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Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain

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Abstract

Excluding obstructive coronary artery disease (CAD) as the etiology of acute chest pain in patients without diagnostic electrocardiographic changes or elevated serum cardiac biomarkers is challenging. Stress testing is a valuable risk-stratifying technique reserved for the subset of these patients with low-risk chest pain who have an intermediate clinical probability of obstructive CAD. Given the risks of radiation inherent to nuclear and computed tomography imaging, both adenosine stress cardiovascular magnetic resonance (AS-CMR) imaging and dobutamine stress echocardiography (DSE) are attractive alternative stress modalities. An essential characteristic of stress modalities is their negative prognostic value; as one must exclude clinically-relevant CAD such that patients can be discharged safely. Therefore, the aim of this study was to validate a favorable negative prognostic value for both AS-CMR and DSE in patients presenting with low-risk acute chest pain. This retrospective study included 255 patients with low-risk acute chest pain and no prior history of CAD presenting to the emergency department at our institution, with 89 patients evaluated by AS-CMR and 166 by DSE. Median follow-up was 292 days, and consisted of medical record review. The primary end-point was the composite of cardiac death, nonfatal acute myocardial infarction, obstructive CAD on invasive coronary angiography (ICA) or recurrent chest pain requiring hospital admission. Test characteristics such as sensitivity and specificity could not be evaluated as patients were not routinely evaluated with ICA. All patients completed the stress protocol without adverse events during testing. 82/89 patients (92.1%) and 164/166 patients (98.8%) had negative AS-CMR and DSE studies, respectively. Both AS-CMR and DSE had excellent negative prognostic values for the primary endpoint, 100 and 99%, respectively. Both AS-CMR and DSE are effective stress modalities for excluding clinically significant coronary artery disease in patients presenting acute low-risk chest pain. Patients without findings to suggest ischemia have an excellent intermediate-term prognosis.

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Abbreviations

AS-CMR:

Adenosine-stress cardiovascular magnetic resonance imaging

DSE:

Dobutamine stress echocardiography

CAD:

Coronary artery disease

ICA:

Invasive coronary angiography

EKG:

Electrocardiogram

CDU:

Clinical decision unit

LGE:

Late gadolinium enhancement

SPECT:

Single photon emission tomography

PET:

Positron emission tomography

SSFP:

Steady-state free procession

THR:

Target heart rate

References

  1. Pitts SR, Niska RW, Xu J, Burt CW (2008) National hospital ambulatory medical care survey: 2006 emergency department summary. Natl Health Stat Report 7:1–38

    PubMed  Google Scholar 

  2. Lau J, Ioannidis JP, Balk EM et al (2001) Diagnosing acute cardiac ischemia in the emergency department: a systematic review of the accuracy and clinical effect of current technologies. Ann Emerg Med 37(5):453–460

    Article  PubMed  CAS  Google Scholar 

  3. Lee TH, Cook EF, Weisberg M et al (1985) Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med 145(1):65–69

    Article  PubMed  CAS  Google Scholar 

  4. Pope JH, Aufderheide TP, Ruthazer R et al (2000) Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 342:1163–1170

    Article  PubMed  CAS  Google Scholar 

  5. Hendel RC, Patel MR, Kramer CM, et al. (2006) American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group; American College of Radiology; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; American Society of Nuclear Cardiology; North American Society for Cardiac Imaging; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol 48(7): 1475–97

  6. Douglas PS, Khandheria B, Stainback RF, et al. (2008) American College of Cardiology Foundation Appropriateness Criteria Task Force; American Society of Echocardiography; American College of Emergency Physicians; American Heart Association; American Society of Nuclear Cardiology; Society for Cardiovascular Angiography and Interventions; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation 117(11): 1478–97

  7. Hendel RC, Berman DS, Di Carli MF, et al. (2009) American College of Cardiology Foundation Appropriate Use Criteria Task Force; American Society of Nuclear Cardiology; American College of Radiology; American Heart Association; American Society of Echocardiography; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance; Society of Nuclear Medicine. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation 119(22): e561–87

  8. Gibler WB, Runyon JP, Levy RC et al (1995) A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med 25(1):1–8

    Article  PubMed  CAS  Google Scholar 

  9. Amsterdam EA, Kirk JD, Bluemke DA, et al. (2010) on behalf of the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain. A Scientific Statement From the American Heart Association. Circulation [Epub ahead of print] PubMed PMID: 20660809

  10. Bholasingh R, Cornel JH, Kamp O et al (2003) Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative troponin T. J Am Coll Cardiol 41:596–602

    Article  PubMed  Google Scholar 

  11. Geleijnse ML, Elhendy A, Kasprzak JD et al (2000) Safety and prognostic value of early dobutamine-atropine stress echocardiography in patients with spontaneous chest pain and a non-diagnostic electrocardiogram. Eur Heart J 21:397–406

    Article  PubMed  CAS  Google Scholar 

  12. Colon PJ, Cheirif J (1999) Long-term value of stress echocardiography in the triage of patients with atypical chest pain presenting to the emergency department. Echocardiography 16:171–177

    Article  PubMed  Google Scholar 

  13. Orlandini A, Tuero E, Paolasso E, Vilamajo OG, Diaz R (2000) Usefulness of pharmacologic stress echocardiography in a chest pain center. Am J Cardiol 86:1247–1250

    Article  PubMed  CAS  Google Scholar 

  14. Lerakis S, Aznaouridis K, Synetos A, et al. (2009) Predictive value of normal dobutamine stress echocardiogram in patients with low-risk acute chest pain. Int J Cardiol (Epub ahead of print)

  15. Ingkanisorn WP, Kwong RY, Bohme NS et al (2006) Prognosis of negative adenosine stress magnetic resonance in patients presenting to an emergency department with chest pain. J Am Coll Cardiol 47(7):1427–1432

    Article  PubMed  Google Scholar 

  16. Lerakis S, McLean DS, Anadiotis AV, Janik M, Oshinski JN, Alexopoulos N, Zaragoza-Macias E, Veledar E, Stillman AE (2009) Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain. J Cardiovasc Magn Reson 11:37

    Article  PubMed  Google Scholar 

  17. Valiyeva E, Russell LB, Miller JE, Safford MM (2006) Lifestyle-related risk factors and risk of future nursing home admission. Arch Intern Med 166(9):985–990

    Article  PubMed  Google Scholar 

  18. Thygesen K, Alpert JS, White HD (2007) Universal definition of myocardial infarction: ESC/ACCF/AHA/WHF expert consensus document. J Am Coll Cardiol 50:2173–2195

    Article  PubMed  Google Scholar 

  19. Klem I, Heitner JF, Shah DJ et al (2006) Improved detection of coronary artery disease by stress perfusion cardiovascular magnetic resonance with the use of delayed enhancement infarction imaging. J Am Coll Cardiol 47:1630–1638

    Article  PubMed  Google Scholar 

  20. Doesch C, Seeger A, Hoevelborn T et al (2008) Adenosine stress cardiac magnetic resonance imaging for the assessment of ischemic heart disease. Clin Res Cardiol 97(12):905–912

    Article  PubMed  CAS  Google Scholar 

  21. Hamon M, Fau G, Née G et al (2010) Meta-analysis of the diagnostic performance of stress perfusion cardiovascular magnetic resonance for detection of coronary artery disease. J Cardiovasc Magn Reson 12(1):29

    Article  PubMed  Google Scholar 

  22. Picano E, Molinaro S, Pasanisi E (2008) The diagnostic accuracy of pharmacological stress echocardiography for the assessment of coronary artery disease: a meta-analysis. Cardiovasc Ultrasound 6:30

    Article  PubMed  Google Scholar 

  23. Abdelmoneim SS, Dhoble A, Bernier M et al (2009) Quantitative myocardial contrast echocardiography during pharmacological stress for diagnosis of coronary artery disease: a systematic review and meta-analysis of diagnostic accuracy studies. Eur J Echocardiogr 10(7):813–825

    Article  PubMed  Google Scholar 

  24. Jahnke C, Nagel E, Gebker R et al (2007) Prognostic value of cardiac magnetic resonance stress tests: adenosine stress perfusion and dobutamine stress wall motion imaging. Circulation 115(13):1769–1776

    Article  PubMed  Google Scholar 

  25. Pilz G, Jesce A, Klos M, Ali E, Hoefling B, Scheck R, Bernhardt P (2008) Prognostic value of normal adenosine–stress cardiac magnetic resonance imaging. Am J Cardiol 101:1408–1412

    Article  PubMed  CAS  Google Scholar 

  26. Fazel R, Krumholz HM, Wang Y et al (2009) Exposure to low-dose ionizing radiation from medical imaging procedures. N Engl J Med 361(9):849–857

    Article  PubMed  CAS  Google Scholar 

  27. Gerber TC, Carr JJ, Arai AE et al (2009) Ionizing radiation in cardiac imaging: a science advisory from the American heart association committee on cardiac imaging of the council on clinical cardiology and committee on cardiovascular Imaging and intervention of the council on cardiovascular radiology and intervention. Circulation 119(7):1056–1065

    Article  PubMed  Google Scholar 

  28. Beller GA (1991) Diagnostic accuracy of thallium-201 myocardial perfusion imaging. Circulation 84(3 Suppl):I1–I6

    PubMed  CAS  Google Scholar 

  29. Hansen CL, Crabbe D, Rubin S (1996) Lower diagnostic accuracy of thallium-201 SPECT myocardial perfusion imaging in women: an effect of smaller chamber size. J Am Coll Cardiol 28(5):1214–1219

    Article  PubMed  CAS  Google Scholar 

  30. Pamboucas CA, Rokas SG (2008) Clinical safety of cardiovascular magnetic resonance: cardiovascular devices and contract agents. Hellenic J Cardiol 49:352–356

    PubMed  Google Scholar 

  31. Mahajan N, Polavaram L, Vankayala H et al (2010) Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis. Heart 96:956–966

    Article  PubMed  CAS  Google Scholar 

  32. Plana JC, Mikati IA, Dokainish H et al (2008) A randomized cross-over study for the evaluation of the effect of image optimization with contrast on the diagnostic accuracy of dobutamine echocardiography in coronary artery disease: the OPTIMIZE trial. JACC Cardiovascular Imaging 1(2):145–152

    Article  PubMed  Google Scholar 

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Conflict of interests

The authors declare that they have no competing interests.

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Authors and Affiliations

  1. Department of Medicine and Division of Cardiology, Emory University School of Medicine, 1365 Clifton Rd, NE, Suite AT-503, Atlanta, GA, 30322, USA

    Gregory Hartlage, Matthew Janik, Athanasios Anadiotis, Emir Veledar & Stamatios Lerakis

  2. Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA

    John Oshinski, Arthur Stillman & Stamatios Lerakis

  3. Department of Cardiology, Attikon General University Hospital, Athens, Greece

    Dimitrios Kremastinos & Stamatios Lerakis

Authors
  1. Gregory Hartlage
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  2. Matthew Janik
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  3. Athanasios Anadiotis
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  4. Emir Veledar
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  5. John Oshinski
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  6. Dimitrios Kremastinos
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  7. Arthur Stillman
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  8. Stamatios Lerakis
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Correspondence to Stamatios Lerakis.

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Hartlage, G., Janik, M., Anadiotis, A. et al. Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain. Int J Cardiovasc Imaging 28, 803–812 (2012). https://doi.org/10.1007/s10554-011-9885-3

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  • DOI: https://doi.org/10.1007/s10554-011-9885-3

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