Long-term outcomes after stress echocardiography in real-world practice: five year follow-up of the EVAREST study

Stress echocardiography is widely used to assess patients with chest pain. The clinical value of a positive or negative test result to inform on likely longer-term outcomes when applied in real-world practice across a national healthcare system has not been previously reported.

We report patient outcome up to five years after stress echocardiogram for patients undergoing a clinically-indicated stress echocardiogram for ischaemic heart disease in a real-world, multi-centre national healthcare system and determine the event-free ‘warranty’ period following a normal stress echocardiogram.

Patients participating in the EVAREST/BSE-NSTEP (Echocardiography: Value and Accuracy at Rest and Stress/ British Society of Echocardiography National Review of Stress Echo Practice) prospective cohort study were recruited from 32 UK NHS hospitals between 2018 and 2022. Medical outcome data up to 2023 was available from NHS England. Stress echocardiography results were related to outcomes, including death, procedures, hospital admissions and relevant cardiovascular diagnoses, using Kaplan-Meier analysis and Cox proportional hazard ratios. Warranty period following a negative stress echocardiogram was defined as time the cumulative event rate of myocardial infarction or cardiac-related death remained below 5%.

5503 patients were included in the analysis with a median follow-up of 829 days (IQR 224 – 1434). A positive stress echocardiogram was associated with a greater risk of myocardial infarction (HR 2.71, 95% CI 1.73 – 4.24, P<0.001), revascularisation (HR 10.52, 95% CI 8.26 – 13.42, P<0.001) and reaching a composite endpoint of cardiac-related mortality and myocardial infarction (HR 2.04, 95% CI 1.41 – 2.93, P<0.001). Hazard ratios for all events increased with ischaemic burden identified at stress echocardiography (Figure 1). A negative stress echocardiogram identified an event-free ‘warranty period’ of at least five years in patients with no prior history of coronary artery disease, and four years for those with disease (Figure 2).

In real-world practice, the degree of ischaemia recorded by clinicians at stress echocardiography correctly categorises risk of future events over the next five years. Reporting a stress echocardiogram as negative correctly identifies patients with no greater than a background risk of cardiovascular events over a similar time period.

Figure 1

Figure 2