CORRESPONDENCE: LETTER TO THE EDITOR
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Sripal Bangalore, MD, MHA and
Farooq A. Chaudhry, MD, FACC*
* Division of Cardiology, Columbia University College of Physicians and Surgeons, St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, New York 10025 (Email: fchaudhr{at}chpnet.org).
We thank Drs. Punnam and Dhoble for their interest in our paper (1) and agree with their comments about the nonischemic causes of right ventricular (RV) asynergy, for example, primary or secondary pulmonary hypertension and pulmonary embolism. However, in our series of 2,703 patients with a mean age of 63 ± 12 years the incidence of primary pulmonary hypertension and pulmonary embolism is low in this cohort of patients referred for stress echocardiography. We do not, however, have the data for either pulmonary hypertension or for pulmonary embolism. Most of the RV wall motion abnormalities were accompanied by left ventricular (LV) wall motion abnormalities, thus decreasing the likelihood of a noncoronary artery disease etiology.
Because smoking is a major risk factor for chronic obstructive pulmonary disease, we reanalyzed the data in nonsmokers. Among the 1,806 nonsmokers, stress RV wall motion score index was able to effectively risk-stratify a normal versus abnormal subgroup (event rates 0.0%/year vs. 11.7%/year; p = 0.006), similar to the main results. When stress LV wall motion analysis was also taken into consideration, RV wall motion analysis was able to further risk-stratify the result of stress echocardiography (global chi-square = 338; p < 0.0001) (Fig. 1).
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Figure 1 Event-Free Survival as a Function of LV and RV Stress Echocardiography Results in Nonsmokers
The number of patients at risk for each follow-up period is given below the graph. Right ventricular (RV) wall motion analysis during stress further risk stratified the results of stress echocardiography on the basis of the left ventricle (LV). Patients with both an abnormal RV and LV had the worst prognosis. Abn = abnormal.
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Although this analysis does account for smokers, it does not account for other causes of pulmonary hypertension and RV asynergy resulting from it (low incidence). Thus, in this group of nonsmokers with known or suspected coronary artery disease referred for routine stress echocardiography, RV wall motion analysis provided prognostic value independent of LV ischemia and ejection fraction. Patients with abnormal RV and LV wall motion during stress have a worse prognosis and should be managed aggressively.
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References
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- Bangalore S, Yao S, Chaudhry FA. Role of right ventricular wall motion abnormalities in risk stratification and prognosis of patients referred for stress echocardiography J Am Coll Cardiol 2007;50:1981-1989.[Abstract/Free Full Text]
Related Article
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Right Ventricular Asynergy as a Prognosticator
- Sujeeth R. Punnam and Abhijeet Dhoble
J. Am. Coll. Cardiol. 2008 51: 1616.
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