Elsevier

American Heart Journal

Volume 151, Issue 1, January 2006, Pages 124-130
American Heart Journal

Clinical Investigation
Imaging and Diagnostic Testing
The additional prognostic value of coronary flow reserve on left anterior descending artery in patients with negative stress echo by wall motion criteria. A Transthoracic Vasodilator Stress Echocardiography Study

https://doi.org/10.1016/j.ahj.2005.03.008Get rights and content

Background

Vasodilator stress echocardiography allows imaging of left anterior descending (LAD) coronary flow reserve (CFR), which may provide additional prognostic information over regional wall motion.

Aim

To assess the prognostic value of CFR in patients with known or suspected coronary artery disease (CAD) and negative stress echo.

Methods

We studied 329 consecutive patients (193 men, age 61 ± 13 years) with known (n = 101) or suspected (n = 228) CAD and negative stress echo by standard wall motion criteria. All patients underwent dipyridamole (up to 0.84 mg/kg in 10 minutes) stress echo with CFR evaluation of LAD by Doppler.

Results

During follow-up (28 ± 10 months), 22 events occurred: 1 cardiac death, 6 nonfatal myocardial infarctions, 5 unstable anginas, and 10 late (>6 months) coronary revascularizations. Moreover, 9 patients underwent early (<6 months) revascularization and were censored. Using a receiver operating characteristic analysis, CFR ≤1.92 was the best predictor of future events (area under the curve = 0.80, sensitivity = 77%, specificity = 85%) and was taken as criterion for reduced CFR accordingly. Sixty-three (19%) patients had reduced and 266 (81%) had normal CFR on LAD. The 36-month event-free survival was higher in patients with normal and lower in patients with reduced CFR (98% vs 64%, P < .0001). At Cox analysis, CFR of LAD (hazard ratio [HR] 16.52, 95% CI 5.76-47.40, P < .0001), left ventricular mass index (HR 1.03 per unit increment, 95% CI 1.00-1.05, P = .01), and smoking habit (HR 3.00, 95% CI 1.24-7.23, P = .01) were independent prognostic indicators. Using an interactive stepwise procedure, CFR on LAD provided additional prognostic information to clinical, resting echo, and angiographic findings.

Conclusions

In patients with known or suspected CAD and negative stress echocardiography by wall motion criteria, CFR provides independent information for prognostic stratification, and a reduced CFR is associated with a less benign long-term outcome.

Section snippets

Patients

We prospectively studied 378 inhospital patients with a chest pain syndrome. They were enrolled in the study starting June 1999 to February 2004 from the Cardiology Division of Mestre-Venezia (n = 323) and Pisa CNR (n = 55). All patients met the following inclusion criteria: (1) stable chest pain syndrome, (2) negative dipyridamole stress echo by standard wall motion criteria, and (3) enrollment in a follow-up program.

Exclusion criteria were the following: (1) technically poor acoustic window

Results

No major complications occurred during the test.

Of 329 patients, 190 (58%) underwent coronary angiography (Table I). No significant CAD was more frequent (P = .001) in patients with normal than in those with reduced CFR, whereas 2-vessel CAD and significant LAD stenosis were more frequent (P = .0004 and P < .0001, respectively) in the latter (Table I).

During a mean follow-up of 28 ± 10 months, there were 22 cardiac events: 1 death, 6 nonfatal myocardial infarctions, 5 unstable anginas, and 10

Discussion

Evaluation of CFR of LAD during vasodilator stress echocardiography is highly feasible, provided that advanced technology and expertise are available in the echocardiography laboratory. When all events are considered, CFR provides independent information for prognostic stratification of patients with known or suspected CAD with negative vasodilator stress echocardiography by standard wall motion criteria.

Conclusions

It is well established that patients with negative stress echocardiograms are at low risk, but some are at lower risk than others. The further risk stratification can be possible on the basis of several features. In our population, the more discriminative variables were normal LV mass index, no smoking habit, and, especially, a preserved CFR on LAD testing. Coronary flow reserve adds prognostic value even when coronary angiographic data are considered. In patients with these clinical, baseline,

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