Risk stratification after successful coronary revascularization: the lack of a role for routine exercise testing

Area of Science:

• Cardiology
• Clinical Exercise Physiology

Background:

• Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines suggest routine exercise testing (EXT) within three years of successful coronary revascularization (CR) offers limited utility.
• This study investigates the ACC/AHA guidelines using data from the Bypass Angioplasty Revascularization Investigation (BARI).

Purpose of the Study:

• To evaluate the ACC/AHA guidelines for exercise testing (EXT) following successful coronary revascularization (CR).

Main Methods:

• Analysis of 1,678 patients randomized to angioplasty or bypass surgery within the BARI study.
• Patients underwent symptom-limited treadmill tests at one, three, and five years post-revascularization.

Main Results:

• Patients who completed EXT at one, three, and five years post-CR demonstrated significantly lower subsequent two-year mortality compared to those who did not (1.9% vs. 9.4%, 3.5% vs. 12.6%, and 3.3% vs. 11.0%, respectively; p < 0.0001 for all).
• Exercise parameters from one- and three-year tests did not enhance a multivariable survival model.
• Achieving Bruce stage 3 or a Duke score >-6 on the five-year test independently predicted two-year survival.
• ST depression on the one-year test correlated with increased revascularization events (RR = 1.6; p < 0.001).

Conclusions:

• Patients with stable multivessel coronary disease who adhered to a protocol-mandated EXT schedule post-CR experienced low subsequent mortality.
• Exercise parameters did not improve mortality prediction at one or three years post-CR.
• These findings support the ACC/AHA guidelines regarding the limited value of routine EXT in stable patients within three years of CR.