Positivity rate of stress echocardiography using regional wall motion abnormalities in chronic coronary syndromes
L Gerra, Q Ciampi, L Cortigiani, G C Kane, R Arbucci, H Rodriguez-Zanella, A Safarova, F Bursi, J Peteiro Vazquez, A Zagatina, A Boshchenko, F Manganelli, A Djordjevic-Dikic, P A Pellikka, E PicanoAbstract
Background
Regional wall motion abnormalities (RWMA) remain the cornerstone of stress echocardiography (SE) for diagnosing myocardial ischemia in chronic coronary syndromes (CCS). Historical positivity rates of 60 – 70% have declined over decades.
Purpose
To evaluate contemporary RWMA-based SE positivity, inter-center and geographic variability, and clinical and procedural factors associated with positivity in CCS.
Methods
In a prospective multicenter study, CCS patients underwent exercise or pharmacological SE according to local protocols. Stress modalities included treadmill or bicycle, dobutamine, dipyridamole, or adenosine. SE positivity was defined by rest-stress wall motion score index increase (ΔWMSI >0.12), corresponding to worsening of one grade (from 1=normal to 4=dyskinetic) in at least two of 17 segments or two grades in one segment. High-risk studies were defined by ΔWMSI >0.40. Continuous variables are mean ± standard deviation and categorical variables counts and percentages. Comparisons used chi-square test. Patients were grouped into four regions: Americas, Asia/Middle East, Eastern Europe/Russia, Western/Southern Europe. Inter-center variability was explored descriptively. Multivariable logistic regression evaluated factors independently associated with inducible RWMA after adjustment for clinical and procedural variables.
Results
A total of 11,831 patients (mean age 65±11 years, 39.1% women) from 33 laboratories in 15 countries were included; 1,458 (12.3%) received ultrasound-enhancing agents. Resting WMSI was 1.09±0.24. Overall, 1,355 (11.4%) demonstrated new or worsening RWMA. Among positive studies, 370 (27.3%) were high-risk (ΔWMSI > 0.40), representing 3.1% of cohort. Positivity differed by stress modality: exercise 16.8%, dobutamine 9.0%, vasodilators 3.2% (p<0.001). Inter-center variability ranged from 1.1 to 46.3% (Figure). Geographic differences were observed, with highest positivity rates in Eastern Europe/Russia and lowest in Western/Southern Europe and Asia/Middle East (p<0.001). Using Western/Southern Europe as reference, differences persisted after multivariable adjustment (Table). Factors associated with inducible RWMA were older age (OR 1.03 per year, 95% CI 1.02–1.03), male sex (OR 1.23, 95% CI 1.08–1.42), diabetes (OR 1.17, 95% CI 1.00–1.36), hypertension (OR 1.30, 95% CI 1.09–1.56), dyslipidemia (OR 1.67, 95% CI 1.42–1.97), exercise stress (OR 2.03, 95% CI 1.81–2.28), ultrasound-enhancing agents (OR 2.63, 95% CI 2.13–3.24), high-volume centers (>500 studies entered in data bank) (OR 1.22, 95% CI 1.02–1.48) (all p<0.05).
Conclusion
SE positivity based solely on RWMA in CCS is currently low and shows inter-center and geographic variability, partly influenced by patient profile and procedural factors. These findings support the need to evolve SE toward a multiparametric and standardized approach to better capture the heterogeneous phenotypes of myocardial ischemia beyond RWMA alone.