Biomedical subjects

Claire E Pothier

Publications and source records attributed to Claire E Pothier.

16 recordsLinked to original sources

PubMed2006

Association of socioeconomic status with functional capacity, heart rate recovery, and all-cause mortality.

CONTEXT: Lower socioeconomic status (SES) confers heightened cardiovascular risk and mortality, although the mediating pathways are unclear. OBJECTIVE: To evaluate the extent to which exercise physiologic characteristics account for the association between lower SES and mortality. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 30 043 consecutive patients living in 7 counties in northeast Ohio referred between 1990 and 2002 for symptom-limited stress testing for evaluation of known or suspected coronary artery disease. Follow-up for mortality continued through February 2004. MAIN OUTCOME MEASURES: Estimated functional capacity in metabolic equivalents and heart rate recovery, physiologic characteristics that are determined directly from exercise; testing and all-cause mortality during a median follow-up of 6.5 years. RESULTS: Multivariable models adjusting for demographics, insurance status, smoking status, and clinical confounders demonstrated a strong association between a composite SES score based on census block data and functional capacity (adjusted odds ratio comparing 25th with 75th percentile values, 1.72; 95% confidence interval [CI], 1.56-1.89; P<.001) as well as heart rate recovery (adjusted odds ratio comparing 25th with 75th percentile values, 1.18; 95% CI, 1.07-1.30; P<.001). There were 2174 deaths, with mortality risk increasing from 5% to 10% as SES decreased by quartile (P<.001). Cox proportional hazards models that included all confounding variables except exercise physiologic characteristics demonstrated increased mortality as SES decreased (adjusted hazard ratio comparing 25th with 75th percentile values, 1.32; 95% CI, 1.22-1.42; P<.001). After further adding functional capacity and heart rate recovery, the magnitude of this relationship was reduced (comparing 25th with 75th percentile values; adjusted hazard ratio, 1.17; 95% CI, 1.08-1.26; P<.001), with these variables explaining 47% of the association. CONCLUSIONS: Impaired functional capacity and abnormal heart rate recovery were strongly associated with lower SES and accounted for a major proportion of the correlation between SES and mortality. Efforts to modify these clinical features among patients with low SES may narrow disparities in mortality.

Adult↗

PubMed2006

Myocardial viability testing and the effect of early intervention in patients with advanced left ventricular systolic dysfunction.

BACKGROUND: The clinical value of revascularization and other procedures in patients with severe systolic heart failure is unclear. It has been suggested that assessing ischemia and viability by positron emission tomography (PET) with fluorodeoxyglucose (FDG) imaging may identify patients for whom revascularization may lead to improved survival. We performed a propensity analysis to determine whether there might be a survival advantage from revascularization. METHODS AND RESULTS: We analyzed the survival of 765 consecutive patients (age 64+/-11 years, 80% men) with advanced left ventricular systolic dysfunction (ejection fraction < or =35%) and without significant valvular heart disease who underwent PET/FDG study at the Cleveland Clinic between 1997 and 2002. Early intervention was defined as any cardiac intervention (surgical or percutaneous) within the first 6 months of the PET/FDG study. In the entire cohort, 230 patients (30%) underwent early intervention (188 [25%] had open heart surgery, most commonly coronary artery bypass grafting, and 42 [5%] had percutaneous revascularization); 535 (70%) were treated medically. Using 39 demographic, clinical and PET/FDG variables, we were able to propensity-match 153 of the 230 patients with 153 patients who did not undergo early intervention. Among the propensity-matched group, there were 84 deaths during a median of 3 years follow-up. Early intervention was associated with a markedly lower risk of death (3-year mortality rate of 15% versus 35%, propensity adjusted hazard ratio 0.52, 95% CI 0.33 to 0.81, P=0.0004). CONCLUSIONS: Among systolic heart failure patients referred for PET/FDG, early intervention may be associated with improved survival irrespective of the degree of viability.

Aged↗

PubMed2006

Exercise-induced QT/R-R-interval hysteresis as a predictor of myocardial ischemia.

OBJECTIVES: Exercise-induced QT/RR hysteresis exists when, for a given R-R interval, the QT interval duration is shorter during recovery after exercise than during exercise. We sought to assess the association between QT/RR hysteresis and imaging evidence of myocardial ischemia. BACKGROUND: Because ischemia induces cellular disturbances known to decrease membrane action potential duration, we hypothesized a correlation between QT/RR and myocardial ischemia. METHODS: We digitally analyzed 4-second samples of QT duration and R-R-interval duration in 260 patients referred for treadmill exercise stress and rest single photon emission computed tomography myocardial perfusion imaging; a cool-down period was used after exercise. None of the patients were in atrial fibrillation or used digoxin, and none had marked baseline electrocardiographic abnormalities. Stress and rest myocardial perfusion images were analyzed visually and quantitatively to define the extent and severity of stress-induced ischemia. QT/RR hysteresis was calculated using a computerized algorithm. RESULTS: There were 82 patients (32%) who manifested myocardial ischemia by single photon emission computed tomography myocardial perfusion imaging. The likelihood of ischemia increased with increasing QT/RR hysteresis, with prevalence according to quartiles of 20%, 30%, 26%, and 49% (P = .003 for trend). In analyses adjusting for ST-segment changes, exercise capacity, heart rate recovery, and other confounders, QT/RR hysteresis was independently predictive of presence of myocardial ischemia (adjusted odds ratio for 100-point increase of QT/RR hysteresis, 1.61; 95% confidence interval, 1.22-2.12; P = .0008). QT/RR hysteresis was also predictive of severe ischemia. CONCLUSION: Exercise-induced QT/RR hysteresis is a strong and independent predictor of myocardial ischemia and provides additional information beyond that afforded by standard ST-segment measures.

Aged↗

PubMed2005

Chronotropic incompetence as a predictor of death among patients with normal electrograms taking beta blockers (metoprolol or atenolol).

Chronotropic incompetence, or an inability to increase heart rate during exercise, independently predicts death in patients not taking beta blockers. Whether it predicts death in patients taking beta blockers is not known. Consecutive patients (n = 3,736; mean age 58 +/- 11 years; 68% men), who were taking either metoprolol tartrate or atenolol and were referred for symptom-limited exercise testing from 1990 to 2002 at a major academic medical center, formed the prospective study cohort. None had heart failure, pacemakers, atrial fibrillation, or any electrocardiographic abnormalities. Patients were followed for a median of 4.5 years for all-cause mortality. Chronotropic response was defined as the percentage of heart rate reserve used. A value of < or =62%, which was noted in 813 patients (22%), was considered abnormal, meaning that chronotropic incompetence was present. There were 173 deaths. After adjusting for age, gender, heart rate at rest, standard risk factors, other medications, Duke treadmill score, and heart rate recovery, chronotropic incompetence predicted death (adjusted hazard ratio 1.94, 95% confidence interval 1.43 to 2.64, p <0.0001). The association of chronotropic incompetence with death was present, irrespective of which drug was taken or the number of half-lives that had elapsed since the last dose. In conclusion, in patients taking beta blockers, chronotropic incompetence is independently predictive of death.

Adrenergic beta-Antagonists↗

PubMed2005

Heart rate response during dipyridamole stress as a predictor of mortality in patients with normal myocardial perfusion and normal electrocardiograms.

Although it is well established that a blunted chronotropic response to exercise is associated with a higher risk of death, recent data suggest a similar association between mortality risk and blunted heart rate response to vasodilatory stress. We investigated the heart rate response to dipyridamole-induced stress as a predictor of death in the setting of normal myocardial perfusion and a normal electrocardiogram. We followed 1,087 patients for 8 years (range 5.7 to 11.8) who underwent dipyridamole vasodilator stress and had normal perfusion scans and electrocardiograms. None had heart failure, known left ventricular systolic dysfunction, pacemaker implantation, or valve disease. Heart rate response was assessed as the ratio of heart rate at peak stress to heart rate at rest. The primary end point was all-cause mortality. Quartile values for the peak-to-rest heart rate ratio were <1.19, 1.19 to 1.30, 1.31 to 1.44, and >1.44. There were 246 deaths. Death rates according to quartiles of heart rate ratio were 103 of 271 (38%), 64 of 272 (24%), 52 of 272 (19%), and 27 of 272 (10%). After adjusting for age, gender, heart rate at rest, blood pressure response, standard cardiovascular risk factors, and other confounders, a blunted heart rate response remained predictive of death (adjusted hazard ratio for lowest vs highest quartile 3.3, 95% confidence interval 2.1 to 5.1, p <0.0001). When considered as a continuous variable, the logarithm of the heart rate ratio was the strongest predictor of death, aside from age. Thus, among patients who have normal myocardial perfusion and normal electrocardiograms, a blunted heart rate response to vasodilator stress is predictive of a marked increase in risk of death.

Aged↗

PubMed2005

Peak oxygen consumption as a predictor of death in patients with heart failure receiving beta-blockers.

BACKGROUND: Peak oxygen uptake (peak VO2) is a strong predictor of mortality and is commonly used in the evaluation of patients for cardiac transplantation. Beta-blockers reduce mortality in patients with heart failure, without influencing peak VO2, raising the possibility that peak VO2 is no longer suitable as an indicator of prognosis in these patients. METHODS AND RESULTS: We analyzed prospectively gathered data on 2105 patients referred for cardiopulmonary testing for all-cause mortality and for occurrence of death or transplantation. Patients receiving beta-blockers were younger, more likely to have coronary disease, and had a greater mean ejection fraction but had a similar peak VO2. There were 555 deaths (26%) and 194 (9%) transplants during a median follow-up of 3.5 years. Peak VO2 was a predictor of mortality irrespective of beta-blocker use; a decrease of 1 mL x kg(-1) x min(-1) resulted in an adjusted hazard ratio (HR) of 1.13 (95% CI 1.09 to 1.17, P<0.0001) in patients not receiving beta-blockers and 1.27 (95% CI 1.18 to 1.36, P<0.0001) in patients receiving beta-blockers. Similar findings were noted when considering death or transplantation as an end point. Beta-blocker use was associated with better outcomes until peak VO2 values became very low (approximately 10 mL x kg(-1) x min(-1)), at which level survival rates were equally poor. CONCLUSION: Peak VO2 is a determinant of survival in patients in heart failure even in the setting of beta-blockade. Because of improved survival in patients treated with beta-blockers, the cut point value of 14 mg x kg(-1) x min(-1) for referral for cardiac transplantation in these patients requires reevaluation, and a lower cut point may be more appropriate.

Adrenergic beta-Antagonists↗

PubMed2005

Prediction of death or myocardial infarction by exercise single photon emission computed tomography perfusion scintigraphy in patients who have had recent coronary artery stenting.

BACKGROUND: Although practice guidelines do not recommend routine exercise testing of patients after coronary stenting, several small studies have suggested that stress myocardial perfusion imaging can provide prognostic information about future adverse cardiac events. We sought to determine if exercise nuclear testing provides independent prognostic information in patients after coronary stenting. METHODS: We analyzed the outcomes of 370 patients who underwent dual isotope exercise nuclear scintigraphy at least 1 month after coronary stenting and had testing between April 1996 and May 2002. Patients were classified according to presence or absence of any ischemia. The primary endpoint was all-cause mortality or myocardial infarction (MI) during a median of 30 months (range 6-59) of follow-up. RESULTS: There were 86 patients (23%) who had ischemia. Major events--death or MI--occurred in 62 patients including 22 deaths. Among patients with no ischemia, the 30-month event rate was 9.1%, whereas among patients with ischemia, the event rate was 17.0% (P = .001). After adjusting for age, sex, standard cardiac risk factors, cardiac history, left ventricular ejection fraction, angiographic findings, procedural variables, exercise capacity, and heart-rate dynamics, the presence of scintigraphic evidence of ischemia predicted death or MI (adjusted hazard ratio 2.08, 95% CI 1.21-3.56, P = .008). The presence of ischemia similarly predicted events in asymptomatic patients (adjusted hazard ratio 2.19, 95% CI 1.17-4.11, P = .015). CONCLUSIONS: In patients with recent coronary stent placement, reversible nuclear perfusion defects independently predicted risk of death or MI.

Angioplasty, Balloon, Coronary↗

PubMed2005

Can we reliably predict long-term mortality after exercise testing? An external validation.

OBJECTIVE: The aim of the study was to derive and externally validate a mortality prediction rule for patients undergoing exercise testing. BACKGROUND: The prognostic value of exercise testing is increasingly appreciated. However, global prognosis estimates ideally should account for numerous routinely obtained variables, including demographics, risk factors, resting electrocardiogram, and multiple exercise test measures. METHODS: A prediction rule was derived by parametric hazards modeling on a derivation set of 46047 Cleveland Clinic patients (age 55 +/- 11 years, 67% male) who had no history of heart failure, valve disease, or atrial fibrillation. Twenty-two variables covering demographics, risk factors, exercise hemodynamics, and electrocardiogram findings at rest and during exercise were considered. The resulting model included 16 variables and was tested on 4981 patients (age 50 +/- 12 years, 55% male) who underwent exercise testing at West Virginia University. RESULTS: In the derivation cohort there were 3173 deaths during a mean of 7 years of follow-up, whereas in the validation cohort there were 180 deaths during a mean of 5 years of follow-up. Comparisons of predicted and observed death rates showed very good agreement among all patients across all spectrums of risk, as well as among prespecified high-risk subgroups. Model discrimination was also good, with c statistic of c = 0.79 in the derivation group and c = 0.81 in the validation cohort. CONCLUSIONS: We have externally validated a mortality prediction rule for patients undergoing exercise testing and confirmed its accuracy among a wide spectrum of patients.

Adult↗

PubMed2004

Heart rate recovery and impact of myocardial revascularization on long-term mortality.

BACKGROUND: Although heart rate recovery (HRR) predicts mortality after exercise testing, its ability to identify patients likely to benefit after revascularization is unknown. We sought to determine whether HRR can identify patients likely to have improved survival after revascularization. METHODS AND RESULTS: A total of 8861 patients undergoing treadmill nuclear or echocardiographic testing were divided into early revascularization (percutaneous coronary intervention or bypass surgery within 3 months) and non-early revascularization groups. Prespecified subgroup analysis was performed based on the presence or absence of ischemia, normal or impaired functional capacity, and normal or abnormal HRR. The primary end point was all-cause mortality. Early revascularization occurred in 552 patients. We propensity-matched 508 early revascularization patients to 508 non-early revascularization patients on the basis of 48 possible confounders. This constituted the present study cohort. During 8-year follow-up, 232 patients died. Overall, revascularization was associated with a slight but not significant decrease in mortality (hazard ratio [HR] 0.80, 95% CI 0.62 to 1.03). A significant decrease in mortality after revascularization was present in patients with imaging evidence of stress-induced ischemia (HR 0.62, 95% CI 0.44 to 0.87). Ischemic patients with normal HRR had significantly lower mortality with revascularization (HR 0.55, 95% CI 0.34 to 0.90), whereas ischemic patients with abnormal HRR did not (HR 0.78, 95% CI 0.47 to 1.29); however, the test for interaction between these 2 groups was not significant (P=0.34). CONCLUSIONS: In patients with imaging evidence of myocardial ischemia, an abnormal HRR is associated with a nonsignificant trend toward blunting the survival improvement associated with early revascularization. HRR does not appear to identify patients likely to have a survival benefit.

Aged↗

PubMed2004

Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program.

CONTEXT: The usefulness of exercise stress test results and global cardiovascular risk systems for predicting all-cause mortality in asymptomatic individuals seen in clinical settings is unclear. OBJECTIVES: To determine the validity for prediction of all-cause mortality of the Framingham Risk Score and of a recently described European global scoring system Systematic Coronary Risk Evaluation (SCORE) for cardiovascular mortality among asymptomatic individuals evaluated in a clinical setting and to determine the potential prognostic value of exercise stress testing once these baseline risks are known. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of 3554 asymptomatic adults between the ages of 50 and 75 years who underwent exercise stress testing as part of an executive health program between October 1990 and December 2002; participants were followed up for a mean of 8 years. MAIN OUTCOME MEASURES: Global risk based on the Framingham Risk Score and the European SCORE. Prospectively recorded exercise stress test result abnormalities included impaired physical fitness, abnormal heart rate recovery, ventricular ectopy, and ST-segment abnormalities. The primary end point was all-cause mortality. RESULTS: There were 114 deaths. The c-index, which corresponds to receiver operating characteristic curve values, and the Akaike Information Criteria found that the European SCORE was superior to the Framingham Risk Score in estimating global mortality risk. In a multivariable model, independent predictors of death were a higher SCORE (for 1% predicted increase in absolute risk, relative risk [RR], 1.07; 95% confidence interval [CI], 1.04-1.09; P<.001), impaired functional capacity (RR, 2.95; 95% CI, 1.98-4.39; P<.001), and an abnormal heart rate recovery (RR, 1.59; 95%, 1.04-2.41; P =.03). ST-segment depression did not predict mortality. Among patients in the highest tertile from the SCORE, an abnormal exercise stress test result, defined as either impaired functional capacity or an abnormal heart rate recovery, identified a mortality risk of more than 1% per year. CONCLUSION: Exercise stress testing when combined with the European global risk SCORE may be useful for stratifying risk in asymptomatic individuals in a comprehensive executive health screening program.

Aged↗

PubMed2004

Prognostic importance of presenting symptoms in patients undergoing exercise testing for evaluation of known or suspected coronary disease.

PURPOSE: Chest symptoms, along with standard cardiovascular risk factors, are commonly factored into pretest risk stratification of patients who are referred for stress testing. We sought to determine the independent prognostic value of chest symptoms. METHODS: We studied the outcomes of 10,870 patients referred for symptom-limited exercise testing who had no history of myocardial revascularization, heart failure, or arrhythmias. Chest symptoms were prospectively characterized according to prespecified definitions. Propensity analysis was used to account for differences in baseline and exercise characteristics. RESULTS: Typical angina was present in 635 patients (6%), atypical angina in 3408 (33%), nonanginal chest pain in 1805 (17%), and dyspnea in 841 (8%). The remaining 4181 patients (38%) were asymptomatic. During a mean follow-up of 4.3 years, there were 381 deaths. After propensity matching patients who had typical angina with asymptomatic patients, symptoms were not predictive of mortality (adjusted hazard ratio [HR] = 0.8; 95% confidence interval [CI]: 0.6 to 1.3; P = 0.4). Among patients who had chest pain, typical angina was associated with a highly significant risk of mortality as compared with nonanginal chest pain (HR = 2.7; 95% CI: 1.4 to 5.1; P = 0.002), but not compared with atypical angina (HR = 1.3; 95% CI: 0.9 to 2.1; P = 0.21). CONCLUSION: After accounting for baseline and exercise characteristics, the presence of symptoms was not independently associated with increased mortality among patients undergoing testing for known or suspected coronary disease. Among patients who actually had chest pain, typical angina carried a higher mortality risk.

Aged↗

PubMed2004

Severe frequent ventricular ectopy after exercise as a predictor of death in patients with heart failure.

OBJECTIVES: The study was done to determine the prognostic importance of frequent ventricular ectopy in recovery after exercise among patients with systolic heart failure (HF). BACKGROUND: Although ventricular ectopy during recovery after exercise predicts death in patients without HF, its prognostic importance in patients with significant ventricular dysfunction is unknown. METHODS: Systematic electrocardiographic data during rest, exercise, and recovery were gathered on 2,123 consecutive patients with left ventricular systolic ejection fraction <or=35% who were referred for symptom-limited metabolic treadmill exercise testing. Severe ventricular ectopy was defined as the presence of ventricular triplets, sustained or nonsustained ventricular tachycardia, ventricular flutter, polymorphic ventricular tachycardia, or ventricular fibrillation. The primary end point was all-cause mortality, with censoring for interval cardiac transplantation. RESULTS: Of 2,123 patients, 140 (7%) had severe ventricular ectopy during recovery. There were 530 deaths (median follow-up among survivors 2.9 years). Severe ventricular ectopy during recovery was associated with an increased risk of death (three-year death rates 37% vs. 22%, hazard ratio [HR] 1.76; 95% confidence interval [CI] 1.32 to 2.34, p < 0.0001). After adjustment for ventricular ectopy at rest and during exercise, peak oxygen uptake, and other potential confounders, severe ventricular ectopy during recovery remained predictive of death (adjusted HR 1.48; 95% CI 1.10 to 1.97; p = 0.0089), whereas ventricular ectopy during exercise was not predictive of death in this cohort. CONCLUSIONS: Severe ventricular ectopy during recovery after exercise is predictive of increased mortality in patients with severe HF and can be used as a prognostic indicator of adverse outcomes in HF cohorts.

Cohort Studies↗

PubMed2004

Is systolic blood pressure recovery after exercise a predictor of mortality?

BACKGROUND: An attenuated systolic blood pressure recovery after exercise has been associated with the severity of atherosclerotic heart disease. METHODS: For 6 years, we observed 12,379 patients who underwent symptom-limited exercise testing. We excluded patients receiving antihypertensive medication and patients with valvular disease, emphysema, end-stage renal disease, heart failure, left ventricular systolic dysfunction, and atrial fibrillation. Blood pressure recovery ratio was defined as the ratio of systolic blood pressure at 3 minutes into recovery to systolic blood pressure at peak exercise; this has been shown to correlate with angiographic severity of coronary disease. RESULTS: The blood pressure recovery ratios ranged from 0.36 to 1.62, with values for increasing quartiles of 0.72 +/- 0.05, 0.82 +/- 0.02, 0.88 +/- 0.02, and 0.99 +/- 0.07. During follow-up, there were 430 deaths (3%). Five-year Kaplan Meier survival rates were 0.975, 0.974, 0.969, and 0.966 in quartiles 1 to 4, respectively. Compared with patients in the lowest quartile of blood pressure recovery ratio, patients in the highest quartile were at somewhat increased risk (hazard ratio, 1.71; 95% CI, 1.31-2.24; P <.001). However, after adjusting for age, sex, body mass index, resting heart rate and blood pressure, peak systolic blood pressure, heart rate recovery, exercise chronotropic response, cardiac history, and standard risk factors, this association was no longer present (adjusted hazard ratio, 1.05; 95% CI, 0.8-1.38; P =.74). CONCLUSIONS: In this low-risk population, abnormal systolic blood pressure recovery after exercise was not independently predictive of mortality after correcting for differences in baseline and exercise characteristics.

Blood Pressure↗

PubMed2004

Impact of donor spontaneous intracranial hemorrhage on outcome after heart transplantation.

Donor cause of death has been suggested to have a significant impact on cardiac transplant morbidity and mortality. Our objective was to evaluate the impact of donor spontaneous intracranial bleeding on clinical outcome after heart transplantation. A group of 160 recipients underwent cardiac transplantation from donors with spontaneous intracranial bleeding (ICB group). These were compared with 197 recipients who were transplanted from trauma donors (Trauma group). A higher 4-year mortality rate was noted in the ICB group (24% vs. 14%, p=0.015). ICB as a cause of donor death was an independent predictor of recipient mortality (adjusted hazard ratio 2.02, 95% CI 1.27-3.40, p<0.0001). Compared with the Trauma group, the ICB group had an increased incidence of post-transplant graft dysfunction during the first week of transplant (10% vs. 3%, p=0.007), and higher incidence of interstitial myocardial fibrosis on their endomyocardial biopsies within 4 weeks of transplant (21% vs. 9%, p=0.0012). There was a trend towards an increased rate of allograft vasculopathy in the ICB group (competing risks adjusted hazard ratio 1.39, 95% CI 0.90-2.13, p = 0.14).

Adult↗

PubMed2003

Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease.

OBJECTIVES: We sought to determine whether abnormal heart rate recovery predicts mortality independent of the angiographic severity of coronary disease. BACKGROUND: An attenuated decrease in heart rate after exercise, or heart rate recovery (HRR), has been shown to predict mortality. There are few data on its prognostic significance once the angiographic severity of coronary artery disease (CAD) is ascertained. METHODS: For six years we followed 2,935 consecutive patients who underwent symptom-limited exercise testing for suspected CAD and then had a coronary angiogram within 90 days. The HRR was abnormal if < or =12 beats/min during the first minute after exercise, except among patients undergoing stress echocardiography, in whom the cutoff was < or =18 beats/min. Angiographic CAD was considered severe if the Duke CAD Prognostic Severity Index was > or =42 (on a scale of 0 to 100), which corresponds to a level of CAD where revascularization is associated with better long-term survival. RESULTS: Severe CAD was present in 421 patients (14%), whereas abnormal HRR was noted in 838 patients (29%). There were 336 deaths (11%). Mortality was predicted by abnormal HRR (hazard ratio [HR] 2.5, 95% confidence interval [CI] 2.0 to 3.1; p < 0.0001) and by severe CAD (HR 2.0, 95% CI 1.6 to 2.6; p < 0.0001); both variables provided additive prognostic information. After adjusting for age, gender, standard risk factors, medications, exercise capacity, and left ventricular function, abnormal HRR remained predictive of death (adjusted HR 1.6, 95% CI 1.2 to 2.0; p < 0.0001); severe CAD was also predictive (adjusted HR 1.4, 95% CI 1.1 to 1.9; p = 0.008). CONCLUSIONS: Even after taking into account the angiographic severity of CAD, left ventricular function, and exercise capacity, HRR is independently predictive of mortality.

Aged↗

PubMed2003

Frequent ventricular ectopy after exercise as a predictor of death.

BACKGROUND: Exercise-induced ventricular ectopy predicts an increased risk of death in population-based cohorts. We sought to examine in a clinical cohort the prognostic importance of ventricular ectopy immediately after exercise, when reactivation of parasympathetic activity occurs. We hypothesized that ventricular ectopy after exercise (i.e., during the recovery phase) would predict an increased risk of death better than ventricular ectopy during exercise. METHODS: We studied 29,244 patients (mean [+/-SD] age, 56+/-11 years; 70 percent men) who had been referred for symptom-limited exercise testing without a history of heart failure, valve disease, or arrhythmia. Frequent ventricular ectopy was defined by the presence of seven or more ventricular premature beats per minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation. RESULTS: Frequent ventricular ectopy occurred only during exercise in 945 patients (3 percent), only during recovery in 589 (2 percent), and during both exercise and recovery in 491 (2 percent). There were 1862 deaths during a mean of 5.3 years of follow-up. Frequent ventricular ectopy during exercise predicted an increased risk of death (five-year death rate, 9 percent, vs. 5 percent among patients without frequent ventricular ectopy during exercise; hazard ratio, 1.8; 95 percent confidence interval, 1.5 to 2.1; P<0.001), but frequent ventricular ectopy during recovery was a stronger predictor (11 percent vs. 5 percent; hazard ratio, 2.4; 95 percent confidence interval, 2.0 to 2.9; P<0.001). After propensity matching for confounding variables, frequent ventricular ectopy during recovery predicted an increased risk of death (adjusted hazard ratio, 1.5; 95 percent confidence interval, 1.1 to 1.9; P=0.003), but frequent ventricular ectopy during exercise did not (adjusted hazard ratio, 1.1; 95 percent confidence interval, 0.9 to 1.3; P=0.53). CONCLUSIONS: Frequent ventricular ectopy during recovery after exercise is a better predictor of an increased risk of death than ventricular ectopy occurring only during exercise.

Aged↗