Comparative analysis of stress echocardiography practice and complications in older compared to younger patients in the UK EVAREST Study: A large-scale, prospective, multicenter, observational study
Authors: Szmigielski C , Johnson C , Krasner S , Woodward W , Mccourt A , Dockerill C , Senior R , Augustine D , Paton M , O'driscoll J , Oxborough D , Pearce K , Robinson S , Willis J , Leeson P 
Published: January 2025

Abstract

Background/Introduction
EVAREST is a large-scale prospective, multicenter, observational study evaluating the use and accuracy of stress echocardiography (SE) in patients recruited from 31 NHS hospitals.

Purpose
Sub-study analysis to assess whether SE practice and outcome varies with age of patients.

Methods
Patients were recruited sequentially on attendance at the SE clinic between March 2015 and March 2020. Differences in SE characteristics and outcomes were compared between two age groups separated by the median age of the study population into Younger and Older patients.

Results
We studied 7846 pts with a median age for all pts of 66 yrs. The mean age in the Younger Group was 55 (range 20-65) years and in the Older Group was 74 (range 66-94) years. An abnormal SE response occurred more commonly in the Older Group (19% vs 13%, p&lt;0.001). Key demographic and risk factors that differed between groups were a higher proportion of females in the Older Group (2185 male, 1769 female) compared to the Younger group (2255 male, 1626 female), p=0.011, higher mean BMI in the Younger Group (29.61±5.8 vs 28.1±5.2 kg/m², p&lt;0.001) and lower resting pulse pressure in the Older Group at 56.3±15.9 (95%CI 55.8-56.8) compared to 65.9±16.6 (95%CI 65.3-66.4), p&lt;0.001. Exercise test was performed more commonly in the Younger Group compared to the Older Group (39% vs 23%, p&lt;0.001). For those undergoing dobutamine stress, atropine was used more commonly in the Younger Group (36% vs 34%, p&lt;0.001). However, dobutamine dosing was similar between groups, with the highest dose (40 µg/kg/min) achieved in 13% of the Younger Group and 14% of the Older Group, p=0.05. Ultrasound contrast was used less frequently in the Older Group (73% vs 70%, p=0.03) compared to the Younger group, (p&lt;0.001). Complication rates were similar between groups with the Older Group having a lower peak SBP (150.7±29.3 (95%CI 149.7-151.7) vs 154.9±30.3 mm Hg (95%CI 153.8-155.9), p&lt;0.001) and similar rates of an exaggerated BP response (defined as a peak SBP ≥220 mm Hg) evident in both groups (20% of the Younger Group compared to 21% of the Older Group, p=0.55). A low BP response (defined as peak systolic blood pressure &lt;120 mm Hg) occurred in 8% of the Younger Group and 11% of the Older Group (p=0.001), while a severe hypotensive response (peak SBP&lt;82 mm Hg) was very rare and occurred 0.31% of the Younger Group and 0.56% of the Older Group (p=0.09).

Conclusions
Stress echocardiography is being performed in patients with a wide age range from 20 to 94 years of age within the UK. Older patients undergoing stress echocardiography are more likely to be female and have a relatively lower cardiovascular risk profile. Delivery of stress echocardiography differs significantly with age, with lower contrast use and more frequent use of dobutamine. However, there is no evidence of higher rates of complications in older patients that might limit use of stress echocardiography in older populations.