Comparison of the prognostic value of negative non-invasive cardiac investigations in patients with suspected or known coronary artery disease–a meta-analysis

Smulders, Martijn W.; Jaarsma, Caroline; Nelemans, Patricia J.; Bekkers, Sebastiaan C.A.M.; Bucerius, Jan; Leiner, Tim; Crijns, Harry J.G.M.; Wildberger, Joachim E.; Schalla, Simon

doi:10.1093/ehjci/jex014

Cited by 70 publications

(31 citation statements)

References 24 publications

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“…The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade for all tests based on myocardial ischemia, most likely due to increased use of anti-ischemic therapy at the time of testing [ 17 ]. Its diagnostic sensitivity and prognostic negative predictive value are suboptimal, for example, its predictive value is lower than that of a test based on perfusion imaging [ 18 , 19 ] and has declined over the last 40 years [ 20 ]. All of the limitations and weaknesses of the SE technique can now be fixed or minimized with the use of state-of-art technology and protocols.…”

Section: Conventional Stress Echocardiography: Strengths and Pitfamentioning

confidence: 99%

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

Zagatina

Wierzbowska−Drabik

Daros

et al. 2020

JCM

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For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study.

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Section: Conventional Stress Echocardiography: Strengths and Pitfamentioning

confidence: 99%

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

Zagatina

Wierzbowska−Drabik

Daros

et al. 2020

JCM

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“…pre-test probability of disease at referral. The predictive value of a negative test for RWMA is low, but not as low as would be desired or as low as for other competing techniques: the annual hard event rate was 1.7% in the years 2000 to 2016 [16,17], while in the early series published in the 1990s, when SE was applied to more diseased populations evaluated off anti-anginal therapy, this rate was < 1% [18][19][20].…”

mentioning

confidence: 90%

Left ventricular contractile reserve in stress echocardiography: the bright side of the force

Bombardini¹,

Preradović²,

Cortigiani³

et al. 2019

Kardiol Pol

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Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologically critical epicardial artery stenosis which determines subendocardial underperfusion. Recently, the core protocol of SE has been enriched by the addition of left ventricular contractile reserve (LVCR) based on force. Changes in force can be caused by microvascular and/or epicardial coronary artery disease, but also by myocardial scar, necrosis, and/or sub-epicardial layer disease. Left ventricular contractile reserve is calculated as the stress-to-rest ratio of force (systolic arterial pressure measured by cuff sphygmomanometer to end-systolic volume determined by two-dimensional echocardiography). In contrast to the ejection fraction, force is not dependent on changes in preload and afterload. Cutoff values for a preserved LVCR are > 2.0 for dobutamine or exercise stress and > 1.1 for vasodilators, which are weaker inotropic stimuli. Patients with a "strong" heart (normal LVCR values) have a better outcome than patients with a "weak" heart (reduced LVCR values), and this is the prognostic "bright side of the force," meaning that the prognostic value of force-based contractile reserve is higher than that of ejection fraction-based contractile reserve or RWMA. The addition of force to standard SE based on RWMA detection increases the spectrum of risk stratification without any significant increase in imaging time and only a slight increase in analysis time. In both ischaemic (with RWMA) and non-ischaemic (without RWMA) hearts, the preserved force is associated with a more benign prognosis. The prospective multicentre international Stress Echo 2020 trial which started in September 2016 has already recruited > 5000 patients with dual RWMA-force imaging and will systematically test the impact of force on the prognosis within and beyond coronary artery disease, including heart failure and hypertrophic cardiomyopathy.

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“…21 And this is without taking into account that the criterion for a ''negative'' test on CCT was ''\50% luminal narrowing,'' thereby not separating the so-called ''normal coronary arteries'' from nonobstructive CAD.…”

Section: How To Look At Coronary Artery Diseasementioning

confidence: 99%

Anatomy and physiology in coronary artery disease imaging

Cademartiri

Maffei

2019

Journal of Nuclear Cardiology

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Comparison of the prognostic value of negative non-invasive cardiac investigations in patients with suspected or known coronary artery disease–a meta-analysis

Cited by 70 publications

References 24 publications

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography

Left ventricular contractile reserve in stress echocardiography: the bright side of the force

Anatomy and physiology in coronary artery disease imaging

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