title: The incremental prognostic value of the incorporation of myocardial perfusion assessment into clinical testing with stress echocardiography study.
abstract: BACKGROUND
  The authors recently demonstrated that simultaneous assessment of myocardial perfusion (MP) and wall motion (WM) by myocardial contrast echocardiography (MCE) is feasible and accurate when incorporated into a clinical stress echocardiography (SE) service. However, it is unknown whether the incremental prognostic value of MP beyond WM, previously shown in research studies, is reproducible when MCE is performed in the clinical arena.
  
  
  METHODS
  In this prospective study, MCE was performed by multiple operators during routine clinical SE, whose results were classified as normal WM and MP, abnormal WM and MP, or normal WM but abnormal MP. Patients were followed for the prospectively determined combined primary outcome of all-cause mortality, nonfatal myocardial infarction, and late revascularization. Cox regression analyses were performed to identify predictors of outcome.
  
  
  RESULTS
  Of 220 patients undergoing simultaneous MCE during SE, 197 patients (90%) with interpretable WM and MP images were available for follow-up at a mean time period of 17 ± 7 months. There were 35 events (six deaths, six myocardial infarctions, and 23 revascularizations). Among prognostic clinical variables, resting left ventricular function, and WM and MP data, abnormal MP at peak stress was the only independent predictor of primary outcome (hazard ratio, 4.41; 95% confidence interval, 1.37-14.20; P = .02). Sequential Cox regression models showed that abnormal MP also carried incremental prognostic value over clinical variables, resting left ventricular function and abnormal WM.
  
  
  CONCLUSIONS
  In keeping with previous research studies, this prospective study demonstrates the incremental prognostic benefit of MP assessment beyond WM when MCE is incorporated into a clinical SE service.
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
authors.forename: Benoy N
authors.initials: BN
authors.lastname: Shah
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Ana M
authors.initials: AM
authors.lastname: Gonzalez-Gonzalez
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Maria
authors.initials: M
authors.lastname: Drakopoulou
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
authors.forename: Navtej S
authors.initials: NS
authors.lastname: Chahal
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Bhattacharyya
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
authors.forename: Wei
authors.initials: W
authors.lastname: Li
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom.
authors.forename: Rajdeep S
authors.initials: RS
authors.lastname: Khattar
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom; Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom. Electronic address: roxysenior@cardiac-research.org.
authors.forename: Roxy
authors.initials: R
authors.lastname: Senior
mesh_terms: D000368:Aged; D015984:Causality; D015897:Comorbidity; D003287:Contrast Media; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000401:mortality*; D025401:Echocardiography, Stress / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D015994:Incidence; D008297:Male; D064847:Multimodal Imaging / Q000379:methods; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000401:mortality*; D055414:Myocardial Perfusion Imaging / Q000706:statistics & numerical data*; D015588:Observer Variation; D011379:Prognosis; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D015996:Survival Rate; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D003287:Contrast Media
keywords: Coronary artery disease; Ischemia; Myocardial contrast echocardiography; Stress echocardiography