Using an outcomes-based approach to identify candidates for risk stratification after exercise treadmill testing

Leslee J. Shaw, Rory Hachamovitch, Eric D. Peterson, Howard C. Lewin, Ami E. Iskandrian, Donald D Miller, Daniel S. Berman

Research output: Contribution to journalArticle

25 Citations (Scopus)

Abstract

OBJECTIVE: To develop a hierarchical approach to cardiac risk stratification after treadmill testing. PATIENTS: Clinical and treadmill test data were used to identify a patient population that may be candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3,620 medically treated patients (42% female, mean age 63 years) with a 2.5% mortality was identified (follow-up 2.5 ± SD 1.5 years). MEASUREMENTS AND MAIN RESULTS: A Cox proportional hazards model was used to estimate a patient's likelihood of cardiac death, Kaplan-Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0.4% (n = 921), 1% (n = 2,498), and 1% (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p = .01), the number of infarcted vascular territories (relative risk per defect 2.4, p = .00001), and the DTS (relative risk per unit 0.97, p = .00001), following adjustment for a patient's pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5%, 1.4%, and 2.5%, respectively (p < .0001). Kaplan-Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise. CONCLUSIONS: For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow-up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.

Original languageEnglish (US)
Pages (from-to)1-9
Number of pages9
JournalJournal of General Internal Medicine
Volume14
Issue number1
DOIs
StatePublished - Feb 6 1999

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Exercise
Exercise Test
Blood Vessels
Kaplan-Meier Estimate
Myocardial Perfusion Imaging
Proportional Hazards Models
Coronary Disease
Perfusion
Outcome Assessment (Health Care)
Survival
Mortality
Population

Keywords

  • Coronary artery disease
  • Exercise testing
  • Prognosis

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Using an outcomes-based approach to identify candidates for risk stratification after exercise treadmill testing. / Shaw, Leslee J.; Hachamovitch, Rory; Peterson, Eric D.; Lewin, Howard C.; Iskandrian, Ami E.; Miller, Donald D; Berman, Daniel S.

In: Journal of General Internal Medicine, Vol. 14, No. 1, 06.02.1999, p. 1-9.

Research output: Contribution to journalArticle

Shaw, Leslee J. ; Hachamovitch, Rory ; Peterson, Eric D. ; Lewin, Howard C. ; Iskandrian, Ami E. ; Miller, Donald D ; Berman, Daniel S. / Using an outcomes-based approach to identify candidates for risk stratification after exercise treadmill testing. In: Journal of General Internal Medicine. 1999 ; Vol. 14, No. 1. pp. 1-9.
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abstract = "OBJECTIVE: To develop a hierarchical approach to cardiac risk stratification after treadmill testing. PATIENTS: Clinical and treadmill test data were used to identify a patient population that may be candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3,620 medically treated patients (42{\%} female, mean age 63 years) with a 2.5{\%} mortality was identified (follow-up 2.5 ± SD 1.5 years). MEASUREMENTS AND MAIN RESULTS: A Cox proportional hazards model was used to estimate a patient's likelihood of cardiac death, Kaplan-Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0.4{\%} (n = 921), 1{\%} (n = 2,498), and 1{\%} (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p = .01), the number of infarcted vascular territories (relative risk per defect 2.4, p = .00001), and the DTS (relative risk per unit 0.97, p = .00001), following adjustment for a patient's pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5{\%}, 1.4{\%}, and 2.5{\%}, respectively (p < .0001). Kaplan-Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise. CONCLUSIONS: For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow-up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.",
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AU - Iskandrian, Ami E.

AU - Miller, Donald D

AU - Berman, Daniel S.

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N2 - OBJECTIVE: To develop a hierarchical approach to cardiac risk stratification after treadmill testing. PATIENTS: Clinical and treadmill test data were used to identify a patient population that may be candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3,620 medically treated patients (42% female, mean age 63 years) with a 2.5% mortality was identified (follow-up 2.5 ± SD 1.5 years). MEASUREMENTS AND MAIN RESULTS: A Cox proportional hazards model was used to estimate a patient's likelihood of cardiac death, Kaplan-Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0.4% (n = 921), 1% (n = 2,498), and 1% (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p = .01), the number of infarcted vascular territories (relative risk per defect 2.4, p = .00001), and the DTS (relative risk per unit 0.97, p = .00001), following adjustment for a patient's pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5%, 1.4%, and 2.5%, respectively (p < .0001). Kaplan-Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise. CONCLUSIONS: For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow-up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.

AB - OBJECTIVE: To develop a hierarchical approach to cardiac risk stratification after treadmill testing. PATIENTS: Clinical and treadmill test data were used to identify a patient population that may be candidates for further risk stratification with stress tomographic myocardial perfusion imaging. A prospective series of 3,620 medically treated patients (42% female, mean age 63 years) with a 2.5% mortality was identified (follow-up 2.5 ± SD 1.5 years). MEASUREMENTS AND MAIN RESULTS: A Cox proportional hazards model was used to estimate a patient's likelihood of cardiac death, Kaplan-Meier survival curves were used to estimate time to cardiac death by nuclear test results. Annual rates of cardiac death were 0.4% (n = 921), 1% (n = 2,498), and 1% (n = 201) for patients with low, intermediate, and high Duke treadmill scores (DTS). For patients with an intermediate DTS, multivariate estimators of cardiac death included the number of ischemic vascular territories (relative risk per defect 1.4, p = .01), the number of infarcted vascular territories (relative risk per defect 2.4, p = .00001), and the DTS (relative risk per unit 0.97, p = .00001), following adjustment for a patient's pretest risk of coronary disease. For patients with an intermediate DTS, the presence of no, one or two, and three vascular territories with defects was associated with annual rates of cardiac death of 0.5%, 1.4%, and 2.5%, respectively (p < .0001). Kaplan-Meier survival curves exhibited a statistically worsening survival for patients with defects by 1 year after treadmill exercise. CONCLUSIONS: For symptomatic patients with an intermediate treadmill test score, the exercise myocardial perfusion scan may be used to stratify their risk of cardiac death over 3 years of follow-up. Patient management may be efficiently guided by further outcome assessment, with an exercise nuclear scan for patients whose treadmill test score is intermediate.

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