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CLINICAL RESEARCH

Treadmill scores in elderly men

Steve Lai, MD^,*, Amir Kaykha, MD^*, Takuya Yamazaki, MD^*, Mary Goldstein, MD, Joshua M. Spin, MD, PhD^*, Jonathan Myers, PhD^* and Victor F. Froelicher, MD

^* Division of Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
Veterans Affairs Health Care System, Palo Alto, California, USA

Manuscript received March 13, 2003; revised manuscript received July 2, 2003, accepted July 15, 2003.

^* Reprint requests and correspondence: Dr. Steve Lai, VA Medical Center Building 1, Box 181G, 4150 Clement Street, San Francisco, California 94121, USA.
slai1{at}itsa.ucsf.edu

OBJECTIVES: This study seeks to further characterize the role of exercise testing in the elderly for prognosis and diagnosis of coronary artery disease.

BACKGROUND: Recent exercise testing guidelines have recognized that statements regarding the elderly do not have an adequate evidence-based quality because the studies they are based on have limitations in sample size and design. The Duke Treadmill Score has been recommended for risk stratification, but recent evidence has suggested that it does not function in the elderly.

METHODS: The study population consisted of male veterans (1,872 patients 65 years; 3,798 patients <65 years) who underwent routine clinical exercise testing with a mean follow-up of six years. A subset who underwent coronary angiography as clinically indicated (elderly, n = 405; younger, n= 809) were included. The primary outcome for all subjects was cardiovascular mortality with coronary angiographic findings as the outcome in those selected for angiography.

RESULTS: In survival analysis, exercise-induced ST depression was prognostic in both age groups only when cardiovascular death was considered as the end point. Peak metabolic equivalents were the most significant predictor for both age groups only when all-cause death was considered as the end point. New age-specific prognostic scores were developed and found to be predictive for cardiovascular mortality in the elderly. Moreover, in the angiographic subset of the elderly, a specific diagnostic score provided significantly better discrimination than exercise ST measurements alone. For any new score, there is a need for validation in another elderly population.

CONCLUSIONS: The mortality end point affected the choice of prognostic variables. This study demonstrates that exercise test scores can be helpful for the diagnosis and prognosis of coronary disease in the elderly.

Abbreviations and Acronyms   AUC = area under the curve   CABG = coronary artery bypass graft   CAD = coronary artery disease   DTS = Duke Treadmill Score   LAD = left anterior descending coronary artery   MET = metabolic equivalent   MI = myocardial infarction   PRP = pressure rate product   ROC = receiver operator characteristic   VA/UWV = Veterans Affairs/University of West Virginia angiographic diagnostic score