Prevalence and Prognostic Significance of Wall- a significant predictor of first cardiovascular events (hazard ratio
Motion Abnormalities in Adults without Clinically (HR) 1.9, P = 0.001), but not of cardiovascular mortality. Similarly,
global WMA predicted cardiovascular events and deaths (HR 2.2
Recognized Cardiovascular Disease: The Strong – 2.7, P < 0.005), even when controlled for age, gender, waist/hip
Heart Study ratio, systolic blood pressure, and DM, but not when EF was entered
into the regression model.
Cicala S, de Simone G, Roman MJ, et al.
Circulation 2007; 116:143-150 Discussion and Comments:
The prevalence of WMA in adults with previously unrecognized
Reviewer: cardiovascular diseases noted in this study (namely, 5 % for seg-
KW Tim Park, MD mental WMA and 1.5 % for global WMA) is similar to what has
Santa Clara Valley Medical Center been noted by Gardin JM et al (Circulation 1995; 91:1739-48) in
San Jose, CA predominantly white adults aged 65 ~ 69. The WMA in this study
were associated with measures of preclinical cardiovascular disease
Background: such as increased LV mass index and albuminuria. The WMA
The presence of qualitative wall-motion abnormalities (WMA) in those without previously recognized cardiovascular diseases
has been shown to be an independent predictor of cardiovascular predicted cardiovascular events and deaths; and the rates of these
events in patients with myocardial infarction (MI), unstable angina, events were similar to the rates in those who were excluded from
typical chest pain, or congestive heart failure (CHF). However, this study because of prevalent cardiovascular diseases. Inciden-
regional WMA’s may occur in patients without clinically recognized tally detected WMA may be due to transient ischemic dysfunction,
cardiovascular disease and the significance of such abnormalities in stunning or hibernation, cardiomyopathy, or unrecognized silent
these patients is not known. In the present study, the authors exam- MI. 5 – 20 % of MI’s go undetected at the time of occurrence, but
ined whether left ventricular (LV) WMA’s predict cardiovascular long-term prognostic significance of silent MI is similar to that of
events in adult patients without overt cardiovascular diseases. recognized MI.
Notable in this study is that the severity of WMA was not entered
Methods: into the regression model. Perhaps because of a relatively small
From the participants in the population-based cohort study number of participants with WMA’s, all those with segmental WMA
(“Strong Heart Study”(SHS)) of American Indians in Arizona, were grouped together, without regard to the severity of WMA.
Oklahoma, and the Dakotas, aged 45 – 74, those who had an echo- Further studies will be needed to determine whether the severity of
cardiogram but no history of coronary artery disease, stroke, or CHF WMA is related to cardiovascular outcome.
at the time of echocardiography were enrolled in this study. Wall The fact that WMA in patients unsuspected of cardiovascular
motion was assessed according to the Mayo criteria in 14 segments diseases may have a prognostic value may have implications on
of the left ventricle. Segmental WMA was considered present for who should have a screening echocardiogram for risk stratification
the purpose of this study, if present in 2 contiguous segments in a prior to undergoing a major surgery. Previous studies on the value
coronary territory. WMA was considered global, if present sym- of a preoperative screening echocardiography tended to examine
metrically in all segments. Patients were followed from the date the value of low LV EF as a prognostic index. Future studies may
of echocardiography to the end of 2003, for fatal and nonfatal car- be indicated to examine the prognostic value of segmental WMA.
diovascular events, including MI, stroke, coronary heart disease, Echocardiography is relatively risk-free and can be performed
and heart failure. Deaths were adjudicated as cardiovascular by an in an ambulatory setting, if appropriate expertise is available. If
independent review panel, if caused by MI, stroke, acute coronary the prognostic value of segmental WMA can be validated even in
syndrome, or CHF. patients without known cardiovascular diseases, the potential use
and indication for preoperative screening echocardiogram may be
Results: greatly expanded.
Of a total of 2864 participants (age 60 ± 8, M:F = 36:64), 140
(5%) had segmental WMA and 42 (1.5 %) had global WMA. Those
with WMA were more likely to be male, had higher mean C-reac-
tive protein, fibrinogen, and creatinine, were more likely to have
micro- or macro-albuminuria, and had higher mean LV mass and
lower LV ejection fraction (EF). Over a follow-up period of 8.2 ±
2.2 years, the cumulative incidences of combined fatal and nonfatal
cardiovascular events and of cardiovascular mortality were 2.5 ~
3-fold higher in those with segmental WMA than those without
WMA (P < 0.0001). These associations remained significant after
adjustment for age, gender, waist-hip ratio, systolic blood pressure,
diabetes mellitus (DM), and LV EF. When smoking, cholesterol,
and creatinine were added in the model, segmental WMA remained