Clinical Investigation
Acute Ischemic Heart Disease
Arm exercise testing predicts clinical outcome

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Background

Treadmill exercise testing provides prognostic and clinical information that is not available for patients with lower extremity disabilities who undergo pharmacologic stress tests. We sought to determine whether arm ergometer (AXT) exercise capacity in resting metabolic equivalents (METs) and hemodynamic and electrocardiographic responses to AXT are predictors of survival, myocardial infarction (MI), or coronary revascularization, individually or as a composite.

Methods

A prospective cohort of 359 veterans aged 63 ± 11 (SD) years, who were unable or unwilling to perform treadmill exercise, underwent AXT stress testing for clinical reasons between 1997 and 2002 and were followed for 63 ± 24 months to an end point of death or December 31, 2006. Average annual mortality, MI, revascularization, and combined event rates were 5.2%, 1.7%, 2.2%, and 7.1%, respectively.

Results

By univariate analysis, AXT METs were highly predictive of survival (P < .01; hazard ratio 0.58, 95% confidence interval 0.46-0.70). A greater delta (peak-rest) heart rate, peak exercise systolic blood pressure, and rate pressure product were associated with survival and event-free outcome (all P < .02). A positive exercise electrocardiogram was predictive of death, revascularization, and combined events (all P < .01), and borderline predictive of MI (P = .058). By Wald χ2 analysis, age, clinical variables, exercise capacity in METs, a positive exercise electrocardiogram, and delta heart rate all had statistically significant incremental prognostic value (P < .05) for survival.

Conclusion

In older veterans with lower extremity disabilities and more comorbidities than most study populations, arm exercise capacity, delta heart rate, and a positive electrocardiogram were independently predictive of survival and/or adverse cardiovascular outcomes.

Section snippets

Patient characteristics

A total of 359 consecutive patients, referred for cardiac stress tests for clinical reasons but unable or unwilling to perform treadmill exercise because of lower extremity disabilities, were included in this analysis. These individuals performed arm ergometer stress tests (52% also underwent nuclear imaging) at the St. Louis Veterans Administration Medical Center (STL-VAMC) between November 1997 and November 2002.

No patients who completed the exercise protocol were excluded, but those

Results

The indications for arm ergometer stress testing were investigation of chest pain syndromes in 55% of patients, preoperative evaluations (25%), determination of functional capacity as part of employment capability, insurance or disability claims or development of a nontraditional exercise prescription for nonambulatory patients (9%), investigation of dyspnea (7%), assessment for coronary artery disease in individuals with coronary risk factors (3%), and evaluation of heart failure, syncope,

Discussion

Arm exercise stress testing has been reported in a few small investigations to have similar utility to treadmill or leg cycle ergometer exercise for detection of cardiac ischemia and anatomic evidence of coronary artery disease.11, 12, 13, 14, 15, 16 We are aware of only one other investigation of arm exercise for prognostication of survival. That study was conducted in apparently healthy subjects who underwent muscle power output evaluations rather than stress testing for clinical reasons.27

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  • Cited by (0)

    Doctor Ilias, who is currently affiliated with the Division of Cardiology of the University of Texas Medical Center at Houston, was supported by an American Medical Association Foundation Seed Grant Research Award for 2007 (Chicago, IL) and by a Washington University Mentors in Medicine research award for 2007 (Washington University, St. Louis, MO). Doctor Xian was supported by National Institutes of Health grants RO1 DA020810, RO1 AG022381-03, and RO1 AG022982-01 (Washington, DC). Ms Inman and Dr Martin were supported by a Merit Review grant from the Veterans Administration (Washington, DC).

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