title: Prognostic implication of appropriateness criteria for pharmacologic stress echocardiography performed in an outpatient clinic [corrected].
abstract: BACKGROUND
  Although appropriateness criteria for stress echocardiography have been developed to deliver high-quality care, the prognostic impact of these criteria remains undefined. Therefore, we sought to assess the prognostic implication of the American College of Cardiology/American Society of Echocardiography appropriateness criteria for pharmacological stress echo in a cohort of ambulatory patients.
  
  
  RESULTS
  The study population consisted of 1552 ambulatory patients who underwent pharmacological (752 dobutamine, 800 dipyridamole) stress echo for the evaluation of known (n=549) or suspected (n=1003) coronary artery disease at a single cardiology center. Patients were followed up for a median of 36 months. Indications were determined for consecutive studies by 2 reviewers and categorized as follows: 984 (63%) patients had appropriate, 145 (9%) uncertain, and 423 (27%) inappropriate indication for stress echo. Ischemia was present in 15% of patients with appropriate, 8% of those with uncertain, and 5% of those with inappropriate indication (P<0.0001). During follow-up, 146 events (89 deaths, 57 nonfatal infarctions) occurred. Annual event rate associated with appropriate, uncertain, and inappropriate study was 3.1%, 3.8%, and 1.3%, respectively. The abnormal test result in patients with appropriate, uncertain, and inappropriate study was associated with 5.0%, 5.6%, and 1.8% annual event rate, respectively, exerting an independent value only in the appropriate and uncertain subset.
  
  
  CONCLUSIONS
  Inappropriate indication for pharmacological stress echo is common, being documented in about 1 of 4 patients evaluated in an ambulatory setting, and is associated with lower rate of positive results and better survival as compared with appropriate and uncertain indication.
authors.affiliation: Division of Cardiology, Campo di Marte Hospital, Lucca, Italy.
authors.forename: Lauro
authors.initials: L
authors.lastname: Cortigiani
authors.forename: Riccardo
authors.initials: R
authors.lastname: Bigi
authors.forename: Francesco
authors.initials: F
authors.lastname: Bovenzi
authors.forename: Sabrina
authors.initials: S
authors.lastname: Molinaro
authors.forename: Eugenio
authors.initials: E
authors.lastname: Picano
authors.forename: Rosa
authors.initials: R
authors.lastname: Sicari
mesh_terms: D000368:Aged; D000554:Ambulatory Care Facilities; D000704:Analysis of Variance; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000175:diagnosis*; D004176:Dipyridamole; D004280:Dobutamine; D025401:Echocardiography, Stress / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D015588:Observer Variation; D011379:Prognosis; D018570:Risk Assessment
chemical_list: D004280:Dobutamine; D004176:Dipyridamole