Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease

Abstract

To identify predictors of mortality in medically treated patients with symptomatic coronary artery disease, 30 variables were analyzed in 4,083 patients. Regression analysis demonstrated that seven variables were independent predictors of survival. A high risk subgroup (annual mortality rate above 5%) was identified, consisting of patients with either a congestive heart failure score of 3 to 4 or 1 mm or greater ST segment depression and final exercise stage of 1 or less. When all 30 variables were analyzed conjointly, the left ventricular contraction pattern (p less than 0.0001) and the number of diseased coronary vessels (p less than 0.003) proved to be the most important predictors of survival. In a subgroup of 572 patients with three vessel coronary disease and preserved left ventricular function, the probability of survival at 4 years ranged from 53% for patients only able to achieve stage 1/2 of exercise to 100% for patients able to exercise into stage 5 (p less than 0.004). Thus, in patients with defined coronary pathoanatomy, clinical and exercise variables primarily relating to the functional state of the left ventricle are helpful in assessing prognosis.

Silent Myocardial Ischemia

“…The presence of inducible ECG features of ischemia, either symptomatic or asymptomatic, on exercise testing has been shown to be associated with adverse outcome. 76,[87][88][89] The strength of the association is most convincing, and the predictive value of ischemia is greatest, when it occurs at low workload. 88 The electrocardiographic severity of ischemia is less useful in identifying those at risk of events.…”

“…The impact of silent ischemia on exercise testing in the population with suspected or confirmed coronary disease is a more challenging question. Over the past 30 years, a large number of studies have been conducted on patients with a history of angina, with or without prior MI, 75,87,88 and in patients after MI, 89 which serve to answer just this question. The presence of inducible ECG features of ischemia, either symptomatic or asymptomatic, on exercise testing has been shown to be associated with adverse outcome.…”

Physiologic risk assessment in stable ischemic heart disease: still superior to the anatomic angiographic approach

“…In patients with defined coronary artery disease, exercise variables primarily relating to the functional state are known to provide incremental prognostic information over coronary anatomy. 6 The treadmill score also adds independent prognostic information to that provided by clinical data, coronary arteriography, and left ventricular (LV) ejection fraction. 7 The predictive power of clinical data also is strengthened by adding the results of dobutamine echocardiography 8 and, to a minor degree, coronary anatomy data.…”

Avaliação e preparo pré-operatório do portador de doença das artérias coronárias

“…Patients with functional capacity below 4 METs and low physical activity level-induced myocardial ischemia (ST segment under-unlevelled) are at high peri and postoperative risk. On the other hand, ischemic patients with functional capacity above 7 METs are considered at low cardiac risk 10 .…”

“…Those patients are at increased risk for peri and postoperative morbidity and mortality and should be evaluated and prepared by a multidisciplinary team, including the anesthesiologist, whose participation is paramount for a successful procedure. 10 .…”