Elsevier

American Heart Journal

Volume 168, Issue 2, August 2014, Pages 229-236
American Heart Journal

Clinical Investigation
Imaging and Diagnostic Testing
Role of simultaneous carotid ultrasound in patients undergoing stress echocardiography for assessment of chest pain with no previous history of coronary artery disease

https://doi.org/10.1016/j.ahj.2014.04.016Get rights and content

Background

We prospectively explored prevalence of carotid disease (CD), its independent association with coronary artery disease (CAD) and outcome as well as potential impact on management, in patients undergoing stress echocardiography (SE) for new onset chest pain without known CAD.

Methods

Accordingly, 591 consecutive patients referred for SE underwent carotid ultrasound. Carotid disease was defined as carotid intima-media thickness (C-IMT) >75th percentile for age and sex and/or presence of plaque.

Results

Myocardial ischemia was demonstrated in only a minority (11%), but there was a high prevalence of CD (70%). Incidence of CD was similar in patients with and without ischemia (76% versus 69%, P = .26). Carotid data led to reclassification of Framingham risk score categories in 65% of patients as well as more than a third of negative SE patients potentially benefitting from primary prevention therapy. Of the 83 patients undergoing coronary arteriography, 59 (71%) demonstrated coronary atherosclerosis (any atheroma) and 33 (40%) CAD. Positive predictive value of SE for CAD was 56%, but presence of carotid plaque improved it to 70%. Although both CD and plaque showed association with CAD and revascularization, after adjustment for conventional risk factors, only carotid plaque maintained significant association (P = .024 and P = .023, respectively).

Conclusions

There is significantly higher prevalence of CD compared with myocardial ischemia in patients undergoing SE and carotid ultrasound for suspected CAD. This can lead to significant Framingham risk score reclassification with important primary prevention implications. Carotid plaque is superior to clinical assessment for the prediction of CAD and improves positive predictive value of SE for CAD in these patients.

Section snippets

Participants

Consecutive consenting patients with recent onset chest pain who were referred for a clinically indicated SE underwent carotid ultrasonography. The principal exclusion criteria were age <35 or >85 years, known CAD (history of myocardial infarction or coronary revascularization), presence of resting wall motion abnormality, significant valve disease or hypertrophic cardiomyopathy, and prior carotid artery intervention (stenting or surgical endarterectomy). Chest pain character, cardiovascular

Results

A total of 591 patients with a mean age of 59 ± 11 years (range 35-85), 46% men, and no history of cardiovascular disease participated in the study. Their demographic and clinical characteristics are depicted in Table I. Most patients (74%) had an intermediate pretest probability of CAD; similarly higher proportion of patients (53%) had intermediate FRS.

Myocardial ischemia was demonstrated in 67 (11%) patients. A higher number of patients underwent exercise (62%) compared with pharmacologic SE (

Discussion

This is the first large prospective study to assess the prevalence of CD in symptomatic patients without a history of cardiovascular disease, undergoing SE for evaluation of myocardial ischemia and its implication on primary preventive therapy. The study demonstrated that, in this population with a pretest probability of CAD of 40%, the prevalence of CD was 70%, whereas the prevalence of myocardial ischemia was only 11%.

In the subset of patients who underwent CA, in which the pretest

Conclusion

This prospective study revealed that carotid ultrasound in symptomatic patients referred for clinically indicated SE can identify early atherosclerosis that may necessitate primary preventive therapy despite reassuring SE result. Simultaneous carotid ultrasound further improved the prediction of CAD by SE and identified patients at high risk of revascularization. Thus, carotid ultrasonography is a simple, rapid, and accurate bedside method for enhancing the diagnostic value with potential for

Disclosures

None.

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