CLINICAL RESEARCH: CARDIAC IMAGING
The incremental prognostic value of percentage of heart rate reserve achieved over myocardial perfusion single-photon emission computed tomography in the prediction of cardiac death and all-cause mortality
Superiority over 85% of maximal age-predicted heart rate
Babak Azarbal, MD*,
Sean W. Hayes, MD*  ,
Howard C. Lewin, MD*,
Rory Hachamovitch, MD, MSc, FACC,
Ishac Cohen, PhD and
Daniel S. Berman, MD, FACC*,*
* Department of Medicine (Division of Cardiology), University of California, Los Angeles, School of Medicine, Los Angeles, California, USA
Department of Imaging (Division of Nuclear Medicine), University of California, Los Angeles, School of Medicine, Los Angeles, California, USA
CSMC Burns & Allen Research Institute, Cedars-Sinai Medical Center, University of California, Los Angeles, School of Medicine, Los Angeles, California, USA
Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
Manuscript received January 30, 2003;
revised manuscript received February 10, 2004,
accepted February 11, 2004.
* Reprint requests and correspondence: Dr. Daniel S. Berman, Cedars-Sinai Medical Center, Taper 1258, 8700 Beverly Boulevard, Los Angeles, California 90048, USA.
Daniel.Berman{at}cshs.org
OBJECTIVES: We sought to determine whether chronotropic incompetence (CI) adds incremental value in predicting cardiac death (CD) and all-cause mortality and to determine which marker of CI is superior.
BACKGROUND: Chronotropic incompetence, defined by either a low percent heart rate (HR) reserve achieved or failure to achieve 85% maximal age-predicted heart rate (MA-PHR), is a predictor of mortality. These variables have not been examined together in a comprehensive myocardial perfusion single-photon emission computed tomographic (SPECT), or MPS, model.
METHODS: A total of 10,021 patients who underwent exercise MPS, evaluated by a summed stress score (SSS), were followed up for 719 ± 252 days. Percent HR reserve = (peak HR – rest HR)/(220 – age – rest HR) x 100, with <80% considered abnormal.
RESULTS: A total of 2,956 patients (29.5%) had low %HR reserve; 1,331 (13.3%) achieved <85% MA-PHR; and 1,296 (13.0%) had both. There were 234 deaths (93 CDs). On multivariate analysis, the SSS, %HR reserve, and inability to achieve 85% MA-PHR were predictors of all-cause mortality and CD (all p < 0.01). Myocardial perfusion SPECT was the most powerful predictor of CD (chi-square = 50). When the %HR reserve and ability to achieve 85% MA-PHR were considered, only the former remained a predictor of CD (p = 0.006 vs. p = 0.59).
CONCLUSIONS: In a comprehensive MPS model, CI was an important predictor of CD and all-cause mortality. Percent HR reserve was superior to the ability to achieve 85% MA-PHR in predicting CD; MPS was superior to both. Combined with previous studies, the findings suggest that %HR reserve should become the standard for assessing the adequacy of HR response during exercise testing, and that it should be routinely incorporated in risk stratification algorithms.
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Abbreviations and Acronyms
| | CAD | = coronary artery disease | | CD | = cardiac death | | CI | = chronotropic incompetence | | HR | = heart rate | | MA-PHR | = maximal age-predicted heart rate | | MPS or SPECT | = myocardial perfusion single-photon emission computed tomography | | SDS | = summed difference score | | SRS | = summed rest score | | SSS | = summed stress score |
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