Noninvasive strategies for the estimation of cardiac risk in stable chest pain patients

Effective allocation of medical resources in stable chest pain patients req uires the accurate diagnosis of coronary artery disease and the stratificat ion of future cardiac risk. We studied the relative predictive value for ca rdiac death of 3 commonly applied noninvasive strategies, clinical assessme nt, stress electrocardiography, and myocardial perfusion tomography, in a l arge, multicenter population of stable angina patients. The multicenter obs ervational series comprised 7 community and academic medical centers and 8, 411 stable chest pain patients. All patients underwent pretest clinical scr eening followed by stress (exercise 84% or pharmacologic 16%) electrocardio graphy and myocardial perfusion tomography. Risk-adjusted multivariable Cox proportional hazards models were developed to predict cardiac death. Kapla n-Meier rates of time to cardiac catheterization were also computed. Cardia c mortality was 3% during the 2.5 +/- 1.5 years of follow-up. The number of infarcted vascular territories and pretest clinical risk factors were stro ng predictors of cardiac mortality, whereas the number of ischemic vascular territories gained increasing importance when determining post-test resour ce use requirements (i.e., the decision to perform cardiac catheterization) . Exertional ST-segment depression in a population with a high frequency of electrocardiographic abnormalities at rest was not a significant different iator of cardiac death risk, Stable chest pain patients are accurately iden tified as being at high risk for near-term cardiac events by both physician s' screening clinical evaluation and by the results of stress myocardial pe rfusion imaging. Disease management strategies for stable chest pain patien ts aimed at risk reduction should incorporate knowledge of relevant end poi nts in treatment and guideline development. (C) 2000 by Excerpta Medica, In c.