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Prediction of Cardiovascular Death in Men Undergoing Noninvasive Evaluation for Coronary Artery Disease

Kiernan Morrow, BA; Charles K. Morris, MD; Victor F. Froelicher, MD; Alisa Hideg, BA; Dodie Hunter, MD; Eileen Johnson, BA; Takeo Kawaguchi, MD; Kenneth Lehmann, MD; Paul M. Ribisl, PhD; Ronald Thomas, PhD; Kenji Ueshima, MD; Erika Froelicher, PhD, RN; and James Wallis, MD
[+] Article, Author, and Disclosure Information

From Palo Alto Veterans Affairs Medical Center, Palo Alto, California; Long Beach Veterans Affairs Medical Center, Long Beach, California. Requests for Reprints: Victor F. Froelicher, MD, Department of Cardiology (111C) Palo Alto Veterans Affairs Medical Center, 3801 Miranda Avenue, Palo Alto, CA 94304. Acknowledgments: The authors thank Margo Hullett and Anita Seifert for technical assistance with the exercise testing, our cardiology fellows for completion of the data forms, David Brown and Matt Lam for writing the VAMC program, and Lesley Anderson for assistance in manuscript preparation. Grant Support: In part by the HSR&D and Cooperative Studies Program of the Department of Veterans Affairs.

Copyright 2004 by the American College of Physicians

Ann Intern Med. 1993;118(9):689-695. doi:10.7326/0003-4819-118-9-199305010-00005
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Objective: To develop prediction rules from clinical and exercise test data identifying patients at high and low risk for cardiovascular events among a group of male veterans.

Design: Prognostic study with prospective gathering of data and routine follow-up of consecutive patients referred for exercise testing. Patients only underwent noninvasive evaluation for coronary artery disease. No validation cohort is yet available.

Setting: A 1200-bed Veterans Affairs Medical Center.

Patients: Of 3609 men referred for exercise testing between 1984 and 1990, 2546 patients remained evaluable after exclusion of those who underwent subsequent cardiac catheterization, those with significant valvular heart disease, and those who had previous coronary artery bypass surgery.

Measurements: Evaluation included recording of clinical data on a standardized form and a standard treadmill test followed by assessment of cardiovascular events.

Results: During a mean follow-up period (SD) of 2.75 ( 1.8) years, 119 cardiovascular deaths and 44 nonfatal myocardial infarctions occurred in 2546 patients. The Cox proportional-hazards model showed the following characteristics to be statistically independent predictors of time until cardiovascular death: history of congestive heart failure or digoxin use, exercise-induced ST depression, change in systolic blood pressure during exercise, and exercise capacity. Using a simple score based on one item of clinical information (history of congestive heart failure or digoxin use) and three exercise test responses (ST depression, exercise capacity, and change in systolic blood pressure), 77% of patients were categorized as low risk (annual cardiac mortality rate, less than 2%), 18% as moderate risk (annual cardiac mortality rate, 7%), and 6% as high risk (annual cardiac mortality rate, 15%; hazard ratio, 10; 95% confidence interval, 6 to 17). This model has not yet been validated.

Conclusions: Variables available from the usual noninvasive work-up of patients with known or suspected coronary artery disease can be used to predict future risk for cardiovascular death.


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Figure 1.
Kaplan-Meier survival curves using the clinical-exercise test score to predict cardiovascular death.
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Figure 2.
Receiver operating characteristic curves using the Duke treadmill score and the Veterans Affairs clinical-exercise test score to predict cardiovascular deaths (the numbers along the curves are respective cut-points of the scores).
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