Key result
Inducible wall motion abnormalities on stress echo linked to ~20% higher all-cause mortality.
Why the study?
Although regional wall motion abnormalities are the cornerstone of stress echocardiography for risk stratification in chronic coronary syndromes, whether a negative test based solely on the absence of inducible abnormalities still reliably identifies a low-risk population (<1% annual mortality) in contemporary practice was uncertain.
Does a negative maximal diagnostic stress echocardiogram based solely on the absence of inducible regional wall motion abnormalities reliably identify a low-risk population for all-cause mortality in patients with chronic coronary syndromes?
Cohort (n=17,810)
Yes
Does a negative maximal diagnostic stress echocardiogram based solely on the absence of inducible regional wall motion abnormalities reliably identify a low-risk population for all-cause mortality in patients with chronic coronary syndromes?
In contemporary patients with chronic coronary syndromes, the absence of inducible regional wall motion abnormalities on stress echocardiography yields an annual all-cause mortality rate of 3.05%, failing to identify the historically established low-risk (<1% annual mortality) category.
Negative stress echocardiography does not identify low-risk chronic coronary syndrome patients; challenges historical <1% mortality benchmarks and leaves open refined stratification.
Background Regional Wall Motion Abnormalities (RWMA) remain the cornerstone of stress echocardiography (SE) for risk stratification in chronic coronary syndromes (CCS). However, the efficient identification of a low-risk category—defined by an annual all-cause mortality rate <1%, as observed in historical series—has not been consistently reported in contemporary practice. Objectives To assess whether a negative maximal diagnostic SE, based solely on the absence of inducible RWMA, can reliably identify a low-risk population among a contemporary cohort of patients with CCS. Methods In a prospective, multicenter study, 17,810 all-comers with known or suspected CCS (mean age 65±11 y, 40.2% women), underwent maximal SE in 35 laboratories across 14 countries. Stress modality—exercise, or pharmacological—was selected according to local practice, expertise, and patient characteristics. A rest-stress (∆) increase in the Wall Motion Score Index (WMSI)≥0.12 was the criterion of positivity, corresponding to the worsening of 1 grade (from 1=normal, to 4=dyskinetic) in 2 of 17 segments or the worsening of 2 grades in 1 segment. All patients were followed for all-cause death as the outcome measure. Results Resting WMSI was 1.16±0.34, peak WMSI was 1.18±0.34, ∆WMSI was 0.02±0.17. The stress modality employed was exercise in 2652 (14.9%) patients, dobutamine in 2523 (14.2%) and vasodilators in 12635 (70.9%). Overall, 1968 patients (11.0%) demonstrated new or worsening RWMA. Positivity rates differed significantly by stressor: exercise (698, 26.3%), dobutamine (269, 10.7%), and vasodilators (1001, 7.9%) (p<0.001). Over a median follow-up of 41 days (IQ range 20-108 months, 98,974 person-years), 3130 (17.6%) deaths were recorded. One-year survival was 98.1±1.9% in patients with a negative SE, and 96.9±3.8% in those with new or worsening RWMA during SE (log-rank p=0.0002). Among 15,842 patients with negative SE, 2,643 deaths occurred (86,694 person-years), yielding an incidence rate of 3.05 per 100 persons-year and a negative predictive value of 83.3%. In contrast, 487 events occurred in the positive WMA group (12,280 person-years), corresponding to an incidence rate of 3.96 per 100 persons-year (Figure 1).HR for death was 1.20 (95% CI 1.09–1.32; p=0.0002, Figure 2), remaining significant after adjustment for age (adjHR 1.22, 95% CI 1.11–1.35; p<0.0001) and after further adjustment for beta-blocker therapy (adjHR 1.22, 95% CI 1.11–1.34; p<0.0001). Conclusion In contemporary CCS patients, RWMA alone does not identify a low-risk subgroup for all-cause death. The historically established low-risk category (<1% annual all-cause mortality) is not efficiently identified by conventional SE. Risk stratification requires integration of clinical and multi-parametric SE variables.Figure 1Figure 2
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Bursi et al. (2026) conducted a cohort in Known or suspected chronic coronary syndromes (CCS) (n=17,810). New or worsening regional wall motion abnormalities (RWMA) on stress echocardiography (∆WMSI ≥0.12) vs. Negative stress echocardiography (absence of inducible RWMA) was evaluated on All-cause death (HR 1.20, 95% CI 1.09-1.32, p=0.0002). Absence of inducible wall motion abnormalities on stress echocardiography yielded an all-cause death rate of 3.05 vs 3.96 per 100 person-years with abnormalities (HR 1.20; 95% CI 1.09-1.32; p=0.0002).
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