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Long-Term Outcomes After Stress Echocardiography in Real-World Practice
TAKE-HOME MESSAGE
- In this multicenter prospective cohort study, stress echocardiography findings indicative of ischemia were associated with more than a twofold increased risk of cardiovascular death and myocardial infarction. Negative stress echocardiogram results identified a "warranty period" of 4 to 5 years, during which the risk of future cardiovascular events was low.
- These findings enhance our understanding of the prognostic value of stress echocardiography in real-world practice, supporting its role in accurately assessing long-term outcomes for patients presenting with chest pain.
abstract
This abstract is available on the publisher's site.
Access this abstract nowAIMS
Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real world practice across a healthcare system has not been previously reported.
METHODS AND RESULTS
5503 patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios. Median follow-up was 829 days (IQR 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction (HR 2.71, 95% CI 1.73-4.24, P<0.001), and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P<0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least five years in patients with no prior history of coronary artery disease, and four years for those with disease.
CONCLUSIONS
In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorises risk of future events over the next five years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.
Additional Info
Disclosure statements are available on the authors' profiles:
Long-Term outcomes after stress echocardiography in real world practice: five-year follow-up of the UK Evarest study
Eur Heart J Cardiovasc Imaging 2024 Nov 12;[EPub Ahead of Print], W Woodward, CL Johnson, S Krasner, J O'Driscoll, A McCourt, C Dockerill, K Balkhausen, B Chandrasekaran, S Firoozan, A Kardos, N Sabharwal, R Sarwar, R Senior, R Sharma, K Wong, DX Augustine, P LeesonFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Stress echocardiography and other functional tests for coronary artery disease risk stratification face two key challenges: the perception of a "warranty period" limited to 1 year and high operator dependency, with academic outcomes often exceeding real-world performance.
This study evaluated the long-term predictive value of stress echocardiography for mortality and major cardiac events in contemporary practice within a large UK hospital network. Among more than 5000 patients across 32 centers, a positive stress echocardiography result was associated with a more than twofold increased risk of cardiac mortality or myocardial infarction. Hazard ratios correlated with ischemic burden, reaffirming the low risk of hard clinical events in patients with negative results. These patients may safely remain on medical therapy for up to 4 years, reducing unnecessary invasive procedures.
The study's strengths include its multicenter design, which enhances generalizability, and the frequent use of contrast agents to improve imaging quality during stress-induced challenges. However, its design, developed a decade ago, reflects older stress echocardiography protocols. The sole positivity criterion was regional wall motion abnormality. Today, additional parameters — readily obtainable from the same stress echocardiography images — offer improved prognostic power, such as heart rate reserve (cardiac sympathetic function) and contractility reserve (end-systolic volume changes). Other biomarkers, including B-lines (pulmonary congestion) and coronary flow velocity reserve, are now recognized as superior predictors of all-cause mortality. These advancements necessitate a shift toward vasodilatory testing and updated protocols.
This study underscores stress echocardiography's robust ability to predict hard cardiac events with an extended 4-year warranty period, even in nonacademic settings. Given its low cost (10 times less than PET), minimal environmental impact (30 times less than CMR), and zero radiation exposure (unlike the equivalent of 500 chest x-rays associated with SPECT), stress echocardiography emerges as a sustainable, effective imaging modality with significant clinical, economic, and environmental implications.