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Seven-Year Follow-up After Dobutamine Stress Echocardiography: Impact of Gender on Prognosis
Noninvasive Cardiology
The Prognostic Value of Predischarge Exercise Testing After Myocardial Infarction Treated With Either Primary PCI or Fibrinolysis: A DANAMI-2 Sub-Study
Abstracts Seven-Year Follow-up After Dobutamine Stress Echocardiography: Impact of Gender on Prognosis
Valeur N, Clemmensen P, Saunamäki K, Grande P. Eur Heart J 2005;26:119 –27.
Biagini E, Elhendy A, Bax JJ, et al. J Am Coll Cardiol 2005;45:93–7.
Study Question: What is the prognostic value of predischarge maximum bicycle exercise testing (BET) after acute myocardial infarction (AMI) treated with either percutaneous intervention (PCI) or thrombolytic therapy (LYTIC)? Methods: This is a substudy of the DANAMI-2 trial evaluating 1462 AMI patients, 1164 of whom (79.6%) underwent BET. Results: After 3 years, death occurred in 6.1% of the BET group vs. 40.9% of the group that was not exercised (p ⬍ 0.0001) and reinfarction occurred in 7.7% and 12.3%, respectively (p ⬍ 0.005). The PCI and LYTIC groups had similar exercise tolerance, maximum heart rates and blood pressure. ST-segment depression (STD) was noted in 15.3% of the PCI group vs. 21.5% of the LYTIC group (p ⫽ 0.007); a similar percentage (24.7% and 22.4%) had a nondiagnostic ST response. Arrhythmias and abnormal heart rate recovery were similar in the two groups. The MET level achieved and STD were significant multivariable predictors of outcome when considering all patients. On subgroup analysis, no BET variable was predictive in the PCI group, whereas MET level and STD remained predictive (risk ratio 0.72 and 1.95%, respectively) in the LYTIC group. An inconclusive ST response was not predictive in either group. Conclusions: Following contemporary AMI therapy, patients unable to perform exercise have a dramatically worse prognosis than do those capable of exercise. Exercise capacity is a strong predictor of survival; however, STD retains prognostic significance only in the LYTIC group. Perspective: This study addresses an important issue of the validity of STD during exercise after intervened AMI. Much of the data supporting the use of exercise testing following AMI was in the preinterventional era, and its relevance to modern treatment has not been conclusively demonstrated. This study spotlights a discrepancy between the prognostic information available, which is dependent on therapy (PCI vs. LYTIC therapy). The reason for this discrepancy is presumably more complete revascularization with PCI and hence a greater likelihood of residual ischemia in the LYTIC group. An additional message is the worsened prognosis in patients incapable of adequate exercise following AMI. WA
Study Question: Does gender affect the assessment of prognosis among patients undergoing dobutamine stress echocardiography (DSE)? Methods: Between 1990 and 2003, follow-up was available for 3381 patients (2276 men and 1105 women) at a single institution who underwent DSE without early revascularization. Retrospectively measured outcomes were cardiac death and nonfatal myocardial infarction (MI). Results: The DSE was normal in 687 men (30%) and 483 women (44%) (p⬍0.0001). Ischemia on DSE was present in 1194 men (52%) and 416 women (38%) (p⬍0.001). During a mean follow-up of 7⫾3.4 years, there were 894 (26%) deaths (442 cardiac) and 145 (4%) nonfatal MIs. Among patients with a normal DSE, the annual cardiac event rate was 2.5% in men and 1.2% in women. In patients with normal DSE, independent predictors of cardiac events were male gender (hazard ratio [HR]: 1.7 [range 1.1–2.8]), age (HR: 1.02 [range 1.01–1.04]), history of heart failure (HR: 3.4 [range 1.5–7.9]), previous MI (HR: 1.7 [range 1.1–2.8]), and diabetes (HR: 2.4 [range 1.3– 4.5]). In patients with an abnormal DSE, independent predictors of cardiac events were age (HR: 1.03 [range 1.02–1.04]), history of heart failure (HR: 1.7 [range 1.3–2.1]), diabetes (HR: 1.4 [range 1.1–1.8]), heart rate at rest (HR: 2.8 [range 1.4 –5.8]), wall motion abnormalities at rest (HR: 1.06 [range 1.04 –1.09]), and ischemia on DSE (HR: 1.04 [range 1.02–1.07]). Myocardial ischemia was an independent predictor of cardiac events in both men and women. Conclusions: Male gender is associated with a higher rate of adverse cardiac events among patients with a normal dobutamine stress echocardiogram. However, DSE provides independent and equivalent prognostic information in both men and women. Perspective: Although men and women may be different in many respects, it appears that the prognostic power of DSE is not affected by gender. Next year, perhaps echocardiographers won’t need to wear red! DB
ACC CURRENT JOURNAL REVIEW May 2005
21
The Prognostic Value of Predischarge Exercise Testing After Myocardial Infarction Treated With Either Primary PCI or Fibrinolysis: A DANAMI-2 Sub-Study
Abstracts Seven-Year Follow-up After Dobutamine Stress Echocardiography: Impact of Gender on Prognosis
Valeur N, Clemmensen P, Saunamäki K, Grande P. Eur Heart J 2005;26:119 –27.
Biagini E, Elhendy A, Bax JJ, et al. J Am Coll Cardiol 2005;45:93–7.
Study Question: What is the prognostic value of predischarge maximum bicycle exercise testing (BET) after acute myocardial infarction (AMI) treated with either percutaneous intervention (PCI) or thrombolytic therapy (LYTIC)? Methods: This is a substudy of the DANAMI-2 trial evaluating 1462 AMI patients, 1164 of whom (79.6%) underwent BET. Results: After 3 years, death occurred in 6.1% of the BET group vs. 40.9% of the group that was not exercised (p ⬍ 0.0001) and reinfarction occurred in 7.7% and 12.3%, respectively (p ⬍ 0.005). The PCI and LYTIC groups had similar exercise tolerance, maximum heart rates and blood pressure. ST-segment depression (STD) was noted in 15.3% of the PCI group vs. 21.5% of the LYTIC group (p ⫽ 0.007); a similar percentage (24.7% and 22.4%) had a nondiagnostic ST response. Arrhythmias and abnormal heart rate recovery were similar in the two groups. The MET level achieved and STD were significant multivariable predictors of outcome when considering all patients. On subgroup analysis, no BET variable was predictive in the PCI group, whereas MET level and STD remained predictive (risk ratio 0.72 and 1.95%, respectively) in the LYTIC group. An inconclusive ST response was not predictive in either group. Conclusions: Following contemporary AMI therapy, patients unable to perform exercise have a dramatically worse prognosis than do those capable of exercise. Exercise capacity is a strong predictor of survival; however, STD retains prognostic significance only in the LYTIC group. Perspective: This study addresses an important issue of the validity of STD during exercise after intervened AMI. Much of the data supporting the use of exercise testing following AMI was in the preinterventional era, and its relevance to modern treatment has not been conclusively demonstrated. This study spotlights a discrepancy between the prognostic information available, which is dependent on therapy (PCI vs. LYTIC therapy). The reason for this discrepancy is presumably more complete revascularization with PCI and hence a greater likelihood of residual ischemia in the LYTIC group. An additional message is the worsened prognosis in patients incapable of adequate exercise following AMI. WA
Study Question: Does gender affect the assessment of prognosis among patients undergoing dobutamine stress echocardiography (DSE)? Methods: Between 1990 and 2003, follow-up was available for 3381 patients (2276 men and 1105 women) at a single institution who underwent DSE without early revascularization. Retrospectively measured outcomes were cardiac death and nonfatal myocardial infarction (MI). Results: The DSE was normal in 687 men (30%) and 483 women (44%) (p⬍0.0001). Ischemia on DSE was present in 1194 men (52%) and 416 women (38%) (p⬍0.001). During a mean follow-up of 7⫾3.4 years, there were 894 (26%) deaths (442 cardiac) and 145 (4%) nonfatal MIs. Among patients with a normal DSE, the annual cardiac event rate was 2.5% in men and 1.2% in women. In patients with normal DSE, independent predictors of cardiac events were male gender (hazard ratio [HR]: 1.7 [range 1.1–2.8]), age (HR: 1.02 [range 1.01–1.04]), history of heart failure (HR: 3.4 [range 1.5–7.9]), previous MI (HR: 1.7 [range 1.1–2.8]), and diabetes (HR: 2.4 [range 1.3– 4.5]). In patients with an abnormal DSE, independent predictors of cardiac events were age (HR: 1.03 [range 1.02–1.04]), history of heart failure (HR: 1.7 [range 1.3–2.1]), diabetes (HR: 1.4 [range 1.1–1.8]), heart rate at rest (HR: 2.8 [range 1.4 –5.8]), wall motion abnormalities at rest (HR: 1.06 [range 1.04 –1.09]), and ischemia on DSE (HR: 1.04 [range 1.02–1.07]). Myocardial ischemia was an independent predictor of cardiac events in both men and women. Conclusions: Male gender is associated with a higher rate of adverse cardiac events among patients with a normal dobutamine stress echocardiogram. However, DSE provides independent and equivalent prognostic information in both men and women. Perspective: Although men and women may be different in many respects, it appears that the prognostic power of DSE is not affected by gender. Next year, perhaps echocardiographers won’t need to wear red! DB
ACC CURRENT JOURNAL REVIEW May 2005
21