title: The clinical impact of contemporary stress echocardiography in morbid obesity for the assessment of coronary artery disease.
abstract: OBJECTIVE
  Non-invasive cardiac imaging may suffer from poor image quality in morbidly obese individuals. This study aimed to determine the clinical value of contemporary stress echocardiography (SE) in morbidly obese patients referred for assessment of suspected coronary artery disease (CAD).
  
  
  METHODS
  This prospective, multicentre observational study was conducted in two district hospitals and one tertiary centre in London, UK. Individuals with body mass index ≥35 kg/m(2) referred for SE were evaluated. The percentage of patients with obstructive CAD on coronary angiography, following abnormal SE, was assessed. Patient outcomes were determined with follow-up for the composite end-point of all-cause mortality, myocardial infarction and late revascularisation.
  
  
  RESULTS
  Over a 13-month period, 209 morbidly obese patients underwent SE, and contrast agent was used in 96% of patients. A diagnostic result was obtained in 200/209 (96%) patients. Of 32 (15%) patients with inducible ischaemia, 25 underwent angiography, 22 (88%) had corresponding significant CAD and, of these, 16 (77%) underwent revascularisation. Conversely, only 2/157 patients (1.3%) with normal SE underwent angiography, and none underwent revascularisation. Over a mean follow-up period of 17.8±5.4 months, there were nine events. The annualised cardiac event rate after a normal SE was 0.95%. Events were more frequent in patients with inducible ischaemia versus those without ischaemia (5/32 (15.6%) vs 4/153 (2.6%); p=0.002). Ejection fraction <50% (HR 9.5; 95% CI 2.4 to 38.0; p=0.002) and inducible ischaemia (HR 9.4; 95% CI 2.5 to 35.8; p=0.001) were predictors of outcome on univariable Cox regression analysis.
  
  
  CONCLUSIONS
  Contemporary SE has excellent feasibility and positive predictive value and resulted in appropriate risk stratification of symptomatic patients with significant obesity. A normal SE portends an excellent outcome over the short-intermediate term in this high-risk patient population.
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, UK Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK Cardiovascular Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, UK.
authors.forename: Benoy N
authors.initials: BN
authors.lastname: Shah
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Zacharias
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Jatinder S
authors.initials: JS
authors.lastname: Pabla
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Karogiannis
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, UK.
authors.forename: Francesca
authors.initials: F
authors.lastname: Calicchio
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Gothandaraman
authors.initials: G
authors.lastname: Balaji
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Abdalla
authors.initials: A
authors.lastname: Alhajiri
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Ihab S
authors.initials: IS
authors.lastname: Ramzy
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Elghamaz
authors.affiliation: Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK.
authors.forename: Sothinathan
authors.initials: S
authors.lastname: Gurunathan
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, UK Cardiovascular Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, UK.
authors.forename: Rajdeep S
authors.initials: RS
authors.lastname: Khattar
authors.affiliation: Department of Echocardiography, Royal Brompton Hospital, London, UK Department of Cardiovascular Medicine, Northwick Park Hospital, Harrow, UK Cardiovascular Biomedical Research Unit, National Heart and Lung Institute, Imperial College, London, UK.
authors.forename: Roxy
authors.initials: R
authors.lastname: Senior
mesh_terms: D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D015992:Body Mass Index; D016009:Chi-Square Distribution; D003287:Contrast Media; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D018572:Disease-Free Survival; D025401:Echocardiography, Stress; D005240:Feasibility Studies; D005260:Female; D006767:Hospitals, District; D006801:Humans; D053208:Kaplan-Meier Estimate; D008131:London; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000628:therapy; D009204:Myocardial Revascularization; D009767:Obesity, Morbid / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D013997:Time Factors
chemical_list: D003287:Contrast Media