A 67-year-old woman presented to her cardiologist with complaints of episodes of chest discomfort. The patient was a current smoker (1 pack per day for 20 years), with a medical history of hypertension and dyslipidemia. Her medication regimen included rosuvastatin 5 mg and enalapril 10 mg daily. She had been suffering from increasing chest discomfort for the past 1-2 years. At first, she noticed the discomfort only when she experienced extreme exertion, such as running for the bus, and these symptoms always promptly resolved when she stopped or slowed down. About 6 months ago, she noted that the chest pain episodes had become more frequent and provoked by physical efforts such as walking up a flight of stairs or two blocks down the street; again, they always resolved with rest. On examination, blood pressure and heart rate were 132/68 mmHg and 65 bpm, respectively. Electrocardiogram at rest showed sinus rhythm without any repolarization abnormalities. Resting transthoracic echocardiography showed a wall motion abnormality in the inferior wall with a left ventricular (LV) ejection fraction of 52%. Stress echocardiography was performed and disclosed wall thickening abnormalities affecting the interventricular septum and entire inferior wall. The patient was diagnosed with stable angina, discharged on guidelines-directed medical therapy, and was referred for coronary angiography. The latter showed severe stenosis of the right coronary artery.
Which of the following characteristics is the most accurate to predict adverse outcomes in this patient with stable angina?
The correct answer is: D. The presence of inducible wall motion abnormalities on stress echocardiography
In patients with new-onset suspected angina, event risk stratification is of utmost importance. Assessment of long-term prognosis of patients with stable angina generally involves baseline clinical evaluation,1 assessment of LV function by resting echocardiography, and, in the majority of cases, noninvasive assessment of myocardial ischemia (by myocardial single-photon emission computed tomography imaging, stress echocardiography, or stress magnetic resonance imaging) or coronary anatomy (with coronary computed tomography angiography). Guidelines have emphasized the key role of noninvasive stress testing for risk assessment of these patients.2,3 Stress echocardiography is effective in assessing the likelihood of coronary artery disease but also stratifying patients with angina according to their risk of subsequent cardiovascular events. It has been shown that patients with inducible wall motion abnormalities in ≥3 of the 17 segments of the standard LV model on stress echocardiography should be regarded as being at high risk of cardiovascular events, and coronary angiography should be considered in this population.4,5
Sekhri N, Perel P, Clayton T, Feder GS, Hemingway H, Timmis A. A 10-year prognostic model for patients with suspected angina attending a chest pain clinic. Heart 2016;102:869-75.
Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 2013;34:2949-3003.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-e164.
Chelliah R, Anantharam B, Burden L, Alhajiri A, Senior R. Independent and incremental value of stress echocardiography over clinical and stress electrocardiographic parameters for the prediction of hard cardiac events in new-onset suspected angina with no history of coronary artery disease. Eur J Echocardiogr 2010;11:875-82.
Lin FY, Dunning AM, Narula J, et al. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study. J Am Coll Cardiol 2013;62:308-16.