Lower Duke Treadmill Score Research Articles

Abstract 12224: Long Term Mortality in Patients With Low-Risk Myocardial Perfusion Imaging

Introduction: Stress testing is utilized for diagnosis and risk stratification for coronary artery disease, with low-risk myocardial perfusion imaging (MPI) indicating less than 1% cardiac mortality per year. We aimed to determine the long-term cardiac mortality in these patients. Methods: We performed a retrospective observational study of 1,300 patients with low-risk MPI in 2015, including pharmacological and exercise studies in a tertiary care center in Central Massachusetts, USA. Each patient was followed from the time of the MPI study for a total duration of 7 years. All-cause mortality and cardiac death were identified. We calculated the pharmacologic and exercise MPI percentage in patients with cardiac death. A cardiac mortality graph was plotted to observe trends over seven years. Results: Out of the 1,300 patients, 3.2% [n=42; mean age 74.6+/-20 years, 78% male (n=32)] of patients had a cardiac death in the follow-up period of 7 years. The pharmacological MPI group had 5% (n=41) cardiac deaths as compared to 0.2% (n=1) in the exercise MPI with the low Duke Treadmill Score group (p-value 0.04) [Figure 1a]. The cardiac death trend over the seven years revealed the highest mortality in year 6 (19%, n= 8) and the lowest in year 4 (7.1%, n=3) [Figure 1b]. Conclusions: The incidence of long-term cardiac deaths is less than 0.5% each year in patients with low-risk MPI, in both groups. Cardiac mortality was higher in patients who underwent pharmacological stress tests indicating appropriate assessment of underlying cardiac pathology. Exercise MPI depends on multiple variables to be optimal, while all patients undergoing pharmacological MPI are maximally stressed. Extensive, multi-center, controlled studies are necessary to evaluate the differences in risk stratification of low-risk MPI between exercise and pharmacological stress tests.

Outcome of patients with high-risk Duke treadmill score and normal myocardial perfusion imaging on spect

BackgroundAnnual mortality rate can range from <1% for patients with normal myocardial perfusion by SPECT to >5% based on a high-risk Duke treadmill score (DTS). Information on the prognosis of patients with the combination of HRDTS and normal SPECT is limited and is the purpose of this study. MethodsData from a large nuclear cardiology registry (n = 17,972 patients) were reviewed. A total of 340 had HRDTS (score ≤ −11) while undergoing SPECT. Combined cardiovascular mortality and non-fatal myocardial infarction (MI) and cardiovascular mortality alone were available in 310 patients at a mean follow-up of 4.01 ± 1.5 years. ResultsThe majority of the patients had abnormal SPECT (n = 270, 71%). The abnormal SPECT patients compared to the normal were older (65.6 vs 62.8 years of age; P = .025), more likely to have abnormal left ventricular ejection fraction (26.1% vs 0%; P < .0001), known coronary artery disease (CAD, 35.9% vs 7.8%; P < .0001) and lower DTS (−14.5 vs −13.2; P = .0006), Kaplan-Meier survival analysis demonstrated a significantly lower cardiovascular mortality (5.4% vs 0%, P = .02) and combined outcome of MI and cardiovascular mortality (15% vs 4.4%, P = .009) in patients with normal versus abnormal SPECT. ConclusionsHigh-risk DTS is associated with abnormal perfusion SPECT in most patients, but nearly one-third of the patients had normal perfusion. Patients with a normal SPECT had a lower cardiovascular event rates.

20th Century methods in 2015 – time to re-look?

Background: Are Pre Test Probability (PTP), and Duke Treadmill Score (DTS) used together still an ‘appropriate’ method for selecting patients for angiography referral, or discharge, following outpatient exercise tolerance tests (ETT)? Methods: Outpatients who were referred for coronary angiogram following an ETT from 1 Jan 2014 – 31st Dec 2014 were assessed. PTP and DSwere calculated. Discharged patients from 1 Jan -Feb 28th 2014 (1 year following ETT)were reviewed. Results:Total=54 (Men41/Woman13),Age (44-82/48-75), High PTP and High risk DTS (12/0), High PTP and Intermediate Risk DTS (23/3), High PTP and Low Risk DTS (1/0), Intermediate PTP andHighRiskDTS (1/0), Intermediate PTP and Intermediate Risk DTS (4/8), Intermediate PTP and Low Risk DTS (0/2). 89 discharged with low to intermediate PTP and DTS. Conclusion: Most patients with intermediate to high PTP and DTS angiography demonstrated ischaemic heart disease to some degree (number = 28 of 39); 1 had muscle bridging, 2 had global TIMI II flow, 8 were normal. Men with a high PTP and intermediate to high risk DTS were more likely to have ischaemic heart disease (IHD). Women with an intermediate PTP and DTS were more likely to have IHD. At one year follow-upnoneof thepatientsdischargedhad significant cardiac events. It is safe to discharge patients following ETT with both a low PTP and DTS. While both tools have limitations, when used together they did demonstrate they are an appropriate method for selecting patients for angiography referral or discharge from service.

Heart rate recovery after exercise and its relation with neutrophil-to-lymphocyte ratio in patients with cardiac syndrome X

The neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) are measures of systemic inflammation. Heart rate recovery (HRR) after exercise is influenced by autonomic function. The aim of this study was to ascertain whether HRR and the Duke Treadmill Score (DTS) values are related to NLR and PLR in patients with cardiac syndrome X (CSX). A total of 350 participants were enrolled in the study. Complete blood counts and high-sensitivity C-reactive protein (hsCRP) were obtained. All participants underwent an exercise test. HRR and DTS were calculated after exercise. Abnormal HRR was defined as 12 beats/min or less. CSX and coronary artery disease (CAD) groups had higher NLR, PLR, and hsCRP, and lower HRR and DTS values than the control group (for all, P<0.05). In both CSX and CAD groups, HRR was positively correlated with DTS (r=0.468, P<0.001 and r=0.491, P<0.001, respectively) and negatively correlated with NLR (r=-0.519, P<0.001 and r=-0.612, P<0.001, respectively), PLR (r=-0.422, P<0.001 and r=-0.438, P<0.001, respectively), and hsCRP (r=-0.553, P<0.001 and r=-0.521, P<0.001, respectively). NLR and hsCRP were important two predictors of the presence of lower HRR in both CSX [NLR: odds ratio (OR), 0.395; 95% confidence interval (CI), 0.168-0.925; P=0.032 and hsCRP: OR, 0.748; 95% CI, 0.591-0.945; P=0.015], and CAD groups (NLR: OR, 0.115; 95% CI, 0.026-0.501; P=0.004 and hsCRP: OR, 0.637; 95% CI, 0.455-0.892; P=0.009). CSX patients have higher NLR and PLR and slower HRR and lower DTS, similar to CAD patients, suggesting that CSX patients may be at a higher risk for developing cardiovascular events in the future. NLR may predict autonomic imbalance assessed by HRR in CSX.

O060 Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction during Dobutamine Stress Echocardiography in Women with Chest Pain: Chest Pain in Korean Women’s Registry

Introduction: Although dobutamine stress echocardiography (DSE) is frequently associated with dynamic left ventricular outflow tract obstruction (LVOTO), its clinical significance in women with chest pain is little known. Objectives: We assessed provked clinical significance of dynamic left ventricular outflow tract obstruction (LVOTO) by dobutamine stress echocardiography (DSE) in women with chest pain. Methods: Of 880 women patients from chest pain in Korean women’s registry (which was a multicenter registry of Korean women who visited in clinic for chest pain, 102 patients (57 10 years) without DSE-provoked ischemia were included. LVOTO was defined by the presence of a systolic flow with dagger-shaped late peaking and peak LVOT pressure gradient equal to or greater than 30mmHg in the LVOT or the midventricular area, not present at baseline and that disappeared after the recovery phase. The presence of CAD was defined as any epicardial coronary artery stenosis 50%. Treadmill test was also performed in all patients and Duke treadmill score (DTS) was calculated. Results: Fifty of 102 patients had no provoked LVOTO (group 1) and 52 (51%) had provoked LVOTO (group 2). Group 2 were older than group 1 (p1⁄40.001). Group 2 had smaller LV diameter but had larger LV mass index and relative wall thickness (all p<0.05). LV diastolic parameters including A velocity, DT and the ratio of E velocity and early diastolic mitral annular velocity (E/e’) were worse in group 2 (all p<0.05). In addition, peak LVOT pressure gradient was mostly related to the LV relative wall thickness (r1⁄40.405, p<0.001) and DT (r1⁄40.328, p1⁄40.001) even with adjusted by age. Of 102 patients, 83 had no CAD and all these findings were consistent with those of all patients. There were no differences of peak LVOT pressure gradient (p1⁄40.24) and prevalence of LVOTO (p1⁄40.73) between patients with CAD and with no CAD, but patients with LVOTO had lower DTS (3.90 4.14 vs 6.32 3.99, p1⁄40.02).

Correlation between clinical prediction tests for coronary heart disease and findings on spect myocardial perfusion scintigraphy and coronary angiography

Predictive clinical tests are important diagnostic tools in determining groups of patients who should undergo further diagnostic methods for detection of coronary artery disease. The aim of this study was to determine the correlation between the probability of the existence of the coronary heart disease (CHD) obtained with Duke's clinical prediction tests for the existence of coronary artery disease and the results obtained by SPECT myocardial perfusion scintigraphy and coronary angiography. Patients and methods: The study included 56 patients with symptoms of angina pectoris (AP), 35 men and 21 women, aging 32-78 years. In all patients, the probability of the existence of coronary artery disease was calculated, i.e. the need for other diagnostic methods, by means of Duke clinical prediction (DCS). The patients subsequently underwent SPECT myocardial perfusion scintigraphy (SPECT MPI) with exercise stress test and with calculating Duke treadmill score (DTS), followed by coronary angiography (CA). The results were statistically analyzed using SPSS statistical tools, nonparametric statistical tests. Results: DCS showed a low CHD probability in 10 (17.9%), while in 46 (82.1%) there was moderate probability. DTS showed low probability in 8 (14.3%) and in 48 (85.7%) high probability of CHD. SPECT MPI resulted in 22 (39.3%) normal and 34 (60.7%) pathologilal states. CA was negative in 21 (37.5%), while in 35 (62.5%) showed significant coronary artery stenosis. In the group with low DCS and DTS probability for CHD there were no perfusion defects in SPECT MPI and no coronary artery stenosis in CA. Conclusion: Predictive clinical tests DCS and DTS, which confirm or reject suspicion of CHD, represent an important diagnostic tool that avoids unnecessary exposure of patients to further diagnostic methods which mean either an invasive diagnostic approach or any unnecessary exposure of patients to ionizing radiation. DCS and DTS have high negative predictive value and are reliable tools for selection of AP patients for further diagnostic modalities.

ASSA13-10-1 Impact of Pre-Existing Coronary Risk Factors on Exercise Outcome

Background Exercise treadmill testing is used to evaluate patients for coronary disease and predict risk of future cardiac events. While it is known that the Duke Treadmill Score (DTS) obtained from this test is a useful composite prognostic index used to determine event-free survival, we are less clear about the impact and interactions of pre-existing coronary risk factors on exercise outcome and ejection fraction. Objective To evaluate the impact of pre-existing coronary risk factors on exercise outcome during cardiac stress testing and cardiac function. Methods We analysed a prospective registry of patients referred for exercise stress myocardial perfusion imaging between 1 January 2006 and 31 December 2008 who had no known coronary disease (CAD). Clinical characteristics including symptoms, medical history and pre-existing coronary risk factors were prospectively collected and validated at time of exercise testing. The DTS was computed immediately after exercise testing by trained cardiologists using standard formula. Cardiac ejection fraction post-stress was obtained by nuclear myocardial perfusion imaging. T-test and ANOVA were used to compare mean DTS between groups. A linear regression model was fitted to determine independent predictors of DTS. Results We looked at 6298 patients (mean age 55 ± 11, 38% females) with diabetes (20%), hypertension (51%), hyperlipidemia (14%), smoking (63%) and family history of CAD (17%). There was a statistically significant correlation between the presence of each risk factor and mean DTS (p 50, median DTS = 8.50; p = 0.006). The association between DTS and EF with risk factors was cumulative; patients who had 3 risk factors were more likely to have lower DTS (OR 1.419, 95% CI 1.296–1.555, p with EF≤30 vs 18% with EF > 50, p Conclusions We found significant associations between pre-existing coronary risk factors and exercise outcome. The impact of risk factors was cumulative; in particular gender and diabetes independently predicted DTS.

Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain

Background— The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results— The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect &gt;50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a &gt;70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis &gt;50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men &lt;40 years old or women &lt;50 years old or individuals who achieved at least 13 metabolic equivalents on ETT. Conclusions— Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of &gt;50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.

Signs and Symptoms of Suspected Myocardial Ischemia in Women: Results from the What is the Optimal Method for Ischemia Evaluation in WomeN? Trial

Much of our understanding of gender differences in chest pain was derived from noncontemporary reports. The aim of the current report was to compare the frequency of chest pain by measures of ischemia in 824 women with suspected myocardial ischemia prospectively enrolled in a clinical trial of exercise testing with electrocardiography (ETT-ECG) alone compared to myocardial perfusion single photon emission computed tomography (SPECT) (ETT-MPS). Women seeking evaluation of chest pain or anginal equivalent symptoms were randomized to ETT-ECG or ETT-MPS with Tc-99m tetrofosmin. The Women's Ischemia Syndrome Evaluation (WISE) and Seattle Angina Questionnaire (SAQ) chest pain and Duke Activity Status Index (DASI) questionnaires were employed in enrolled women. Higher SAQ scores denote improved symptoms or functioning. Eight hundred twenty-four women, average age 63 years, at intermediate-high coronary artery disease (CAD) likelihood were enrolled from 43 North American centers. Traditional cardiac risk factors were prevalent, with nearly half of women having a family history of premature coronary disease, hypertension, and hyperlipidemia. Chest pain symptoms occurring at least one to three times per week were reported in 60% of women. An examination of the SAQ domains revealed that although women reported minimal physical limitations (median, interquartile range [IQR] 88, 75-100), there was a greater frequency of stable chest pain symptoms (median, IQR=40, 30-50). The majority of women (79%) reported moderate to heavy physical activity levels at home, with the average ETT and DASI estimated metabolic equivalents (METs) of 8.6±2.6 and 11.5±3.8. Women with more frequent daily episodes of chest pain were more likely to have a lower Duke Treadmill Score (DTS), 1 or mm of ST segment depression, and an abnormal MPS. The current report details a contemporary evaluation of female-specific symptomatology and measures of myocardial ischemia. Women reporting frequent angina were more likely to exhibit ischemia and this may characterize a female-specific typical angina pattern.

065 The prognostic value of Heart Rate Recovery and Chronotropic Index in patients with ST-elevation myocardial infarction and betablocker therapy

A HRR<12 beats/min at 1 min and <22 b/min at 2 min and a HRCI < 70% are two strong predictors of mortality of any causes. These parameters were not yet studied in patients (pts) recovering from STEMI) under BB. To assess the HRR and HRCI in pts. with STEMI, receiving BBs. In 102 patients with STEMI (age 32–83 years, ejection fraction (EF) > 40% BB therapy), submaximal exercise ramp treadmill test (ETT) at 9–12-th days, and maximal ETTs at 21–30 day, 1 and 3 years were performed. The target maximal parameter was the number of METs required according to Buehlmann Nomogram. The HRR and HRCI and their correlation with Duke Treadmill Score (DTS), and clinical events during 5 years after STEMI (mortality, heart failure = HF, reinfarctization,) were assesed. 41.1% pts. had pathological HRR values; 2 from them had a: low risk DTS, 29 had a moderate and high-risk DTS, and from all pts with low risk DTS (45), those with impaired HRR developped clinical events after 5 yrs (OR = 6.34) All pts with Borg scala >15 had impaired HRR. Ten pts with low HRR at 2 min had HF NYHA class II-III after 5 years. The re-infarction occured in 2 pts, (1 pt with low HRR) 94.11% had an HRCI <70%, but 93 had EF >45%, with no association with the HF. No relation between impaired HRR and HRCI was found. The Borg corrected HRCI seemed to be more sensitive with the occurrence of HF. 1. The BB therapy strongly influences the HRCI i No association with HF was notticed suggesting that under BBs, a lower cut-off HRCI value should be considered. The Borg corrected HRCI could be an alternative. 2. BB in STEMI does not seem to influence the HRR index. 3. An impaired HRR value seems to be a good criteria in prediction of the development of heart failure in STEMI pts and an independent predictor of cardiac events in a 5 yrs follow-up.

Comparison of Findings on Stress Myocardial Perfusion Imaging in Men With Versus Without Erectile Dysfunction and Without Prior Heart Disease

Erectile dysfunction (ED) has been associated with a future risk of myocardial infarction, yet the findings on stress testing in men with ED and without previous coronary artery disease are unknown. Stress myocardial perfusion single-photon emission computed tomographic imaging (MPI) allows detection of coronary artery disease and predicts cardiovascular prognosis. Our goal was to determine the association between ED and findings at stress MPI testing in men without previous coronary artery disease. Five hundred seventy-five men without previous coronary artery disease referred for stress MPI were prospectively screened for ED with the validated International Index of Erectile Function. ED was present in 46% of subjects, and ED was associated with more mild (summed stress score >or=4) and severe (summed stress score >8) coronary artery disease and with more composite high-risk stress MPI findings (summed stress score >8, left ventricular ejection fraction <40%, transient ischemic dilation). In patients referred for exercise, ED was associated with a lower Duke treadmill score. On multivariate analysis, ED was found to be an independent predictor of a summed stress score >or=4, a summed stress score >8, and composite high-risk MPI findings. In conclusion, in men without known coronary artery disease referred for stress MPI testing, ED is associated with adverse prognostic indicators at MPI testing including coronary artery disease and high-risk MPI findings.

Prediction of Coronary Heart Disease by Erectile Dysfunction in Men Referred for Nuclear Stress Testing

Recent evidence suggests a strong link between erectile dysfunction (ED) and atherosclerotic vascular disease. Stress myocardial perfusion single-photon emission computed tomography (MPS) is a widely used noninvasive imaging modality that allows diagnosis of coronary heart disease and stratification of cardiovascular risk. We sought to determine the relationship between ED and coronary heart disease in men referred for MPS. A total of 221 men referred for MPS were prospectively screened for ED with a validated questionnaire. Patient characteristics, MPS findings, and exercise results were correlated with ED. Erectile dysfunction was present in 54.8% of the patients. Patients with ED exhibited more severe coronary heart disease (MPS summed stress score >8) (43.0% vs 17.0%; P<.001) and left ventricular dysfunction (left ventricular ejection fraction <50%) (24.0% vs 11.0%; P=.01) than those without ED. Erectile dysfunction was associated with a shorter exercise time (8.0 vs 10.1 minutes; P<.001) and lower Duke treadmill score (4.4 vs 8.4; P<.001). Multivariate analysis showed ED to be an independent predictor of severe coronary heart disease (odds ratio, 2.50; 95% confidence interval, 1.24-5.04; P = .01) and high-risk MPS findings (summed stress score >8, transient ischemic dilation, or left ventricular ejection fraction <35%) (odds ratio, 2.86; 95% confidence interval, 1.43-5.74; P = .003). Erectile dysfunction is common in men referred for MPS, is associated with markers of adverse cardiovascular prognosis, and is an independent predictor of severe coronary heart disease and high-risk MPS findings. These results suggest that questioning about sexual function may be a useful tool for stratifying risk in individuals with suspected coronary heart disease.