title: Value of reserve pulse pressure in improving the risk stratification of patients with normal myocardial perfusion imaging.
abstract: OBJECTIVE
  To evaluate the incremental prognostic value of reserve-pulse pressure (reserve-PP: exercise-PP minus rest-PP) to standard risk factors among patients with suspected coronary artery disease (CAD) but normal exercise myocardial perfusion imaging (MPI).
  
  
  RESULTS
  We studied 4269 consecutive symptomatic patients without known CAD who were referred for exercise MPI but had normal MPI results (mean age 58 ± 12 years, 56% females, 84% referred for evaluation of chest pain or dyspnoea, 95% with intermediate pretest likelihood of CAD). There were 202 deaths over 5.1 ± 1.4 years of follow-up. Reserve-PP was abnormal (<44 mmHg increase in PP from rest) in 1894 patients (44%). Patients with an abnormal reserve-PP had a higher risk of death compared with patients with normal reserve-PP [hazard ratio (HR): 2.47, 95% CI, 1.8-3.3]. In multivariable models adjusting for age, sex, ejection fraction, medications, heart rate recovery, Duke treadmill score (DTS), and rest-PP, each 10 mmHg lower reserve-PP was associated with a 20.6% increase in risk-adjusted mortality (adjusted HR 0.83, 95% CI 0.76-0.91). Models incorporating reserve-PP significantly reclassified risk compared with models without these parameters (net reclassification index 14.3%, P = 0.0007; integrated discrimination index 0.69, P = 0.01).
  
  
  CONCLUSIONS
  In patients without a history of CAD and a normal MPI, an abnormal reserve-PP identified and reclassified those at higher risk of death independent of known risk factors and DTS.
authors.affiliation: The Noninvasive Cardiovascular Imaging Program, Department of Medicine (Cardiology), Brigham and Women's Hospital, Boston, MA 02115, USA.
authors.forename: Deepak
authors.initials: D
authors.lastname: Thomas
authors.forename: Mouaz
authors.initials: M
authors.lastname: Al-Mallah
authors.forename: Usha
authors.initials: U
authors.lastname: Govindarajulu
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Forman
authors.forename: Samia
authors.initials: S
authors.lastname: Mora
authors.forename: Marcelo F
authors.initials: MF
authors.lastname: Di Carli
authors.forename: Sharmila
authors.initials: S
authors.lastname: Dorbala
mesh_terms: D001794:Blood Pressure / Q000502:physiology*; D015331:Cohort Studies; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000401:mortality; D015444:Exercise / Q000502:physiology*; D005080:Exercise Test / Q000379:methods; D005260:Female; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging; D011379:Prognosis; D011674:Pulse; D018570:Risk Assessment
keywords: Myocardial perfusion imaging; Normal; Prognosis; Pulse pressure; SPECT
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