Does chest shape influence exercise stress echocardiographic results in patients with suspected coronary artery disease?

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Abstract
Despite the good specificity of exercise stress echocardiography (ESE) for the detection of coronary artery disease (CAD),
false positive (FP) results may occur. We have previously reported that chest abnormalities may affect parameters of cardiac
contractility. The influence of chest shape on ESE results has never been previously investigated. We retrospectively analyzed
160 consecutive patients (64.4 ± 13.0-year old, 91 women) who had undergone coronary angiography at our Institution
because of positive ESE, between June 2014 and May 2020. Modified Haller index (MHI; chest transverse diameter over
the distance between sternum and spine) was assessed in all patients. Obstructive CAD was diagnosed by ≥ 70% stenosis
in any epicardial coronary artery. Outcome was false-positivity at ESE. 80.6% of patients were diagnosed with obstructive
CAD, while 19.4% had no CAD (FP). We separately analyzed patients with normal chest shape (MHI ≤ 2.5) and those with
concave-shaped chest wall (MHI > 2.5). These latter were mostly women with small cardiac chambers, mitral valve prolapse
(MVP) and exercise-induced ST-segment changes. Likelihood of false-positivity was significantly higher in subjects with
MHI > 2.5 than those with MHI ≤ 2.5 (30.7% vs 9.4%, p = 0.001). By multivariate logistic regression analysis, MHI > 2.5
(OR 4.04, 95%CI 1.45–11.2, p = 0.007), MVP (OR 3.47, 95%CI 1.32–9–12, p = 0.01) and dyssynergy in the left circumflex
territory (OR = 3.35, 95%CI 1.26–8.93, p = 0.01) were independently associated with false-positivity. Concave-shaped chest
wall (MHI > 2.5) may be associated with false-positive stress echocardiographic result. Mechanisms underpinning this finding
need to be further explored.