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European Heart Journal 1988 9(4):427-434;
Copyright © 1988 by the European Society of Cardiology.
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© 1988 The European Society of Cardiology

Improved risk stratification in patients with coronary artery disease. Application of a survival function using continuous exercise and angiographic variables

H. GOHLKE, P. BETZ and H. ROSKAMM

Rehabilitationszentrum für Herz-und Kreislaufkranke Bad Krozingen, F.R.G.

Received 10 June 1987; revised 2 October 1987; .

Address for correspondence: Helmut Gohlke, M.D., Rehabilitationszentrum für Herz- und Kreislaufkranke, D-7812 Bad Krozingen, F.R.G.

Abstract

Assessment of prognosis plays an important role in the management of patients with CAD. The objective of the study was to improve risk stratification in patients with known coronary angiographic findings. We analyzed the prognostic importance of 13 angiographic, exercise, and clinical variables in 1183 medically treated patients with documented CAD. Five-year actuarial survival rate (5-YSR) was 87%. Multivariate analysis with the proportional hazards regression model revealed four continuous and one discrete variable to be of independent prognostic importance (X2 value): cardiac output at the highest work load (COmax) (X2 = 80.7); coronary score (X2= 18.6); heart volume by X-ray (X2= 14.7); maximal pulmonary wedge pressure during exercise (X2=5.3), and history of myocardial infarction (X2= 4.8).

Inclusion of these variables in the survival function according to the regression model resulted in excellent prediction of 5-YSR, e.g. in the patients with three-vessel disease (N= 399): actuarial 5-YSR was 80%, calculated 81%. Patients with three-vessel disease and COmax > 11.21 min–1 (N= 188) had an actuarial 5-YSR of 88%, calculated 89%; if COmax was < 11.21 min–1 the actuarial 5-YSR was 71%, calculated 70%. Patients with three-vessel disease from an independent cohort of surgically treated patients (N = 507) had a calculated 5- YSR under an assumed medical regimen of 77%. The actuarial 5- YSR with bypass surgery, including operative mortality, was 92%, suggesting a 19% gain in 5-YSR. The subgroup with three-vessel disease and low ( < 10.61 min–1) COmax before surgery (N = 273) had an estimated 40% gain in 5-YSR.

Application of this survival function with continuous angiographic and exercise variables provides an improved and rational approach to the assessment of prognosis in patients with CAD. Comparability of patient cohorts can be assessed as well as the potential gain of survival by bypass surgery. As occurrence of angina is not an independent predictor of prognosis, this survival function might also be applicable to asymptomatic patients with documented CAD.

Key Words: Prognosis • coronary arteriography • exercise testing • risk stratification


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