Prognostic value of cardiopulmonary exercise testing using percent achieved of predicted peak oxygen uptake for patients with ischemic and dilated cardiomyopathy.

OBJECTIVES: We tested the hypothesis that percent achieved of predicted peak oxygen uptake (predicted VO2max) improves the prognostic accuracy of identifying high risk ambulatory patients with congestive heart failure considered for heart transplantation compared with absolute peak oxygen uptake (VO2max) in 181 patients with ischemic or dilated cardiomyopathy. BACKGROUND: Peak oxygen uptake during exercise has been shown to be a useful prognostic measurement to risk stratify patients with heart failure. The prognostic value of percent predicted VO2max has not been assessed in these patients. METHODS: We retrospectively studied 181 ambulatory patients referred to the Saint Louis University Heart Failure Unit. Clinical, hemodynamic (137 patients) and coronary angiographic (145 patients) data were recorded, and all patients underwent symptom-limited cardiopulmonary exercise. RESULTS: During a mean follow-up period of 12 +/- 6 months, 26 patients died, and 18 were listed as Status 1 priority for heart transplantation. The actuarial 1- and 2-year survival of the 89 patients who achieved < or = 50% predicted VO2max was 74% and 43%, respectively, compared with 98% and 90% in the 92 who achieved > 50% predicted VO2max (p = 0.001). Multivariable analysis selected < or = 50% predicted VO2max as the most significant predictor of cardiac death (p = 0.007) and cardiac death or Status 1 priority (p = 0.0005). CONCLUSIONS: Percent achieved of predicted VO2max provides important information that can be used to risk stratify ambulatory patients with heart failure with ischemic or dilated etiology that exceeds that provided by measurement of VO2max alone. Patients who achieve > 50% predicted VO2max have an excellent short-term prognosis when treated medically, and heart transplantation can be safely deferred.

Gender differences in the noninvasive evaluation and management of patients with suspected coronary artery disease.

OBJECTIVE: To determine if gender-based differences exist in the post-test management and clinical outcome of patients with clinically suspected coronary artery disease who have stress electrocardiographic or myocardial perfusion imaging evaluation. DESIGN: Retrospective cohort study. SETTING: University medical center. PATIENTS: From a cohort of 3975 middle-aged patients referred for outpatient stress testing, 840 (47% women) were evaluated noninvasively for clinically suspected coronary artery disease. MEASUREMENTS: The rates of subsequent diagnostic procedures and the incidence of subsequent coronary revascularization, myocardial infarction, or cardiac death were determined for women and men. RESULTS: Pretest cardiac risk profiles were similar, except hypertension and hypercholesterolemia were more frequent in women. Atypical angina was more common in women than in men (57.5% compared with 44.5%, respectively; P < 0.001). Rates of initial test positivity (defined as exercise-induced horizontal or downsloping ST-segment depression > or = 1.0 mm or > or = 1 reversible thallium-201 defect) were similar in women and men. Compared with men, most women with an initial positive test result had no additional coronary artery disease evaluation (62.3% compared with 38.0%; P = 0.002). Coronary revascularization procedures were done more frequently in men (4.9% [22 of 449] compared with 2.0% [8 of 391]; P = 0.03). Cardiac death or myocardial infarction occurred more often in women during 2 years of follow-up (6.9% [27 of 391] compared with 2.4% [11 of 449]; P = 0.002). CONCLUSIONS: Women with suspected coronary artery disease have fewer additional diagnostic tests than men after an initial abnormal noninvasive stress test result, even though the incidence of typical angina, cardiac risk factors, and initial diagnostic test positivity rates are similar.