Chest
Volume 125, Issue 3, March 2004, Pages 1124-1131
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Exercise and the Heart
Prognostic Value of Stress Testing in Patients Over 75 Years of Age With Chronic Angina

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Study objectives

To define the prognostic value of stress testing (STRT) in patients ≥ 75 years of age.

Design

Multicenter prospective randomized trial.

Setting

Tertiary care centers.

Patients

Two hundred ninety-two patients of the Trial of Invasive vs Medical Treatment of Elderly Patients aged ≥ 75 years with chronic angina despite receiving two or more antianginal drugs were prospectively observed for 1 year.

Intervention

STRT (88% exercise ECG; 12% pharmacologic stress imaging) was performed if possible, and ischemia was diagnosed using current guidelines. Death for any reason and nonfatal myocardial infarction were outcome events.

Results

Patients who could perform STRT (148 patients) were younger, had a lower risk profile, received less medication, and had less severe angina than patients who could not perform STRT (144 patients). The 1-year mortality rate was only 1.4% in patients with negative STRT results (72 patients) compared to 5.3% in patients with positive STRT results (76 patients) and 13.7% in patients who had not undergone STRT due to unstable symptoms (95 patients). The corresponding 1-year rates of death/infarction were 2.8%, 15.8%, and 26.3%, respectively. After adjustment for baseline differences, mortality rates were no longer significantly different. However, compared to patients with negative STRT results, infarction and death/infarction rates remained higher in patients with provocable ischemia (hazard ratio [HR], 8.9 [p = 0.04]; HR, 6.1 [p = 0.02], respectively) and in patients without STRT due to unstable angina (HR, 11.8 [p = 0.02]; HR, 8.6 [p = .004], respectively).

Conclusions

STRT in elderly patients is feasible and provides important prognostic information for their future management. Patients with negative STRT results after receiving therapy have a good prognosis, and their conditions may be managed conservatively.

Section snippets

Patients

Enrolled into the TIME study were 301 patients aged ≥ 75 years who were referred to one of 14 Swiss centers for assessment of class 2 or greater angina pectoris according to the classification of the Canadian Cardiovascular Society (CCS) despite having received at least two antianginal drugs. In every patient, STRT was recommended as part of a routine clinical evaluation in order to document angina/ischemia despite receiving standard antianginal therapy. Then, and after informed consent had

Patients and Stress Tests

In 292 of the 301 TIME study patients (97%), pertinent STRT data were available. In the remaining nine patients (3%), test data were not available for unreported reasons, and the patients were excluded from this analysis. The 292 patients formed the study population for the present analysis.

STRT could be performed in 148 of these 292 study patients (51%), whereas a test was not performed in 95 patients (33%) because of severe or unstable symptoms, in 24 patients (8%) because of limiting

Discussion

The present analysis of the prognostic power of STRT in 80-year-old patients with chronic angina despite receiving standard medical therapy shows the following several important findings. First, a symptom-limited exercise test is possible in more than half of these patients. Second, the test provides prognostic value despite concurrent antianginal drug therapy. Regarding nonfatal MI and the combined death/nonfatal MI end point, patients who could perform STRT had a better outcome than patients

Conclusions

This outcome analysis of 80-year-old patients with chronic angina despite receiving standard antianginal therapy shows that STRT is feasible in more than half of these patients and adds relevant information to their management. Patients with provocable ischemia despite receiving antianginal therapy and those unable to perform STRT due to unstable symptoms have sixfold and eightfold the risk of death/nonfatal MI, respectively, than patients without ischemia, and they may benefit particularly

ACKNOWLEDGMENT

We gratefully acknowledge the contribution of all participating patients, and the work done by all investigators, advisors, and the critical event committee.

References (22)

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  • Cited by (0)

    The TIME study was supported by grants from the Swiss Heart Foundation and the Adumed Foundation, Switzerland.

    A list of all TIME investigators is contained in reference 14.

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