See page 423 for the editorial comment on this article (doi:10.1093/eurheartj/ehi129) Aims Prior research is limited with regard to the diagnostic and prognostic accuracy of commonplace cardiac imaging modalities in women. The aim of this study was to examine 5-year mortality in 4234 women and 6898 men undergoing exercise or dobutamine stress echocardiography at three hospitals. Methods and results Univariable and multivariable Cox proportional hazards models were used to estimate time to cardiac death in this multi-centre, observational registry. Of the 11 132 patients, women had a greater frequency of cardiac risk factors (P , 0.0001). However, men more often had a history of coronary disease including a greater frequency of echocardiographic wall motion abnormalities (P , 0.0001). During 5 years of follow-up, 103 women and 226 men died from ischaemic heart disease (P , 0.0001). Echocardiographic estimates of left ventricular function (P , 0.0001) and the extent of ischaemic wall motion abnormalities (P , 0.0001) were highly predictive of cardiac death. Risk-adjusted 5-year survival was 99.4, 97.6, and 95% for exercising women with no, single, and multi-vessel ischaemia (P , 0.0001). For women undergoing dobutamine stress, 5-year survival was 95, 89, and 86.6% for those with 0, 1, and 2-3 vessel ischaemia (P , 0.0001). Exercising men had a 2.0-fold higher risk at every level of worsening ischaemia (P , 0.0001). Significantly worsening cardiac survival was noted for the 1568 men undergoing dobutamine stress echocardiography (P , 0.0001); no ischaemia was associated with 92% 5-year survival as compared with death rates of !16% for men with ischaemia on dobutamine stress echocardiography (P , 0.0001). Conclusion Echocardiographic measures of inducible wall motion abnormalities and global and regional left ventricular function are highly predictive of long-term outcome for women and men alike.
OBJECTIVE -This study sought to determine whether stress echocardiography using exercise (when feasible) or dobutamine echo could be used to predict mortality in patients with diabetes. RESEARCH DESIGN AND METHODS -Stress echo was performed in 937 patientswith diabetes (aged 59 Ϯ 13 years, 529 men) for symptom evaluation (42%) and follow-up of known coronary artery disease (CAD) (58%). Stress echocardiography using exercise was performed in 333 patients able to exercise maximally, and dobutamine echo using a standard dobutamine stress was used in 604 patients. Patients were followed for Յ9 years (mean 3.9 Ϯ 2.3) for all-cause mortality.RESULTS -Normal studies were obtained in 567 (60%) patients; 29% had resting left ventricular (LV) dysfunction, and 25% had ischemia. Abnormalities were confined to one territory in 183 (20%) patients and to multiple territories in 187 (20%) patients. Death (in 275 [29%] patients) was predicted by referral for pharmacologic stress (hazard ratio [HR] 3.94, P Ͻ 0.0001), ischemia (1.77, P Ͻ 0.0001), age (1.02, P ϭ 0.002), and heart failure (1.54, P ϭ 0.01). The risk of death in patients with a normal scan was 4% per year, and this was associated with age and selection for pharmacologic stress testing. In stepwise models replicating the sequence of clinical evaluation, the predictive power of independent clinical predictors (age, selection for pharmacologic stress, previous infarction, and heart failure; model 2 ϭ 104.8) was significantly enhanced by addition of stress echo data (model 2 ϭ 122.9).CONCLUSIONS -The results of stress echo are independent predictors of death in diabetic patients with known or suspected CAD. Ischemia adds risk that is incremental to clinical risks and LV dysfunction. Diabetes Care 25:1042-1048, 2002A pproximately 50% of mortality in diabetic patients is related to coronary disease (1), and diabetes has a significant impact on outcome in patients with established coronary disease (2). This increased risk in the diabetic population is equivalent to the risk of nondiabetic patients after infarction (3), a finding that has engendered calls for more aggressive risk factor intervention in this group. A further strategy would be to screen patients for existing evidence of coronary disease, with the intent of myocardial revascularization in those at greatest risk. In nondiabetic patients, a number of factors may be used to stratify the level of risk of coronary disease, including clinical history, resting ventricular function, exercise capacity, the presence and extent of ischemia at single-photon emissioncomputed tomography (SPECT), or stress echo. The detection of a spectrum of risk within the diabetic group is more difficult; sex and lipids levels are less predictive in diabetic than nondiabetic patients (4), and silent ischemia is more common (5). However, resting ST segment changes may be false positive responses for epicardial coronary disease (5), and false positive ST segment changes and poor exercise capacity may reduce the utility of standard exercise el...
Background-In studies generally involving short follow-up, exercise echocardiography has been shown to predict composite end points. We sought to study the prediction of mortality with this test and to devise a strategy for combination with standard exercise testing. Methods and Results-Clinical, exercise testing, and echocardiographic data were collected in 5375 patients (aged 54Ϯ14 years, 3880 men) undergoing exercise echocardiography. The Duke treadmill score was derived from the results of treadmill exercise testing. Resting left ventricular (LV) function and the presence and severity of ischemia were interpreted by expert observers. Follow-up at 10.6 years (mean 5.5Ϯ1.9 years) was complete in 5211 patients (97%
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