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CLINICAL RESEARCH: CARDIAC IMAGING

Prediction of Mortality and Major Cardiac Events by Exercise Echocardiography in Patients With Normal Exercise Electrocardiographic Testing

Alberto Bouzas-Mosquera, MD^_*,_*, Jesús Peteiro, MD, PhD^_*, Nemesio Álvarez-García, MD^_*, Francisco J. Broullón, MS, Victor X. Mosquera, MD, Lourdes García-Bueno, MD^_*, Luis Ferro, MD^_* and Alfonso Castro-Beiras, MD, PhD^_*,

^_* Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
Department of Health Information Technology, Hospital Universitario A Coruña, A Coruña, Spain
Department of Cardiac Surgery, Hospital Universitario A Coruña, A Coruña, Spain
Red Temática de Investigación Cardiovascular (RECAVA)-Instituto de Salud Carlos III, Madrid, Spain

Manuscript received October 23, 2008; revised manuscript received January 6, 2009, accepted January 19, 2009.

^_* Reprint requests and correspondence: Dr. Alberto Bouzas-Mosquera, Department of Cardiology, Hospital Universitario A Coruña, As Xubias 84, 15006 A Coruña, Spain (Email: aboumos{at}canalejo.org).

Part of this study was presented during the Young Investigators' Award Session at the European Society of Cardiology Congress 2008, Munich, Germany, September 2008.

Objectives: We sought to assess the value of exercise echocardiography (EE) for predicting outcome in patients with known or suspected coronary artery disease and normal exercise electrocardiogram (ECG) testing.

Background: The prognostic value of EE in patients with normal exercise ECG testing has not been characterized.

Methods: We studied 4,004 consecutive patients (2,358 men, mean age [± SD] 59.6 ± 12.5 years) with interpretable ECG who underwent treadmill EE and did not develop chest pain or ischemic ECG abnormalities during the tests. Wall motion score index (WMSI) was evaluated at rest and with exercise, and the difference (WMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (MACE).

Results: Overall, 669 patients (16.7%) developed ischemia with exercise. During a mean follow-up of 4.5 ± 3.4 years, 313 patients died, and 183 patients had a MACE before any revascularization procedure. The 5-year mortality and MACE rates were 6.4% and 4.2% in patients without ischemia versus 12.1% and 10.1% in those with ischemia, respectively (p < 0.001). In the multivariate analysis, WMSI remained an independent predictor of mortality (hazard ratio [HR]: 2.73, 95% confidence interval [CI]: 1.40 to 5.32, p = 0.003) and MACE (HR: 3.59, 95% CI: 1.42 to 9.07, p = 0.007). The addition of the EE results to the clinical, resting echocardiographic and exercise hemodynamic data significantly increased the global chi-square of the models for the prediction of mortality (p = 0.005) and MACE (p = 0.009).

Conclusions: The use of EE provides significant prognostic information for predicting mortality and MACE in patients with interpretable ECG and normal exercise ECG testing.

Key Words: exercise test • stress echocardiography • prognosis

Abbreviations and Acronyms   CAD = coronary artery disease   ECG = electrocardiogram   EE = exercise echocardiography   MACE = major adverse cardiac event(s)   WMA = wall motion abnormalities   WMSI = wall motion score index

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