Stress Echocardiography in Patients With Moderate or Severe Myocardial Ischemia: Insights From the ISCHEMIA Trial.
Michael H Picard, Kyle Saysana, Derek D Cyr, Xin Zeng, Marielle Scherrer-Crosbie, Leslee J Shaw, Roxy Senior, Kian Keong Poh, Sripal Bangalore, Jonathon A Leipsic, Gb John Mancini, Matthew J Budoff, Cameron J Hague, James K Min, Sean M O'Brien, Judith S Hochman, David J Maron, Harmony R Reynolds, ISCHEMIA Research Group
Author Information
Michael H Picard: Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts. Electronic address: mhpicard@mgh.harvard.edu.
Kyle Saysana: Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts.
Derek D Cyr: Duke Clinical Research Institute, Durham, North Carolina.
Xin Zeng: Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts.
Marielle Scherrer-Crosbie: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Leslee J Shaw: Icahn School of Medicine at Mount Sinai, New York, New York.
Roxy Senior: Northwick Park Hospital-Royal Brompton, London, United Kingdom.
Kian Keong Poh: National University Heart Center Singapore, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
Sripal Bangalore: Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, New York.
Jonathon A Leipsic: Center for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.
Gb John Mancini: Center for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.
Matthew J Budoff: Lundquist Institute, Los Angeles, California.
Cameron J Hague: University of British Columbia, St. Paul's Hospital Department of Radiology, Vancouver, British Columbia, Canada.
James K Min: Cleerly Inc., New York, New York.
Sean M O'Brien: Duke Clinical Research Institute, Durham, North Carolina.
Judith S Hochman: Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, New York.
David J Maron: Department of Medicine, Stanford University School of Medicine, Stanford, California.
Harmony R Reynolds: Cardiovascular Clinical Research Center, NYU Grossman School of Medicine, New York, New York.
BACKGROUND: This study examined stress echocardiography in relation to coronary artery anatomy and outcome in subjects randomized in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. METHODS: Of 5,179 patients randomized to initial invasive or conservative strategy, stress echocardiography was performed in 1,079. Coronary computed tomographic angiogram (CCTA) excluded left main disease and quantified coronary lesions. Degree of ischemia was defined by number of segments with stress-induced wall motion abnormalities (mild < 3, moderate = 3, and severe > 3). Transient ischemic dilation was defined as a 10% increase in stress left ventricular end-systolic volume. Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS: On CCTA, 607/715 (84%) with CCTA evaluable for ≥70% lesion had 1 such lesion. Features associated with coronary lesions ≥70% were number of ischemic/infarcted segments, 3 or more ischemic segments in the anterior territory, and inability to augment left ventricular ejection fraction 10 percentage points. Transient ischemic dilation, present in 28.5% of cases, was significantly associated with severity of ischemia. For every 0.10 increase in peak wall motion score index, there was a 12% increased risk of cardiovascular death or myocardial infarction (adjusted hazard ratio = 1.12; 95% CI, 1.04, 1.21; P = .003). CONCLUSION: In patients with chronic coronary disease and moderate or severe myocardial ischemia receiving contemporary therapies, stress echocardiography identified subjects with significant coronary artery disease and wall motion score index provided prognostic value.
