Key result
Appropriate stress echo indications identify patients at ~4-fold higher MI or death risk versus inappropriate indications.
Why the study?
Appropriateness criteria for stress echocardiography have been published to reduce inappropriate testing, but their clinical impact and prognostic value require investigation.
Do stress echocardiography appropriateness criteria predict inducible ischemia and adverse clinical events in patients evaluated for coronary artery disease?
Cohort (n=250)
No
Do stress echocardiography appropriateness criteria predict inducible ischemia and adverse clinical events in patients evaluated for coronary artery disease?
Absolute Event Rate: 11.5% vs 2.8%
p-value: p=0.01
Appropriateness criteria for stress echocardiography effectively differentiate patients at high risk of ischemia and adverse events from those at low risk, highlighting the potential to reduce unnecessary testing.
Appropriateness criteria may enhance risk stratification with stress echocardiography; leaves open need for randomized confirmation of outcome benefit.
OBJECTIVE: Appropriateness criteria for stress echocardiography (SE) have been published to reduce the rate of inappropriate testing. We sought to investigate the clinical impact and prognostic value of these criteria. METHODS: 250 consecutive patients undergoing SE for evaluation of coronary artery disease were classified into appropriate, uncertain and inappropriate categories according to appropriateness criteria. A positive SE was defined as the development of new wall motion abnormalities or a biphasic response. The primary end point was the composite of myocardial infarction and death. RESULTS: Of the 250 SE, 120 (48%) were dobutamine studies and 130 (52%) were exercise studies. 156 (62.4%), 71 (28.4%) and 23 (9.2%) were classified as appropriate, inappropriate and uncertain, respectively. A significantly greater proportion of studies classified as appropriate 71 (45.5%) demonstrated inducible ischaemia compared with inappropriate studies 9 (12.7%) or uncertain studies 4 (17.4%), p<0.0001. During a median follow-up of 12.4 months, events occurred in 18 (11.5%), 2 (2.8%) and 0 patients classified as appropriate, inappropriate and uncertain, respectively. Event-free survival was significantly reduced in patients with a SE demonstrating ischaemia compared with patients without inducible ischaemia, p<0.0001. Kaplan-Meier curves demonstrated reduced event-free survival in patients with whose studies were classified as appropriate compared to inappropriate (p=0.01) or uncertain (p=0.05). CONCLUSIONS: Appropriateness criteria differentiate between patients at high risk of ischaemia, subsequent revascularisation/cardiac events (appropriate group) and those at low risk of events (inappropriate group). A large proportion of SE is currently performed in inappropriate patients. Implementation of the criteria in clinical practice would reduce unnecessary testing.
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Bhattacharyya et al. (2013) conducted a cohort in coronary artery disease (n=250). Appropriate indication for stress echocardiography vs. Inappropriate or uncertain indication was evaluated on composite of myocardial infarction and death (p=0.01). Appropriate indications for stress echocardiography identified patients at higher risk for myocardial infarction or death compared to inappropriate indications (11.5% vs 2.8%; p=0.01).
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