Circulation, Vol 64, 535-544, Copyright © 1981 by American Heart Association
JR Corbett, GJ Dehmer, SE Lewis, W Woodward, E Henderson, RW Parkey, CG Blomqvist and JT Willerson
To test the hypothesis that patients at risk of future cardiac events can
be identified by sub-maximal exercise testing with radionuclide
ventriculography (RVG), 61 patients were studied a mean of 19 +/- 1.0 days
(+/- SEM) after acute myocardial infarction (MI). RVGs were used to measure
left ventricular ejection fraction (LVEF), wall motion score (WMS),
end-diastolic volume (EDV) and end-systolic volume (ESV), and the ratio of
systolic blood pressure to ESV (P/V index) at rest and during submaximal
exercise. Frank lead ECGs were analyzed for ST- segment change and
arrhythmias. These patients were followed for a mean of 9.6 months (60 for
6 months or more and one for 3 months) to determine the incidence of
cardiac death, recurrent MI, unstable or medically refractory angina,
persistent congestive heart failure (CHF) or limiting angina; these
problems were considered to be important cardiac events. At the 6-month
follow-up, 37 patients had important complications: four patients died,
five had MI, seven had unstable or medically refractory angina, 11 had
persistent CHF and 10 had severe limiting angina. The sensitivity and
specificity of RVG in predicting the important postinfarct complications
listed above were 95% and 96% for failure to increase LVEF by at least 5
units, 95% and 96% for an increase in ESV of more than 5%, 97% and 88% for
failure of the P/V index to increase by more than 35%, and 81% and 88%,
respectively, for a decrease in WMS. The sensitivity and specificity of the
ECG in predicting important complications were 54% and 58%, respectively.
The rest and submaximal exercise RVG variables, the ECG, a history of MI,
the location of the infarction, Killip class III, age, sex, and maximal
work load performed were analyzed statistically to determine the best
predictors of prognosis. The change with exercise in LVEF, ESV and the P/V
index were most significant variables in predicting prognosis during the
6-month follow-up period. When patients with subsequent cardiac events were
separated into those with death, recurrent MI and unstable or medically
refractory angina as major cardiac events, and patients with persistent CHF
and limiting angina as less important ("minor") cardiac events, only the
peak submaximal exercise LVEF and history of MI were significant in
distinguishing these groups. In patients without important cardiac events
during the 3- and 6-month follow-up, 70% and 88%, respectively, no
abnormality in the responses of LVEF, ESV, or P/V index to submaximal
exercise. These results suggest that submaximal exercise testing with RVG
is a highly sensitive means of classifying patients at the time of hospital
discharge after MI according to the likelihood of having cardiac events
during the ensuing 6 months.
ARTICLES
The prognostic value of submaximal exercise testing with radionuclide ventriculography before hospital discharge in patients with recent myocardial infarction
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