Long-term prognostic value of exercise testing in men and women from the coronary artery surgery study (CASS) registry

doi:10.1016/S0002-9149(99)80677-8

The American Journal of Cardiology

Volume 75, Issue 14, 1 May 1995, Pages 865-870

https://doi.org/10.1016/S0002-9149(99)80677-8 Get rights and content

Many prior studies involving a predominantly male population have demonstrated the importance of exercise test results in determining the outcome of patients with coronary artery disease. The prognostic significance of exercise testing in women is unknown. In our study, a total of 3,086 men and 747 women underwent maximal treadmill exercise testing, coronary angiography, and were prospectively followed for up to 16 years. They were divided into 3 groups (high, intermediate, and low risk) on the basis of exercise testing. Sixteen-year survival based on exercise test groups ranged from 38% to 61% in men and from 44% to 79% in women (p < 0.001). Among men, 12-year survival was enhanced by coronary artery bypass surgery versus medical therapy in the high-risk subgroup (69% vs 55%, respectively, p = 0.0025), but the 2 therapies were similar in the intermediate- and low-risk subgroups. Among women, neither medical nor surgical therapy resulted in improved 12-year survival rates in any of the 3 subgroups. These results suggest that exercise testing is helpful in assessing long-term survival in men and women. However, only exercise testing in men could identify a high-risk subset whose survival was enhanced by coronary artery bypass graft surgery.

References (24)

WeinerDA
Risk stratification in angina pectoris
MorrisCK et al.
Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization
Am Heart J
(1993)
WeinerDA et al.
Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease
J Am Coll Cardiol
(1984)
PeduzziP et al.
Prognostic value of baseline exercise tests
Prog Cardiovasc Dis
(1986)
WeinerDA et al.
The role of exercise testing in identifying patients with improved survival after coronary artery bypass surgery
J Am Coll Cardiol
(1986)
National Heart, Lung, and Blood Institute Coronary Artery Surgery Study
Circulation
(1981)
BruceRA et al.
Exercise stress testing in evaluation of patients with ischemic heart disease
Prog Cardiovasc Dis
(1979)
CoxDR
Regression models and life tables
J R Stat Soc B
(1972)
KalbfleischJD et al.
The Statistical Analysis of Failure Time Data
AldermanEL et al.
Results of coronary artery surgery in patients with poor left ventricular function (CASS)
Circulation
(1983)

GershBJ et al.

Comparison of coronary bypass surgery and medical therapy in patients 65 years of age or older. A nonrandomized study from the Coronary Artery Surgery Study (CASS) registry

N Engl J Med

(1985)

EakerED et al.

Epidemiology and risk factors for coronary heart disease in women

Cardiovasc Clin

(1989)

Cited by (89)

Usefulness of Excellent Functional Capacity in Men and Women With Ischemic Exercise Electrocardiography to Predict a Negative Stress Imaging Test and Very Low Late Mortality
2019, American Journal of Cardiology
Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.
Exercise and Bayes’ Theorem: Some things never go out of style
2016, Journal of Nuclear Cardiology
Characteristics and outcomes of patients who achieve high workload (≥10 metabolic equivalents) during treadmill exercise echocardiography
2013, Mayo Clinic Proceedings
To determine the frequency and prognostic significance of abnormal exercise echocardiographic results for patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise echocardiography.
Patients who underwent treadmill exercise echocardiography from November 1, 2003, through December 31, 2008, and exercised for 9 or more minutes using the Bruce protocol (N=7236) were included. Clinical and exercise echocardiographic characteristics and outcomes were evaluated. Variables associated with abnormal exercise echocardiographic results and mortality were identified.
Exercise echocardiographic results were positive for ischemia in 862 patients (12%). Extensive ischemia developed in 265 patients (4%). For patients with normal exercise echocardiographic results, all-cause and cardiovascular mortality rates were 0.30% and 0.05% per person-year of follow-up, respectively. For patients who had extensive ischemia, all-cause and cardiovascular mortality rates were 0.84% and 0.25% per person-year of follow-up, respectively. Patients at highest risk were those who had extensive and severe regional wall motion abnormalities at rest (n=58), and their all-cause and cardiovascular mortality rates were 2.65% and 0.76% per person-year of follow-up. Exercise echocardiographic variables did not identify sizable patient subgroups at risk for death and did not provide incremental prognostic information (C statistic was 0.74 compared with 0.73 for the clinical plus exercise electrocardiography model).
Patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise testing do not often have extensive ischemic abnormalities on exercise echocardiography. Although exercise echocardiographic results provide some prognostic information, it is not of incremental value for these patients, whose short-term and medium-term prognosis is excellent.
Coronary revascularization does not decrease cardiac events in patients with stable ischemic heart disease but might do in those who showed moderate to severe ischemia
2012, International Journal of Cardiology
Citation Excerpt :
There have been some randomized control trials (RCTs) regarding the survival benefit of early revascularization relative to baseline stress testing data. Data from two major RCTs [21,22] and the CASS registry [23,24] indicating that reduced mortality is associated with early revascularization versus medical therapy alone in patients with abnormal stress test findings were confirmed in a study of pooled RCT data [25]. Although ischemia can be detected by exercise stress ECG, exercise stress ECG is inferior to stress MPS in terms of the evaluation of the amount of ischemic myocardium.
As an initial management strategy for stable ischemic heart disease (IHD), coronary revascularization therapy is thought to be equal to optimal medical therapy alone regarding prognosis.
Whether or not the effects of revascularization on the prognosis of patients with stable IHD are associated with the amount of ischemic myocardium detected by nuclear stress imaging was evaluated. This retrospective study analyzed data from 4629 patients with suspected or known IHD who underwent gated stress myocardial-perfusion SPECT at 117 hospitals in Japan. The follow-up periods were three years and the combined endpoints consisted of cardiac death, nonfatal myocardial infarction, and congestive heart failure requiring hospitalization. After matching propensity scores between patients who underwent early revascularization and those who did not (n = 316 per group), we compared cardiac event rates in relation to the amount of ischemic myocardium.
Cardiac event rates did not significantly differ between patients who underwent early revascularization and those who did not (5.4% vs. 6.4%). Among patients with ≤ 5%, 6–10%, and > 10% ischemic myocardium, cardiac event rates were 8%, 3% and 0% respectively, who underwent early revascularization compared with 4.5%, 6.1%, and 12.3%, respectively, among those who did not. Cardiac event rates were significantly lower among patients with > 10% ischemic myocardium who underwent early revascularization compared with those who did not (0% vs. 12.3%, p = 0.0062).
Coronary revascularization for stable IHD does not decrease major cardiac events in all patients but might do in patients with moderate to severe ischemia.
An Update on Exercise Stress Testing
2012, Current Problems in Cardiology
Exercise stress testing is the most commonly used noninvasive method to evaluate for coronary artery disease in men and women. Although emphasis has been placed on the diagnostic value of ST-segment depression, the exercise stress test provides other valuable diagnostic and prognostic data, beyond ST-segment depression. The value of these variables, which include exercise capacity, chronotropic response, heart rate recovery, blood pressure response, and the Duke Treadmill Score, are reviewed in this article. In addition, the gender differences seen with these exercise testing variables are reviewed. In this modern era of exercise stress testing, making use of all the information from a stress test and creating a comprehensive stress testing report are recommended in the evaluation of patients with suspected coronary artery disease who undergo exercise stress testing.
Diagnostic value of the «beyond ST» parameters in the stress test interpretation
2010, Revista Colombiana de Cardiologia
Recientemente se han descrito nuevos parámetros y sistemas de puntaje que pretenden aumentar el valor diagnóstico y pronóstico de la prueba de esfuerzo, Este estudio tiene como objetivo describir la frecuencia de los parámetros más allá del ST en la población de pacientes que realizaron prueba de esfuerzo y calcular su valor diagnóstico adicional al rendimiento diagnóstico de la prueba con una población que realizó prueba de esfuerzo y coronariografía.
Estudio de validez de pruebas diagnósticas, en el que se calculó el rendimiento diagnóstico de los siguientes parámetros de la prueba de esfuerzo: MET alcanzados cuando la prueba se hace positiva, índice de Duke, doble producto y ajuste del ST según la frecuencia cardiaca, por medio del cálculo de sensibilidad y especificidad.
Se incluyeron 270 pacientes a quienes se les realizó prueba de esfuerzo y coronariografía, se calculó una sensibilidad de 70,74% y una especificidad de 46,34%, y posteriormente se realizó un nuevo análisis incluyendo los parámetros no ST (MET, índice ST/FC y doble producto) observando una mejoría en el rendimiento diagnóstico con una sensibilidad de 82,4% y especificidad 59,7%.
Los parámetros más allá del ST constituyen una herramienta para la clasificación adecuada de falsos positivos y falsos negativos de la prueba de esfuerzo.
New parameters and score systems have been described recently pretending to increase the diagnostic and prognostic value of the stress test. The objective of this study is to describe the frequency of these parameters beyond the ST in the population of patients who underwent stress test and coronary angiography, and to calculate its diagnostic value.
Observational retrospective study in which the diagnostic performance of the following parameters of the stress test was calculated: MET obtained when the test becomes positive, Duke index, double product and ST adjustment according to the heart rate by the sensibility and specificity calculation.
270 patients that underwent stress test and coronary angiography were included. By means of a similar calculation to that of sensibility, named pseudo-sensibility (p sensibility) and pseudospecificity (p specificity), we calculated a sensibility of 70.74% and a specificity of 46.34%. A new analysis was further realized including non-ST parameters (METS, ST/HR index and double product), observing an improvement in diagnostic yield with a sensibility of 82.4% and a specifity of 59.7%.
Beyond ST parameters represent a main tool for the adequate classification of false positives and false negatives of the stress test.

View all citing articles on Scopus

: This study was supported in part by Grant 1 HV62923 from the National Institutes of Health, Bethesda, Maryland.

View full text

Long-term prognostic value of exercise testing in men and women from the coronary artery surgery study (CASS) registry

Am Heart J

J Am Coll Cardiol

Prog Cardiovasc Dis

J Am Coll Cardiol

National Heart, Lung, and Blood Institute Coronary Artery Surgery Study

Circulation

Exercise stress testing in evaluation of patients with ischemic heart disease

Prog Cardiovasc Dis

Regression models and life tables

J R Stat Soc B

The Statistical Analysis of Failure Time Data

Results of coronary artery surgery in patients with poor left ventricular function (CASS)

Circulation

Comparison of coronary bypass surgery and medical therapy in patients 65 years of age or older. A nonrandomized study from the Coronary Artery Surgery Study (CASS) registry

N Engl J Med

Epidemiology and risk factors for coronary heart disease in women

Cardiovasc Clin