocardial revascularization. If a patient had more than one negative or inconclusive result test

Population Characteristics

Between January 2008 and December 2017, 4,241 patients underwent exercise echocardiography. Of these, 516 tests were performed in patients who previously had percutaneous coronary revascularization, and these composed the study population (Figure 1). Exercise echocardiographic results were negative for myocardial ischemia in 245 patients (47.5%), inconclusive for myocardial ischemia in 144 (27.9%), and positive for myocardial ischemia in 127 (24.6%).

Eighty-three percent of the 516 patients were

Discussion

Our study evaluating the prognostic value of exercise echocardiography in patients with known coronary artery disease subjected to percutaneous revascularization demonstrated that patients with negative test results have high cardiac event–free survival rates.

Patients who underwent percutaneous coronary intervention and subsequently underwent treadmill exercise echocardiography with inconclusive or positive results, those who underwent the test because of typical angina, and those who had

Conclusion

Patients who underwent percutaneous coronary intervention and subsequently had negative results on treadmill exercise echocardiography at an adequate level of stress are at low risk for hard events.

Patients with inconclusive results are at higher risk for cardiac events than those with negative results. It is therefore recommended, whenever possible, to withhold negative chronotropic medical therapy at the time of testing to reduce the number of inconclusive results.

The detection of patients

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Conflicts of interest: None.

Drs. Lopes and H. Pereira are joint senior authors.

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2020 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.