Revisiting the prognostic role of wall motion abnormalities in stress echocardiography: is the low-risk category still valid in contemporary chronic coronary syndrome?
F Bursi, Q Ciampi, L Cortigiani, A Zagatina, G C Kane, R Arbucci, H Rodriguez Zanella, A Safarova, K Wierzbowska Drabik, A Boshchenko, F Manganelli, A Djordjevic Dikic, L Gerra, P A Pellikka, E PicanoAbstract
Background
Regional Wall Motion Abnormalities (RWMA) remain the cornerstone of stress echocardiography (SE) for risk stratification in chronic coronary syndromes (CCS). However, the efficient identification of a low-risk category—defined by an annual all-cause mortality rate <1%, as observed in historical series—has not been consistently reported in contemporary practice.
Objectives
To assess whether a negative maximal diagnostic SE, based solely on the absence of inducible RWMA, can reliably identify a low-risk population among a contemporary cohort of patients with CCS.
Methods
In a prospective, multicenter study, 17,810 all-comers with known or suspected CCS (mean age 65±11 y, 40.2% women), underwent maximal SE in 35 laboratories across 14 countries. Stress modality—exercise, or pharmacological—was selected according to local practice, expertise, and patient characteristics. A rest-stress (∆) increase in the Wall Motion Score Index (WMSI)≥0.12 was the criterion of positivity, corresponding to the worsening of 1 grade (from 1=normal, to 4=dyskinetic) in 2 of 17 segments or the worsening of 2 grades in 1 segment. All patients were followed for all-cause death as the outcome measure.
Results
Resting WMSI was 1.16±0.34, peak WMSI was 1.18±0.34, ∆WMSI was 0.02±0.17. The stress modality employed was exercise in 2652 (14.9%) patients, dobutamine in 2523 (14.2%) and vasodilators in 12635 (70.9%). Overall, 1968 patients (11.0%) demonstrated new or worsening RWMA. Positivity rates differed significantly by stressor: exercise (698, 26.3%), dobutamine (269, 10.7%), and vasodilators (1001, 7.9%) (p<0.001). Over a median follow-up of 41 days (IQ range 20-108 months, 98,974 person-years), 3130 (17.6%) deaths were recorded. One-year survival was 98.1±1.9% in patients with a negative SE, and 96.9±3.8% in those with new or worsening RWMA during SE (log-rank p=0.0002). Among 15,842 patients with negative SE, 2,643 deaths occurred (86,694 person-years), yielding an incidence rate of 3.05 per 100 persons-year and a negative predictive value of 83.3%. In contrast, 487 events occurred in the positive WMA group (12,280 person-years), corresponding to an incidence rate of 3.96 per 100 persons-year (Figure 1).HR for death was 1.20 (95% CI 1.09–1.32; p=0.0002, Figure 2), remaining significant after adjustment for age (adjHR 1.22, 95% CI 1.11–1.35; p<0.0001) and after further adjustment for beta-blocker therapy (adjHR 1.22, 95% CI 1.11–1.34; p<0.0001).
Conclusion
In contemporary CCS patients, RWMA alone does not identify a low-risk subgroup for all-cause death. The historically established low-risk category (<1% annual all-cause mortality) is not efficiently identified by conventional SE. Risk stratification requires integration of clinical and multi-parametric SE variables.Figure 1Figure 2