PROGNOSTIC VALUE OF STRESS ECHOCARDIOGRAPHY IN THE EVALUATION OF ATYPICAL CHEST PAIN PATIENTS WITHOUT KNOWN CORONARY-ARTERY DISEASE

Patients with atypical chest pain frequently lack significant coronary artery disease (CAD) and are, therefore, at low risk for future adver se cardiovascular events. We hypothesized that in this group of patien ts, stress echocardiography could identify those at risk for cardiac e vents, We retrospectively reviewed (mean follow-up 23.0 +/- 7.2 months ) the prognostic value of stress echocardiography for major (cardiac d eath, myocardial infarction, congestive heart failure, and unstable an gina) and total (major events plus coronary revascularization) cardiac events in 661 patients with atypical chest pain, normal global left v entricular (LV) systolic function, and no history of CAD. A positive s tress echocardiogram was defined as the development of new or worsenin g wall motion abnormalities with exercise stress (80%) or dobutamine ( 20%), A total of 41 cardiac and 16 major events were noted, The event- free survival for total cardiac events was 97% for a normal stress ech ocardiogram and 93% for a normal stress electrocardiogram (ECG) at 30 months. A positive stress ECG predicted an event-free rate of 86% comp ared with 74% for stress-induced wall motion abnormalities and 42% if stress-induced LV dysfunction accompanied the wall motion abnormalitie s. A strategy recommending invasive studies based on positive stress e chocardiogram results increased the per-patient cost, but led to great er savings per cardiac event predicted and provided incremental progno stic value for future cardiac events beyond clinical and stress electr ocardiographic data. Thus, stress echocardiography in low-risk patient s for CAD appears to be more cost effective than a stress ECG. (C) 199 8 by Excerpta Medica, Inc.