Reassessment of treadmill stress testing for risk stratification in patients with acute myocardial infarction treated by thrombolysis.

R Stevenson, V Umachandran, K Ranjadayalan, P Wilkinson, B Marchant and A D Timmis

Department of Cardiology, London Chest Hospital.

OBJECTIVES--To evaluate the role of a treadmill stress test for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis. BACKGROUND--The natural history of myocardial infarction has changed with the introduction of thrombolytic treatment; there is a lower mortality but a higher incidence of recurrent thrombotic events (reinfarction, unstable angina). The treadmill stress continues to be recommended for risk stratification after acute myocardial infarction even though its value has never been formally reassessed in the thrombolytic era. METHODS--Prospective observational study in which 256 consecutive patients who presented with acute myocardial infarction treated by thrombolysis underwent an early treadmill stress test and were followed up for 10 (range 6-12) months. RESULTS--Recurrent ischaemic events occurred in 41 patients (unstable angina 15, reinfarction 21, death five) and a further 21 required revascularisation. Both ST depression at a low workload and low exercise tolerance (< 7 metabolic equivalents of the task (METS) were predictive of recurrent events, with respective hazard ratios of 1.93 (95% confidence interval (95% CI) 1.17-3.20; p < 0.01)) and 1.67 (95% CI 1.0-2.78; p < 0.05). These variables identified 50% and 70% of patients who subsequently sustained a recurrent ischaemic event, but the corresponding values for positive predictive accuracy were only 26% and 21%. Thus they are of limited value as a screening measure for identifying patients likely to benefit from invasive investigation and revascularisation. None of the other variables (ST elevation, haemodynamic responses, ventricular extrasystoles, angina) was significantly associated with recurrent ischaemic events. CONCLUSIONS--The treadmill stress test is of limited value for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis.

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Article

Which patients should have exercise testing after myocardial infarction treated by thrombolysis?

R G Murray
Heart 1993 70: 399. [PDF]

This article has been cited by other articles:

• Desideri, A, Fioretti, P M, Cortigiani, L, Trocino, G, Astarita, C, Gregori, D, Bax, J, Velasco, J, Celegon, L, Bigi, R, Pirelli, S, Picano, E (2005). Pre-discharge stress echocardiography and exercise ECG for risk stratification after uncomplicated acute myocardial infarction: results of the COSTAMI-II (cost of strategies after myocardial infarction) trial. Heart 91: 146-151 [Abstract] [Full Text]  
• Awad-Elkarim, A A, Bagger, J P, Albers, C J, Skinner, J S, Adams, P C, Hall, R J C (2003). A prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing. Heart 89: 843-847 [Abstract] [Full Text]  
• Abboud, L., Hir, J., Eisen, I., Cohen, A., Markiewicz, W. (2000). Long-term Value of Exercise Testing After Acute Myocardial Infarction: Influence of Thrombolytic Therapy. Chest 117: 556-561 [Abstract] [Full Text]  
• Jensen-Urstad, K, Samad, B A, Bouvier, F, Hulting, J, Hojer, J, Ruiz, H, Jensen-Urstad, M (1999). Prognostic value of symptom limited versus low level exercise stress test before discharge in patients with myocardial infarction treated with thrombolytics. Heart 82: 199-203 [Abstract] [Full Text]  
• Previtali, M., Fetiveau, R., Lanzarini, L., Cavalotti, C., Klersy, C. (1998). Prognostic value of myocardial viability and ischemia detected by dobutamine stress echocardiography early after acute myocardial infarction treated with thrombolysis. J Am Coll Cardiol 32: 380-386 [Abstract] [Full Text]  
• Basu, S., Senior, R., Raval, U., Lahiri, A. (1997). Superiority of Nitrate-Enhanced 201Tl Over Conventional Redistribution 201Tl Imaging for Prognostic Evaluation After Myocardial Infarction and Thrombolysis. Circulation 96: 2932-2937 [Abstract] [Full Text]  
• Basu, S., Senior, R., Dore, C., Lahiri, A. (1996). Value of thallium-201 imaging in detecting adverse cardiac events after myocardial infarction and thrombolysis: a follow up of 100 consecutive patients. BMJ 313: 844-848 [Abstract] [Full Text]  
• Pitt, B. (1995). Evaluation of the Postinfarct Patient. Circulation 91: 1855-1860 [Full Text]  
• Flapan, A D (1994). Fortnightly Review: Management of patients after their first myocardial infarction. BMJ 309: 1129-1134 [Full Text]