Study examines exercise testing in asymptomatic patients after coronary revascularization

May 14, 2012, JAMA and Archives Journals

Asymptomatic patients who undergo treadmill exercise echocardiography (ExE) after coronary revascularization may be identified as being at high risk but those patients do not appear to have more favorable outcomes with repeated revascularization, according to a report published Online First by Archives of Internal Medicine, a JAMA Network publication. The article is part of the journal's Less is More series.

Cardiac events and recurrent ischemia (a temporary shortage of oxygen caused by impaired blood flow; identified in the study as new or worsening cardiac wall motion abnormality shown on the echocardiogram) are common after , both (PCI) and coronary bypass graft surgery (CABG).

Guidelines of the American College of Cardiology/ recommend evaluation with stress imaging tests, including ExE, in symptomatic patients after revascularization, but evaluating "is more controversial," the authors note in the study background.

"Testing is considered inappropriate early after PCI (<2 years) and CABG (<5 years), but the justification for these cutoffs is ill defined," the study notes.

Serge C. Harb, M.D., and colleagues at the Cleveland Clinic Heart and Vascular Institute, Ohio, examined the effectiveness of testing asymptomatic patients early and late postrevascularization. Their observational study was conducted with data from asymptomatic patients with a history of PCI or CABG who were referred for ExE at the Cleveland Clinic from January 2000 through November 2010.

ExE was performed in 2,105 asymptomatic patients (average age 64; 310 were women; 845 [40 percent] had a history of [heart attack]; 1,143 [54 percent] had undergone PCI and 962 [46 percent] had undergone CABG an average of 4.1 years before the ExE).

Ischemia was detected in 262 patients and 88 of them underwent repeated revascularization. A total of 97 patients died over an average followup period of 5.7 years, and death was associated with ischemia in groups tested both early (less than two years after PCI or less than five years after CABG) and late (two or more years after PCI, or five or more years after CABG), according to the study results. The main predictor of outcome appeared to be exercise capacity, "suggesting that risk evaluation could be obtained from a standard exercise test rather than exercise echocardiography," the authors note.

"In conclusion, the results of this study suggest that asymptomatic patients who undergo treadmill ExE after coronary revascularization may be identified as being at high risk but do not seem to have more with RVs [repeated revascularization]," the authors conclude. "Given the very large population of post-PCI and post-CABG patients, careful consideration is warranted before the screening of asymptomatic patients is considered appropriate at any stage after revascularization."

In an invited commentary, Mark J. Eisenberg, M.D., M.P.H., of McGill University, Montreal, Canada, writes: "A strategy of routine periodic stress testing in asymptomatic patients following is associated with high rates of resource utilization and high costs. Most positive test results using such a strategy will be false-positives and will lead to further testing and additional angiographic procedures."

Eisenberg continues: "Despite the fact that current evidence discourages the use of routine testing, this strategy is still commonly observed in practice. Thus, the time has arrived for a large, well-controlled trial randomizing asymptomatic patients postrevascularization to routine periodic stress testing vs. conservative management."

"Until well-supported data become available supporting such a strategy, routine testing in asymptomatic patients is probably not worth the effort," Eisenberg concludes.

Explore further: Study examines multivessel mortality rates

More information: Arch Intern Med. Published online May 14, 2012. doi:10.1001/archinternmed.2012.1355
Arch Intern Med. Published online May 14, 2012. doi:10.1001/archinternmed.2012.1910

Related Stories

Study examines multivessel mortality rates

December 29, 2011
(Medical Xpress) -- A new study led by University at Albany School of Public Health Distinguished Professor Emeritus Edward L. Hannan finds a link between higher mortality rates and incomplete revascularization procedures ...

Financial reimbursement increases cardiac stress tests

November 8, 2011
Patients treated by physicians who billed for both technical (practice/equipment) and professional (supervision/ interpretation) components of nuclear and echocardiographic stress imaging tests were more likely to undergo ...

Study shows drop off in coronary artery bypass surgeries for heart patients

May 3, 2011
New research from the University of Pennsylvania School of Medicine shows a substantial decrease in one type of revascularization procedure, coronary artery bypass graft (CABG) surgery, while rates of utilization of the other ...

Variations in cardiac procedures related to physician recommendations and hospital characteristics

December 12, 2011
Physician preferences and hospital characteristics influence the type of procedures performed on blockages of the heart, leading to significant variations in rates of bypass, stent or angioplasty procedures, found an article ...

Recommended for you

A nanoparticle inhalant for treating heart disease

January 18, 2018
A team of researchers from Italy and Germany has developed a nanoparticle inhalant for treating people suffering from heart disease. In their paper published in the journal Science Translational Medicine, the group describes ...

Starting periods before age of 12 linked to heightened risk of heart disease and stroke

January 15, 2018
Starting periods early—before the age of 12—is linked to a heightened risk of heart disease and stroke in later life, suggests an analysis of data from the UK Biobank study, published online in the journal Heart.

'Decorated' stem cells could offer targeted heart repair

January 10, 2018
Although cardiac stem cell therapy is a promising treatment for heart attack patients, directing the cells to the site of an injury - and getting them to stay there - remains challenging. In a new pilot study using an animal ...

Two simple tests could help to pinpoint cause of stroke

January 10, 2018
Detecting the cause of the deadliest form of stroke could be improved by a simple blood test added alongside a routine brain scan, research suggests.

Exercise is good for the heart, high blood pressure is bad—researchers find out why

January 10, 2018
When the heart is put under stress during exercise, it is considered healthy. Yet stress due to high blood pressure is bad for the heart. Why? And is this always the case? Researchers of the German Centre for Cardiovascular ...

Heart-muscle patches made with human cells improve heart attack recovery

January 10, 2018
Large, human cardiac-muscle patches created in the lab have been tested, for the first time, on large animals in a heart attack model. This clinically relevant approach showed that the patches significantly improved recovery ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.