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April 15, 1988, Vol 259, No. 15 >
ARTICLE | April 15, 1988

Finding the High-Risk Patient With Coronary Artery Disease FREE

Melvin D. Cheitlin, MD
[+] Author Affiliations

This article is one of a series sponsored by the American Heart Association.

Reprint requests to Department of Medicine, San Francisco General Hospital, Room 5G1, 1001 Potrero Ave, San Francisco, CA 94110 (Dr Cheitlin).


JAMA. 1988;259(15):2271-2277. doi:10.1001/jama.1988.03720150047035
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Article
References

OVER the years, many clinical studies have been reported that relate clinical, angiographic, and hemodynamic variables to prognosis in the patient with coronary artery disease.1-4 The complications of coronary disease considered to constitute "bad" prognosis vary and include congestive heart failure, myocardial infarction, and death, as well as reversible end points such as the development of life-threatening arrhythmias, unstable angina, and angina requiring bypass surgery. These studies have been both retrospective and prospective and have identifed a number of clinical and laboratory variables related to the selected prognostic end points, first in a univariate and then in a multivariate analysis. This allows subdivision of the patients into high- and low-risk groups, relating risk to the morbidity and mortality achievable by medical treatment of patients with coronary artery disease.

Because coronary atherosclerosis progresses with time, whatever risk stratification is done should be periodically repeated. The interval depends on whether there

REFERENCES

1 +
Taylor GT, Humphries J, Mellits ED, et al:  Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation 1980;;62:960-970.
2 +
Bruschke AVG, Proudfit WL, Sones FM Jr:  Progress and study of 590 consecutive nonsurgical cases of coronary disease followed five to 19 years: I. Arteriographic correlation. Circulation 1973;; 47:1147.
3 +
 The Multicenter Postinfarction Research Group: Risk stratification and survival after myocardial infarction. N Engl J Med 1983;;309:331-336.
4 +
Bruce RA, DeRonen T, Peterson DR, et al:  Noninvasive predictors of sudden cardiac death in men with coronary heart disease. Am J Cardiol 1977;;39:833-840.
5 +
Moss AJ, DeCamilla J, Davis H:  Cardiac death in the first six months after myocardial infarction: Potential for mortality reduction in the early post-hospital period. Am J Cardiol 1977;;39:816-820.
6 +
Klein LW, Helfant RH:  The Q-wave and non-Q-wave myocardial infarction: Differences and similarities. Prog Cardiovasc Dis 1986;;29:205-220.
7 +
Schroeder JS, Lamb IH, Harrison DC:  Patients admitted to the coronary care unit for chest pain: High risk subgroup for subsequent cardiovascular death. Am J Cardiol 1977;;39:829-832.
8 +
Harris PF, Harrell FE Jr, Lee KL, et al:  Survival in medically treated coronary artery disease. Circulation 1979;;60:1259-1269.
9 +
Rahimtoola SH:  Coronary bypass surgery for unstable angina. Circulation 1984;;69:842-848.
10 +
Elayda MA, Hall RJ, Gray AG, et al:  Coronary revascularization in the elderly patient. J Am Coll Cardiol 1984;;3:1398-1402.
11 +
Cohn PF:  Time for a new approach to management of patients with both symptomatic and asymptomatic episodes of myocardial infarction. Am J Cardiol 1984;;54:1358-1359.
12 +
Rautaharju PM, Prineas RJ, Eifler WJ, et al:  Prognostic value of exercise electrocardiography in men at high risk of future coronary heart disease: Multiple Risk Factor Intervention Trial experience. J Am Coll Cardiol 1986;;8:1-10.
13 +
Gordon DJ, Ekelund LG, Karon JM, et al:  Predictive value of the exercise tolerance test for mortality in North American men: The Lipid Research Clinics Mortality Follow-up Study. Circulation 1986;;74:252-261.
14 +
Bredlau CE, Roubin GS, Leimgruber PP, et al:  In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation 1985;;72:1044-1052.
15 +
Holmes DK, Vlietstra RE:  Percutaneous transluminal coronary angioplasty: Current status and future trends. Mayo Clin Proc 1986;;61:865-876.
16 +
Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group:  Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med 1984;;311:1333-1339.
17 +
European Coronary Surgery Study Group:  Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982;;2:1173-1180.
18 +
CASS Principal Investigators and Their Associates:  Coronary Artery Surgery Study (CASS): A randomized trial of coronary artery bypass surgery: Survival data. Circulation 1983;;68:939.
19 +
Campeau L, Enjalbert M, Lespérance J, et al:  The relation of risk factors to the development of atherosclerosis in saphenous vein bypass grafts and the progression of disease in a native population: A study ten years after aortocoronary bypass surgery. N Engl J Med 1984;;311:1329-1332.
20 +
Loop FD, Lytle BW, Cosgrove DM, et al:  Influence of the internal mammary artery graft on ten-year survival and other cardiac events. N Engl J Med 1986;;314:1-6.
21 +
CASS Principal Investigators and Their Associates:  Coronary Artery Surgery Study (CASS): A' randomized trial of coronary artery bypass surgery: Quality of life in patients randomly assigned to treatment groups. Circulation 1983;;68:951-960.
22 +
Kent KM, Borer JS, Green MV, et al:  Effect of coronary artery bypass on global and regional left ventricular function during exercise. N Engl J Med 1978;;298:1434-1439.
23 +
Tilkian A, Pfeifer J, Barry W, et al:  The effect of coronary artery bypass surgery on exercise induced ventricular arrhythmias. Am Heart J 1976;;92:707-714.
24 +
Leutenegger F, Giger G, Fuhn P, et al:  Evaluation of aortocoronary venous bypass grafting for prevention of cardiac arrhythmias. Am Heart J 1979;;98:15-19.
25 +
DeSoyza N, Murphy M, Bissett J, et al:  Ventricular arrhythmias in chronic stable angina pectoris with surgical or medical treatment. Ann Intern Med 1978;;89:10-14.
26 +
Bigger JR, Fleiss JL, Rolnitzky LM, et al:  Prevalence, characteristics and significance of ventricular tachycardia detected by 24-hour continuous electrocardiographic recordings in the late hospital phase of acute myocardial infarction. Am J Cardiol 1986;;58:1151-1160.
27 +
Josephson ME:  Treatment of ventricular arrhythmias after myocardial infarction. Circulation 1986;;74:653-658.
28 +
Kirklin JW, Blackston EH, Rogers WJ:  The plights of the invasive treatment of ischemic heart disease. J Am Coll Cardiol 1985;;5:158-167.
29 +
Passamani E, Davis KB, Gillespie MJ, et al:  A randomized trial of coronary artery bypass surgery: Survival of patients with a low ejection fraction. N Engl J Med 1985;;312:1665-1671.
30 +
Schulze RA Jr, Strauss HW, Pitt B:  Sudden death in the year following myocardial infarction: Relation to ventricular premature contractions in the late hospital phase and left ventricular ejection fraction. Am J Med 1977;;62:192-199.
31 +
Rapaport E, Remedios P:  The high risk patient after recovery from myocardial infarction: Recognition and management. J Am Coll Cardiol 1983;;1( (suppl 1) ):391-400.
32 +
DeBusk RF, Blomqvist G, Kouchoukos NT, et al:  Identification and treatment of low-risk patients after acute myocardial infarction and coronary-artery bypass graft surgery. N Engl J Med 1986;;314:161-166.
33 +
Dwyer EM Jr, McMaster P, Greenberg H, et al:  Nonfatal cardiac events and recurrent infarction in the year after acute myocardial infarction. J Am Coll Cardiol 1984;;4:695-702.
34 +
Chaitman BR:  The changing role of the exercise electrocardiogram as a diagnostic and prognostic test for chronic ischemic heart disease. J Am Coll Cardiol 1986;;8:1195-1210.
35 +
Ellestad MH, Wan HKC:  Predictive implications of stress testing: Follow-up of 2700 subjects after maximum treadmill stress testing. Circulation 1975;;51:363-369.
36 +
Weiner DA, Ryan TJ, McCabe CH, et al:  Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984;;3:772-779.
37 +
Bonow RO, Kent KS, Rosing DR, et al:  Exercise-induced ischemia in mildly asymptomatic patients with coronary-artery disease and preserved left ventricular function. N Engl J Med 1984;; 311:1339-1345.
38 +
Ryan TJ, Weiner DA, McCabe CH, et al:  Exercise testing in the Coronary Artery Surgery Study: Randomized population. Circulation 1985;;72( (suppl 5) ):31-38.
39 +
Gohlke H, Samek L, Betz P, et al:  Exercise testing provides additional prognostic information in angiographically defined subgroups of patients with coronary artery disease. Circulation 1983;; 68:979-985.
40 +
Cheitlin MD, Davia JE, DeCastro CM, et al:  Correlation of 'critical' left coronary lesions with positive submaximal exercise tests in patients with chest pain. Am Heart J 1975;;89:305-310.
41 +
Levites R, Anderson GJ:  Detection of critical coronary artery lesions with treadmill exercise testing: Fact or fiction? Am J Cardiol 1978;;42:533-538.
42 +
Ellestad MH: Stress Testing: Principles and Practice . Philadelphia, FA Davis Co, 1975;, p 171.
43 +
Opasich C, Cobelli F, Assandri J, et al:  Incidence and prognostic significance of symptomatic and asymptomatic exercise-induced ischemia in patients with recent myocardial infarction. Cardiology 1984;;71:284-291.
44 +
Théroux P, Waters DD, Halphen C, et al:  Prognostic value of exercise testing soon after myocardial infarction. N Engl J Med 1979;;301:341-345.
45 +
Starling MR, Crawford MH, Kennedy OT, et al:  Exercise testing early after myocardial infarction: Predictive value for subsequent unstable angina and death. Am J Cardiol 1980;;46:909-914.
46 +
Thompson PD, Keleman MH:  Hypotension accompanying the onset of exertional angina. Circulation 1975;;42:28.
47 +
Weld FM, Chu K-L, Bigger JT Jr, et al:  Risk stratification with low-level exercise testing two weeks after acute myocardial infarction. Circulation 1981;;64:306-314.
48 +
DeFeyter PJ, VanEenige MJ, Dighton DH, et al:  Prognostic value of exercise testing, coronary angiography and left ventriculography six to eight weeks after myocardial infarction. Circulation 1982;;66:527-536.
49 +
Fioretti P, Brower RW, Simoons ML, et al:  Prediction of mortality during the first year after acute myocardial infarction from clinical variables and stress test at hospital discharge. Am J Cardiol 1985;;55:1313-1318.
50 +
Waters DD, Bosch X, Bouchard A, et al:  Comparison of clinical variables and variables derived from a limited predischarge exercise test as predictors of early and late mortality after myocardial infarction. J Am Coll Cardiol 1985;;5:1-8.
51 +
Warnowicz MA, Parker H, Cheitlin MD:  Prognosis of patients with acute pulmonary edema and normal ejection fraction after acute myocardial infarction. Circulation 1983;;67:330.
52 +
Hung J, Goris ML, Nash E, et al:  Comparative value of maximal treadmill testing, exercise thallium myocardial perfusion scintigraphy and exercise radionuclide ventriculography for distinguishing high- and low-risk patients soon after myocardial infarction. Am J Cardiol 1984;;53:1221-1227.
53 +
Morris ICG, Palmeri ST, Califf RM, et al:  Value of radionuclide angiography for predicting specific cardiac events after acute myocardial infarction. Am J Cardiol 1985;;55:318-324.
54 +
Gibson RS, Watson DD, Craddock GB, et al:  Prediction of cardiac events after uncomplicated myocardial infarction: A prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography. Circulation 1983;;68:321-336.
55 +
Beller GA, Gibson RS:  Sensitivity, specificity, and prognostic significance of noninvasive testing for occult or known coronary disease. Prog Cardiovasc Dis 1987;;29:241-270.

Figures

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Taylor GT, Humphries J, Mellits ED, et al:  Predictors of clinical course, coronary anatomy and left ventricular function after recovery from acute myocardial infarction. Circulation 1980;;62:960-970.
2 +
Bruschke AVG, Proudfit WL, Sones FM Jr:  Progress and study of 590 consecutive nonsurgical cases of coronary disease followed five to 19 years: I. Arteriographic correlation. Circulation 1973;; 47:1147.
3 +
 The Multicenter Postinfarction Research Group: Risk stratification and survival after myocardial infarction. N Engl J Med 1983;;309:331-336.
4 +
Bruce RA, DeRonen T, Peterson DR, et al:  Noninvasive predictors of sudden cardiac death in men with coronary heart disease. Am J Cardiol 1977;;39:833-840.
5 +
Moss AJ, DeCamilla J, Davis H:  Cardiac death in the first six months after myocardial infarction: Potential for mortality reduction in the early post-hospital period. Am J Cardiol 1977;;39:816-820.
6 +
Klein LW, Helfant RH:  The Q-wave and non-Q-wave myocardial infarction: Differences and similarities. Prog Cardiovasc Dis 1986;;29:205-220.
7 +
Schroeder JS, Lamb IH, Harrison DC:  Patients admitted to the coronary care unit for chest pain: High risk subgroup for subsequent cardiovascular death. Am J Cardiol 1977;;39:829-832.
8 +
Harris PF, Harrell FE Jr, Lee KL, et al:  Survival in medically treated coronary artery disease. Circulation 1979;;60:1259-1269.
9 +
Rahimtoola SH:  Coronary bypass surgery for unstable angina. Circulation 1984;;69:842-848.
10 +
Elayda MA, Hall RJ, Gray AG, et al:  Coronary revascularization in the elderly patient. J Am Coll Cardiol 1984;;3:1398-1402.
11 +
Cohn PF:  Time for a new approach to management of patients with both symptomatic and asymptomatic episodes of myocardial infarction. Am J Cardiol 1984;;54:1358-1359.
12 +
Rautaharju PM, Prineas RJ, Eifler WJ, et al:  Prognostic value of exercise electrocardiography in men at high risk of future coronary heart disease: Multiple Risk Factor Intervention Trial experience. J Am Coll Cardiol 1986;;8:1-10.
13 +
Gordon DJ, Ekelund LG, Karon JM, et al:  Predictive value of the exercise tolerance test for mortality in North American men: The Lipid Research Clinics Mortality Follow-up Study. Circulation 1986;;74:252-261.
14 +
Bredlau CE, Roubin GS, Leimgruber PP, et al:  In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation 1985;;72:1044-1052.
15 +
Holmes DK, Vlietstra RE:  Percutaneous transluminal coronary angioplasty: Current status and future trends. Mayo Clin Proc 1986;;61:865-876.
16 +
Veterans Administration Coronary Artery Bypass Surgery Cooperative Study Group:  Eleven-year survival in the Veterans Administration randomized trial of coronary bypass surgery for stable angina. N Engl J Med 1984;;311:1333-1339.
17 +
European Coronary Surgery Study Group:  Long-term results of prospective randomised study of coronary artery bypass surgery in stable angina pectoris. Lancet 1982;;2:1173-1180.
18 +
CASS Principal Investigators and Their Associates:  Coronary Artery Surgery Study (CASS): A randomized trial of coronary artery bypass surgery: Survival data. Circulation 1983;;68:939.
19 +
Campeau L, Enjalbert M, Lespérance J, et al:  The relation of risk factors to the development of atherosclerosis in saphenous vein bypass grafts and the progression of disease in a native population: A study ten years after aortocoronary bypass surgery. N Engl J Med 1984;;311:1329-1332.
20 +
Loop FD, Lytle BW, Cosgrove DM, et al:  Influence of the internal mammary artery graft on ten-year survival and other cardiac events. N Engl J Med 1986;;314:1-6.
21 +
CASS Principal Investigators and Their Associates:  Coronary Artery Surgery Study (CASS): A' randomized trial of coronary artery bypass surgery: Quality of life in patients randomly assigned to treatment groups. Circulation 1983;;68:951-960.
22 +
Kent KM, Borer JS, Green MV, et al:  Effect of coronary artery bypass on global and regional left ventricular function during exercise. N Engl J Med 1978;;298:1434-1439.
23 +
Tilkian A, Pfeifer J, Barry W, et al:  The effect of coronary artery bypass surgery on exercise induced ventricular arrhythmias. Am Heart J 1976;;92:707-714.
24 +
Leutenegger F, Giger G, Fuhn P, et al:  Evaluation of aortocoronary venous bypass grafting for prevention of cardiac arrhythmias. Am Heart J 1979;;98:15-19.
25 +
DeSoyza N, Murphy M, Bissett J, et al:  Ventricular arrhythmias in chronic stable angina pectoris with surgical or medical treatment. Ann Intern Med 1978;;89:10-14.
26 +
Bigger JR, Fleiss JL, Rolnitzky LM, et al:  Prevalence, characteristics and significance of ventricular tachycardia detected by 24-hour continuous electrocardiographic recordings in the late hospital phase of acute myocardial infarction. Am J Cardiol 1986;;58:1151-1160.
27 +
Josephson ME:  Treatment of ventricular arrhythmias after myocardial infarction. Circulation 1986;;74:653-658.
28 +
Kirklin JW, Blackston EH, Rogers WJ:  The plights of the invasive treatment of ischemic heart disease. J Am Coll Cardiol 1985;;5:158-167.
29 +
Passamani E, Davis KB, Gillespie MJ, et al:  A randomized trial of coronary artery bypass surgery: Survival of patients with a low ejection fraction. N Engl J Med 1985;;312:1665-1671.
30 +
Schulze RA Jr, Strauss HW, Pitt B:  Sudden death in the year following myocardial infarction: Relation to ventricular premature contractions in the late hospital phase and left ventricular ejection fraction. Am J Med 1977;;62:192-199.
31 +
Rapaport E, Remedios P:  The high risk patient after recovery from myocardial infarction: Recognition and management. J Am Coll Cardiol 1983;;1( (suppl 1) ):391-400.
32 +
DeBusk RF, Blomqvist G, Kouchoukos NT, et al:  Identification and treatment of low-risk patients after acute myocardial infarction and coronary-artery bypass graft surgery. N Engl J Med 1986;;314:161-166.
33 +
Dwyer EM Jr, McMaster P, Greenberg H, et al:  Nonfatal cardiac events and recurrent infarction in the year after acute myocardial infarction. J Am Coll Cardiol 1984;;4:695-702.
34 +
Chaitman BR:  The changing role of the exercise electrocardiogram as a diagnostic and prognostic test for chronic ischemic heart disease. J Am Coll Cardiol 1986;;8:1195-1210.
35 +
Ellestad MH, Wan HKC:  Predictive implications of stress testing: Follow-up of 2700 subjects after maximum treadmill stress testing. Circulation 1975;;51:363-369.
36 +
Weiner DA, Ryan TJ, McCabe CH, et al:  Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984;;3:772-779.
37 +
Bonow RO, Kent KS, Rosing DR, et al:  Exercise-induced ischemia in mildly asymptomatic patients with coronary-artery disease and preserved left ventricular function. N Engl J Med 1984;; 311:1339-1345.
38 +
Ryan TJ, Weiner DA, McCabe CH, et al:  Exercise testing in the Coronary Artery Surgery Study: Randomized population. Circulation 1985;;72( (suppl 5) ):31-38.
39 +
Gohlke H, Samek L, Betz P, et al:  Exercise testing provides additional prognostic information in angiographically defined subgroups of patients with coronary artery disease. Circulation 1983;; 68:979-985.
40 +
Cheitlin MD, Davia JE, DeCastro CM, et al:  Correlation of 'critical' left coronary lesions with positive submaximal exercise tests in patients with chest pain. Am Heart J 1975;;89:305-310.
41 +
Levites R, Anderson GJ:  Detection of critical coronary artery lesions with treadmill exercise testing: Fact or fiction? Am J Cardiol 1978;;42:533-538.
42 +
Ellestad MH: Stress Testing: Principles and Practice . Philadelphia, FA Davis Co, 1975;, p 171.
43 +
Opasich C, Cobelli F, Assandri J, et al:  Incidence and prognostic significance of symptomatic and asymptomatic exercise-induced ischemia in patients with recent myocardial infarction. Cardiology 1984;;71:284-291.
44 +
Théroux P, Waters DD, Halphen C, et al:  Prognostic value of exercise testing soon after myocardial infarction. N Engl J Med 1979;;301:341-345.
45 +
Starling MR, Crawford MH, Kennedy OT, et al:  Exercise testing early after myocardial infarction: Predictive value for subsequent unstable angina and death. Am J Cardiol 1980;;46:909-914.
46 +
Thompson PD, Keleman MH:  Hypotension accompanying the onset of exertional angina. Circulation 1975;;42:28.
47 +
Weld FM, Chu K-L, Bigger JT Jr, et al:  Risk stratification with low-level exercise testing two weeks after acute myocardial infarction. Circulation 1981;;64:306-314.
48 +
DeFeyter PJ, VanEenige MJ, Dighton DH, et al:  Prognostic value of exercise testing, coronary angiography and left ventriculography six to eight weeks after myocardial infarction. Circulation 1982;;66:527-536.
49 +
Fioretti P, Brower RW, Simoons ML, et al:  Prediction of mortality during the first year after acute myocardial infarction from clinical variables and stress test at hospital discharge. Am J Cardiol 1985;;55:1313-1318.
50 +
Waters DD, Bosch X, Bouchard A, et al:  Comparison of clinical variables and variables derived from a limited predischarge exercise test as predictors of early and late mortality after myocardial infarction. J Am Coll Cardiol 1985;;5:1-8.
51 +
Warnowicz MA, Parker H, Cheitlin MD:  Prognosis of patients with acute pulmonary edema and normal ejection fraction after acute myocardial infarction. Circulation 1983;;67:330.
52 +
Hung J, Goris ML, Nash E, et al:  Comparative value of maximal treadmill testing, exercise thallium myocardial perfusion scintigraphy and exercise radionuclide ventriculography for distinguishing high- and low-risk patients soon after myocardial infarction. Am J Cardiol 1984;;53:1221-1227.
53 +
Morris ICG, Palmeri ST, Califf RM, et al:  Value of radionuclide angiography for predicting specific cardiac events after acute myocardial infarction. Am J Cardiol 1985;;55:318-324.
54 +
Gibson RS, Watson DD, Craddock GB, et al:  Prediction of cardiac events after uncomplicated myocardial infarction: A prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography. Circulation 1983;;68:321-336.
55 +
Beller GA, Gibson RS:  Sensitivity, specificity, and prognostic significance of noninvasive testing for occult or known coronary disease. Prog Cardiovasc Dis 1987;;29:241-270.

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