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The Long-Term Prognostic Value of Negative Contrast Stress Echocardiography

John Lisko, Shuang Lin, Ioannis Parastatidis and Stamatios Lerakis

Stress echocardiography is a sensitive and specific noninvasive technique for evaluation of my-ocardial ischemia. Stress echocardiography is portable and does not involve ionizing radiation. A known limitation of stress echocardiography is inadequate definition of the endocardial border, especially in patients with suboptimal imaging windows.

Contrast echocardiography is indicated for detection or definition in these patients or in cases where more than two cardiac segments are not adequately visualized. To date, few studies have evaluated the long-term prognostic value of contrast stress echocardiography. This study sought to determine the prognostic value of contrast stress echocardiography in patients at low to intermediate risk of coronary atherosclerotic disease.

Methods: Patients referred to the Emory University Hospital echocardiography lab for stress echocardiography and received Optison (R) contrast for left ventricular (LV) endocardial enhancement were included in this study. Patients received contrast when two or more cardiac segments were not adequately visualized. Demographic data and indication for examination was collected for each patient. Each study was classified as either negative for ischemia or positive if there was a new wall motion abnormality or worsening of a baseline abnormality.

The comprehensive electronic medical record was subsequently reviewed for major adverse cardiovascular events including death from any cause, death from a cardiovascular cause, myocardial infarction, congestive heart failure exacerbation, need for hospitalization for anginal chest pain, need for revascularization. This study was approved by the Emory University Hospital institutional review board.

Results: Fifty-one patients met the inclusion criteria for this study. Three patients had a positive stress echocardiogram. Of these three patients, one was treated with optimal medical therapy and the other two underwent angiography with percutaneous coronary intervention. During the mean follow-up period of 2.2 +/- 1.02 years (median 1.95 years) there was one death attributed to a patient discharge to Hospice, and there were no deaths attributable to a cardiac etiology.

There was one hospitalization for unstable angina and one hospitalization for a congestive heart failure exacerbation in the same patient. No patients underwent revascularization or had a myocardial infarction. Three cardiac catheterizations were performed during the follow-up period with no significant coronary artery disease.

Conclusions: Contrast stress echocardiography is useful for the noninvasive assessment of myocardial is-chemia. A negative contrast stress echocardiogram conveys a favorable prognosis over a two year period with a 98.0% negative predictive value.