X-Message-Number: 24883
Date: Wed, 20 Oct 2004 20:22:51 -0700 (PDT)
From: Doug Skrecky <>
Subject: testing for predicting all-cause mortality

JAMA. 2004 Sep 22;292(12):1462-8.

Global risk scores and exercise testing for predicting all-cause mortality
in a preventive medicine program.
  CONTEXT: The usefulness of exercise stress test results and global
cardiovascular risk systems for predicting all-cause mortality in
asymptomatic individuals seen in clinical settings is unclear. OBJECTIVES:
To determine the validity for prediction of all-cause mortality of the
Framingham Risk Score and of a recently described European global scoring
system Systematic Coronary Risk Evaluation (SCORE) for cardiovascular
mortality among asymptomatic individuals evaluated in a clinical setting
and to determine the potential prognostic value of exercise stress testing
once these baseline risks are known. DESIGN, SETTING, AND PARTICIPANTS:
Prospective cohort study of 3554 asymptomatic adults between the ages of
50 and 75 years who underwent exercise stress testing as part of an
executive health program between October 1990 and December 2002;
participants were followed up for a mean of 8 years. MAIN OUTCOME
MEASURES: Global risk based on the Framingham Risk Score and the European
SCORE. Prospectively recorded exercise stress test result abnormalities
included impaired physical fitness, abnormal heart rate recovery,
ventricular ectopy, and ST-segment abnormalities. The primary end point
was all-cause mortality. RESULTS: There were 114 deaths. The c-index,
which corresponds to receiver operating characteristic curve values, and
the Akaike Information Criteria found that the European SCORE was
superior to the Framingham Risk Score in estimating global mortality
risk. In a multivariable model, independent predictors of death were a
higher SCORE (for 1% predicted increase in absolute risk, relative risk
[RR], 1.07; 95% confidence interval [CI], 1.04-1.09; P<.001), impaired
functional capacity (RR, 2.95; 95% CI, 1.98-4.39; P<.001), and an abnormal
heart rate recovery (RR, 1.59; 95%, 1.04-2.41; P =.03). ST-segment
depression did not predict mortality. Among patients in the highest
tertile from the SCORE, an abnormal exercise stress test result, defined
as either impaired functional capacity or an abnormal heart rate
recovery, identified a mortality risk of more than 1% per year.
CONCLUSION: Exercise stress testing when combined with the European global
risk SCORE may be useful for stratifying risk in asymptomatic individuals
in a comprehensive executive health screening program.

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