European Heart Journal Advance Access originally published online on July 3, 2009
European Heart Journal 2009 30(20):2478-2484; doi:10.1093/eurheartj/ehp270
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Increase in end-systolic volume after exercise independently predicts mortality in patients with coronary heart disease: data from the Heart and Soul Study
1 Department of Medicine (Cardiovascular Medicine), Stanford University, Stanford, CA, USA
2 Cardiac Arrhythmia Service, Palo Alto Veterans Affairs Health Care System, 3801 Miranda Ave, Cardiology 111C, Palo Alto, CA 94304-5588, USA
3 Cardiology Division, University of Massachusetts Medical Center, Worcester, MA, USA
4 Department of Medicine, University of California, San Francisco, CA, USA
5 Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
6 Section of General Internal Medicine, Veterans Affairs Medical Center, San Francisco, CA, USA
Received 25 June 2008; revised 1 June 2009; accepted 11 June 2009; online publish-ahead-of-print 3 July 2009.
* Corresponding author. Tel: +1 650 858 3932, Fax: +1 866 756 3025, Email: mintu{at}stanford.edu
Aims: The predictive value of changes in global left ventricular (LV) size after exercise has not been studied. Left ventricular end-systolic volume (ESV) is a relatively load-independent echocardiographic marker of contractility that is easily measured. We investigated the role of the change in ESV at rest and after peak exercise on mortality among patients with stable coronary heart disease (CHD).
Methods and results: We performed exercise treadmill testing with stress echocardiography in 934 ambulatory subjects with CHD. End-systolic volume was measured immediately before and after exercise using 2D echocardiography. We defined ESV reversal as an increase in ESV after exercise, and we examined the association of ESV reversal with all-cause mortality during a median follow-up of 3.92 years. Of the 934 participants, 199 (21%) had ESV reversal. At the end of follow-up, mortality was higher among participants with ESV reversal than those without (26 vs. 11%; P < 0.001). After adjustment for clinical covariates, ESV reversal remained predictive of all-cause mortality (HR 2.0; 95% CI 1.4–2.9; P = 0.001). The association of ESV reversal with mortality also persisted after adjustment for exercise-induced wall-motion abnormalities (HR 1.7; 95% CI 1.1–2.3, P = 0.006). To determine if the effect of ESV reversal was independent from other echocardiographic measurements, we created a separate model adjusting for resting LV ejection fraction, ESV, end-diastolic volume, and LV mass. End-systolic volume reversal was the only significant predictor of mortality in this model (HR 2.1, 95% CI 1.4–3.0, P < 0.001).
Conclusion: End-systolic volume reversal is a novel parameter that independently predicts mortality in patients with CHD undergoing exercise treadmill echocardiography, even after adjustment for a wide range of clinical, echocardiographic, and treadmill exercise variables. Because measurement of ESV is simple, reproducible, and requires no additional imaging views, identification of ESV reversal during exercise echocardiography can provide useful complementary information for risk stratification.
Key Words: Ischaemic heart disease • Exercise stress testing • Exercise echocardiography • Risk stratification