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Prediction of cardiovascular death in men undergoing noninvasive evaluation for coronary artery disease
K Morrow1, C K Morris, V F Froelicher
1Palo Alto Veterans Affairs Medical Center, California.
Insights
This study developed a simple risk score using clinical and exercise test data to predict cardiovascular events in male veterans. The score effectively categorizes patients into low, moderate, and high-risk groups for cardiac mortality.
Area of Science:
- Cardiology
- Preventive Medicine
- Clinical Risk Stratification
Background:
- Cardiovascular disease remains a leading cause of mortality in male veterans.
- Accurate risk prediction is crucial for guiding preventive strategies and patient management.
- Non-invasive evaluations are frequently used to assess patients with known or suspected coronary artery disease.
Purpose of the Study:
- To develop and validate prediction rules for cardiovascular events using clinical and exercise test data.
- To identify patients at high and low risk for cardiovascular events among male veterans.
- To create a simple risk score for predicting cardiovascular mortality.
Main Methods:
- A prognostic study involving prospective data collection and routine follow-up of consecutive patients referred for exercise testing.
- Included 2546 male veterans evaluated between 1984 and 1990 at a Veterans Affairs Medical Center.
- Utilized the Cox proportional hazards model to identify independent predictors of cardiovascular death.
Main Results:
- A simple risk score incorporating clinical history (congestive heart failure/digoxin use) and exercise test responses (ST depression, blood pressure change, exercise capacity) was developed.
- The model identified 77% of patients as low risk ( < 2% annual cardiac mortality), 18% as moderate risk (7% annual cardiac mortality), and 6% as high risk (15% annual cardiac mortality).
- Statistically independent predictors of cardiovascular death included history of congestive heart failure or digoxin use, exercise-induced ST depression, change in systolic blood pressure during exercise, and exercise capacity.
Conclusions:
- Clinical and exercise test variables are valuable for predicting future cardiovascular death risk.
- A readily applicable risk score can aid in stratifying patients with known or suspected coronary artery disease.
- Further validation of the developed risk model is warranted.
Objective:
To develop prediction rules from clinical and exercise test data identifying patients at high and low risk for cardiovascular events among a group of male veterans.
Design:
Prognostic study with prospective gathering of data and routine follow-up of consecutive patients referred for exercise testing. Patients only underwent noninvasive evaluation for coronary artery disease. No validation cohort is yet available.
Setting:
A 1200-bed Veterans Affairs Medical Center.
Patients:
Of 3609 men referred for exercise testing between 1984 and 1990, 2546 patients remained evaluable after exclusion of those who underwent subsequent cardiac catheterization, those with significant valvular heart disease, and those who had previous coronary artery bypass surgery.
Measurements:
Evaluation included recording of clinical data on a standardized form and a standard treadmill test followed by assessment of cardiovascular events.
Results:
During a mean follow-up period (+/- SD) of 2.75 (+/- 18) years, 119 cardiovascular deaths and 44 nonfatal myocardial infarctions occurred in 2546 patients. The Cox proportional hazards model showed the following characteristics to be statistically independent predictors of time until cardiovascular death: history of congestive heart failure or digoxin use, exercise-induced ST depression, change in systolic blood pressure during exercise, and exercise capacity. Using a simple score based on one item of clinical information (history of congestive heart failure or digoxin use) and three exercise test responses (ST depression, exercise capacity, and change in systolic blood pressure), 77% of patients were categorized as low risk (annual cardiac mortality rate, less than 2%), 18% as moderate risk (annual cardiac mortality rate, 7%), and 6% as high risk (annual cardiac mortality rate, 15%; hazard ratio, 10; 95% confidence interval, 6 to 17). This model has not yet been validated.
Conclusions:
Variables available from the usual non-invasive work-up of patients with known or suspected coronary artery disease can be used to predict future risk for cardiovascular death.
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