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Prediction of atherosclerotic cardiovascular death in men using a prognostic score
V Froelicher1, K Morrow, M Brown
1Cardiology Section, Palo Alto Veterans Affairs Medical Center, California 94304.
Insights
A new Veterans Affairs Prognostic Score predicts cardiovascular death risk in patients undergoing exercise testing for coronary artery disease. This score can help identify patients unlikely to benefit from invasive procedures like cardiac catheterization.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Risk Stratification
Background:
- Coronary artery disease (CAD) evaluation often involves exercise testing.
- Risk stratification is crucial for guiding patient management and resource allocation.
- Identifying patients who will not benefit from invasive procedures is essential.
Purpose of the Study:
- To develop and validate a prognostic score for predicting cardiovascular death in patients evaluated for CAD.
- To assess the utility of the developed score in identifying patients for whom cardiac catheterization may be unnecessary.
Main Methods:
- Prospective data collection from 3,134 male patients undergoing exercise testing for CAD evaluation.
- Application of Cox proportional-hazards model to identify independent predictors of cardiovascular death.
- Construction of the Veterans Affairs Prognostic Score based on significant predictors.
- Analysis of the score's association with cardiovascular mortality and its implications for cardiac catheterization decisions.
Main Results:
- Key independent predictors of cardiovascular death identified: congestive heart failure/digoxin use, exercise-induced ST depression, change in systolic blood pressure, and exercise capacity (METs).
- The Veterans Affairs Prognostic Score effectively stratified patients by cardiovascular mortality risk.
- In a subgroup selected for cardiac catheterization, over half had a score indicating low annual mortality (<2%), suggesting the procedure was potentially unnecessary for prognosis improvement.
Conclusions:
- The Veterans Affairs Prognostic Score is a valuable tool for risk stratification in patients undergoing exercise testing for CAD.
- The score can help clinicians avoid unnecessary invasive procedures like cardiac catheterization in low-risk patients.
- Accurate prognostic assessment can optimize patient care and resource utilization in cardiology.
Abstract:
Treadmill and clinical data were gathered prospectively on consecutive patients who underwent exercise testing for evaluation for coronary artery disease in a 1,200 bed Veterans Affairs Medical Center. From 3,609 men referred for exercise testing from 1984 to 1990, 3,134 patients remained after excluding those with significant valvular heart disease and those with prior coronary artery bypass surgery. Of these, 588 were selected for clinical reasons to undergo cardiac catheterization within 3 months of evaluation leaving 2,546 who were not selected. Over 3 years, there were 158 cardiovascular deaths, 99 nonfatal myocardial infarcts and 183 patients who underwent coronary artery bypass surgery. In the total population, the Cox proportional-hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death: a history of congestive heart failure and/or taking digoxin, exercise-induced ST depression, the change in systolic blood pressure during exercise, and exercise capacity in METs. Using the Cox model coefficients to weight the variables, a simple score (the Veterans Affairs Prognostic Score) was constructed based on these items. Average annual cardiovascular mortality was plotted against the score enabling its estimation for any given patient. In the subgroup selected for cardiac catheterization (n = 588), the mean score was greater, consistent with a poorer prognosis, compared with the total population; 53% (n = 312) had a score < -2 associated with an annual mortality < 2%. Thus, in over half of the patients selected for catheterization, the catheterization was unnecessary if performed to lessen their chance of cardiovascular death, since no intervention could improve their prognosis.(ABSTRACT TRUNCATED AT 250 WORDS)