Heart Rate Recovery in association with exercise stress testing

Transcription

1 Heart Rate Recovery in association with exercise stress testing Daniel E. Forman, M.D. Director, Exercise Laboratory Brigham and Women s Hospital April 21, 2006

2 Stress Testing Historical Rationale for Exercise Testing Test sensitive and specific to diagnose CAD Symptoms and ECG changes Has this rationale for testing changed? Diagnosis is often not the question Shifting emphasis on prognosis What constitutes meaningful endpoints?

3 Limitations of Stress Test for CAD: Progression lumen may be patent Compensatory expansion maintains constant lumen Normal vessel Minimal CAD Expansion overcome: lumen narrows Moderate CAD Adapted from Glagov et al. N Engl J Med. 1987;316: Severe CAD

4 Limitation of Stress Test for CAD: Cardiac Cath is a flawed Gold Standard 3.1 mm 3.1 mm We ve based our diagnostic standards on 2D imaging Courtesy of Steven Nissen

5 Limitations of Stress Test for CAD: No assessment of plaque stability

6 Bottom Line It is often hard to detect ischemia And even when ischemia is detected, it is difficult to discern the implications Prognosis is more important than diagnosis

7 Prognostic Endpoints Functional capacity Prognostic Scores HR indices: heart rate recovery

8 Heart Rate Exercise Heart Rate Responses Rest Vagal Reactivation Vagal withdrawal Sympathetic increase Exercise Recovery Peak Heart Rate Recovery 1 minute

9 Heart Rate Recovery Biological rationale Seminal research Confounding, interactions External validation Clinical applications

10 Heart Rate Recovery Biological rationale Seminal studies Confounding, interaction External validation Clinical applications

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12 Log Heart Rate HR Recovery: After Atropine Athlete Normal Heart Failure Recovery Time (minutes) Imai JACC 24;1529;

13 Autonomic Function and Mortality Sympathetic Tone Vagal Tone Chronotropic Incompetence HR Recovery Increased Risk of Death

14 Heart Rate Recovery Biological rationale Seminal studies Confounding, interaction External validation Clinical applications

15 Heart Rate Recovery and Mortality 1.00 Normal (93/1789) Abnormal (120/639) 0.85 Abnormal < 12 bpm Log rank χ2=115, P< Hazard Ratio 4.0 (95% CI ) Years of Follow up Cole, Lauer. N Engl J Med 1999;341:

16 HRR and Duke Exercise Score Both normal 1.00 Abnormal HRR Survival 0.95 Abnormal Treadmill Score Both Abnormal Log rank χ2 = 383, P < Years of Follow up Nishime, Lauer, JAMA 2000;284:

17 Heart Rate Recovery Biological rationale Seminal studies Confounding, interaction External validation Clinical applications

18 Demographic Subsets Abnormal 6 Year Mortality (%) Normal P<0.001 P<0.001 P< P<0.001 P< P< Men Women >65 Cole, Lauer. N Engl J Med 1999;341:1351 <65 CAD No CAD

19 Test Subsets Abnormal 6 Year Mortality (%) 35 P< Normal P< P< P< Exercise HR abnormal Exercise HR normal Cole, Lauer. N Engl J Med 1999;341:1351 Thallium abnormal Thallium normal

20 Abnormal P<0.001 Normal P<0.001 P<0.001 P=0.15 P<0.001 P<0.001 N o B bl oc ke rs C a bl oc ke rs N o C a bl oc ke rs Va so di la to N rs o Va so di la to rs B bl oc ke rs 6 Year Mortality (%) Medication Subsets Cole, Lauer. N Engl J Med 1999;341:1351

21 Relative Risk Heart Rate Recovery (BPM) Cole, Lauer. N Engl J Med 1999;341:

22 Stress Echocardiography Survival 1.00 Normal heart rate recovery (N=4633, 115 deaths) 0.95 Abnormal heart rate recovery, (N=805, 75 deaths) 0.90 Log rank χ2 = 99, P < Cut off = 18 bpm 2 Years After Test Watanabe, Lauer. Circulation 2001;104:

23 HR Recovery and LVEF Both Normal 1.00 Abnormal HRR only Survival Abnormal LV only Both Abnormal Log rank χ23 = 170, P< Years After Test Watanabe, Lauer. Circulation 2001;104:

24 HR Recovery and Angiography 1 Both Normal Survival 0.9 Severe CAD 0.8 Abnormal HR Recovery 0.7 Both Abnormal Years After Stress Test Vivikenathan D and Lauer MS, J Am Coll Cardiol 2003;42:

25 Heart Rate Recovery Biological rationale Seminal studies Confounding, interaction External validation Clinical applications

26 External Validation: Stanford % Survival 100 Two minutes post 22 bpm drop 75 Two minutes post < 22 bpm drop Years Follow up Shetler K. J Am Coll Cardiol. 2001;38:

27 Technical differences 1 minute vs. 2 minute recovery Cool down vs. supine recovery protocol

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29 Ventricular Ectopic Activity 1.00 Neither Exercise Both Recovery 1862 deaths Log rank χ32 = 133, P < Years After Test Frolkis JP, Lauer MS, N Engl J Med 2003;

30 Heart Rate Recovery Biological rationale Seminal studies Confounding, interaction External validation Clinical applications

31 Combining Prognostic Indices: Function and HR recovery Shetler et al. JACC.2001;38:1980 7

32 Risk for CV death according to FRS categories and HRR/METs groups Mora, S. et al. Circulation 2005;112:

33 Clinical Implications Does this supplant the emphasis on diagnostic testing with imaging?

34 Adjusted Predicted 8 Year Mortality Treatment Implications of HRR 0.35 N= revascularization 929 deaths Revascularization No Revascularization HR Recovery (beats per minute) Chen M, Lauer M Circulation 2004;110: