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Risk stratification after successful coronary revascularization: the lack of a role for routine exercise testing
R J Krone1, R M Hardison, B R Chaitman
1Washington University School of Medicine, St Louis, Missouri, USA.
Insights
Routine exercise testing (EXT) after coronary revascularization (CR) is valuable. Patients undergoing EXT one, three, and five years post-CR had significantly lower mortality, supporting guideline evaluations.
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.
Objective:
The objective of this study was to evaluate the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for exercise testing (EXT) after successful coronary revascularization (CR) using the Bypass Angioplasty Revascularization Investigation experience.
Background:
The ACC/AHA guidelines state that EXT within three years of successful CR is not useful.
Methods:
The 1,678 patients randomized to CR by either angioplasty or bypass surgery were required to take symptom-limited treadmill tests one, three and five years after revascularization.
Results:
Patients who took the test at each specified time had a much lower subsequent two-year mortality than those who did not (1.9% vs. 9.4%, 3.5% vs. 12.6% and 3.3% vs. 11.0% at one, three and five years, respectively, after CR [p < 0.0001 for each]). Exercise parameters at the one- and three-year test did not improve a multivariable model of survival after including clinical parameters. Exercising to Bruce stage 3 or generating a Duke score >-6 were independently predictive of two-year survival after the five-year test. ST depression on the one-year test was associated with more revascularizations (relative risk = 1.6; p < 0.001).
Conclusions:
Patients with stable multivessel coronary disease who took a protocol-mandated exercise test at one, three and five years after revascularization were at low risk for mortality in the two years subsequent to each test. Exercise parameters did not improve prediction of mortality in the two years after the one- and three-year tests. The ACC/AHA guidelines on exercise testing after CR (no value for routine testing in stable patients for three years after revascularization) are supported by these results.
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