Stress Echo With Carotid Ultrasound for CAD Prognosis

Study Questions:

Among patients with chest pain but no documented history of coronary artery disease (CAD) referred for stress echocardiography (SE), does atherosclerosis assessment on carotid ultrasound (US) provide incremental prognostic information?


Consecutive patients with suspected angina but no history of CAD prospectively underwent simultaneous SE and carotid US, to respectively assess myocardial ischemia and carotid plaque burden (CPB). Patients were followed for major adverse events (MAEs) consisting of all-cause mortality, nonfatal myocardial infarction, and unplanned coronary revascularization.


Of 591 patients, 580 (46% men, mean age 59 ± 11 years) patients were available for follow-up. SE demonstrated myocardial ischemia in 12%, but carotid plaque was present on 59%. During a mean follow-up of 1,117 ± 361 days, there were 40 first MAEs. In a multivariable regression model, pretest probability of CAD (p = 0.001), abnormal SE (p < 0.0001), and CPB (p < 0.0001) predicted MAEs. MAE rates per year increased from 0.9% to 1.97% to 4.3% to 9.7% among patients with no carotid plaque and normal SE versus patients who had plaque and normal SE versus those with no plaque and abnormal SE versus patients with both plaque and abnormal SE, respectively (p < 0.0001). In hierarchical analysis, plaque burden provided incremental prognostic value over pretest probability of CAD and SE; likewise, SE was incremental to pretest probability of CAD and CPB (p < 0.0001 for both).


Among patients with suspected stable angina without known CAD, simultaneous SE (for ischemia) and carotid US (for atherosclerosis) provided incremental prognostic value.


Although the performance of cardiac and carotid US historically have been separated by discipline (cardiology vs. radiology or vascular medicine), in some circumstances, it makes sense to interrogate both at the same time. This interesting study suggests that CPB assessed on carotid US has incremental prognostic value over the presence or absence of ischemia on SE among patients referred for SE because of symptoms of chest pain, but no prior history of CAD.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Stable Ischemic Heart Disease, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and SIHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Chronic Angina

Keywords: Angina, Stable, Atherosclerosis, Coronary Artery Disease, Carotid Artery Diseases, Diagnostic Imaging, Echocardiography, Stress, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Plaque, Atherosclerotic, Ultrasonography, Vascular Diseases

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