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Dennis T Ko

Publications and source records attributed to Dennis T Ko.

18 recordsLinked to original sources
PubMed2007

Long-term health outcomes associated with detectable troponin I concentrations.

BACKGROUND: Recent data suggest that older men with detectable cardiac troponin I (cTnI) concentrations that remain below the 99th percentile concentration cutoff are at increased risk for subsequent cardiovascular events. We designed this study to extend this observation by examining risk prediction in both men and women presenting to an emergency department with chest discomfort. METHODS: We obtained data for all-cause mortality and hospital discharges associated with either acute myocardial infarction (AMI) or congestive heart failure (CHF) for up to 8 years after the initial presentation in 448 patients who originally presented in 1996 with acute coronary syndrome (ACS). We performed retrospective analysis for cTnI (AccuTnI; Beckman Coulter) in frozen plasma samples based on the patients' reported time from onset of symptoms. Peak cTnI concentration was used for risk assessment. RESULTS: Patients with cTnI concentrations > or =0.02 microg/L (i.e., limit of detection), including those whose peak values remained below the 99th percentile (0.04 microg/L), were at greater risk for death and AMI/CHF readmissions at 2, 5, and 8 years of follow-up compared with those with peak cTnI <0.02 microg/L. All results were statistically significant (P <0.05) except for death within 2 years among patients with normal but detectable cTnI (0.02 to 0.03 microg/L), relative to the group with values <0.02 microg/L. Kaplan-Meier analyses indicated that both men and women with cTnI > or =0.02 microg/L had worse outcomes (P <0.001). CONCLUSION: Both men and women who present with possible ACS with detectable cTnI concentrations that remain below the 99th percentile are at a greater risk for future adverse events.

Aged↗
PubMed2006

Regional differences in process of care and outcomes for older acute myocardial infarction patients in the United States and Ontario, Canada.

BACKGROUND: Previous comparisons of acute myocardial infarction (AMI) treatment between the United States and Canada are limited because they compared selected patients from randomized trials, used administrative data that lacked clinical detail, or did not consider regional differences in AMI treatment. METHODS AND RESULTS: We compared medication use, invasive cardiac procedure use, and 30-day risk-standardized mortality rates of 38,886 fee-for-service Medicare beneficiaries hospitalized with AMI in the United States and 5634 similarly aged patients in Ontario, Canada, from 1998 and 2001. Baseline characteristics and illness severity across the US regions and Ontario were not substantially different. Cardiac catheterization use in AMI patients was significantly higher in the United States compared with Ontario (38.7% versus 16.8%, P<0.001), but significant regional variations existed, in which the northeastern United States had significantly lower utilization rates (25.6%) compared with other US regions. Beta-blocker use among ideal candidates was highest in the northeastern United States (77.6% versus 69.7% in the United States as a whole, P<0.001) and angiotensin-converting enzyme inhibitor use was highest in Ontario (69.1% versus 58.2% in the United States, P<0.001). Risk-standardized mortality rates at 30 days were not substantially different across the regions. CONCLUSIONS: Previous studies have suggested a clear divergence in invasive cardiac therapy for AMI patients between the United States and Canada on the basis of health care financing and structural differences. Our findings of similar treatment patterns in the northeastern United States and Ontario suggest that regional practices may have a greater impact on treatment patterns than the respective health care delivery systems.

Aged↗
PubMed2006

Risks associated with statin therapy: a systematic overview of randomized clinical trials.

BACKGROUND: Although statins reduce the risk of cardiovascular events, concerns about adverse effects may deter physicians from prescribing these agents. We performed a systematic overview of randomized statin trials to quantify the risks of musculoskeletal, renal, and hepatic complications associated with therapy. METHODS AND RESULTS: Major statin trials were identified by electronic search of the MEDLINE database from 1966 to December 2005. We included English language reports of adults with documented hyperlipidemia; double-blind, random allocation of > or = 100 patients to statin monotherapy versus placebo; and reports of myalgia, creatine kinase elevations, rhabdomyolysis, transaminase elevations, and discontinuation due to adverse events. Among 74,102 subjects enrolled in 35 trials (follow-up range, 1 to 65 months), statin therapy (excluding cerivastatin) did not result in significant absolute increases in risks of myalgias (risk difference/1000 patients [RD], 2.7; 95% CI, -3.2 to 8.7), creatine kinase elevations (RD, 0.2; 95% CI, -0.6 to 0.9), rhabdomyolysis (RD, 0.4; 95% CI, -0.1 to 0.9), or discontinuation due to any adverse event (RD, -0.5; 95% CI, -4.3 to 3.3). The absolute risk of transaminase elevations was significantly higher with statin therapy (RD, 4.2; 95% CI, 1.5 to 6.9). CONCLUSIONS: On the basis of data available from published clinical trials, statin therapy is associated with a small excess risk of transaminase elevations, but not of myalgias, creatine kinase elevations, rhabdomyolysis, or withdrawal of therapy compared with placebo. Further study is necessary to determine whether the results from these published clinical trials are similar to what occurs in routine practice, particularly among patients who are older, have more severe comorbid conditions, or receive higher statin doses than most patients in these clinical trials.

Adult↗
PubMed2006

Health outcomes categorized by current and previous definitions of acute myocardial infarction in an unselected cohort of troponin-naïve emergency department patients.

BACKGROUND: In a population originally classified for acute myocardial infarction (AMI) by the World Health Organization (WHO) definition, we compared the health outcomes after retrospectively reclassifying with the European Society of Cardiology and the American College of Cardiology (ESC/ACC) AMI definition, using the peak cardiac troponin I (cTnI) concentrations. The health outcomes were based on the WHO definition and occurred in an era that preceded the use of cardiac troponin biomarkers. METHODS: For 448 patients who presented to the emergency department with symptoms suggestive of cardiac ischemia in 1996, we obtained data for all-cause mortality and recurrent AMI for up to 1 year after the initial presentation. We performed retrospective analysis of the patients' frozen plasma samples to measure cTnI (AccuTnI, Beckman Coulter). RESULTS: At 30, 120, and 360 days, the risk for AMI/death in patients positive for AMI by only the ESC/ACC criteria was significantly lower than the risk in patients positive by both ESC/ACC and WHO criteria, and significantly higher than in patients negative according to both criteria. In a separate analysis, patients with a peak cTnI>0.10 microg/L were at greater risk for AMI/death than patients with cTnI concentrations of 0.04-0.10 microg/L. Patients negative by both definitions or with peak cTnI concentrations<0.04 microg/L had the highest event-free survival rates (92% and 94%, respectively) at 1 year. CONCLUSION: In a troponin-naïve population, patients classified as positive for AMI by only the ESC/ACC criteria have a prognosis that appears to be intermediate between those classified positive by both the WHO and ESC/ACC definitions and those who meet neither criteria.

Aged↗
PubMed2006

Factors explaining the under-use of reperfusion therapy among ideal patients with ST-segment elevation myocardial infarction.

AIMS: To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment. METHODS AND RESULTS: Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication (n = 909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood chi2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood chi2 31.6, P < 0.001), higher intracerebral haemorrhage risk (likelihood chi2 27.1, P < 0.001), higher baseline cardiovascular risk (likelihood chi2 25.4, P < 0.001), and greater number of chronic comorbid conditions (likelihood chi2 15.4, P < 0.001). The importance of each factor on non-utilization was independent, additive, not explained by age effects alone, or driven by subgroups traditionally under-represented in clinical trials. CONCLUSION: Care gaps in the use of reperfusion therapy widen with both increasing baseline cardiovascular risk and increasing intracerebral haemorrhage risk. Future studies should examine whether the implementation of clinical decision tools which allow for more accurate risk-benefit tradeoff predictions improve the treatment gaps when using life-saving therapies in this patient population.

Angina Pectoris↗
PubMed2006

Appropriateness of spironolactone prescribing in heart failure patients: a population-based study.

BACKGROUND: The Randomized Aldactone Evaluation Study (RALES) established the safety and benefit of spironolactone for heart failure (HF) patients with systolic dysfunction. However, recent data have raised concerns regarding hyperkalemia secondary to spironolactone use and suggest it occurs more commonly in routine practice. METHODS AND RESULTS: We explored factors potentially associated with hyperkalemia from spironolactone therapy in a population-based cohort of 9165 HF patients hospitalized in Ontario, Canada, between 1999 and 2001. Compared with patients enrolled in RALES, community-based patients were older (mean age 75 years versus 65 years, P < .001) and were more likely to be female (50% versus 27%, P < .001). Of the 1502 patients that were prescribed spironolactone at discharge, 18% had elevated serum potassium levels (>5 mmol/L) during hospitalization and 23% were discharged on concurrent potassium supplements. Although only 8% of patients had serum creatinine >2.5 mg/dL, many patients had stage III (53.1%), stage IV (12.8%), or stage V (3.9%) chronic renal insufficiency according to glomerular filtration rate. CONCLUSION: Spironolactone was often prescribed to inappropriate HF candidates because of the presence of relative or absolute contraindications. These findings highlight the need for more careful patient selection when prescribing spironolactone to minimize potential life-threatening hyperkalemia.

Aged↗
PubMed2005

Quality of care and outcomes of older patients with heart failure hospitalized in the United States and Canada.

BACKGROUND: Health care expenditure per person is significantly higher in the United States compared with Canada, but whether there are differences in quality of care of many conditions is unknown. We compared the process of care and outcomes of patients with heart failure, the most common cause of hospitalization for individuals 65 years and older in both countries. METHODS: We compared processes of care and 30-day and 1-year risk-standardized mortality rates among 28,521 US Medicare beneficiaries and 8180 similarly aged patients in Ontario, Canada, hospitalized with heart failure from 1998 to 2001. RESULTS: More US patients underwent left ventricular ejection fraction assessment during hospitalization compared with Canadian patients (61.2% vs 41.7%, P<.001). At discharge, patients in the United States were prescribed beta-blockers more frequently (28.7% vs 25.4%, P<.001) but angiotensin-converting enzyme inhibitors less frequently (54.3% vs 63.4%, P<.001). Among ideal candidates, prescription of beta-blockers (32.5% vs 29.7%, P = .08) or angiotensin-converting enzyme inhibitors (78.3% vs 77.6%, P = .68) was not significantly different between the 2 countries. The US patients had lower risk characteristics on admission and lower crude mortality rates at 30 days and 1 year. Thirty-day risk-standardized mortality was significantly lower for the US patients (8.9% vs 10.7%, P<.001), but 1-year risk-standardized mortality was no longer significantly different (32.2% vs 32.3%, P = .98). CONCLUSION: Patients with heart failure who are hospitalized in the United States had lower short-term mortality at 30 days, but 1-year mortality rates were not significantly different between the United States and Canada.

Aged↗
PubMed2005

Risk-treatment mismatch in the pharmacotherapy of heart failure.

CONTEXT: Patients with heart failure have a wide spectrum of mortality risks. To maximize the benefit of available pharmacotherapies, patients with high mortality risk should receive high rates of drug therapy. OBJECTIVE: To examine patterns of drug therapy and underlying mortality risk in patients with heart failure. DESIGN, SETTING, AND PATIENTS: In the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) population-based cohort (1999-2001) of 9942 patients with heart failure hospitalized in Ontario, Canada, we evaluated 1418 patients with documented left ventricular ejection fraction of 40% or less and aged 79 years or younger with low-, average-, and high-predicted risk of death within 1 year; all patients survived to hospital discharge. Administration of angiotensin-converting enzyme (ACE) inhibitors, ACE inhibitors or angiotensin II receptor blockers (ARBs), and beta-adrenoreceptor antagonists was evaluated according to predicted risk of death. MAIN OUTCOME MEASURE: Heart failure drug administration rates at time of discharge and 90 days after hospital discharge. RESULTS: At hospital discharge, prescription rates for patients in the low-, average-, and high-risk groups were 81%, 73%, 60%, respectively, for ACE inhibitors; 86%, 80%, 65%, respectively, for ACE inhibitors or ARBs; and 40%, 33%, 24%, respectively, for beta-adrenoreceptor antagonists (all P<.001 for trend). Within 90 days following hospital discharge, the rates were 83%, 76%, and 61% for ACE inhibitors; 89%, 83%, and 67% for ACE inhibitors or ARBs; and 43%, 36%, and 28% for beta-adrenoreceptor antagonists for the 3 risk groups, respectively (all P<.001 for trend). The pattern of lower rates of drug administration in those patients at increasing risk was maintained up to 1 year postdischarge (P<.001). After accounting for varying survival time and potential contraindications to therapy, low-risk patients were more likely to receive ACE inhibitors or ARBs (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.49-1.74) and beta-adrenoreceptor antagonists (HR, 1.80; 95% CI, 1.60-2.01) compared with high-risk patients (both P<.001). CONCLUSIONS: Patients with heart failure at greatest risk of death are least likely to receive ACE inhibitors, ACE inhibitors or ARBs, and beta-adrenoreceptor antagonists. Understanding the reasons underlying this mismatch may facilitate improvements in care and outcomes for patients with heart failure.

Adrenergic beta-Antagonists↗
PubMed2005

Quality of care of international and Canadian medical graduates in acute myocardial infarction.

BACKGROUND: International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established. METHODS: We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians' service payments, hospital discharge abstracts, and patients' vital status. We included 127,275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates. RESULTS: Of the 127,275 admitted AMI patients, 28,061 (22.0%) were treated by IMGs and 99,214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate-treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year. CONCLUSIONS: The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients.

Adult↗
PubMed2005

Association between lipid testing and statin therapy in acute myocardial infarction patients.

BACKGROUND: Clinical guidelines recommend lipid testing in all hospitalized acute myocardial infarction (AMI) patients. Inhospital lipid testing has also been proposed as a quality indicator for AMI care, but little is known about its use or importance. We sought to examine rates of inhospital lipid testing and its association with statin therapy at hospital discharge. METHODS: We performed an analysis using medical chart abstraction data that included demographic and comprehensive clinical information for patients hospitalized in Ontario, Canada, with an AMI from 1999 to 2001. RESULTS: Among 11,468 patients, inhospital lipid testing was performed in 6,019 (52.5%) patients and in 4,169 (36.4%) patients within 24 hours of admission. Patients who had lipid testing were significantly more likely to be discharged on statin therapy compared with patients not tested (41.4% vs 23.0%, P < .001). In addition, inhospital lipid testing was strongly associated (odds ratio 3.61, 95% CI 3.15-4.14) with statin therapy prescription at hospital discharge after adjusting for other clinical, physician, and hospital factors. CONCLUSIONS: Despite endorsements from practice guidelines, less than half of all admitted AMI patients received lipid testing within 24 hours of hospital admission. Because inhospital lipid testing was strongly associated with the initiation of statin therapy at discharge, many opportunities to initiate statin therapy were lost. Efforts to increase the use of lipid testing in hospitalized AMI patients may translate into higher rates of lipid-lowering therapy and improved patient outcomes.

Aged↗
PubMed2004

Adverse effects of beta-blocker therapy for patients with heart failure: a quantitative overview of randomized trials.

BACKGROUND: Beta-blockers substantially improve survival in patients with chronic heart failure (HF) with left ventricular systolic dysfunction, but concerns about cardiovascular adverse effects may deter physicians from prescribing this therapy. We performed an overview of randomized beta-blocker trials in patients with HF to quantify the risks of these adverse effects. METHODS: Heart failure trials of beta-blockers were identified by electronic searches of the MEDLINE database from 1966 to 2002. The random-effects model was used to combine results from individual trials and calculate estimates of risks associated with therapy. RESULTS: beta-Blocker therapy was associated with significant absolute annual increases in risks of hypotension (11 per 1000; 95% confidence interval [CI], 0-22), dizziness (57 per 1000; 95% CI, 11-104), and bradycardia (38 per 1000; 95% CI, 21-54). There was no significant absolute risk of fatigue associated with therapy (3 per 1000; 95% CI, -2 to 9). beta-Blocker therapy was associated with a reduction in all-cause withdrawal of medication (14 per 1000; 95% CI, -2 to 29) as well as significant reductions in all-cause mortality (34 per 1000; 95% CI, 20-49), HF hospitalizations (40 per 1000; 95% CI, 22-58), and worsening HF (52 per 1000; 95% CI, 10-94). CONCLUSIONS: Although beta-blocker therapy was associated with hypotension, dizziness, and bradycardia, the absolute increases in risk were small, and overall fewer patients were withdrawn from beta-blocker therapy than from placebo. This information should alleviate concerns about prescribing this life-saving therapy to patients with HF.

Adrenergic beta-Antagonists↗
PubMed2004

Lipid-lowering therapy with statins in high-risk elderly patients: the treatment-risk paradox.

CONTEXT: The benefits of cardiovascular therapies such as statins for secondary prevention have been well documented, although they may not be optimally used in patients most likely to benefit. Ideally, aggressiveness in the use of these beneficial therapies should correlate with baseline cardiovascular risk. OBJECTIVE: To examine the association between physicians' treatment aggressiveness and baseline cardiovascular risk. DESIGN, SETTING, AND PATIENTS: Retrospective cohort study incorporating the use of multiple linked health care administrative databases covering more than 1.4 million elderly residents of Ontario. We included 396,077 patients aged 66 years or older who had a history of cardiovascular disease or diabetes while undergoing medical treatment and who were alive on April 1, 1998. Baseline cardiovascular risk was derived using a risk-adjustment index in which we modeled probability of death after 3 years of follow-up. MAIN OUTCOME MEASURE: Likelihood of statin use, stratified by baseline cardiovascular risk, after adjusting for age, sex, socioeconomic status, and rural or urban residence. RESULTS: Only 75,617 patients (19.1%) in this secondary prevention cohort were prescribed statins. In patients 66 to 74 years old, the adjusted probabilities of statin prescription were 37.7%, 26.7%, and 23.4% in the categories of low, intermediate, and high baseline risk, respectively. The likelihood of statin prescription was 6.4% lower (adjusted odds ratio, 0.94; 95% confidence interval, 0.93-0.95) for each year of increase in age and each 1% increase in predicted 3-year mortality risk. The influence of age also interacted synergistically with baseline risk on the prescription of statins (P<.001). CONCLUSIONS: We found that prescription of statins diminished progressively as baseline cardiovascular risk and future probability of death increased. Since the benefits of a therapy are dependent on the baseline risk, the maximum benefits of statins may not be fully realized until implementation of therapy includes patients at highest risk.

Aged↗
PubMed2003

The association of left ventricular ejection fraction, mortality, and cause of death in stable outpatients with heart failure.

OBJECTIVES: The aim of this study was to assess the prognostic importance of left ventricular ejection fraction (LVEF) in stable outpatients with heart failure (HF). BACKGROUND: Although LVEF is an accepted prognostic indicator of prognosis in HF patients, the relationship of LVEF and mortality across the full spectrum of LVEF is incompletely understood. METHODS: We examined the association of LVEF and outcomes among 7,788 stable HF patients enrolled in the Digitalis Investigation Group trial. RESULTS: During mean follow-up of 37 months, mortality was substantial in all LVEF groups (range, LVEF 55%, 23.5%). Among patients with LVEF 45% both before (LVEF 46% to 55%: 23.3%; LVEF > 55%: 23.5%; p = 0.25), and after multivariable adjustment (LVEF 46% to 55%: HR 0.92, 95% CI 0.77 to 1.10; LVEF > 55%: HR 0.88, 95% CI 0.71 to 1.09; LVEF 36% to 45%: referent). Patients with lower LVEF were at increased absolute risk of death due to arrhythmia and worsening HF, but these were leading causes of death in all LVEF groups. CONCLUSIONS: Among HF patients in sinus rhythm, higher LVEFs were associated with a linear decrease in mortality up to an LVEF of 45%. However, increases above 45% were not associated with further reductions in mortality.

Aged↗
PubMed2002

Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction.

CONTEXT: beta-Blocker therapy remains substantially underused in cardiac patients despite its proven mortality benefits. Reluctance to prescribe these agents may derive from concerns about their association with symptoms of depression, fatigue, and sexual dysfunction. OBJECTIVE: To determine the association of beta-blockers with depressive symptoms, fatigue, and sexual dysfunction by performing a quantitative review of randomized trials that tested beta-blockers in myocardial infarction, heart failure, and hypertension. DATA SOURCES: Randomized trials of beta-blockers used in the treatment of myocardial infarction, heart failure, or hypertension were identified by searching the MEDLINE database for English-language articles (1966-2001). In addition, we searched the reference lists of previously published trials and reviews of beta-blockers for additional studies. STUDY SELECTION: Criteria for inclusion of trials in the review were: random allocation of study treatments, placebo control, noncrossover design, enrollment of at least 100 patients, and a minimum of 6 months of follow-up. The initial search produced 475 articles, 42 of which met these criteria. Fifteen of these trials reported on depressive symptoms, fatigue, or sexual dysfunction and were selected for inclusion. DATA EXTRACTION: For each trial, 1 author abstracted the frequency of adverse events in the beta-blocker and placebo groups and the numbers of patients randomized to the treatment groups. Two other authors verified the counts of events, and all authors adjudicated any discrepancies. Two different types of information on adverse events were abstracted: patient-reported symptoms and withdrawal of therapy due to a specified symptom. We categorized the tested beta-blockers by generation (early vs late) and lipid solubility (high vs low to moderate). DATA SYNTHESIS: The 15 trials involved more than 35,000 subjects. beta-Blocker therapy was not associated with a significant absolute annual increase in risk of reported depressive symptoms (6 per 1000 patients; 95% confidence interval [CI], -7 to 19). beta-Blockers were associated with a small significant annual increase in risk of reported fatigue (18 per 1000 patients; 95% CI, 5-30), equivalent to 1 additional report of fatigue for every 57 patients treated per year with beta-blockers. beta-Blockers were also associated with a small, significant annual increase in risk of reported sexual dysfunction (5 per 1000 patients; 95% CI, 2-8), equivalent to one additional report for every 199 patients treated per year. None of the risks of adverse effects differed significantly by degree of beta-blocker lipid solubility. The risk associated with reported fatigue was significantly higher for early-generation than for late-generation beta-blockers (P =.04). CONCLUSION: The conventional wisdom that beta-blocker therapy is associated with substantial risks of depressive symptoms, fatigue, and sexual dysfunction is not supported by data from clinical trials. There is no significant increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction. The risks of these adverse effects should be put in the context of the documented benefits of these medications.

Adrenergic beta-Antagonists↗
PubMedDate not supplied

The prognostic value of vasodilator myocardial perfusion imaging in octogenarians.

The ability of single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to stratify risk in octogenarians is poorly defined. The authors identified 439 octogenarians who underwent vasodilator SPECT MPI between 1994 and 2000. Over a mean 2.5 years of follow-up, moderate and large stress defects were associated with increased crude mortality (normal: 24.5%, small defect: 21.9%, moderate or large stress defect: 41.4%, p for trend < 0.001). The degree of defect reversibility was also strongly associated with increased mortality (normal: 24.5%, no reversibility: 22.0%, small reversible defect: 36.5%, moderate or large reversible defect: 50.0%, p for trend < 0.001). In multivariable analysis, stress defects were the strongest predictor of mortality (hazard ratio, 2.39; 95% confidence interval, 1.56-3.65). The mortality of octogenarians with moderate or large perfusion defects is nearly double that of patients with normal or mildly abnormal MPI. Appropriately selected octogenarians with abnormal vasodilator SPECT imaging may benefit from more aggressive management of their cardiac disease.

Adenosine↗