title: Prediction of mortality and major cardiac events by exercise echocardiography in patients with normal exercise electrocardiographic testing.
abstract: OBJECTIVE
  We sought to assess the value of exercise echocardiography (EE) for predicting outcome in patients with known or suspected coronary artery disease and normal exercise electrocardiogram (ECG) testing.
  
  
  BACKGROUND
  The prognostic value of EE in patients with normal exercise ECG testing has not been characterized.
  
  
  METHODS
  We studied 4,004 consecutive patients (2,358 men, mean age [+/- SD] 59.6 +/- 12.5 years) with interpretable ECG who underwent treadmill EE and did not develop chest pain or ischemic ECG abnormalities during the tests. Wall motion score index (WMSI) was evaluated at rest and with exercise, and the difference (DeltaWMSI) was calculated. Ischemia was defined as the development of new or worsening wall motion abnormalities with exercise. End points were all-cause mortality and major cardiac events (MACE).
  
  
  RESULTS
  Overall, 669 patients (16.7%) developed ischemia with exercise. During a mean follow-up of 4.5 +/- 3.4 years, 313 patients died, and 183 patients had a MACE before any revascularization procedure. The 5-year mortality and MACE rates were 6.4% and 4.2% in patients without ischemia versus 12.1% and 10.1% in those with ischemia, respectively (p < 0.001). In the multivariate analysis, DeltaWMSI remained an independent predictor of mortality (hazard ratio [HR]: 2.73, 95% confidence interval [CI]: 1.40 to 5.32, p = 0.003) and MACE (HR: 3.59, 95% CI: 1.42 to 9.07, p = 0.007). The addition of the EE results to the clinical, resting echocardiographic and exercise hemodynamic data significantly increased the global chi-square of the models for the prediction of mortality (p = 0.005) and MACE (p = 0.009).
  
  
  CONCLUSIONS
  The use of EE provides significant prognostic information for predicting mortality and MACE in patients with interpretable ECG and normal exercise ECG testing.
authors.affiliation: Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain. aboumos@canalejo.org
authors.forename: Alberto
authors.initials: A
authors.lastname: Bouzas-Mosquera
authors.forename: Jesús
authors.initials: J
authors.lastname: Peteiro
authors.forename: Nemesio
authors.initials: N
authors.lastname: Alvarez-García
authors.forename: Francisco J
authors.initials: FJ
authors.lastname: Broullón
authors.forename: Victor X
authors.initials: VX
authors.lastname: Mosquera
authors.forename: Lourdes
authors.initials: L
authors.lastname: García-Bueno
authors.forename: Luis
authors.initials: L
authors.lastname: Ferro
authors.forename: Alfonso
authors.initials: A
authors.lastname: Castro-Beiras
mesh_terms: D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000517:prevention & control*; D025401:Echocardiography, Stress / Q000379:methods*; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013030:Spain / Q000453:epidemiology; D015996:Survival Rate / Q000639:trends