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CLINICAL STUDY: CORONARY ARTERY DISEASE

Exercise performance-based outcomes of medically treated patients with coronary artery disease and profound ST segment depression

Craig A. Thompson, MD^*, Samer Jabbour, MD, MPH^*, Robert J. Goldberg, PhD, Renee Y. S. McClean, BS^*, Brian Z. Bilchik, MD, FACC^*, Charles M. Blatt, MD, FACC^*, Shmuel Ravid, MD, FACC^* and Thomas B. Graboys, MD, FACC^*

^* Lown Cardiovascular Research Foundation, Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA

Manuscript received April 10, 2000; revised manuscript received June 28, 2000, accepted August 18, 2000.

Reprint requests and correspondence: Dr. Craig A. Thompson, Lown Cardiovascular Center, 21 Longwood Avenue, Brookline, Massachusetts 02446-5239

OBJECTIVES

We sought to determine the relationship between exercise duration and cardiovascular outcomes in patients with profound (2 mm) ST segment depression during exercise treadmill testing (ETT).

BACKGROUND

Patients with stable symptoms but profound ST segment depression during ETT are often referred for a coronary intervention on the basis that presumed severe coronary artery disease (CAD) will lead to unfavorable cardiovascular outcomes, irrespective of symptomatic and functional status. We hypothesized that good exercise tolerance in such patients treated medically is associated with favorable long-term outcomes.

METHODS

We prospectively followed 203 consecutive patients (181 men; mean age 73 years) with known stable CAD and 2 mm ST segment depression who are performing ETT according to the Bruce protocol for an average of 41 months. The primary end point was occurrence of myocardial infarction (MI) or death.

RESULTS

Eight (20%) of 40 patients with an initial ETT exercise duration 6 min developed MI or died, as compared with five (6%) of 84 patients who exercised between 6 and 9 min and three (3.8%) of 79 patients who exercised 9 min (p = 0.01). Compared with patients who exercised 6 min, increased ETT duration was significantly associated with a reduced risk of MI/death (6 to 9 min: relative risk [RR] = 0.25, 95% confidence interval [CI] 0.08 to 0.76; >9 min: RR = 0.14, 95% CI 0.04 to 0.53). This protective effect persisted after adjustment for potentially confounding variables. We observed a 23% reduction in MI/death for each additional minute of exercise the patient was able to complete during the index ETT.

CONCLUSIONS

Optimal medical management in stable patients with CAD with profound exercise-induced ST segment depression but good ETT duration is an appropriate alternative to coronary revascularization and is associated with low rates of MI and death.

Abbreviations and Acronyms   CAD = coronary artery disease   CHF = congestive heart failure   CI = confidence interval   ECG = electrocardiographic or electrocardiogram   ETT = exercise treadmill test   HMG-CoA = hydroxymethyl glutaryl coenzyme A   LBBB = left bundle branch block   MI = myocardial infarction   NYHA = New York Heart Association   PHR = peak heart rate   RR = relative risk

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