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Exercise and the Heart |

Clinical and Exercise Test Predictors of All-Cause Mortality*: Results From > 6,000 Consecutive Referred Male Patients

Manish Prakash, MD; Jonathan Myers, PhD; Victor F. Froelicher, MD; Rachel Marcus, MD; Dat Do, MD; Damayanthi Kalisetti, MD; J. Edwin Atwood, MD
Author and Funding Information

*From the Division of Cardiovascular Medicine, Stanford University Medical Center and the University of California Irvine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.

Correspondence to: Victor Froelicher, MD, Cardiology Division (111C), Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304; e-mail: vicmd@aol.com



Chest. 2001;120(3):1003-1013. doi:10.1378/chest.120.3.1003
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Objective: To report the prevalence of abnormal treadmill test responses and their association with mortality in a large consecutive series of patients referred for standard exercise tests, with testing performed and reported in a standardized fashion.

Background: Exercise testing is widely performed, but few databases exist of large numbers of consecutive tests performed on patients referred for routine clinical purposes using standardized methods. Even fewer of the available databases have information regarding all-cause mortality as an outcome.

Methods: All patients referred for evaluation at two university-affiliated Veterans Affairs medical centers who underwent exercise treadmill testing for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security death index after a mean 6.2 years (median, 7 years) of follow-up. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. All-cause mortality was utilized as the end point for follow-up. Standard survival analysis was performed, including Kaplan-Meier curves and a Cox hazard model.

Results: There were 6,213 male patients (mean ± SD age, 59 ± 11 years) who underwent standard exercise ECG treadmill testing over the study period with a mean follow-up duration of 6.2 ± 3.7 years. There were no complications of testing in this clinically referred population, 78% of whom were referred for chest pain, or risk factors or signs or symptoms of ischemic heart disease. Overlapping thirds had typical angina or history of myocardial infarction (MI). Five hundred seventy-nine patients had prior coronary artery bypass surgery, and 522 patients had a history of congestive heart failure (CHF). Indications for testing were in accordance with published guidelines. Twenty percent died over the follow-up period, for an average annual mortality rate of 2.6%. Cox hazard function chose the following variables in rank order as independently and significantly associated with time to death: exercise capacity (metabolic equivalents < 5, age > 65 years, history of CHF, and history of MI. A score based on these variables (summing up the four variables [if yes = 1 point]) classified patients into low-risk, medium-risk, and high-risk groups. The high-risk group (score ≥ 3) has a hazard ratio of 5.0 (95% confidence interval, 4.7 to 5.3) and a 5-year mortality rate of 31%.

Conclusion: This comprehensive analysis provides rates of various abnormal responses that can be expected in patients referred for exercise testing at a typical medical center. Four simple variables combined as a score powerfully stratified patients according to prognosis.

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