Extent and severity of myocardial hypoperfusion as predictors of prognosis in patients with suspected coronary artery disease

The ability of exercise-induced myocardial hypoperfusion on thallium scintigraphy to predict coronary events was assessed in 1,689 patients with symptoms suggestive of coronary artery disease but without prior myocardial infarction or coronary artery bypass surgery. A total of 74 patients had a coronary event in the year after testing (12 cardiac deaths, 20 nonfatal infarctions and 42 referrals for bypass surgery more than 60 days after testing). Stepwise logistic regression identified only three independent predictors: the number of myocardial regions with reversible hypoperfusion (an index of the extent of hypoperfusion), the maximal magnitude of hypoperfusion (an index of the severity of hypoperfusion) and the achieved heart rate (an index of exercise performance). Both extent and severity were exponentially correlated with event rate (r > 0.97 and p < 0.01 for each), whereas achieved heart rate was linearly correlated with event rate (r = 0.79 and p < 0,05). On the basis of these data, a prognostic model was defined that employs extent and severity as stress-dependent orthogonal variables. Using this model, the predicted coronary event rate ranged over two orders of magnitude—from a low of 0.4% in patients able to exercise adequately without developing hypoperfusion, to a high of 78% in patients developing severe and extensive hypoperfusion at a low heart rate (<85% of their maximal predicted heart rate). Extent and severity of myocardial hypoperfusion, therefore, are important independent variables of prognosis in patients with suspected coronary artery disease.