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J Am Coll Cardiol, 2004; 43:194-199, doi:10.1016/j.jacc.2003.09.029 © 2004 by the American College of Cardiology Foundation |
* Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Department of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Manuscript received March 4, 2003; revised manuscript received July 23, 2003, accepted September 9, 2003.
* Reprint requests and correspondence: Dr. Raymond J. Gibbons, Nuclear Cardiology, Charlton 2, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA.
gibbons.raymond{at}mayo.edu
OBJECTIVES: The purpose of this study was to determine whether a previously validated clinical score (CS) could identify patients with a low-risk Duke treadmill score who had a higher risk of adverse events and, therefore, in whom myocardial perfusion imaging would be valuable for risk stratification.
BACKGROUND: Current American College of Cardiology/American Heart Association guidelines recommend using a standard exercise test without imaging as the initial test in patients who have an interpretable electrocardiogram and are able to exercise.
METHODS: We studied 1,461 symptomatic patients with low-risk Duke treadmill scores (
5) who underwent myocardial perfusion imaging. The CS was derived by assigning one point to each of the following variables: typical angina, history of myocardial infarction, diabetes, insulin use, male gender, and each decade of age over 40 years. A CS cutoff 5 or <5 was used to categorize patients as high risk (n = 303 [21%]) or low risk (n = 1,158 [79%]). Perfusion scans were categorized as low, intermediate, or high risk on the basis of the global stress score (GSS).
RESULTS: High-risk scans were more common in patients with a high-risk CS (26.4% vs. 9.5%, p < 0.0001). The CS and GSS were significant independent predictors of cardiac death. However, in patients with a low CS, seven-year cardiac survival was excellent, regardless of the GSS (99% for normal scans, 99% for mildly abnormal scans, and 99% for severely abnormal scans). In contrast, patients with a high CS had a lower seven-year survival rate (92%), which varied with GSS (94% for normal scans, 94% for mildly abnormal scans, and 84% for severely abnormal scans; p < 0.001).
CONCLUSIONS: In symptomatic patients with low-risk Duke treadmill scores and low clinical risk, myocardial perfusion imaging is of limited prognostic value. In patients with low-risk Duke treadmill scores and high clinical risk, annual cardiac mortality (>1%) is not low, and myocardial perfusion imaging has independent prognostic value.
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