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Intraindividual comparison of three stress tests during the early postinfarction period in stable patients with
1Department of Cardiology, Herzzentrum Ludwigshafen, Städtisches Klinikum Ludwigshafen, Germany.
Insights
Comparing stress tests after myocardial infarction reveals poor agreement among common methods. Stress-induced angina showed the strongest correlation with residual stenosis and reduced heart function.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Medicine
Background:
- Acute myocardial infarction (AMI) management involves risk stratification using stress testing.
- Noninvasive stress tests are crucial for assessing myocardial ischemia post-AMI.
- Optimized medical treatment and thrombolytic therapy are standard post-AMI care.
Purpose of the Study:
- To compare the diagnostic yield of three noninvasive stress tests in patients early after acute myocardial infarction.
- To evaluate the intraindividual concordance of bicycle ergometry, 99mTc perfusion scintigraphy, and stress-echocardiography.
- To determine the correlation of stress test results with angiographic data and left ventricular function.
Main Methods:
- Prospective study of 107 stable patients post-AMI within three weeks.
- Utilized bicycle ergometry, 99mTc perfusion scintigraphy, and stress-echocardiography.
- Coronary angiography performed for all patients to assess stenosis severity.
Main Results:
- 99mTc perfusion scintigraphy showed the highest positive test rate (61%), followed by stress-echocardiography (34%) and bicycle ergometry (32%).
- At least one positive ischemic parameter was found in 79% of patients.
- Concordance among three positive stress parameters was low (27%); only stress-echocardiography and stress-induced angina showed moderate agreement (kappa = 0.44).
- Stress-induced angina correlated significantly with residual coronary stenosis and reduced left ventricular function.
Conclusions:
- Concordance among common stress tests for detecting myocardial ischemia post-AMI is poor.
- Stress-echocardiography and stress-induced angina demonstrate moderate agreement.
- Stress-induced angina is the most reliable indicator of residual coronary artery disease severity and impaired cardiac function post-AMI.
Abstract:
The intention of the study was to intraindividually compare the ischemic yield of three stress tests early after acute myocardial infarction. At a large community hospital 107 stable patients who survived acute transmural myocardial infarction after thrombolytic therapy followed by an individual optimized medical treatment, were prospectively investigated by three noninvasive stress tests. All patients received bicycle ergometry, 99mTc perfusion scintigraphy and stress-echocardiography within three weeks after the acute event. Each patient underwent diagnostic cardiac catheterization for determination of angiographic data. 99mTc perfusion scintigraphy had the highest rate of positive test results (61%), as compared to bicycle ergometry (32%), stress echocardiography (34%) and stress induced angina in any of the stress tests performed (40%). In 79% of the patients studied, at least one of four ischemic parameters was positive. The combination of bicycle ergometry, stress induced angina and 99mTc perfusion scintigraphy detected myocardial ischemia in 78% of the patients studied. Concordance of at least three positive parameters was seen in only 27%. Intraindividual comparison between positive and negative test results was inconclusive. Only stress-echocardiography versus stress-induced angina showed a moderate agreement (kappa = 0.44). Stress-induced angina was the only ischemic parameter which corresponded to the grade of the residual stenosis of the infarct related coronary artery (p < 0.01) and reduced left ventricular function (p < 0.005). These findings show, that concordance of three common stress tests in detecting myocardial ischemia anywhere in patients after acute transmural myocardial infarction and thrombolytic therapy is poor. Stress-echocardiography and stress inducible angina show a moderate agreement. Follow-up studies of these patients are currently performed to clarify prognostic significance and therapeutic consequences of positive test results in these patients.