title: Cardiovascular mortality prediction in veterans with arm exercise vs pharmacologic myocardial perfusion imaging.
abstract: BACKGROUND
  No data exist comparing outcome prediction from arm exercise vs pharmacologic myocardial perfusion imaging (MPI) stress test variables in patients unable to perform treadmill exercise.
  
  
  METHODS
  In this retrospective study, 2,173 consecutive lower extremity disabled veterans aged 65.4 ± 11.0years (mean ± SD) underwent either pharmacologic MPI (1730 patients) or arm exercise stress tests (443 patients) with MPI (n = 253) or electrocardiography alone (n = 190) between 1997 and 2002. Cox multivariate regression models and reclassification analysis by integrated discrimination improvement (IDI) were used to characterize stress test and MPI predictors of cardiovascular mortality at ≥10-year follow-up after inclusion of significant demographic, clinical, and other variables.
  
  
  RESULTS
  Cardiovascular death occurred in 561 pharmacologic MPI and 102 arm exercise participants. Multivariate-adjusted cardiovascular mortality was predicted by arm exercise resting metabolic equivalents (hazard ratio [HR] 0.52, 95% CI 0.39-0.69, P < .001), 1-minute heart rate recovery (HR 0.61, 95% CI 0.44-0.86, P < .001), and pharmacologic and arm exercise delta (peak-rest) heart rate (both P < .001). Only an abnormal arm exercise MPI prognosticated cardiovascular death by multivariate Cox analysis (HR 1.98, 95% CI 1.04-3.77, P < .05). Arm exercise MPI defect number, type, and size provided IDI over covariates for prediction of cardiovascular mortality (IDI = 0.074-0.097). Only pharmacologic defect size prognosticated cardiovascular mortality (IDI = 0.022).
  
  
  CONCLUSIONS
  Arm exercise capacity, heart rate recovery, and pharmacologic and arm exercise heart rate responses are robust predictors of cardiovascular mortality. Arm exercise MPI results are equivalent and possibly superior to pharmacologic MPI for cardiovascular mortality prediction in patients unable to perform treadmill exercise.
authors: Division of Cardiology, Department of Internal Medicine, St Louis Veterans Administration Medical Center, St Louis, MO; Washington University School of Medicine, St Louis, MO. Electronic address: Wade.Martin@va.gov.
authors: Wade H
authors: WH
authors: Martin
authors: Department of Biostatistics, College of Public Health and Social Justice, St Louis University, St Louis, MO.
authors: Hong
authors: H
authors: Xian
authors: Department of Epidemiology, College of Public Health and Social Justice, St Louis University, St Louis, MO.
authors: Pooja
authors: P
authors: Chandiramani
authors: Department of Internal Medicine, Washington University School of Medicine, St Louis, MO.
authors: Emily
authors: E
authors: Bainter
authors: Division of Cardiology, Department of Internal Medicine, St Louis Veterans Administration Medical Center, St Louis, MO; Division of Cardiology, Department of Internal Medicine, St Louis University School of Medicine, St Louis, MO.
authors: Andrew J P
authors: AJ
authors: Klein
mesh_terms: D000368:Aged; D001132:Arm / Q000502:physiology*; D000072038:Cardiac Rehabilitation; D002318:Cardiovascular Diseases / Q000000981:diagnostic imaging / Q000401:mortality*; D004562:Electrocardiography; D015444:Exercise / Q000502:physiology*; D005080:Exercise Test / Q000379:methods; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods*; D014728:Veterans