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Published on: October 17, 2018
The association of clinical indication for exercise stress testing with all-cause mortality: the FIT Project
Joonseok Kim1, Mouaz Al-Mallah2, Stephen P Juraschek3
1Division of Cardiology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
Insights
The reason for a stress test predicts mortality risk. Shortness of breath (SOB) may indicate higher mortality than chest pain, especially in patients with coronary artery disease (CAD).
Area of Science:
- Cardiology
- Clinical Medicine
- Epidemiology
Background:
- Physician-indicated reasons for stress testing are crucial in patient management.
- Understanding the prognostic value of these indications is essential for risk stratification.
Purpose of the Study:
- To determine if the indication for stress testing independently predicts all-cause mortality.
- To investigate the interaction between referral indications and coronary artery disease (CAD) status on mortality risk.
Main Methods:
- Analysis of 48,914 patients from The Henry Ford Exercise Testing Project (The FIT Project) without known congestive heart failure.
- Utilized hierarchical multivariable Cox proportional hazards regression, controlling for confounders and exercise capacity.
- Abstracted referral indications from clinical test orders.
Main Results:
- Referral for shortness of breath (SOB) and pre-operative evaluation was associated with increased mortality risk compared to chest pain.
- Referral for palpitations and risk factors only was associated with lower mortality risk.
- Shortness of breath (SOB) increased mortality risk primarily in patients with established coronary artery disease (CAD).
Conclusions:
- The indication for stress testing is an independent predictor of all-cause mortality.
- There is a significant interaction between referral indication and CAD status in predicting mortality.
- Shortness of breath (SOB) as an indication warrants careful consideration, particularly in patients with CAD, due to its association with higher mortality.
Introduction:
We hypothesized that the indication for stress testing provided by the referring physician would be an independent predictor of all-cause mortality.
Material And Methods:
We studied 48,914 patients from The Henry Ford Exercise Testing Project (The FIT Project) without known congestive heart failure who were referred for a clinical treadmill stress test and followed for 11 ±4.7 years. The reason for stress test referral was abstracted from the clinical test order, and should be considered the primary concerning symptom or indication as stated by the ordering clinician. Hierarchical multivariable Cox proportional hazards regression was performed, after controlling for potential confounders including demographics, risk factors, and medication use as well as additional adjustment for exercise capacity in the final model.
Results:
A total of 67% of the patients were referred for chest pain, 12% for shortness of breath (SOB), 4% for palpitations, 3% for pre-operative evaluation, 6% for abnormal prior testing, and 7% for risk factors only. There were 6,211 total deaths during follow-up. Compared to chest pain, those referred for palpitations (HR = 0.72, 95% CI: 0.60-0.86) and risk factors only (HR = 0.72, 95% CI: 0.63-0.82) had a lower risk of all-cause mortality, whereas those referred for SOB (HR = 1.15, 95% CI: 1.07-1.23) and pre-operative evaluation (HR = 2.11, 95% CI: 1.94-2.30) had an increased risk. In subgroup analysis, referral for palpitations was protective only in those without coronary artery disease (CAD) (HR = 0.75, 95% CI: 0.62-0.90), while SOB increased mortality risk only in those with established CAD (HR = 1.25, 95% CI: 1.10-1.44).
Conclusions:
The indication for stress testing is an independent predictor of mortality, showing an interaction with CAD status. Importantly, SOB may be associated with higher mortality risk than chest pain, particularly in patients with CAD.
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