Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: report of 3,400 patients from a single center

Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.

OBJECTIVES: We sought to determine the relative influence of estimated functional capacity and thallium-201 (Tl-201) single-photon emission computed tomographic (SPECT) findings on prediction of short-term all-cause and cardiac-related mortality. BACKGROUND: Decreased functional capacity and abnormal Tl-201 SPECT findings are predictive of increased cardiovascular risk and mortality. However, the relative importance of these variables as predictors of all-cause mortality is not well established. METHODS: Analyses were based on 3,400 consecutive adults undergoing symptom-limited exercise Tl-201 SPECT testing at the Cleveland Clinic Foundation between September 1990 and December 1993; none had previous invasive procedures, heart failure or valve disease. Estimated functional capacity, classified by age and gender, and thallium perfusion defects, expressed as a stress extent thallium score on a 12-segment scale, were analyzed to determine their relative prognostic importance during 2 years of follow-up. RESULTS: Of 3,400 patients, 108 (3.2%) died during follow-up; 32 deaths were identified as cardiac related. On univariable analysis, estimated functional capacity was a strong predictor of death, with 62 (57%) deaths occurring in patients achieving < 6 metabolic equivalents (METs) (log-rank chi-square 86, p < 0.0001). On multivariable analysis, the strongest independent predictors of all-cause mortality were fair or poor functional capacity (adjusted relative risk [RR] 3.96, 95% confidence interval [CI] 2.36 to 6.64, chi-square 27, p < 0.0001) and age (adjusted RR for 10 years 2.25, 95% CI 1.80 to 2.80, chi-square 27, p < 0.0001). The presence of SPECT thallium perfusion defects was a less powerful predictor of death (for each two additional segments with defects, adjusted RR 1.21, 95% CI 1.03 to 1.43, chi-square 5, p = 0.02). Cardiac mortality was predicted by both fair or poor functional capacity (adjusted RR 4.37, 95% CI 1.59 to 12.00, chi-square 8, p = 0.004) and by stress extent thallium score (adjusted RR 1.62, 95% CI 1.25 to 2.11, chi-square 13, p = 0.0003). CONCLUSIONS: In this clinically low risk group, estimated functional capacity was a strong and overwhelmingly important independent predictor of all-cause mortality among patients undergoing exercise Tl-201 SPECT testing. The extent of myocardial perfusion defects was of comparable importance for the prediction of cardiac mortality.

This article has been cited by other articles:

				A. K. Chan, N. A. Ilias-Khan, H. Xian, C. Inman, and W. H. Martin III Arm exercise stress perfusion imaging predicts clinical outcome J Appl Physiol, December 1, 2011; 111(6): 1546 - 1553. [Abstract] [Full Text] [PDF]

				M. A. Jolly, D. M. Brennan, and L. Cho Impact of Exercise on Heart Rate Recovery Circulation, October 4, 2011; 124(14): 1520 - 1526. [Abstract] [Full Text] [PDF]

				A. P. Morise Exercise Testing in Nonatherosclerotic Heart Disease: Hypertrophic Cardiomyopathy, Valvular Heart Disease, and Arrhythmias Circulation, January 18, 2011; 123(2): 216 - 225. [Full Text] [PDF]

				G. D. Lewis, L. Farrell, M. J. Wood, M. Martinovic, Z. Arany, G. C. Rowe, A. Souza, S. Cheng, E. L. McCabe, E. Yang, et al. Metabolic Signatures of Exercise in Human Plasma Science Translational Medicine, May 26, 2010; 2(33): 33ra37 - 33ra37. [Abstract] [Full Text] [PDF]

				J. Peteiro, A. Bouzas-Mosquera, F. J. Broullon, A. Garcia-Campos, P. Pazos, and A. Castro-Beiras Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease Eur. Heart J., January 2, 2010; 31(2): 187 - 195. [Abstract] [Full Text] [PDF]

				J. M. Bourque, B. H. Holland, D. D. Watson, and G. A. Beller Achieving an Exercise Workload of >=10 Metabolic Equivalents Predicts a Very Low Risk of Inducible Ischemia: Does Myocardial Perfusion Imaging Have a Role? J. Am. Coll. Cardiol., August 4, 2009; 54(6): 538 - 545. [Abstract] [Full Text] [PDF]

				R. J. Gibbons Noninvasive Diagnosis and Prognosis Assessment in Chronic Coronary Artery Disease: Stress Testing With and Without Imaging Perspective Circ Cardiovasc Imaging, November 1, 2008; 1(3): 257 - 269. [Full Text] [PDF]

				R. Arena, J. Myers, and M. Guazzi The Clinical Significance of Aerobic Exercise Testing and Prescription: From Apparently Healthy to Confirmed Cardiovascular Disease American Journal of Lifestyle Medicine, November 1, 2008; 2(6): 519 - 536. [Abstract] [PDF]

				M. S. LAUER and T. D. MILLER The exercise treadmill test: Estimating cardiovascular prognosis Cleveland Clinic Journal of Medicine, June 1, 2008; 75(6): 424 - 430. [Abstract] [Full Text] [PDF]

				K P Savonen, T A Lakka, J A Laukkanen, T H Rauramaa, J T Salonen, and R Rauramaa Workload at the heart rate of 100 beats/min and mortality in middle-aged men with known or suspected coronary heart disease Heart, April 1, 2008; 94(4): e14 - e14. [Abstract] [Full Text] [PDF]

				P. N. Peterson, D. J. Magid, C. Ross, P. M. Ho, J. S. Rumsfeld, M. S. Lauer, E. E. Lyons, S. S. Smith, and F. A. Masoudi Association of Exercise Capacity on Treadmill With Future Cardiac Events in Patients Referred for Exercise Testing Arch Intern Med, January 28, 2008; 168(2): 174 - 179. [Abstract] [Full Text] [PDF]

				R. Arena, J. Myers, M. A. Williams, M. Gulati, P. Kligfield, G. J. Balady, E. Collins, and G. Fletcher Assessment of Functional Capacity in Clinical and Research Settings: A Scientific Statement From the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing Circulation, July 17, 2007; 116(3): 329 - 343. [Full Text] [PDF]

				L. D. Metz, M. Beattie, R. Hom, R. F. Redberg, D. Grady, and K. E. Fleischmann The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography: A Meta-Analysis J. Am. Coll. Cardiol., January 16, 2007; 49(2): 227 - 237. [Abstract] [Full Text] [PDF]

				P. Kligfield and M. S. Lauer Exercise Electrocardiogram Testing: Beyond the ST Segment Circulation, November 7, 2006; 114(19): 2070 - 2082. [Full Text] [PDF]

				E. S. Kaufman, D. M. Bloomfield, R. C. Steinman, P. B. Namerow, O. Costantini, R. J. Cohen, and J. T. Bigger Jr "Indeterminate" Microvolt T-Wave Alternans Tests Predict High Risk of Death or Sustained Ventricular Arrhythmias in Patients With Left Ventricular Dysfunction J. Am. Coll. Cardiol., October 3, 2006; 48(7): 1399 - 1404. [Abstract] [Full Text] [PDF]

				L A Gondoni, A Liuzzi, A M Titon, O Taronna, F Nibbio, P Ferrari, and G Leonetti A simple tool to predict exercise capacity of obese patients with ischaemic heart disease Heart, July 1, 2006; 92(7): 899 - 904. [Abstract] [Full Text] [PDF]

				M. H. Shishehbor, D. Litaker, C. E. Pothier, and M. S. Lauer Association of Socioeconomic Status With Functional Capacity, Heart Rate Recovery, and All-Cause Mortality JAMA, February 15, 2006; 295(7): 784 - 792. [Abstract] [Full Text] [PDF]

				L. J. Shaw, M. B. Olson, K. Kip, S. F. Kelsey, B. D. Johnson, D. B. Mark, S. E. Reis, S. Mankad, W. J. Rogers, G. M. Pohost, et al. The Value of Estimated Functional Capacity in Estimating Outcome: Results From the NHBLI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study J. Am. Coll. Cardiol., February 7, 2006; 47(3_Suppl_S): S36 - S43. [Abstract] [Full Text] [PDF]

				K. G. Tarakji, R. Brunken, P. M. McCarthy, M. O. Al-Chekakie, A. Abdel-Latif, C. E. Pothier, E. H. Blackstone, and M. S. Lauer Myocardial Viability Testing and the Effect of Early Intervention in Patients With Advanced Left Ventricular Systolic Dysfunction Circulation, January 17, 2006; 113(2): 230 - 237. [Abstract] [Full Text] [PDF]

				M. Lauer, E. S. Froelicher, M. Williams, and P. Kligfield Exercise Testing in Asymptomatic Adults: A Statement for Professionals From the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention Circulation, August 2, 2005; 112(5): 771 - 776. [Abstract] [Full Text] [PDF]

				Z. Y. Fang, J. Sharman, J. B. Prins, and T. H. Marwick Determinants of Exercise Capacity in Patients With Type 2 Diabetes Diabetes Care, July 1, 2005; 28(7): 1643 - 1648. [Abstract] [Full Text] [PDF]

				J. H. Mieres, L. J. Shaw, A. Arai, M. J. Budoff, S. D. Flamm, W. G. Hundley, T. H. Marwick, L. Mosca, A. R. Patel, M. A. Quinones, et al. Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association Circulation, February 8, 2005; 111(5): 682 - 696. [Abstract] [Full Text] [PDF]

				M. S. Chen, E. H. Blackstone, C. E. Pothier, and M. S. Lauer Heart Rate Recovery and Impact of Myocardial Revascularization on Long-Term Mortality Circulation, November 2, 2004; 110(18): 2851 - 2857. [Abstract] [Full Text] [PDF]

				M. K. Aktas, V. Ozduran, C. E. Pothier, R. Lang, and M. S. Lauer Global Risk Scores and Exercise Testing for Predicting All-Cause Mortality in a Preventive Medicine Program JAMA, September 22, 2004; 292(12): 1462 - 1468. [Abstract] [Full Text] [PDF]

				M. S. Lauer Chronotropic incompetence: Ready for prime time J. Am. Coll. Cardiol., July 21, 2004; 44(2): 431 - 432. [Full Text] [PDF]

				N. Seshadri, T. R. Gildea, K. McCarthy, C. Pothier, M. S. Kavuru, and M. S. Lauer Association of an Abnormal Exercise Heart Rate Recovery With Pulmonary Function Abnormalities Chest, April 1, 2004; 125(4): 1286 - 1291. [Abstract] [Full Text] [PDF]

				G. A. Beller and D. D. Watson Risk stratification using stress myocardial perfusion imaging: don't neglect the value of clinical variables J. Am. Coll. Cardiol., January 21, 2004; 43(2): 209 - 212. [Full Text] [PDF]

				T. Kavanagh, D. J. Mertens, L. F. Hamm, J. Beyene, J. Kennedy, P. Corey, and R. J. Shephard Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation J. Am. Coll. Cardiol., December 17, 2003; 42(12): 2139 - 2143. [Abstract] [Full Text] [PDF]

				D. B. Mark and M. S. Lauer Exercise Capacity: The Prognostic Variable That Doesn't Get Enough Respect Circulation, September 30, 2003; 108(13): 1534 - 1536. [Full Text] [PDF]

				D. P. Vivekananthan, E. H. Blackstone, C. E. Pothier, and M. S. Lauer Heart rate recovery after exercise is apredictor of mortality, independent of the angiographic severity of coronary disease J. Am. Coll. Cardiol., September 3, 2003; 42(5): 831 - 838. [Abstract] [Full Text] [PDF]

				M. S. Lauer The "exercise" part of exercise echocardiography J. Am. Coll. Cardiol., April 17, 2002; 39(8): 1353 - 1355. [Full Text] [PDF]

				A. M. Arruda-Olson, E. M. Juracan, D. W. Mahoney, R. B. McCully, V. L. Roger, and P. A. Pellikka Prognostic value of exercise echocardiographyin 5,798 patients: is there a gender difference? J. Am. Coll. Cardiol., February 20, 2002; 39(4): 625 - 631. [Abstract] [Full Text] [PDF]

				J. Watanabe, M. Thamilarasan, E. H. Blackstone, J. D. Thomas, and M. S. Lauer Heart Rate Recovery Immediately After Treadmill Exercise and Left Ventricular Systolic Dysfunction as Predictors of Mortality: The Case of Stress Echocardiography Circulation, October 16, 2001; 104(16): 1911 - 1916. [Abstract] [Full Text] [PDF]

				P. A. Gum, M. Thamilarasan, J. Watanabe, E. H. Blackstone, and M. S. Lauer Aspirin Use and All-Cause Mortality Among Patients Being Evaluated for Known or Suspected Coronary Artery Disease: A Propensity Analysis JAMA, September 12, 2001; 286(10): 1187 - 1194. [Abstract] [Full Text] [PDF]

				L. A. Diaz, R. C. Brunken, E. H. Blackstone, C. E. Snader, and M. S. Lauer Independent contribution of myocardial perfusion defects to exercise capacity and heart rate recovery for prediction of all-cause mortality in patients with known or suspected coronary heart disease J. Am. Coll. Cardiol., May 1, 2001; 37(6): 1558 - 1564. [Abstract] [Full Text] [PDF]

				R Bigi, A Desideri, A Galati, J J Bax, C Coletta, C Fiorentini, and P M Fioretti Incremental prognostic value of stress echocardiography as an adjunct to exercise electrocardiography after uncomplicated myocardial infarction Heart, April 1, 2001; 85(4): 417 - 423. [Abstract] [Full Text]

				C. A. Thompson, S. Jabbour, R. J. Goldberg, R. Y. S. McClean, B. Z. Bilchik, C. M. Blatt, S. Ravid, and T. B. Graboys Exercise performance-based outcomes of medically treated patients with coronary artery disease and profound ST segment depression J. Am. Coll. Cardiol., December 1, 2000; 36(7): 2140 - 2145. [Abstract] [Full Text] [PDF]

				E. O. Nishime, C. R. Cole, E. H. Blackstone, F. J. Pashkow, and M. S. Lauer Heart Rate Recovery and Treadmill Exercise Score as Predictors of Mortality in Patients Referred for Exercise ECG JAMA, September 20, 2000; 284(11): 1392 - 1398. [Abstract] [Full Text] [PDF]

				G. Vanzetto, O. Ormezzano, D. Fagret, M. Comet, B. Denis, and J. Machecourt Long-Term Additive Prognostic Value of Thallium-201 Myocardial Perfusion Imaging Over Clinical and Exercise Stress Test in Low to Intermediate Risk Patients : Study in 1137 Patients With 6-Year Follow-Up Circulation, October 5, 1999; 100(14): 1521 - 1527. [Abstract] [Full Text] [PDF]

				M. S. Lauer, G. S. Francis, P. M. Okin, F. J. Pashkow, C. E. Snader, and T. H. Marwick Impaired Chronotropic Response to Exercise Stress Testing as a Predictor of Mortality JAMA, February 10, 1999; 281(6): 524 - 529. [Abstract] [Full Text] [PDF]

				M. S. Lauer, R. Mehta, F. J. Pashkow, P. M. Okin, K. Lee, and T. H. Marwick Association of chronotropic incompetence with echocardiographic ischemia and prognosis J. Am. Coll. Cardiol., November 1, 1998; 32(5): 1280 - 1286. [Abstract] [Full Text] [PDF]

				Functional Capacity Predicts Mortality Journal Watch Cardiology, September 18, 1997; 1997(918): 7 - 7. [Full Text]

				FUNCTIONAL CAPACITY POWERFUL PREDICTOR OF MORTALITY Journal Watch (General), September 5, 1997; 1997(905): 6 - 6. [Full Text]