Michael S. Lauer, MD; Claire E. Pothier, MPH; David J. Magid, MD, MPH; S. Scott Smith, MD; Michael W. Kattan, PhD
Acknowledgment: The authors thank Ethan Katz and Susana Arrigain for their help with statistical analyses.
Grant Support: By the National Heart, Lung, and Blood Institute (grants NHLBI HL66004 and HL072771).
Potential Financial Conflicts of Interest: None disclosed.
Reproducible Research Statement: Statistical code is available by contacting Dr. Lauer at firstname.lastname@example.org. The study protocol and data set are not available.
Requests for Single Reprints: Michael S. Lauer, MD, Division of Prevention and Population Science, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Bethesda, MD 20892; e-mail, email@example.com.
Current Author Addresses: Dr. Lauer: Division of Prevention and Population Science, National Heart, Lung, and Blood Institute, 6701 Rockledge Drive, Bethesda, MD 20892.
Ms. Pothier: Cleveland Clinic, 9500 Euclid Avenue, JJ5-801, Cleveland, OH 44195.
Dr. Magid: Kaiser Permanente, 10065 East Harvard Avenue, Suite 300, Denver, CO 80231.
Dr. Smith: Kaiser Permanente, 10350 East Dakota Avenue, Denver, CO 80247.
Dr. Kattan: Cleveland Clinic, 9500 Euclid Avenue, Wb4, Cleveland, OH 44195.
Author Contributions: Conception and design: M.S. Lauer.
Analysis and interpretation of the data: M.S. Lauer, D.J. Magid, M.W. Kattan.
Drafting of the article: M.S. Lauer, M.W. Kattan.
Critical revision of the article for important intellectual content: M.S. Lauer, C.E. Pothier, D.J. Magid, S.S. Smith, M.W. Kattan.
Final approval of the article: M.S. Lauer, D.J. Magid, M.W. Kattan.
Provision of study materials or patients: M.S. Lauer.
Statistical expertise: M.S. Lauer, M.W. Kattan.
Obtaining of funding: M.S. Lauer.
Collection and assembly of data: C.E. Pothier.
Lauer M., Pothier C., Magid D., Smith S., Kattan M.; An Externally Validated Model for Predicting Long-Term Survival after Exercise Treadmill Testing in Patients with Suspected Coronary Artery Disease and a Normal Electrocardiogram. Ann Intern Med. 2007;147:821-828. doi: 10.7326/0003-4819-147-12-200712180-00001
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Published: Ann Intern Med. 2007;147(12):821-828.
Exercise treadmill testing is recommended for assessing prognosis in patients with symptoms suggestive of coronary artery disease and at least an intermediate probability for disease, as assessed by age, sex, and symptoms (1). Current guidelines focus on the Duke treadmill score, which incorporates functional capacity, electrocardiographic evidence of ischemia, and test-induced angina pectoris (2–4). However, this scheme of risk stratification based primarily on age, sex, symptom status, and the Duke treadmill score does not take into account other simple historical measures that have known diagnostic and prognostic value (5, 6), as well as more recently discovered exercise test predictors of risk (7), such as heart rate recovery (8–11) and stress-related ventricular ectopy (12).
William H Carter, MD, FACC
West Virginia University, Charleston Division
January 18, 2008
In Defense of the Value of the History Taken from Patients with Chest Pain
The excellent article by Lauer evaluating clinical predictors of survival after stress testing further refines the predictive value of exercise treadmill testing beyond that of the valuable Duke Treadmill Score.1 However, we are concerned that some readers will assume that a history of typical angina has no clinical value, an assumption we doubt Lauer et al meant to imply.
The study found no correlation with the history of typical angina versus other types of chest pain with the future survival. The authors correctly noted prior conflicting studies including a report by many of the same authors of the above report.2
A typical history of angina depends on how the history is taken. Open ended questions are known to lead to more valid conclusions compared to leading questions.3 The questions in the current study were all leading questions versus open ended questions. "Is the pain or discomfort substernal?" vs. "Where is the pain?". "Is the pain or discomfort brought on by physical activity or emotional stress?" vs. "What causes the pain?", etc. Would the findings of the prognostic value of the history been different had open ended questions been asked?
The Diamond/Forrester study and the combined CASS and Duke Database all demonstrate the strong predictive value of the history in predicting the presence of coronary disease, (versus all cause mortality at five years), and have been incorporated. Thus we should keep in perspective the findings of this study considering the (1) methodology of taking the chest pain history and (2) the totality of prior evidence supporting the clinical value of the history in the chest pain patientsepeatedly in stress testing guidelines.4
1. Lauer MS,. Pothier CE, Magid DJ, MD, Smith SS, Kattan MW, An Externally Validated Model for Predicting Long-Term Survival after Exercise Treadmill Testing in Patients with Suspected Coronary Artery Disease and a Normal Electrocardiogram. Ann Internal medicine: 2007, 147:821-828
2. Jones RC, Pothier CE, Blackstone EH, Lauer MS,: Prognostic Importance of Presenting Symptoms in Patients Undergoing Exercise Testing for Evaluation of Known or Suspected Coronary Disease., Am J Med. 2004;117:380 "“389.
3. Roter, DL Physicians Interviewing Styles and Medical Information Obtained from Patients. Journal of General Internal Medicine; Vol. 2, 1987:325-329.
4. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic
Stable Angina: J Am Coll Cardiol, 2003; 41: 159-68 (full text of guidelines www.acc.org pg 13)
D. Scott Grubbs
St. Francis Hospital System
January 29, 2008
Did treatment of positive tests obscure prediction?
Dr. Lauer, et al have published a very intriguing study, which seems to corroborate others in many respects. I wonder, however, if the fact that ST segment changes and anginal symptoms during the test have negative correlation might indicate something else.
There is no indication that I can find that this was simply an observational study, with the subjects sent home to usual care regardless of the test findings. I suspect that those patients who demonstrated those classically positive changes went on to catheterization and other interventions and therefore avoided cardiac events that would have otherwise caused a positive correlation.
Absent assurance that this was not the case, I would be very hesitant to employ the nomogram (as least pertaining to ST and Angina) the next time I encounter them doing a stress test.
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Cardiology, Cardiac Diagnosis and Imaging, Coronary Heart Disease.
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