CLINICAL STUDY
Risk stratification after successful coronary revascularization: the lack of a role for routine exercise testing
Ronald J. Krone, MD, FACC*,
Regina M. Hardison, MS ,
Bernard R. Chaitman, MD, FACC ,
Raymond J. Gibbons, MD, FACC ,
George Sopko, MD, MPH, FACC||,
Richard Bach, MD, FACC* and
Katherine M. Detre, MD, DrPH
* Washington University School of Medicine, St. Louis, Missouri, USA
University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
St. Louis University Health Sciences Center, St. Louis, Missouri, USA
Mayo Clinic, Rochester, Minnesota, USA
|| National Heart Lung and Blood Institute, Bethesda, Maryland, USA
Manuscript received August 8, 2000;
revised manuscript received March 13, 2001,
accepted March 28, 2001.
Reprint requests and correspondence: Dr. Katherine Detre, c/o BARI Coordinating Center, University of Pittsburgh, 127 Parran Hall, 130 DeSoto Street, Pittsburgh, Pennsylvania 15261
OBJECTIVE
The objective of this study was to evaluate the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for exercise testing (EXT) after successful coronary revascularization (CR) using the Bypass Angioplasty Revascularization Investigation experience.
BACKGROUND
The ACC/AHA guidelines state that EXT within three years of successful CR is not useful.
METHODS
The 1,678 patients randomized to CR by either angioplasty or bypass surgery were required to take symptom-limited treadmill tests one, three and five years after revascularization.
RESULTS
Patients who took the test at each specified time had a much lower subsequent two-year mortality than those who did not (1.9% vs. 9.4%, 3.5% vs. 12.6% and 3.3% vs. 11.0% at one, three and five years, respectively, after CR [p < 0.0001 for each]). Exercise parameters at the one- and three-year test did not improve a multivariable model of survival after including clinical parameters. Exercising to Bruce stage 3 or generating a Duke score >–6 were independently predictive of two-year survival after the five-year test. ST depression on the one-year test was associated with more revascularizations (relative risk = 1.6; p < 0.001).
CONCLUSIONS
Patients with stable multivessel coronary disease who took a protocol-mandated exercise test at one, three and five years after revascularization were at low risk for mortality in the two years subsequent to each test. Exercise parameters did not improve prediction of mortality in the two years after the one- and three-year tests. The ACC/AHA guidelines on exercise testing after CR (no value for routine testing in stable patients for three years after revascularization) are supported by these results.
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Abbreviations and Acronyms
| | ACC/AHA | = American College of Cardiology/American Heart Association | | BARI | = Bypass Angioplasty Revascularization Investigation | | CABG | = coronary artery bypass grafting | | CAD | = coronary artery disease | | CEL | = Core Electrocardiographic Laboratory | | CR | = coronary revascularization | | ECG | = electrocardiogram | | EXT | = exercise test | | MI | = myocardial infarction | | PTCA | = percutaneous transluminal coronary angioplasty | | RR | = relative risk |
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