Screening for Asymptomatic Coronary Artery Disease: Table 4. Association between Exercise Predictors and Coronary Heart Disease Events in Asymptomatic Persons

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Table 4. Association between Exercise Predictors and Coronary Heart Disease Events in Asymptomatic Persons^a

Author, Year (Reference)	Sample	Exclusion Criteria	Mean Years of Followup	Test	Definition of Abnormal Test Result	Prevalence of Predictor	Cumulative Event Rate	Relative Risk for CHD Events with Positive Test	Sensitivity for CHD Events	Positive Predictive Value of Abnormal Test	Relative Risk Adjusted for the Following Variables
Ekelund et al., 1988³⁵	3,106 (healthy white men) in Lipid Research Clinics Prevalence Survey in united States and Canada Age range: 30-69 y 100% men	Men with CVD symptoms or hypertension were analyzed separately	8.5	Modified submaximal Bruce	Heart rate during stage 2 of exercise tolerance test and exercise time	Increase of 2 SD in stage 2 heart rate Decrease of 2 SD in time on the treadmill	0.26-1.69%^b	3.2 (1.5-6.7) for abnormal heart rate recovery 2.8 (1.3-6.1) for decrease in exercise time	NR	NR	Age, smoking, HDL cholesterol level, LDL cholesterol level, systolic blood pressure
Lauer et al., 1996⁴⁴	1,575 subjects in Framingham Offspring Study (predominantly white) Mean age: 43 y 100% men	Prevalent CAD, inability to reach stage 2 in Bruce protocol, use of beta-blockers at time of exercise tolerance test	7.7	Submaximal Bruce	Failure to achieve age- and sex-predicted target heart rate on exercise tolerance test	21%	3% for those who reached target heart rate (all cause death) 6% for those who failed to reach heart rate^c	No significant association of predictor with all cause death 1.75 (1.11-2.74)^b	46%	14%	Age, ST-segment response, physical activity, BMI, smoking, hypertension, hypertension medication, diabetes mellitus, total cholesterol level/HDL cholesterol level
Wei et al., 1999⁴⁸ Blair et al., 1996⁴⁹	25,714 patients at a preventive med clinic in Texas Aerobics Center Longitudinal Study (>95% white), 10% of men with known CVD Mean age: 43.8 y 100% men	History of cancer, BMI <18.5 kg/m², age <20 y, or <1 y of follow-up	24	Maximal treadmill	Low fitness using age-based MET cut points on exercise tolerance test	Normal weight: 10% Overweight: 19% Obese: 51%	Overall 1.7/1,000 person years^b	Normal Weight 1.7 (1.1-2.5)^b 1.6 (1.3-2.1)^c Overweight 1.9 (1.4-2.5)^b 1.7 (1.4-2.6)^c Obese 2.0 (1.2-3.6)^b 2.3 (1.5-3.4)^c	36% 52% 79%	4.6% 5.4% 3.4%	Diabetes mellitus, cholesterol level, hypertension, current smoking, history of CVD, abnormal electrocardiogram at rest, age, BMI parental history of CVD, examination year
Cole et al., 2000³⁴	5,234 in Lipid Research Clinics Prevalence Survey in United States and Canada Mean age: >30 y 39% men	Age <30 y, use of beta-blockers, digoxin, antiarrhythmic agents or nitrates, history of cardiovascular disease, unable to reach stage 2	12	Bruce or modified submaximal Bruce	Abnormal heart rate recovery defined as heart rate change of 42 beats/min or less from peak exercise to that measured 2 min later	33%	Normal heart rate recovery 4% died Abnormal heart rate recovery 10% died	1.95 (1.11-3.42)^b 1.55 (1.22-1.98)^c	54%	10%	Age, sex, BMI, ethnicity, systolic blood pressure, hypertension medication, exercise habits, physical fitness, smoking, diabetes mellitus, lipids, ST-segment response, heart rate, chronotropic index, socioeconomic status
Jouven and Ducimetier 2000⁴⁵	6,101 French men in Paris civil service Age range: 42-53 y 100% men	Known or suspected CVD, systolic blood pressure =180 at rest, or resting electrocardio-graphic abnormality	23	Bicycle ergometry	Premature ventricular complex constituting more than 10% of all ventricular depolarizations during exercise	2.3%	Normal exercise tolerance test result 6.4% Abnormal exercise tolerance test result 16.1%^b	2.53 (1.65-3.88)^b 1.1 (0.8-1.5)	5%^b	17%^b	Age, BMI, heart rate, systolic blood pressure, tobacco use, level of physical activity, diabetes mellitus, total cholesterol, presence or absence of premature ventricular depolarizations before or after exercise
Morshedi-Meibodi et al., 2002⁴⁷	2,967 participants in Framingham Offspring Study Mean age ±SD: 43 ±10 y 47% men	Prevalent CVD, chronic obstructive pulmonary disease, use of digoxin or beta-blockers, resting electrocardio-graphic abnormal-ities, inability to complete stage 1 of exercise	15	Submaximal Bruce	Heart rate recovery index - decrease in peak heart rate to 2 min of <42 beats/min	N/A	Overall 7.2%	0.8 (0.5-1.1)^c	NA	NA	Age, BMI, smoking, SBP, diastolic blood pressure, anti-hypertensive medication, diabetes mellitus, total cholesterol level, HDL cholesterol level, resting heart rate and peak heart rate
Rywik et al., 2002²¹	1,083 participants in the Baltimore Longitudinal Study of Aging Mean age ±SD: 52 ±18 y 57% men	History of angina or heart failure, Q wave on rest electrocardio-gram, valvular disease, use of antiarrhythmic drugs, inability to achieve 85% of max heart rate	7.9	Modified Balke	Duration of exercise	N/A	Overall 7%	0.87 (0.79-0.96) (For CHD event for 1 minute increase in exercise duration)	NR	NR	Age, cholesterol, sex, ST-segment changes
Frolkis et al., 2003⁴⁶	29,244 persons referred to Cleveland Clinic for exercise tolerance testing Mean age ±SD: 56 ±11 y 70% men	Age <30 y, symptomatic heart failure, use of digoxin, valvular disease, end-stage renal disease, pacer, atrial fibrillation, heart block, frequent ventricular ectopic arrhythmia at rest, heart transplant, concurrent evaluation for an arrhythmia	5.3	Submaximal Bruce	Frequent ventricular ectopic arrhythmia (>7 ventricular premature contractions/min), ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation	No ventricular ectopic arrhythmia Frequent ventricular ectopic arrhythmia during recovery 2% Frequent ventricular ectopic arrhythmia during exercise 3%	5%^c 11%^c 9%^c	1.0 1.5 (1.1-1.9)^c 1.1 (0.9-1.3)^c	3% 4%	12% 9%	Age, sex, diabetes mellitus, hypertension, smoking, previous CAD, medication use, BMI, resting heart rate, systolic blood pressure, ST- segment changes, chronotropic incompetence, abnormal heart rate recovery, peak exercise capacity
Mora et al., 2003⁴²	2994 women enrolled in the Lipid Research Clinics Prevalence Study Age range 30-80 y 0% men	Pregnancy or significant cardiovascular disease	20.3	Maximal Bruce	Low exercise capacity (<7.5 METS) and low heart rate recovery (<55 beats/minute)	31%	Normal and abnormal results on exercise tolerance test 5%^b 14%^c	3.52 (1.57-7.86)^b 2.11 (1.47-3.04)^c	71%	11%	Age, smoking, diabetes, family history of premature heart disease, obesity, HDL cholesterol level, LDL cholesterol level, triglycerides, hypertension
Gulati et al., 2003⁴³	5721 women from the Chicago area (86% white) Mean age 52 y 0% men	Self reported CHD, Percutaneous coronary intervention, coronary bypass surgery, congestive heart failure	9	Maximal Bruce	Exercise capacity, in METS	N/A	3.2%^c	0.83 (0.78-0.89) for each 1 MET increase in exercise capacity	-	-	Framingham Risk Score

^a Events are CHD events unless otherwise indicated. BMI = body mass index; CAD = coronary artery disease; CHD = coronary heart disease; CVD = cardiovascular disease; HDL = high-density lipoprotein cholesterol; LDL = low-density lipoprotein cholesterol; MET = metabolic equivalent; NA = not applicable; NR = not reported
^b CHD death.
^c All-cause death

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Table 4. Association between Exercise Predictors and Coronary Heart Disease Events in Asymptomatic Personsa

Table 4. Association between Exercise Predictors and Coronary Heart Disease Events in Asymptomatic Persons^a