CLINICAL STUDY: STRESS TESTING
Prognostic value of the Duke treadmill score in the elderly
Jennifer M. F. Kwok, MD*,
Todd D. Miller, MD, FACC*,
David O. Hodge, MS and
Raymond J. Gibbons, MD, FACC*,*
* Division of Cardiovascular Diseases and Department of Internal Medicine, Rochester, Minnesota, USA
Department of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Manuscript received July 26, 2001;
revised manuscript received January 22, 2002,
accepted February 5, 2002.
* Reprint requests and correspondence: Dr. Raymond J. Gibbons, Mayo Clinic E-16A, 200 First Street SW, Rochester, Minnesota 55905, USA.
gibbons.raymond{at}mayo.edu
OBJECTIVES: The purpose of this study was to test the hypothesis that the Duke treadmill score works less well for risk stratification in patients age 75 years or above.
BACKGROUND: Although the Duke treadmill score is generally effective for risk stratification, its prognostic value in the elderly may be limited because they have a higher prevalence of coronary artery disease (CAD), more severe CAD and a lower exercise tolerance.
METHODS: The study population consisted of 247 patients age 75 years or above, and the control population consisted of 2,304 patients below 75 years of age. All patients were symptomatic, had undergone exercise thallium testing between 1989 and 1991 and were followed for a median of >6.5 years. The Cox regression model was used to test the association of the Duke score (utilized both as a continuous variable and using previously published risk group cutoffs) with outcomes (cardiac death, nonfatal myocardial infarction [MI], late revascularization).
RESULTS: Using the Duke score to risk-stratify the elderly, 26% were in the low risk group, 68% were in the intermediate risk group and 6% were in the high risk groups; seven-year cardiac survival was 86%, 85% and 69%, respectively (p = 0.45). There was also no significant association between these Duke score risk groups and all other outcome end points in the elderly. The Duke score as a continuous variable did not predict cardiac death (p = 0.43) or cardiac death or MI (p = 0.42), but did predict total cardiac events (which included late revascularization) (p = 0.0027). For the control population, more patients (55%) were in the low risk group, and the Duke score (as a continuous variable or in risk groups) was highly predictive of all end points (p = 0.0001).
CONCLUSIONS: The Duke score predicted cardiac survival in younger patients but not in patients age 75 years or above. The majority of the elderly were classified as intermediate risk by the Duke score. Only a minority of the elderly were classified as low risk, but this group still had an annual cardiac mortality of 2%/year.
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Abbreviations and Acronyms
| | ACC/AHA | | American College of Cardiology/American Heart Association | | CAD | | coronary artery disease | | CABG | | coronary artery bypass grafting | | ECG | | electrocardiogram/electrocardiographic | | MI | | myocardial infarction | | PTCA | | percutaneous transluminal coronary angioplasty |
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