Usefulness of contrast stress-echocardiography or exercise-electrocardiography to predict long-term acute coronary syndromes in patients presenting with chest pain without electrocardiographic abnormalities or 12-hour troponin elevation

Am J Cardiol. 2011 Jan 15;107(2):161-7. doi: 10.1016/j.amjcard.2010.08.066. Epub 2010 Dec 2.


The evaluation of patients presenting to the hospital with a recent episode of chest pain suggestive of myocardial ischemia, nondiagnostic electrocardiographic findings, and normal 12-hour cardiac troponin levels remains a challenge for the clinician. We selected 1,081 consecutive patients who presented to the emergency department during 2008 for a chest pain complaint of suspected cardiac origin without significant electrocardiographic abnormalities or troponin elevation. These patients underwent either contrast-enhanced stress-echocardiography with myocardial perfusion imaging or exercise-electrocardiography within 5 days of the index admission. We analyzed their 1-year cardiac outcome (i.e., unstable angina, myocardial infarction, or cardiac death). A post test likelihood of cardiac events was determined on the basis of the results of the provocative testing. Significantly better event-free survival (log-rank p <0.0001) was found for both hard (cardiac death and nonfatal myocardial infarction) and combined (acute coronary syndrome) end points in patients with normal contrast-enhanced stress-echocardiographic findings. However, this was not the case for patients in the exercise-electrocardiographic group, for whom event-free survival was not significantly different among the 3 possible result categories (normal, indeterminate, and abnormal test findings; log-rank p = NS). In conclusion, inducible ischemia detected by contrast-enhanced stress-echocardiography predicted the 1-year incidence of acute coronary syndrome (11.3% for positive vs 0.8% for negative results). However, this was not the case for exercise-electrocardiography, with a 2.7%, 2.3%, and 2.9% 1-year incidence of acute coronary syndromes for positive, negative, and indeterminate results, respectively.

Publication types

  • Comparative Study

MeSH terms

  • Acute Coronary Syndrome / blood
  • Acute Coronary Syndrome / diagnostic imaging*
  • Acute Coronary Syndrome / epidemiology
  • Aged
  • Chest Pain / diagnosis*
  • Chest Pain / etiology
  • Chest Pain / physiopathology
  • Echocardiography, Stress / methods*
  • Electrocardiography*
  • Female
  • Follow-Up Studies
  • Humans
  • Incidence
  • Italy / epidemiology
  • Male
  • Prognosis
  • Retrospective Studies
  • Time Factors
  • Troponin / blood*


  • Troponin