title: Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain.
abstract: Excluding obstructive coronary artery disease (CAD) as the etiology of acute chest pain in patients without diagnostic electrocardiographic changes or elevated serum cardiac biomarkers is challenging. Stress testing is a valuable risk-stratifying technique reserved for the subset of these patients with low-risk chest pain who have an intermediate clinical probability of obstructive CAD. Given the risks of radiation inherent to nuclear and computed tomography imaging, both adenosine stress cardiovascular magnetic resonance (AS-CMR) imaging and dobutamine stress echocardiography (DSE) are attractive alternative stress modalities. An essential characteristic of stress modalities is their negative prognostic value; as one must exclude clinically-relevant CAD such that patients can be discharged safely. Therefore, the aim of this study was to validate a favorable negative prognostic value for both AS-CMR and DSE in patients presenting with low-risk acute chest pain. This retrospective study included 255 patients with low-risk acute chest pain and no prior history of CAD presenting to the emergency department at our institution, with 89 patients evaluated by AS-CMR and 166 by DSE. Median follow-up was 292 days, and consisted of medical record review. The primary end-point was the composite of cardiac death, nonfatal acute myocardial infarction, obstructive CAD on invasive coronary angiography (ICA) or recurrent chest pain requiring hospital admission. Test characteristics such as sensitivity and specificity could not be evaluated as patients were not routinely evaluated with ICA. All patients completed the stress protocol without adverse events during testing. 82/89 patients (92.1%) and 164/166 patients (98.8%) had negative AS-CMR and DSE studies, respectively. Both AS-CMR and DSE had excellent negative prognostic values for the primary endpoint, 100 and 99%, respectively. Both AS-CMR and DSE are effective stress modalities for excluding clinically significant coronary artery disease in patients presenting acute low-risk chest pain. Patients without findings to suggest ischemia have an excellent intermediate-term prognosis.
authors.affiliation: Department of Medicine and Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA. GHartla@emory.edu
authors.forename: Gregory
authors.initials: G
authors.lastname: Hartlage
authors.forename: Matthew
authors.initials: M
authors.lastname: Janik
authors.forename: Athanasios
authors.initials: A
authors.lastname: Anadiotis
authors.forename: Emir
authors.initials: E
authors.lastname: Veledar
authors.forename: John
authors.initials: J
authors.lastname: Oshinski
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Kremastinos
authors.forename: Arthur
authors.initials: A
authors.lastname: Stillman
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
mesh_terms: D000241:Adenosine; D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000209:etiology* / Q000401:mortality; D016009:Chi-Square Distribution; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000401:mortality; D004280:Dobutamine; D025401:Echocardiography, Stress; D004636:Emergency Service, Hospital; D005080:Exercise Test; D005260:Female; D005845:Georgia; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology; D011237:Predictive Value of Tests; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors
chemical_list: D004280:Dobutamine; D000241:Adenosine