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Aims The aim of this study was to assess the prognostic value of myocardial viability recognized as a contractile response to vasodilator stimulation in patients with left ventricular dysfunction in a large scale, prospective, multicentre, observational study.Methods and Results Three hundred and seven patients (mean age 60±10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction and severe left ventricular dysfunction (ejection fraction <35%; mean ejection fraction: 28±7%) were enrolled in the study. Each patient underwent low dose dipyridamole echo (0·28mg.kg−1in 4min). Myocardial viability was identified as an improvement of ≥0·20 in the wall motion score index. By selection, all patients were followed up for a median of 36 months. One-hundred and twenty-four were revascularized either by coronary artery bypass grafting (n=83) or coronary angioplasty (n=41). The only end-point analysed was cardiac death. In the revascularized group, cardiac death occurred in one of the 41 patients with and in 16 of the 83 patients without a viable myocardium (2·4% vs 19·3%,P <0·01). Outcome, as estimated by Kaplan–Meier survival, was better for patients with, compared to patients without, a viable myocardium, who underwent coronary revascularization (97·6 vs 77·4%,P =0·01). Using a Cox proportional hazards model, the presence of myocardial viability was shown to exert a protective effect on survival (chi-square 4·6, hazard ratio 0·1, 95% CI 0·01–0·8,P <0·03). The survival rate in medically treated patients was lower than in revascularized patients irrespective of the presence of a viable myocardium (79·7% vs 86·2,P =ns).Conclusion In severe left ventricular ischaemic dysfunction, myocardial viability, as assessed by low dose dipyridamole echo, is associated with improved survival in revascularized patients. [ABSTRACT FROM PUBLISHER]

Aims The value of exercise electrocardiography in evaluating women with suspected coronary artery disease is limited. Conversely, stress echocardiography is effective for both diagnostic and prognostic purposes in females. The purpose of the study was to determine the relative prognostic value of exercise electrocardiography and pharmacological stress echocardiography in a cohort of women with chest pain of unknown origin, in order to verify whether criteria could be established for the daily non-invasive evaluation of such a low-risk profile population.Methods and Results Exercise electrocardiography and pharmacological stress echocardiography (171 dipyridamole, 73 dobutamine) were performed in 244 women (age 60±10 years) with chest pain and known coronary artery disease. A positive result of exercise electrocardiography (ST-segment shift ≥1mm at 80ms after the J point) was detected in 95 patients; a positive result of stress echocardiography (new regional wall motion abnormalities) was observed in 33 patients. During follow-up (36±18 months), two deaths, five infarctions, seven unstable anginas, and 11 coronary revascularizations occurred. Using Cox analysis, the positive result of stress echocardiography (odds ratio=40·1) alone, was independently related to hard cardiac events (death, infarction). With spontaneous cardiac events (death, infarction, and unstable angina) as end-points, the multivariate prognostic predictors were a positive result of stress echocardiography (odds ratio= 37·0), a family history of coronary artery disease (odds ratio=4·1), typical chest pain (odds ratio=3·7), and a positive exercise electrocardiography result with a rate–pressure product ≤20000 (odds ratio=3·5). By adopting an interactive stepwise procedure, the prognostic value of stress echocardiography was incremental to that of clinical and exercise electrocardiography data. Nevertheless, the negative result of exercise electrocardiography and pharmacological stress predicted a very high and comparable (P=ns) 24-month survival rate when both hard and spontaneous cardiac events were taken as end-points.Conclusions In women with chest pain, stress echocardiography is a strong and independent prognostic indicator, incremental to that shown by exercise electrocardiography. However, the two tests have a similar high negative predictive value in this population. Therefore, exercise electrocardiography has to be considered the initial approach and the only test when the result is negative, whereas stress echocardiography is warranted in selected conditions, including those in women with uninterpretable electrocardiograms, those unable to exercise maximally, and those with an ambiguous or ischaemic response to exercise electrocardiography. [ABSTRACT FROM PUBLISHER]

Dipyridamole stress is the forerunner and prototype of pharmacological stress echo tests in the diagnosis of coronary artery disease. Among the various stress echo tests, it is probably the least technically demanding to perform and the easiest to interpret. Its accuracy is similar to dobutamine stress echocardiography but its feasibility is higher. The prognostic impact of dipyridamole stress echo has also been proven for presentation of hard end-points such as cardiac death. The safety and prognostic value of this test has been conclusively demonstrated as a result of extensive experience in large scale multicentre projects.Dipyridamole stress is many different tests in one: dipyridamole—atropine is best for diagnosis; dipyridamole—dobutamine or dipyridamole—exercise is highly sensitive for the detection of minor forms of coronary artery disease; low and high dose dipyridamole is best suited for prognostic stratification; infra-low dipyridamole with low dose dobutamine administration is probably best suited for selective myocardial viability identification. Each patient should have their own test, tailored on the basis of the clinical picture and the diagnostic issue. [ABSTRACT FROM PUBLISHER]

Aim: The aim of this study was to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicentre, international, effectiveness study. Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, electrocardiogram-based heart rate reserve., Methods and Results: From July 2016 to November 2020, we enrolled 3574 all-comers (age 65 ± 11 years, 2070 males, 58%; ejection fraction 60 ± 10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent clinically indicated ABCDE-SE. The employed stress modality was exercise (n = 952, with semi-supine bike, n = 887, or treadmill, n = 65 with adenosine for step D) or pharmacological stress (n = 2622, with vasodilator, n = 2151; or dobutamine, n = 471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only endpoint. Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D, and 37% for E steps. During a median follow-up of 21 months (interquartile range: 13-36), 73 deaths occurred. Global X2 was 49.5 considering clinical variables, 50.7 after step A only (P = NS (not significant)) and 80.6 after B-E steps (P < 0.001 vs. step A). Annual mortality rate ranged from 0.4% person-year for score 0 up to 2.7% person-year for score 5., Conclusion: ABCDE-SE allows an effective prediction of survival in patients with chronic coronary syndromes., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Myocardial ischaemia during pharmacological stress echocardiography is a strong prognostic predictor in patients with a left bundle branch block (LBBB). However, the additive value of Doppler-derived coronary flow reserve (CFR) during pharmacological stress testing remains to be investigated in this subset of patients., Methods and Results: The study group consisted of 324 LBBB patients (187 men; age 68 ± 10 years) with known (n = 74) or suspected (n = 250) coronary artery disease who had undergone dipyridamole (up to 0.84 mg/kg over 6') stress echocardiography with CFR assessment of left anterior descending (LAD) by Doppler. A value of CFR ≤ 2.0 was considered abnormal. The median duration of follow-up was 15 months (first to third quartile: 8-34 months). Of the 324 patients, 52 (16%) had ischaemia at stress echo by wall motion criteria, and 139 (43%) had a CFR ≤ 2. During follow-up, 51 (16%) events occurred: 37 deaths and 14 myocardial infarctions (MIs). Age (HR: 1.09, 95% CI: 1.04-1.15, P < 0.0001), resting wall motion score index (HR: 5.29, 95% CI: 2.36-11.89, P < 0.0001), smoking habit (HR: 4.38, 95% CI: 1.93-9.91, P < 0.0001), and CFR ≤ 2 (4.69, 95% CI: 1.96-11.19, P = 0.001) were independently correlated with mortality, while CFR ≤ 2 (HR: 3.91, 95% CI: 1.90-8.04, P < 0.0001), age (HR: 1.06, 95% CI: 1.02-1.10, P = 0.001), smoking habit (HR: 2.25, 95% CI: 1.18-4.30, P = 0.01), ischaemia at stress echo (HR: 2.30, 95% CI: 1.11-4.77, P = 0.02), and resting wall motion score index (HR: 2.17, 95% CI: 1.11-4.25, P = 0.02) were independently correlated with death or MI. Four-year mortality and 4-year hard event rate were markedly higher in patients with CFR ≤ 2 than in those with CFR >2 (49 vs. 6% and 56 vs. 8%, respectively; P < 0.0001 for both). A CFR of ≤ 2 was associated with a significantly higher annual hard event rate independently of age, sex, ejection fraction, history of coronary artery disease, diabetes, and hypertension. Moreover, it was correlated with an increased (P < 0.0001) yearly mortality and event rate in patients with non-ischaemic stress echo conducted on therapy. At incremental analysis, a CFR of ≤ 2 added prognostic value to clinical findings, resting wall motion score index, ongoing anti-ischaemic therapy, and ischaemia at stress echo when both death and death or MI were the clinical endpoints., Conclusions: Abnormal CFR on LAD is a strong and independent indicator of mortality and death or MI in patients with LBBB, and is associated with markedly increased risk also in the subset of patients with stress echo negative for ischaemia on therapy.

Aims: The aim of the study was to evaluate the prognostic value of Doppler echocardiographic-derived coronary flow reserve (CFR) over regional wall motion in patients with known or suspected coronary artery disease (CAD) undergoing dipyridamole echocardiography test (DET)., Methods and Results: In a prospective, multicentre, observational study, we evaluated 1145 patients (702 males; 64 +/- 11 years) who underwent high-dose dipyridamole (0.84 mg/kg over 6 min) stress echo with CFR evaluation of LAD by Doppler. DET was positive for regional wall motion abnormalities in 291 (25%) and negative in 854 (74%) patients. Mean CFR was 2.2 +/- 0.5. At individual patient analysis 702 patients had normal (CFR > 2.0) and 443 had abnormal CFR on LAD. During a median follow-up of 27 months, 109 events occurred: 16 deaths, 17 non-fatal myocardial infarctions, 76 re-hospitalizations for unstable angina. The 30 months infarction-free survival showed the best outcome for those patients with negative DET by wall motion criteria and normal CFR and the worst outcome for patients with positive DET by wall motion and abnormal CFR (99 vs. 68%, P < 0.001). At multivariable analysis, CFR on LAD [hazard ratio (HR) 2.4, 95% CI 1.1-5.4, P = 0.030], medical therapy at time of testing (HR 2.8, 95% CI 1.2-6.6, P = 0.022), DET positivity for regional wall motion abnormalities (HR 3.6, 95% CI 1.5-8.7, P = 0.000), and angina on effort (HR 6.3, 95% CI 2.7-14.8, P = 0.000) were independent prognostic predictors of hard cardiac events., Conclusion: In patients with known or suspected CAD, DET result by wall motion criteria and CFR are additive and complementary for the identification of patients at risk of experiencing hard events.

Aims: Coronary flow-reserve (CFR) can be impaired in non-ischaemic dilated cardiomyopathy (DCM), unmasking a coronary microcirculatory dysfunction of potential prognostic impact. The aim of the present study is to evaluate the prognostic value of Doppler echocardiographic-derived CFR in patients with DCM., Methods and Results: We evaluated 129 DCM patients (85 male; age 62+/-11) by transthoracic dipyridamole (0.84 mg/kg in 10 min) stress echocardiography. All patients had an ejection fraction<40% (mean 32+/-7) and angiographically normal coronary arteries with NYHA class2.0) and 83 had abnormal CFR. During follow-up, 18 patients died and 33 showed worsening of NYHA class. The worse event-free survival was observed in those patients with an abnormal CFR when compared with those having a normal CFR at high dose of dipyridamole (70 vs. 22%, at 75 months of follow-up, P<0.0001). In the multivariable analysis, severity of mitral insufficiency (HR=1.9, 95% CI=1.06-2.87), abnormal CFR (HR=4.0, 95% CI=1.1-15.6), resting wall motion score index (HR=6.9, 95% CI=1.5-30.7) were independent predictors of survival., Conclusion: In DCM patients, CFR is often impaired. A reduced CFR during vasodilator stress is an independent prognostic marker of bad prognosis.

Background: Exercise testing after acute myocardial infarction has limited prognostic accuracy. We prospectively used stress-recovery, heart rate-adjusted, ST-segment analysis to predict cardiac death in this clinical setting., Methods: The stress-recovery index, defined as the difference in absolute values of the areas designated by ST depression in the heart-rate domain during exercise and recovery, was derived in 708 survivors of a first myocardial infarction. To assess whether it contributed additional prognostic information to routinely obtained information, clinical data, resting ejection fraction, and exercise testing data were entered into a sequential Cox model; the stress-recovery index was entered last. Model validation was performed by bootstrapping adjusted for the degree of optimism in estimates. Survival curves were set up using Kaplan-Meier analysis and compared by the log-rank test., Results: Hypertension (OR 1.3, 95%CI 0.9-4.6), exercise capacity (OR 0.6, 95%CI 0.3-1.1 for the interquartile difference in kilopounds per minute), and the stress-recovery index (OR 0.7, 95%CI 0.5-0.9 for the interquartile difference) were independent predictors of cardiac death at a median follow-up of 32 months. However, the stress-recovery index enhanced the prognostic power of the model on top of clinical and exercise testing variables in all diagnostic subgroups according to ST-segment analysis and significantly discriminated survival. A simple nomogram was generated from the fitted Cox model to estimate risk in individual patients., Conclusions: Stress-recovery, heart rate-adjusted, ST-segment analysis predicts cardiac death after acute myocardial infarction and provides additional prognostic information over clinical and exercise testing data.

Dipyridamole stress is the forerunner and prototype of pharmacological stress echo tests in the diagnosis of coronary artery disease. Among the various stress echo tests, it is probably the least technically demanding to perform and the easiest to interpret. Its accuracy is similar to dobutamine stress echocardiography but its feasibility is higher. The prognostic impact of dipyridamole stress echo has also been proven for presentation of hard end-points such as cardiac death. The safety and prognostic value of this test has been conclusively demonstrated as a result of extensive experience in large scale multicentre projects. Dipyridamole stress is many different tests in one: dipyridamole atropine is best for diagnosis; dipyridamole dobutamine or dipyridamole-exercise is highly sensitive for the detection of minor forms of coronary artery disease; low and high dose dipyridamole is best suited for prognostic stratification; infra-low dipyridamole with low dose dobutamine administration is probably best suited for selective myocardial viability identification. Each patient should have their own test, tailored on the basis of the clinical picture and the diagnostic issue.