Heart 100:370-374 doi:10.1136/heartjnl-2013-304949
  • Coronary artery disease
  • Original article

Clinical and prognostic value of stress echocardiography appropriateness criteria for evaluation of coronary artery disease in a tertiary referral centre

Editor's Choice
  1. Roxy Senior1,2
  1. 1Department of Cardiology & Echocardiography Laboratory, Royal Brompton & Harefield NHS Trust, London, UK
  2. 2Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, UK
  1. Correspondence to Professor Roxy Senior, Department of Cardiology & Echocardiography Laboratory, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK; roxysenior{at}
  • Received 10 September 2013
  • Revised 13 November 2013
  • Accepted 14 November 2013
  • Published Online First 5 December 2013


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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