title: Prediction of death and myocardial infarction by screening with exercise-thallium testing after coronary-artery-bypass grafting.
abstract: BACKGROUND
  The role of myocardial-perfusion imaging in calculating risk in symptom-free patients who have had coronary-artery-bypass grafting (CABG) is unclear. Practice guidelines have argued against routine screening of these patients. We sought to find out the independent and incremental prognostic value of exercise thallium-201 single-photon-emission computed tomography (SPECT) for prediction of death and non-fatal myocardial infarction (MI) in these patients.
  
  
  METHODS
  Analyses were based on 873 symptom-free patients undergoing symptom-limited exercise thallium-201 SPECT between September, 1990, and December, 1993. All had undergone CABG and none had recurrent angina or other major intercurrent coronary events. Exercise and thallium-perfusion variables were analysed to determine their prognostic importance during 3 years of follow-up.
  
  
  RESULTS
  Myocardial-perfusion defects were noted in 508 (58%) patients. There were 57 deaths and 72 patients had major events (death or non-fatal MI). Patients with thallium-perfusion defects were more likely to die (9% vs 3%, p=0.0004) or suffer a major event (11% vs 4%, p=0.0002). Reversible defects were also predictive of death (12% vs 5%, p=0.002) and major events (13% vs 7%, p=0.004). The exercise variable with the strongest predictive power was an impaired (< or = 6 METs [measure of oxygen consumption equal to 3.5 mL/kg/min]) exercise capacity; poor exercise capacity was predictive of death (18% vs 4%, p<0.0001) and death or non-fatal MI (19% vs 5%, p<.00001). After adjusting for baseline clinical variables, surgical variables, time elapsed since CABG, and standard cardiovascular risk factors, thallium-perfusion defects remained predictive of death (adjusted relative risk 2.78, 95% CI 1.44-5.39) and major events (2.63, 1.49-4.66). Similarly, impaired exercise remained strongly predictive of death (4.16, 2.38-7.29) and major events (3.61, 2.22-5.87) after adjusting for confounders.
  
  
  CONCLUSIONS
  In this group of patients who were symptom-free after CABG, thallium-perfusion defects and impaired exercise capacity were strong and independent predictors of subsequent death or non-fatal MI. Recommendations against routine screening exercise myocardial-perfusion studies in this setting should be reconsidered.
authors.affiliation: Department of Cardiology, George M and Linda H Kaufman Center for Heart Failure, Cleveland Clinic Foundation, Ohio 44195, USA. lauerm@cesmtp.ccf.org
authors.forename: M S
authors.initials: MS
authors.lastname: Lauer
authors.forename: B
authors.initials: B
authors.lastname: Lytle
authors.forename: F
authors.initials: F
authors.lastname: Pashkow
authors.forename: C E
authors.initials: CE
authors.lastname: Snader
authors.forename: T H
authors.initials: TH
authors.lastname: Marwick
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass; D005080:Exercise Test / Q000191:economics / Q000379:methods*; D005260:Female; D017048:Health Care Costs; D006321:Heart / Q000000981:diagnostic imaging*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000401:mortality; D011183:Postoperative Complications / Q000000981:diagnostic imaging*; D011379:Prognosis; D012307:Risk Factors; D013223:Statistics as Topic; D013794:Thallium Radioisotopes; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon
chemical_list: D013794:Thallium Radioisotopes