Are routine non-invasive tests useful in prediction of outcome after myocardial infarction in elderly people?

doi:10.1016/0140-6736(93)92060-7

The Lancet

Volume 342, Issue 8879, 30 October 1993, Pages 1069-1072

https://doi.org/10.1016/0140-6736(93)92060-7 Get rights and content

Abstract

Summary

Many patients with acute myocardial infarction undergo tests to identify ischaemia, left-ventricular dysfunction, and arrhythmias. We examined the usefulness of these tests in clinical practice by comparing the ability of a cardiologist to predict outcome at 1 year after infarction with and without knowledge of the results of an exercise test, radionuclide angiogram, and 24 h Holter electrocardiographic (ECG) recording. The study was limited to patients older than 65 years, who have a greater risk of cardiovascular sequelae and undergo fewer interventional procedures.

The patient's own cardiologist predicted outcome on a standard rating scale, based on clinical findings and routine hospital tests. He then made a second prediction after seeing the non-invasive test results. Two other cardiologists not involved in the care of the patient independently made similar predictions. Success in predicting outcome was assessed by comparison of differences between the first and second predictions in the area under receiver operating characteristic curves. During 1 year's follow-up there were 24 cardiovascular deaths and 3 recurrent myocardial infarctions among the 147 patients. There were no significant differences in mean curve areas between the first and second predictions for the patients' own cardiologist (0·62 [SE 0·06] vs 0 60 [0·06]) or the other cardiologists (0 63 [0·06] vs 0·64 [0·06] and 0·61 [0 06] vs 0·65 [0·06]). All predictions were significantly (p < 0·05) better than chance.

Prediction of outcome in older patients after myocardial infarction is not improved by knowledge of the results of an exercise test, radionuclide angiogram, or 24 h Holter ECG recording.

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Cited by (11)

Conventional stress test: Is it useful to improve patients prognosis post myocardial infarction? Arguments against
1998, Revista Espanola de Cardiologia
La prueba de esfuerzo está considerada como unade las exploraciones básicas en la estratificacióndel riesgo postinfarto. Su principal utilidad, con elobjetivo de mejorar el pronóstico, sería la de identificara pacientes de alto riesgo de eventos coronarios. En este sentido, su gran limitación es elbajo valor predictivo positivo, especialmente en lospacientes tratados con trombolíticos, lo que dificultatomar decisiones clínicas ante un pacientedeterminado. Finalmente, tomar decisiones de revascularizacióncon angioplastia o cirugía de bypassbasadas exclusivamente en el resultado positivode una ergometría no ha demostrado, por elmomento, una prolongación en la esperanza devida de los pacientes. Estas consideraciones debenhacer meditar sobre actitudes clínicas que muchasveces parecen incuestionadas.
Exercise testing is considered to play a majorrole in risk stratification after myocardial infarction. With the aim of improving prognosis, an exercisetest should be able to identify patients at higherrisk of coronary events. In this sense, its majorlimitation is a low positive predictive value, especiallyin patients who have been treated with thrombolyticagents. This fact limits its clinical valuein the decision making process in individual patients. Finally, the decision to revascularize withangioplasty or surgery when only a positive exercisetest result is taken into account, has not beenproven to prolong life in these patients. All theseconsiderations should make us think about someclinical attittudes that are taken for granted.
Limited usefulness of exercise testing and thallium scintigraphy in evaluation of ambulator patients several months after recovery from an acute coronary event: Implications for management of stable coronary heart disease
1994, Journal of the American College of Cardiology
Objectives. This study evaluated the value of noninvasive testing to predict cardiac events in patients with stable coronary disease after hospital admission (and risk stratification) for an acute coronary event.
Background. Exercise testing with thallium perfusion imaging identifies patients with obstructive coronary artery disease and has been used to stratify patients after myocardial infarction. Its usefulness for predicting cardiac events in patients with stable coronary disease after recovery from an acute coronary event was explored.
Methods. Nine hundred thirty-six patients were enrolled 1 to 6 months after hospital admission for a coronary event Patients underwent exercise treadmill testing with planar thallium-201 scintigraphy and were followed up for an average of 23 months (range 6 to 43). End points were 1) unstable angina requiring hospital admission, nonfatal myocardial infarction or cardiac death; 2) nonfatal infarction or cardiac death; or 3) cardiac death alone.
Results. Twelve patients died of cardiac causes (1.2%); 32 had a nonfatal myocardial infarction (3.4%); and 79 patients (8.4%) developed unstable angina in the first year. Exercise testing improved proportional hazards models constructed from clinical variables for all three end points (p < 0.05). The perfusion scan further improved models for the end points (nonfatal infarction or cardiac death and cardiac death alone, p < 0.05). However, the exercise test with or without thallium added little to the overall prediction of primary events (area under the receiver operating curve increased from 0.649 to 0,663), and only 2% to 13% of patients with abnormal results either had a nonfatal infarction or died.
Conclusions. Thallium-201 scintigraphy and exercise testing variables identify patients at risk for subsequent cardiac events. However, the poor predictive performance of these tests in this group of patients with stable coronary disease severely limits their usefulness. These results suggest a limited role for exercise and thallium testing in predicting cardiac events in patients with known coronary disease.
Does thrombolysis affect the prognostic value of the post-infarct exercise test?
1994, International Journal of Cardiology
There has been some debate on usefulness of the exercise test in risk stratification after myocardial infarction in the thrombolytic era. This was assessed in 295 patients of whom 184 were treated with thrombolysis. Each had an exercise test using a modified Naughton protocol within 14 days of acute myocardial infarction. The tests were graded as high risk positive (112), low risk positive (83), or negative (100). These gradings predicted use of multiple drug therapy (p = 0.05), severity of coronary artery disease (p < 0.01), and coronary artery bypass grafting (p < 0.01). There was no influence on heart failure, recurrent myocardial infarction or death. This was independent of the use of thrombolytic therapy. The whole group had a good prognosis with a mortality of 2.4% after 56 weeks' follow-up. The exercise test is still a useful screening test after myocardial infarction. In this study, there was a high negative predictive accuracy of 91% for any event. Its use is not altered by thrombolysis. The finding of a lack of influence of the exercise test on major events may be a reflection of the current good prognosis after myocardial infarction and the prompt use of revascularisation.
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2001, Italian Heart Journal Supplement
Incremental prognostic value of stress echocardiography as an adjunct to exercise electrocardiography after uncomplicated myocardial infarction
2001, Heart
Management and outcome of acute myocardial infarction in older patients in the thrombolytic era
1999, Journal of the American Geriatrics Society

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ArticlesAre routine non-invasive tests useful in prediction of outcome after myocardial infarction in elderly people?

Abstract

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Specialized testing after recent acute myocardial infarction

Ann Intern Med

Prognosis and management after a first myocardial infarction

N Engl J Med

Articles
Are routine non-invasive tests useful in prediction of outcome after myocardial infarction in elderly people?