Prognostic significance of maximal exercise testing after myocardial infarction treated with thrombolytic agents: the GISSI-2 data-base. Gruppo Italiano per lo Studio della Sopravvivenza Nell'Infarto.
ABSTRACT Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over the past decade acute myocardial infarction treatment has changed because of new thrombolytic therapies and consequently, the value of exercise testing is under debate. The GISSI-2 database allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 patients, on average 28 days after randomisation. The test was not performed 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 stress test result, 33% had symptoms, whereas 67% had silent myocardial ischaemia. The mortality rate was 7.1% among patients who did not have an exercise test and 1.7% [correction of 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 diagnostic test. In the adjusted analysis, symptomatic induced ischaemia, submaximal positive result, low work capacity, and abnormal systolic blood 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 tested 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 with a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation should be devoted to the patients who cannot undergo exercise testing, because the potential to influence outcome appears to be much greater.
Article: Exercise testing after myocardial infarction: with or without therapy? How does thrombolysis affects its predictivity?[show abstract] [hide abstract]
ABSTRACT: In the text we focused our attention on beta-blocker therapy, considering the great importance of these drugs in the treatment of myocardial infarction, also in the early phase of the postinfarction clinical course. Moreover, as for other anti-ischemic therapies--i.e. nitrodrivatives and calcium-antagonists--the management of this therapy is more difficult, because it takes time to up titrate and to wash out. In our opinion, it's unadvisable to interrupt this treatment in the early phase of the postinfarction course, and it's necessary to perform predischarge exercise testing on beta-blocker therapy; and we explain all the reasons in the text. Even if these drugs may reduce the diagnostic sensitivity for inducible ischemia of the predischarge exercise testing, their effect does not seem to modify negatively the prognostic accuracy of the provocative test, also in the "trombolytic era". In fact, beta-blockers hide but, also, cure inducible ischemia characterized by a low clinical risk; the forms of inducible ischemia that occur also with this therapy are probably dangerous and need myocardial revascularization. It's important to emphasize that predischarge exercise testing is more frequently positive in the patients treated with thrombolytic therapy, a subgroup at lower clinical risk. This finding is probably due to the presence of residual stenosis in the infarct-related vessel. The higher incidence of reinfarction and ischemic events related to plaque instability is the main cause of the lower negative predictive value of the test in these patients; in fact, none of the provocative tests can predict accurately these events.Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace / Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato respiratorio, Università di Napoli, Secondo ateneo 04/2003; 60(1):55-61.
European Heart Journal 03/2001; 22(4):273-6. · 10.48 Impact Factor