Role of simultaneous carotid ultrasound in patients undergoing stress echocardiography for assessment of chest pain with no previous history of coronary artery disease
File(s)
Author(s)
Ahmadvazir, Shahram
Type
Thesis
Abstract
Background: Stress echocardiography (SE) is utilised to assess new onset chest pain. While a negative study infers absence of flow-limiting coronary artery disease (FL-CAD), it does not verify non-flow limiting CAD (where plaque rupture is common, resulting in myocardial infarction (MI) and death). This can be indirectly assessed by carotid ultrasound, detecting carotid plaque (CP). In large epidemiological studies in asymptomatic population, CP was associated with CAD and MI beyond traditional risk factors, but no outcome data on combining SE (functional) and CP (anatomical) in symptomatic patients.
Methods: 591 consecutive patients, referred for SE, underwent simultaneous carotid ultrasound. Composite end-point of major adverse event (MAE) (all-cause mortality, MI and later than 3 months, unplanned, coronary angioplasty) was assessed.
Results: While 67 (11%) patients had abnormal SE, CD was detected in 415 (70%). While both abnormal SE and CP were independent predictors of FL-CAD, pre-test probability had no significant association on multivariate analysis. The positive predictive value of SE for the detection of FL-CAD improved from 56% to 70% when CP was present. Pre-test probability of CAD, abnormal SE, and CPB predicted MAE, both in medium- (3 years) and long-term (7.2 years) follow up. MAE rates per year increased in a step-by-step fashion: CP-ve and SE-ve, CP+ve and SE-ve, CP-ve and SE+ve versus CP+ve and SE+ve, both in medium- and long-term (p<0.0001).Absence of CPBurden in females with abnormal SE ruled out flow-limiting CAD on coronary angiography in 93% versus 57% in males. CPB was the only independent predictor of MAE in females, whereas in males both SE and CPB remained significant.
Discussion: A combined assessment of functional and anatomical assessment of patients with new onset chest pain infers incremental prognostic information, beyond pre-test probability and SE alone. These findings have implications for routine use of carotid ultrasound during SE.
Methods: 591 consecutive patients, referred for SE, underwent simultaneous carotid ultrasound. Composite end-point of major adverse event (MAE) (all-cause mortality, MI and later than 3 months, unplanned, coronary angioplasty) was assessed.
Results: While 67 (11%) patients had abnormal SE, CD was detected in 415 (70%). While both abnormal SE and CP were independent predictors of FL-CAD, pre-test probability had no significant association on multivariate analysis. The positive predictive value of SE for the detection of FL-CAD improved from 56% to 70% when CP was present. Pre-test probability of CAD, abnormal SE, and CPB predicted MAE, both in medium- (3 years) and long-term (7.2 years) follow up. MAE rates per year increased in a step-by-step fashion: CP-ve and SE-ve, CP+ve and SE-ve, CP-ve and SE+ve versus CP+ve and SE+ve, both in medium- and long-term (p<0.0001).Absence of CPBurden in females with abnormal SE ruled out flow-limiting CAD on coronary angiography in 93% versus 57% in males. CPB was the only independent predictor of MAE in females, whereas in males both SE and CPB remained significant.
Discussion: A combined assessment of functional and anatomical assessment of patients with new onset chest pain infers incremental prognostic information, beyond pre-test probability and SE alone. These findings have implications for routine use of carotid ultrasound during SE.
Version
Open Access
Date Issued
2021-09-21
Date Awarded
2026-03-01
Copyright Statement
Attribution-NonCommercial 4.0 International Licence (CC BY-NC)
License URL
Advisor
Senior, Roxy
Collins, Peter
Publisher Department
National Heart & Lung Institute
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)