PROGNOSTIC-SIGNIFICANCE OF MAXIMAL EXERCISE TESTING AFTER MYOCARDIAL-INFARCTION TREATED WITH THROMBOLYTIC AGENTS - THE GISSI-2 DATABASE

Exercise testing helped in diagnosing postinfarction patients in the p rethrombolytic era. Over the past decade acute myocardial infarction t reatment has changed because of new thrombolytic therapies and consequ ently, the value of exercise testing is under debate. The GISSI-2 data base allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 pati ents, on average 28 days after randomisation. The test was not perform ed in 3923 patients because of contraindications. The test was judged positive for residual ischaemia in 26% of the patients, negative in 38 %, and non-diagnostic in 36%. Among the patients with a positive stres s test result, 33% had symptoms, whereas 67% had silent myocardial isc haemia. The mortality rate was 7.1% among patients who did not have an exercise test and 7.1% for those with a positive test, 0.9% for those who had a negative test, and 1.3% for those who did not have a diagno stic test, In the adjusted analysis, symptomatic induced ischaemia, su bmaximal positive result, low work capacity, and abnormal systolic blo od pressure were independent predictors of 6-month mortality (relative risks [RR] 2.54, 95% CI 1.27-5.08, 2.28, 1.17-4.45, 2.05, 1.23-3.42, and 1.86, 1.05-3.31, respectively). However, when these factors were t ested simultaneously, only symptomatic induced ischaemia and low work capacity were confirmed as independent predictors of mortality (RR Cox 2.07, 95% CI 1.02-4.23 and 1.78, 1.06-2.99, respectively). Patients w ith a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation shoul d be devoted to the patients who cannot undergo exercise testing, beca use the potential to influence outcome appears to be much greater.