Stress Echocardiography in Patients With Moderate or Severe Myocardial Ischemia: Insights From the ISCHEMIA Trial

• Published in: Journal of the American Society of Echocardiography Vol. 38; no. 6; pp. 465 - 481
• Main Authors: Picard, Michael H., Saysana, Kyle, Cyr, Derek D., Zeng, Xin, Scherrer-Crosbie, Marielle, Shaw, Leslee J., Senior, Roxy, Poh, Kian Keong, Bangalore, Sripal, Leipsic, Jonathon A., Mancini, GB John, Budoff, Matthew J., Hague, Cameron J., Min, James K., O'Brien, Sean M., Hochman, Judith S., Maron, David J., Reynolds, Harmony R.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.06.2025
• Subjects: Aged; Cardiovascular; Coronary artery disease; Echocardiography, Stress - methods; Echocardiography, Stress - statistics & numerical data; Female; Humans; ISCHEMIA trial; Male; Middle Aged; Myocardial ischemia; Myocardial Ischemia - diagnostic imaging; Myocardial Ischemia - mortality; Prognosis; Reproducibility of Results; Severity of Illness Index; Stress echocardiography; eGFR; Q1; Stress echocardiography; EF; Q3; Prognosis; WMSI; CAD; LVEF; Myocardial ischemia; ISCHEMIA; HR; LV; ISCHEMIA trial; Coronary artery disease; TID; CVD; HDL; CCTA; LDL; CABG; MI; Myocardial infarction; Left ventricular; Cardiovascular death; Estimated glomerular filtration rate; Hazard ratio; Transient ischemic dilation; Left ventricular ejection fraction; First quartile; Coronary computed tomographic angiogram; Third quartile; Coronary artery bypass graft; Low-density lipoprotein; International Study of Comparative Health Effectiveness with Medical and Invasive Approaches; High-density lipoprotein; Wall motion score index; Ejection fraction
• ISSN: 0894-7317; 1097-6795; 1097-6795
• DOI: 10.1016/j.echo.2025.03.006

This study examined stress echocardiography in relation to coronary artery anatomy and outcome in subjects randomized in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial. Of 5,179 patients randomized to initial invasive or conservative strategy, stress echocardiography was performed in 1,079. Coronary computed tomographic angiogram (CCTA) excluded left main disease and quantified coronary lesions. Degree of ischemia was defined by number of segments with stress-induced wall motion abnormalities (mild < 3, moderate = 3, and severe > 3). Transient ischemic dilation was defined as a 10% increase in stress left ventricular end-systolic volume. Primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. On CCTA, 607/715 (84%) with CCTA evaluable for ≥70% lesion had 1 such lesion. Features associated with coronary lesions ≥70% were number of ischemic/infarcted segments, 3 or more ischemic segments in the anterior territory, and inability to augment left ventricular ejection fraction 10 percentage points. Transient ischemic dilation, present in 28.5% of cases, was significantly associated with severity of ischemia. For every 0.10 increase in peak wall motion score index, there was a 12% increased risk of cardiovascular death or myocardial infarction (adjusted hazard ratio = 1.12; 95% CI, 1.04, 1.21; P = .003). In patients with chronic coronary disease and moderate or severe myocardial ischemia receiving contemporary therapies, stress echocardiography identified subjects with significant coronary artery disease and wall motion score index provided prognostic value. Left panel: Representative images of contrast-enhanced mid-systolic frames of the apical 4-chamber view during exercise stress echocardiogram (rest [top left], immediate postexercise [top right], recovery [bottom left]). Middle top: Significant stress echocardiographic features associated with significant CAD on CCTA (≥70% stenosis) in the ISCHEMIA trial population. Middle bottom: Stress echocardiography features associated with various outcomes in the ISCHEMIA trial population (footnotes specify the outcomes). Right panel: Plot of the predicted probabilities for the total stress echocardiography population in the ISCHEMIA trial primary end point at 4-year follow-up as a function of stress WMSI. [Display omitted] •The ISCHEMIA trial studied chronic CAD and moderate or greater ischemia.•Stress echo was the entry test in 1,079 of the 5,179 ISCHEMIA trial participants.•Many stress echo findings were associated with disease on CCTA.•Resting wall motion abnormality was associated with 21% increased risk of death.