Improving Stress Echocardiography for Enhanced Detection of Left Main and Multivessel Coronary Artery Disease

Stress echocardiography (SE) is a well established method for diagnosing and assessing coronary artery disease (CAD). However, accurately identifying high-risk patients remains a challenge. The aim of the study is to explore the potential of novel predictors to enhance the diagnostic precision of SE for detecting left-main or triple-vessel CAD.

We included consecutive patients who underwent invasive coronary angiography within 6 months of SE between January 2018 and April 2022. Traditional high-risk SE features included extensive wall-motion abnormalities, a reduction in left ventricular ejection fraction $\ge$ 10% or left ventricular dilation at peak stress, and low ischemic threshold. Wall-motion score index and global longitudinal strain (GLS) at rest and peak stress, as well as the change in each from rest to peak were considered as potential additional indicators of high-risk anatomy, defined as significant stenoses in the left main and/or triple-vessel CAD.

Of the 257 patients (mean age 66 ± 9 years) included in the analysis, 53 (21%) had high-risk CAD. Multivariate analyses identified traditional high-risk SE features, as well as ≥ 5% absolute reduction in GLS, as independent predictors of high-risk anatomy. Integrating $\Delta$ GLS ≥ 5% into standard stress echocardiography evaluation significantly improved sensitivity from 69% to 90% (P = 0.003), with an associated specificity of 72%; also improved was the area under the curve of SE, increasing from 0.77 to 0.81 for detection of high-risk CAD.

In a real-world cohort, adding the change in GLS with exercise stress can improve the performance of SE for the detection of high-risk CAD.