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Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease

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Abstract

The hypothesis that modified Haller index (MHI) integration with the existing appropriate use criteria (AUC) categories may predict exercise stress echocardiography (ESE) results and outcome of patients with suspected coronary artery disease (CAD) has never been previously investigated. We retrospectively analyzed 1230 consecutive patients (64.8 ± 13.1 years, 58.9% men) who underwent ESE for suspected CAD between February 2011 and September 2019 at our institution. MHI (chest transverse diameter over the distance between sternum and spine) was assessed in all patients. A true positive (TP) ESE was a positive ESE with obstructive CAD according to subsequent coronary angiography. During follow-up time, we evaluated the occurrence of any of the following: (1) cardiovascular (CV) hospitalizations; (2) Cardiac death or sudden death. Overall, 734 (59.7%), 357 (29.0%) and 139 (11.3%) indications for ESE were classified as appropriate (Group 1), rarely appropriate (Group 2) and which may be appropriate (Group 3), respectively. A funnel chest (defined by an MHI > 2.5) was detected in 30.3%, 82.1% and 49.6% of Groups 1, 2 and 3 subjects, respectively (p < 0.0001). On multivariate logistic regression analysis, male sex (OR 1.41, 95%CI 1.02–2.03, p = 0.01) and type-2 diabetes (OR 3.63, 95%CI 2.49–5.55, p = 0.001) were directly correlated to a TP ESE, while “rarely appropriate” indication for ESE with MHI > 2.5 (OR 0.16, 95%CI 0.11–0.22, p < 0.0001) showed a significant inverse correlation with the outcome. During a mean follow-up of 2.5 ± 1.9 years, 299 CV events occurred: 76.4%, 3.5% and 20.1% in Groups 1, 2 and 3, respectively. On multivariate Cox regression analysis, smoking (HR 1.33, 95%CI 1.19–1.48), type 2 diabetes (HR 2.28, 95%CI 1.74–2.97), dyslipidemia (HR 3.51, 95%CI 2.33–5.15), beta-blockers (HR 0.55, 95%CI 0.41–0.75), statins (HR 0.60, 95%CI 0.45–0.80), peak exercise average E/e′ ratio (HR 1.08, 95%CI 1.06–1.09), positive ESE (HR 3.12, 95%CI 2.43–4.01) and finally “rarely appropriate” indication for ESE with MHI > 2.5 (HR 0.15, 95%CI 0.08–0.23) were independently associated with CV events. The implementation of AUC categories with MHI assessment may select a group of patients with extremely low probability of both TP ESE and adverse CV events over a medium-term follow-up. A simple noninvasive chest shape assessment could reduce unnecessary exams.

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Abbreviations

2D:

Two-dimensional

ACS:

Acute coronary syndromes

ANOVA:

Analysis of variance

A-P:

Anteroposterior

AS:

Aortic stenosis

AUC:

Appropriate use criteria

BP:

Blood pressure

BSA:

Body surface area

CAD:

Coronary artery disease

CHF:

Congestive heart failure

CI:

Confidence interval

CV:

Cardiovascular

ECG:

Electrocardiogram

ESE:

Exercise stress echocardiography

FP:

False positive

HR:

Heart rate

ICC:

Intraclass correlation coefficient

L-L:

Latero-lateral

LV:

Left ventricular

LVEF:

Left ventricular ejection fraction

LVWM:

Left ventricular wall motion

MHI:

Modified Haller index

MR:

Mitral regurgitation

OR:

Odds ratio

PTP:

Pre-test probability

ROC:

Receiver operating characteristics

SaO2 :

Arterial oxygen saturation

SE:

Stress echocardiography

SPAP:

Systolic pulmonary artery pressure

TAPSE:

Tricuspid annular plane systolic excursion

TP:

True positive

TRV:

Tricuspid regurgitation velocity

TTE:

Transthoracic echocardiography

VPBs:

Ventricular premature beats

WMSI:

Wall motion score index

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Acknowledgements

This work has been supported by Italian Ministry of Health Ricerca Corrente—IRCCS MultiMedica.

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Authors and Affiliations

  1. Department of Cardiology, Ospedale San Giuseppe MultiMedica, Via San Vittore 12, 20123, Milan, Italy

    Andrea Sonaglioni, Elisabetta Rigamonti & Michele Lombardo

  2. Department of Cardiology, Policlinico San Giorgio, Pordenone, Italy

    Gian Luigi Nicolosi

  3. Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy

    Andrea Sonaglioni

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  1. Andrea Sonaglioni
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Contributions

AS: Conceptualization; Data curation; Investigation; Methodology; Software; Visualization; Writing—original draft. ER: Conceptualization; Data curation; Methodology; Writing—review & editing. GLN: Conceptualization; Supervision; Validation; Writing—review & editing. ML: Conceptualization; Supervision; Validation; Writing—review & editing.

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Correspondence to Andrea Sonaglioni.

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We wish to confirm that there are no conflicts of interest associated with this publication. Andrea Sonaglioni declares that he has no conflict of interest. Elisabetta Rigamonti declares that she has no conflict of interest. Gian Luigi Nicolosi declares that he has no conflict of interest. Michele Lombardo declares that he has no conflicts of interest.

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All procedures performed in the present study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

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Sonaglioni, A., Rigamonti, E., Nicolosi, G.L. et al. Appropriate use criteria implementation with modified Haller index for predicting stress echocardiographic results and outcome in a population of patients with suspected coronary artery disease. Int J Cardiovasc Imaging 37, 2917–2930 (2021). https://doi.org/10.1007/s10554-021-02274-4

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