Mulvagh_Cardiology_book_temp 26/10/2009 12:13 Page 18
Imaging
Table 2: Selected Studies Enrolling More than 500 Patients Assessing the Value of Stress Echocardiography in
Predicting Cardiac Events in Patients with Known or Suspected Coronary Artery Disease
Study Type of SE Total Number Outcome Measured Follow up (years) Predictors Hazard Ratio (95% CI),
of Patients (Mean±SD) p-value
Picano et al., 1989
120
Dipyridamole 539 Cardiac deaths/non-fatal MI/ 3 Extent of RWMA 2.7; p<0.0001
coronary revascularization
procedures/all-cause deaths
Chuah et al., 1998
121
Dobutamine 860 Cardiac deaths/non-fatal MI 2±0.8 Peak WMSI 1.14 (1.05–1.23); p<0.0001
Poldermans et al., 1999
122
Dobutamine 1,659 Cardiac deaths/non-fatal MI 3 (0.5–8)* Extent of RWMA 3.3(2.4–4.4); p<0.0001
Elhendy et al., 2001
123
†
Treadmill 1,810 Cardiac deaths/non-fatal MI 3 Exercise WMSI 2.1 (1.3–3.4); p=0.003
Marwick et al., 2001
124
Dobutamine 3,156 Cardiac deaths 3.8±1.9 Extent of RWMA 1.83 (1.36–2.47); p<0.0001
Marwick et al., 2001
125
Treadmill 5,375 Total deaths 5.5±1.9 Extent of RWMA 4.44 (2.28–8.66); p<0.0001,
Arruda-Olson et al., 2002
33
Treadmill 5,798 Cardiac deaths/non-fatal MI 3.2±1.7 Peak WMSI Men: 1.53 (1.32–1.77);
p<0.0001
Women: 1.49 (1.14–1.94);
p=0.003
Elhendy et al., 2002
126
Treadmill 4,347 Cardiac deaths/non-fatal MI 3 Extent of RWMA 7.2 (4.1–12.8); p<0.0001
McCully et al., 2002
127
Treadmill 1,874 Cardiac deaths/non-fatal MI 3.1±1.6 Extent of RWMA 1.55 (1.3–1.9) ; p<0.0001
Sicari et al., 2003
29
Dobutamine 7,333 Total deaths/cardiac deaths 2.6±3 Peak WMSI 5.1 (3.6–7.03); p<0.0001
Dipyridamole (EPIC)
Yao et al., 2003
128
Dobutamine 1,500 Cardiac deaths/non-fatal MI 2.7±1.0 Peak WMSI 2.1 (1.0–4.4); p=0.04
Treadmill
Shaw et al., 2005
129
Dobutamine 11,132 Cardiac deaths 4.8 (3.4–6.3)* Extent of RWMA Dobutamine: 1.27
(1.07–1.52); p=0.007
Treadmill Treadmill: 1.45 (1.20–1.74);
p<0.0001
Biagini et al., 2005
77
Dobutamine 3,381 Cardiac deaths/non-fatal MI 7±3.4 Extent of RWMA Men: 2.2 (1.7–2.9);
p<0.0001
Women: 3.2 (1.7–6.3 );
p<0.0001
SE = stress echocardiography; CI = confidence interval; MI = myocardial infarction; EPIC = Echo Persantine International Cooperative–Echo Dobutamine International Cooperative data bank; SD =
standard deviation; RWMA = regional wall motion abnormality; WMSI = wall motion score index.
†
*Median and interquartile range. Patients with low pre-test probability of coronary artery disease.
rate for normal SE and nuclear perfusion scans.
27,30–32
In addition, the cost.
45
It is in patients with intermediate risk for CAD that exercise
prognostic value of SE has been established in specific groups of SE can enhance cost-effectiveness. In a major study evaluating
patients, including those referred for pre-operative assessment,
31
7,565 patients undergoing both exercise testing and exercise SE,
women,
33
the elderly,
34
diabetics,
35
post-acute myocardial infarction exercise SE was associated with a greater incremental life
(MI),
36
post-coronary revascularization,
37
hypertensives,
38
patients with expectation and a lower cost of additional diagnostic procedures
electronic pacemakers,
39
patients with left bundle branch block,
40
and compared with exercise ECG alone.
46
In a similar study, SE resulted in
patients with atrial fibrillation.
41
Although less frequently utilized, a higher rate of hospital discharge compared with exercise ECG, with
transesophageal atrial pacing SE (TAPSE) has also been found to have associated cost savings.
47
prognostic value as an independent predictor of cardiac events;
patients with positive TAPSE are 12 times more likely to have cardiac In general, the choice of SE over nuclear perfusion will depend on the
events (deaths and MI).
42,43
overall perceived biological risk related to the use of radiation, as well
as factors associated with local expertise. One of the first randomized
SE also has a unique role in the hemodynamic assessment of valvular clinical trials looking at the cost-effectiveness of diagnosis and
heart disease, diastolic dysfunction, and pulmonary hypertension, and management of patients presenting with possible CAD using several
can be used in combination with oxygen consumption testing for the diagnostic modalities showed a satisfactory safety rate for both
differentiation of cardiopulmonary syndromes in dyspneic patients. tests.
48
Another study addressing the cost-effectiveness of exercise
SE versus stress single positron emission computed tomograpy
Cost-effectiveness (SPECT) imaging supported the use of SE in patients at low risk with
Cost-effectiveness evaluation can assist healthcare decision-makers suspected CAD and SPECT in those at higher risk.
49
Recent
in resource allocation for maximization of the net public health publications addressing concerns regarding radiation exposure from
benefit; downstream costs arising from the use of a less accurate medical testing have stimulated awareness and debate in the
initial test may have the unintended result of increasing total costs.
44
scientific and lay communities regarding the significant contribution
In patients with a high likelihood of CAD, direct coronary angiography of cardiovascular medical testing, and nuclear cardiology in particular,
was the most cost-effective strategy despite its higher immediate to patient radiation dose.
50
18 US CARDIOLOGY