Does stress echocardiography predict the site of future myocardial infarction? A large-scale multicenter study

Objectives. We sought to assess whether the site of future myocardial infarction can be predicted on the basis of induced dyssynergy (“area at risk”) recognized by stress echocardiography. Background. The severity and extent of stress-induced dyssynergy are strong predictors of subsequent major cardiac events. However, high grade stenotic lesions are not strictly associated with the site of future coronary occlusions. Methods. From the stress echocardiography multicenter trials data bank, we selected 70 patients (56 men; mean age ± SD 58 ± 11 years) meeting the following inclusion criteria: 1) dipyridamole (n = 53) or dobutamine (n = 17) stress echocardiography; 2) a spontaneously occurring infarction, with no intercurrent revascularization procedure between the initial study and the infarction; and 3) a follow-up rest echocardiogram obtained 41 ± 90 days after the infarction. Results. A complete ischemia-infarction mismatch (infarct-related dysfunction in a patient with negative stress test results) occurred in 29 patients (41%). A partial mismatch (ischemic dysfunction in a territory different from the infarct area) occurred in nine patients (13%). A match (ischemia-related and infarction-related dyssynergy involving the same region) occurred in 32 patients (46%). The average time interval between the stress examination and the occurrence of infarction or reinfarction was 144 ± 160 days in patients with a match and 439 ± 622 days in patients with a mismatch (p < 0.05). Conclusions. Induced ischemia (imaged as transient dyssynergy by pharmacologic stress echocardiography) inconsistently identifies the site of future infarction. The majority of spontaneous coronary occlusions leading to infarction unheralded by induced ischemia. However, most infarctions occurring within 1 year of stress testing are in the area identified as ischemic during testing.