Introduction
Method
Study cohort
Transthoracic echocardiography
Dobutamine stress echocardiography
Follow-up
Statistical analysis
Results
Characteristics | Survived (n = 5103) | All-cause mortality (n = 1642) |
p value |
---|---|---|---|
Demographics | |||
Age (years) | 64.8 ± 11.8 | 65.4 ± 13.3 | 0.114 |
Gender | <0.001 | ||
Male | 2698 (52.9) | 733 (44.6) | |
Female | 2405 (47.1) | 909 (55.4) | |
Height (cm) | 169 ± 9.3 | 169 ± 9 | 0.926 |
Weight (kg) | 81 ± 14.9 | 79.9 ± 14.4 | 0.009 |
Body mass index (kg m2) | 28 ± 4.9 | 27.9 ± 5 | 0.009 |
Clinical history | |||
Angiogram | 894 (17.5) | 266 (16.2) | 0.218 |
Hypertension | 2905 (56.9) | 877 (53.4) | 0.034 |
Diabetes mellitus | 1337 (26.2) | 410 (25) | 0.326 |
Hypercholesterolemia | 2310 (45.3) | 775 (47.2) | 0.174 |
Family history of CVD | 1240 (24.3) | 425 (26.6) | 0.195 |
Prior myocardial infarction | 466 (9.1) | 148 (9.3) | 0.901 |
Prior PCI | 1224 (24) | 371 (23.2) | 0.432 |
Prior CABGS | 531 (10.4) | 267 (16.7) | <0.001 |
Revascularization | 515 (10.1) | 195 (11.9) | 0.024 |
Smoking history | 0.001 | ||
Never smoked | 3956 (77.5) | 1320 (82.5) | |
Ex-smoker | 784 (15.4) | 203 (12.7) | |
Current smoker | 359 (7) | 115 (7.2) | |
Canadian cardiovascular society angina classification | <0.001 | ||
Class I | 2827 (55.4) | 582 (36.4) | |
Class II | 1959 (38.4) | 678 (42.4) | |
Class III | 317 (6.2) | 382 (23.9) | |
Long term cardiac medication | |||
ACE inhibitor | 1863 (36.5) | 580 (36.3) | 0.365 |
Angiotensin II receptor antagonist | 984 (19.3) | 327 (20.4) | 0.590 |
Aspirin | 2824 (55.3) | 968 (60.5) | 0.012 |
Beta blockers | 2162 (42.4) | 730 (45.6) | 0.148 |
Calcium antagonists | 1582 (31) | 521 (32.6) | 0.602 |
Diuretic | 1127 (22.1) | 407 (25.4) | 0.024 |
Lipid-lowering agents | 3387 (66.4) | 1119 (70) | 0.207 |
Nitrates | 761 (14.9) | 249 (15.6) | 0.819 |
Warfarin | 322 (6.3) | 100 (6.3) | 0.740 |
At least 1 anti-anginal medication | 3247 (63.6) | 1108 (67.5) | 0.005 |
Transthoracic echocardiography data | |||
LVESD (cm) | 2.9 ± 0.7 | 3.2 ± 0.8 | 0.041 |
LVEDD (cm) | 4.68 ± 1.2 | 4.92 ± 1 | 0.046 |
LV ejection fraction (%) | 57.2 ± 7.7 | 54.7 ± 10 | <0.001 |
Maximal LVEDD wall thickness (cm) | 1.11 ± 0.3 | 1.18 ± 0.2 | 0.398 |
Left atrial size (mm) | 36.1 ± 15 | 38.8 ± 14 | 0.06 |
Mitral E/A | 1.08 ± 0.68 | 1.13 ± 0.9 | 0.081 |
Mitral E deceleration (ms) | 201 ± 77 | 213 ± 83 | 0.216 |
Mitral E/E’ | 9.7 ± 5.8 | 11.5 ± 5.1 | 0.032 |
Mitral annular calcification | 163 (3.2) | 109 (6.8) | <0.001 |
Mitral regurgitation (MR) | <0.001 | ||
None or trace MR | 4551 (89.2) | 1175 (71.6) | |
Mild MR | 308 (6) | 214 (13) | |
Moderate MR | 206 (4) | 165 (10) | |
Severe MR | 38 (0.7) | 88 (5.4) | |
Aortic stenosis | 125 (2.4) | 36 (2.3) | 0.556 |
Aortic regurgitation | 115 (2.3) | 55 (3.4) | 0.014 |
Dobutamine stress echocardiography test | |||
Baseline heart rate (b min−1) | 70.9 ± 15.8 | 68.2 ± 19.7 | <0.001 |
Peak heart rate (b min−1) | 135.2 ± 21.8 | 134.1 ± 20 | 0.068 |
Target heart rate achieved | 4276 (83.8) | 1384 (86.5) | 0.636 |
Baseline sBP (mmHg) | 133.3 ± 24.5 | 132.5 ± 24.8 | 0.294 |
Peak sBP (mmHg) | 151.8 ± 38.9 | 151.7 ± 43.7 | 0.944 |
Baseline dBP (mmHg) | 71.8 ± 20.6 | 72.9 ± 20.8 | 0.075 |
Peak dBP (mmHg) | 74.8 ± 18.1 | 76.2 ± 19.2 | 0.011 |
Resting wall motion score index | 1.04 ± 0.11 | 1.06 ± 0.14 | <0.001 |
Peak wall motion score index | 1.06 ± 0.14 | 1.15 ± 0.2 | <0.001 |
Fixed wall motion abnormality | 683 (13.4) | 353 (22.1) | <0.001 |
New wall motion abnormality | 929 (18.2) | 713 (44.6) | <0.001 |
Transthoracic echocardiography
Characteristics | Degree of mitral regurgitation | ||||
---|---|---|---|---|---|
None/trace (n = 5726) | Mild (n = 522) | Moderate (n = 371) | Severe (n = 126) |
p value | |
Demographics | |||||
Age (years) | 64.1 ± 12.3 | 68.5 ± 11.1 | 70.3 ± 9.9 | 72.9 ± 9.4 | <0.001 |
Men | 2901 (50.7) | 273 (52.3) | 198 (53.4) | 59 (46.8) | 0.874 |
History | |||||
Angiogram | 997 (17.4) | 92 (17.6) | 56 (15.1) | 15 (11.9) | 0.274 |
Hypertension | 3282 (57.3) | 261 (50) | 186 (50.1) | 58 (46) | <0.001 |
Diabetes mellitus | 1518 (26.5) | 114 (21.8) | 92 (24.8) | 23 (18.3) | 0.02 |
Hypercholesterolemia | 2661 (46.5) | 205 (39.3) | 158 (42.6) | 61 (48.4) | 0.008 |
Family history of CVD | 1503 (26.2) | 86 (16.5) | 55 (14.8) | 21 (16.7) | <0.001 |
Prior myocardial infarction | 459 (8) | 72 (13.8) | 59 (15.9) | 24 (19) | <0.001 |
Prior PCI | 1307 (22.8) | 149 (28.5) | 112 (30.2) | 28 (22.2) | <0.001 |
Prior CABGS | 550 (9.6) | 128 (24.5) | 85 (22.9) | 35 (27.8) | <0.001 |
Revascularization | 590 (10.3) | 67 (12.8) | 42 (11.3) | 11 (8.7) | 0.268 |
Smoking history | <0.001 | ||||
Never smoked | 4403 (76.9) | 457 (87.5) | 318 (85.7) | 98 (77.8) | |
Ex-smoker | 889 (15.5) | 47 (9) | 40 (10.8) | 19 (15.1) | |
Current smoker | 434 (7.6) | 18 (3.4) | 13 (3.5) | 9 (7.1) | |
CCSA classification | <0.001 | ||||
Class I | 3103 (54.2) | 165 (31.6) | 112 (30.2) | 29 (23) | |
Class II | 2161 (37.7) | 245 (46.9) | 173 (46.6) | 58 (46) | |
Class III | 462 (8.1) | 112 (21.5) | 86 (23.2) | 39 (31) | |
Long term cardiac medication | |||||
ACEI | 2089 (36.5) | 180 (34.5) | 131 (35.3) | 43 (34.1) | 0.734 |
Angiotensin II receptor antagonist | 1110 (19.4) | 97 (18.6) | 77 (20.8) | 27 (21.4) | 0.8 |
Aspirin | 3211 (56.1) | 297 (56.9) | 209 (56.3) | 75 (59.5) | 0.885 |
Beta blockers | 2427 (42.4) | 232 (44.4) | 161 (43.4) | 72 (57.1) | 0.01 |
Calcium antagonists | 1779 (31.1) | 166 (31.8) | 112 (30.2) | 46 (36.5) | 0.593 |
Diuretic | 1281 (22.4) | 118 (22.6) | 100 (27) | 35 (27.8) | 0.127 |
Lipid-lowering agents | 3817 (66.7) | 342 (65.5) | 257 (69.3) | 90 (71.4) | 0.432 |
Nitrates | 872 (15.2) | 70 (13.4) | 48 (12.9) | 20 (15.9) | 0.458 |
Warfarin | 365 (6.4) | 21 (4) | 24 (6.5) | 12 (9.5) | 0.075 |
At least 1 anti-anginal medication | 3699 (64.6) | 326 (62.5) | 240 (64.7) | 90 (71.4) | 0.306 |
Echocardiography parameters | |||||
LV ejection fraction (%) | 57.7 ± 7 | 51.2 ± 11.5 | 49.7 ± 12.8 | 49.5 ± 12.6 | <0.001 |
Resting wall motion score index | 1.03 ± 0.1 | 1.09 ± 0.2 | 1.1 ± 0.2 | 1.12 ± 0.2 | <0.001 |
Peak wall motion score index | 1.06 ± 0.1 | 1.15 ± 0.2 | 1.15 ± 0.2 | 1.2 ± 0.2 | <0.001 |
Fixed wall motion abnormality | 738 (12.9) | 134 (25.7) | 114 (30.7) | 50 (39.7) | <0.001 |
New wall motion abnormality | 1108 (19.4) | 195 (37.4) | 111 (29.9) | 57 (45.2) | <0.001 |
Dobutamine stress echocardiography
Clinical outcomes
Characteristics | Hazard ratio (95% CI) |
p value | |
---|---|---|---|
Demographics | |||
Age (years) | 1.01 (0.95–1.06) | 0.82 | |
Gender | 0.95 (0.93–1.76) | 0.09 | |
Body mass index (kg·m2) | 0.99 (0.98–1.01) | 0.52 | |
History | |||
Angiogram | 1.24 (0.94–1.65) | 0.13 | |
Hypertension | 0.39 (0.06–4.6) | 0.57 | |
Diabetes mellitus | 0.74 (0.69–6.97) | 0.74 | |
Hypercholesterolemia | 1.25 (1.11–1.42) | <0.001 | |
Family history of CVD | |||
Prior myocardial infarction | 1.07 (0.64–3.31) | 0.97 | |
Prior PCI | 0.84 (0.74–0.96) | 0.008 | |
Prior CABGS | 0.97 (0.83–1.13) | 0.71 | |
Revascularization | 0.67 (0.53–0.86) | 0.001 | |
Smoking history | 0.63 | ||
Never smoked | 1 (Reference) | ||
Ex-smoker | 1.04 (0.85–1.28) | ||
Current smoker | 1.06 (0.89–1.26) | ||
Canadian Cardiovascular Society angina classification | <0.001 | ||
Class I | 1 (Reference) | ||
Class II | 1.14 (1–1.31) | ||
Class III | 1.89 (1.6–2.22) | ||
Long term cardiac medication | |||
ACEI | 0.9 (0.8–1) | 0.05 | |
Angiotensin II receptor antagonist | 0.89 (0.78–1.02) | 0.09 | |
Aspirin | 1.06 (0.94–1.19) | 0.34 | |
Beta blocker | 1.02 (0.92–1.14) | 0.69 | |
Calcium antagonists | 1 (0.9–1.11) | 0.99 | |
Diuretic | 1.07 (0.95–1.21) | 0.25 | |
Lipid-lowering agents | 0.59 (0.23–0.87) | 0.02 | |
Nitrates | 0.95 (0.82–1.09) | 0.44 | |
Wafarin | 1.06 (0.86–1.32) | 0.59 | |
At least 1 anti-anginal medication | 1.07 (1.03–1.19) | 0.04 | |
Baseline echocardiography data | |||
LVESD (cm) | 0.99 (0.87–1.14) | 0.94 | |
LVEDD (cm) | 1.11 (0.9–1.36) | 0.34 | |
LV ejection fraction (%) | 1 (0.99–1.01) | 0.61 | |
Mitral E/E’ | 0.99 (0.98–1.53) | 0.32 | |
Mitral annular calcification | 1.11 (0.89–1.39) | 0.34 | |
Mitral regurgitation (MR) | <0.001 | ||
None or trace MR | 1 (Reference) | ||
Mild MR | 0.97 (0.83–1.13) | ||
Moderate MR | 2.78 (2.17–3.57) | ||
Severe MR | 3.62 (2.89–4.53) | ||
Aortic regurgitation | 1.6 (0.96–1.79) | 0.14 | |
Dobutamine stress echocardiography test | |||
Baseline heart rate (b min−1) | 1 (0.99–1) | 0.4 | |
Peak dBP (mmHg) | 0.99 (0.99–1) | 0.37 | |
Resting wall motion score index | 1.07 (1.02–1.25) | <0.001 | |
Peak wall motion score index | 17.2 (6.43–46.15) | <0.001 | |
Fixed wall motion abnormality | 1.31 (1.05–1.63) | 0.02 | |
New wall motion abnormality | 1.32 (1.11–1.74) | 0.004 |
Parameter | C-statistic |
p value |
---|---|---|
Risk factors | 0.553 | – |
Risk factors + anti-anginal therapy | 0.557 | 0.73 |
Risk factors + anti-anginal therapy + LVEF | 0.595 | 0.002 |
Risk factors + anti-anginal therapy + LVEF + scar | 0.602 | 0.27 |
Risk factors + anti-anginal therapy + LVEF + scar + ischemia | 0.681 | <0.001 |
Risk factors + anti-anginal therapy + LVEF + scar + ischemia + MR | 0.704 | 0.02 |