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Aims Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported. Methods and results Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan–Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224–1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73–4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41–2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease. Conclusion In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period. [ABSTRACT FROM AUTHOR]

BACKGROUND Use of artificial intelligence (AI) in cardiovascular imaging may potentially augment clinical decision-making in disease management, but no prospective randomized controlled trials have assessed the impact on cardiovascular outcomes. This study evaluates whether AI-augmented decision-making is non-inferior to standard decision-making when selecting participants for invasive coronary angiography following stress echocardiography. METHODS PROTEUS was a multicenter, parallel-group randomized controlled trial. We enrolled participants undergoing a stress echocardiogram at 20 centers across the United Kingdom between November 2021 and June 2023. Participants were randomly assigned to standard clinical decision-making (control) or decision-making augmented by AI (intervention). The primary end point was appropriate referral for coronary angiography, with true positives defined as severe coronary disease requiring revascularization in participants referred for invasive angiography and false negatives defined as an acute coronary event within 6 months. Secondary analysis examined intervention versus control in prespecified subgroups where interpretation is known to be more challenging. RESULTS Out of 2341 randomly assigned participants, 2213 (94.53%) completed 6 months' follow-up. Eighty-five participants were referred for angiography, 61 of whom had significant coronary disease. Of the participants not referred, 41 participants had acute coronary syndrome or died within 6 months. The difference between the area under the receiver operating characteristic curve (AUROC) for the intervention (0.63; 95% confidence interval (CI), 0.43 to 0.83) and control (0.55; 95% CI, 0.33 to 0.80), did not meet the prespecified non-inferiority margin of -0.05 (difference, 0.09; 95% CI, -0.22 to 0. 39). The sensitivity in the intervention (64.2%; 95% CI, 33.3 to 80.0%) and control (55.1%; 95% CI, 43.7 to 84.2%) was similar (difference, 9.1%; 95% CI, -21.8 to 39.6%). Likewise, the specificity in the intervention (98.6%; 95% CI, 98.1 to 99.8%) and control (99.2%; 95% CI, 97.2 to 99.5%) was similar (difference, 0.6%; 95% CI, -2.1 to 0.9%). Subgroup analyses suggest potential benefit of AI-augmentation in low-volume stress echocardiography centers. CONCLUSIONS AI-augmented decision-making in stress echocardiography did not meet the non-inferiority end point when evaluated in a large, prospective randomized controlled trial, but may be beneficial in low-volume centers. (Funded by the Accelerated Access Collaborative and others; ClinicalTrials.gov number, NCT05028179; ISRCTN number, ISRCTN15113915. [ABSTRACT FROM AUTHOR]

Background: Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. Methods: Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. Results: Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384–1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually. Conclusion: This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning. [ABSTRACT FROM AUTHOR]

Aims: Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a healthcare system has not been previously reported., Methods and Results: Five thousand five hundred and three patients recruited across 32 UK NHS hospitals between 2018 and 2022, participating in the EVAREST/BSE-NSTEP prospective cohort study, with data on medical outcomes up to 2023 available from NHS England were included in the analysis. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions, and relevant cardiovascular diagnoses, based on Kaplan-Meier analysis and Cox proportional hazard ratios (HRs). Median follow-up was 829 days (interquartile range 224-1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction [HR 2.71, 95% confidence interval (CI) 1.73-4.24, P < 0.001] and a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.03, 95% CI 1.41-2.93, P < 0.001). Hazard ratios increased with ischaemic burden. A negative stress echocardiogram identified an event-free 'warranty period' of at least 5 years in patients with no prior history of coronary artery disease and 4 years for those with disease., Conclusion: In real-world practice, the degree of myocardial ischaemia recorded by clinicians at stress echocardiography correctly categorizes risk of future events over the next 5 years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period., Competing Interests: Conflict of interest: A.K. has received an educational grant from Lantheus Medical Imaging and honoraria from Bracco and Tom-Tec-Phillips. K.W. is a member of the British Cardiovascular Society Guidelines and Practice Committee (unpaid role). R.Se. has received honoraria from Bracco, Lantheus Medical Imaging, and GE Healthcare. P.L. is a shareholder and founder of Ultromics Ltd and has received personal consultancy fees from Ultromics Ltd. P.L. is an inventor on patients in the field of echocardiography. All other authors have no conflicts of interest to declare., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)