Effect of stress echocardiography testing on changes in cardiovascular risk behaviors in postmenopausal women: a prospective survey study

BACKGROUND

We evaluated the impact of contrast stress echocardiography (CSE) testing results on cardiovascular (CV) risk behaviors in postmenopausal women presenting with chest pain symptoms. This was a substudy of the Stress Echocardiography in Menopausal Women at Risk for Coronary Artery Disease (SMART) trial.

METHODS

From 2004 to 2007, 366 women (mean age 54.4 ± 5.5 years, range 40-65; body mass index (BMI) 31.4 ± 6.68; Caucasian in 95%) completed CSE and were invited to participate in the Women's Heart Clinic Risk Assessment Questionnaire (WHCRAQ survey) at the time of CSE and after 2 years. Of the 366, 203 (55%) postmenopausal women completed both the baseline and 2-year follow-up surveys (age 61 ± 5 years; Framingham risk score 6 ± 4%, 81% treadmill CSE, 19% dobutamine CSE). WHCRAQ assessed medical history, hormone therapy (HT), and CV risk behaviors (cigarette smoking history, including current smoking and mean cigarettes smoked per day; physical activity or exercise, including mean exercise minutes per week; and dietary fat intake, alcohol intake, and mean alcohol drinks per week). Abnormal CSE was defined as a new or worsening stress wall motion abnormality. Post-CSE changes in CV risk behaviors were determined by comparing baseline versus 2-year data.

RESULTS

Of the 203 women who completed the survey at baseline and 2-year CSE, 29 were excluded to avoid confounding effect (coronary angiography [CA] was performed during follow-up). Of 174 women (55% hypertensive, 10% diabetic, 76% hyperlipidemic, and 25% on HT), CSE was abnormal in 10%. Baseline characteristics were not significantly different in normal versus abnormal CSE, apart from diabetes (8% vs. 24%, p=0.04). Slightly more women with normal CSE were taking HT than not (27% vs. 12%, p=0.19). CV risk behaviors that were different in normal versus abnormal CSE included current smoking, alcohol drinks per week, and higher fat diet (8% vs. 24%, p=0.03; 2.5 ± 3.5 vs. 1.94±5.2, p=0.031; and 92% vs. 76%, p=0.03, respectively). Cigarette smoking decreased (mean difference of -1.5 cigarettes per day, p=0.014) in the abnormal-CSE group, whereas number of alcohol drinks per week increased (mean difference +0.38, p=0.009) in the normal-CSE group.

CONCLUSION

We observed an association of lifestyle changes with CSE test results in postmenopausal women.

A multicenter, prospective study to evaluate the use of contrast stress echocardiography in early menopausal women at risk for coronary artery disease: trial design and baseline findings

AIMS

This multisite prospective trial, Stress Echocardiography in Menopausal Women At Risk for Coronary Artery Disease (SMART), aimed to evaluate the prognostic value of contrast stress echocardiography (CSE), coronary artery calcification (CAC), and cardiac biomarkers for prediction of cardiovascular events after 2 and 5 years in early menopausal women experiencing chest pain symptoms or risk factors. This report describes the study design, population, and initial test results at study entry.

METHODS

From January 2004 through September 2007, 366 early menopausal women (age 54±5 years, Framingham risk score 6.51%±4.4 %, range 1%-27%) referred for stress echocardiography were prospectively enrolled. Image quality was enhanced with an ultrasound contrast agent. Tests for cardiac biomarkers [high-sensitivity C-reactive protein (hsCRP), atrial natriuretic protein (ANP), brain natriuretic protein (BNP), endothelin (ET-1)] and cardiac computed tomography (CT) for CAC were performed.

RESULTS

CSE (76% exercise, 24% dobutamine) was abnormal in 42 women (11.5%), and stress electrocardiogram (ECG) was positive in 22 women (6%). Rest BNP correlated weakly with stress wall motion score index (WMSI) (r=0.189, p<0.001). Neither hsCRP, ANP, endothelin, nor CAC correlated with stress WMSI. Predictors of abnormal CSE were body mass index (BMI), diabetes mellitus, family history of premature coronary artery disease (CAD), and positive stress ECG. Twenty-four women underwent clinically indicated coronary angiography (CA); 5 had obstructive (≥50%), 15 had nonobstructive (10%-49%), and 4 had no epicardial CAD.

CONCLUSIONS

The SMART trial is designed to assess the prognostic value of CSE in early menopausal women. Independent predictors of positive CSE were BMI, diabetes mellitus, family history of premature CAD, and positive stress ECG. CAC scores and biomarkers (with the exception of rest BNP) were not correlated with CSE results. We await the follow-up data.

Rapid Detection of Coronary Artery Stenoses With Real-Time Perfusion Echocardiography During Regadenoson Stress

Background—

Real-time myocardial contrast echocardiography permits the detection of myocardial perfusion abnormalities during stress echocardiography, which may improve the accuracy of the test in detecting coronary artery stenoses. We hypothesized that this technique could be used after a bolus injection of the selective A2A receptor agonist regadenoson to rapidly and safely detect coronary artery stenoses.

Methods and Results—

In 100 patients referred for quantitative coronary angiography, real-time myocardial contrast echocardiography was performed during a continuous intravenous infusion of 3% Definity at baseline and at 2-minute intervals for up to 6 minutes after a regadenoson bolus injection (400 μg). Myocardial perfusion was assessed by examination of myocardial contrast replenishment after brief high mechanical index impulses. A perfusion defect was defined as a delay (>2 seconds) in myocardial contrast replenishment in 2 contiguous segments. Wall motion was also analyzed. The overall sensitivity/specificity/accuracy for myocardial perfusion analysis in detecting a >50% diameter stenosis was 80%/74%/78%, whereas for wall motion analysis it was 60%/72%/66% ( P <0.001 for differences in sensitivity). Sensitivity for myocardial perfusion analysis was highest on images obtained during the first 2 minutes after regadenoson bolus ( P <0.001 compared with wall motion), whereas wall motion sensitivity was highest at the 4-to-6–minute period after the bolus. No significant side effects occurred after regadenoson bolus injection.

Conclusions—

Regadenoson real-time myocardial contrast echocardiography appears to be a feasible, safe, and rapid noninvasive method for the detection of significant coronary artery stenoses.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT0087369.