Circulation, Vol 85, 237-248, Copyright © 1992 by American Heart Association
SG Pollock, RD Abbott, CA Boucher, GA Beller and S Kaul
BACKGROUND. The additive prognostic value of tests done in a hierarchical
order for the detection of coronary artery disease (CAD) is not always
known. The principal goal of this study, therefore, was to assess the
incremental prognostic value of data obtained in succession (clinical,
exercise stress testing, 201Tl imaging, and coronary angiography) in
patients with suspected CAD. A second goal was to develop models for
determining prognosis based on results of these tests and to test the
clinical validity of these models in unrelated patients. METHODS AND
RESULTS. Data from two groups of patients who had undergone such evaluation
and had been followed for a mean of 4.4 years were analyzed. There were 204
patients from Massachusetts General Hospital (MGH) and 299 from the
University of Virginia (UVA). There were 20 deaths and 21 nonfatal
infarctions in the MGH group and 41 deaths and nine infarctions in the UVA
group. Both univariate and multivariate Cox regression analyses were
performed to assess the individual and incremental prognostic value of
these tests. In both groups, 201Tl imaging provided significant additional
prognostic information compared with clinical and exercise stress test data
(p less than 0.05). At MGH, where the lung/heart 201Tl ratio had been
analyzed, coronary angiography did not provide additional prognostic
information. In this group of patients, the combination of clinical and
exercise 201Tl variables provided greater prognostic information than the
combination of clinical and angiographic data (p less than 0.001). In the
UVA cohort, in which the lung/heart ratio had not been analyzed, coronary
angiography provided incremental prognostic information compared with
clinical and exercise 201Tl data alone (p less than 0.05). When models
developed using data from either sample were applied to the other unrelated
sample, there was often close agreement between the overall observed rates
and those predicted by the models. This was also true for the low-risk and
high-risk subgroups. Some models, however, did not perform as well as other
models, which suggests that models that do well in one sample may not
always be generalized to other groups. CONCLUSIONS. Tests performed in
hierarchical order for the evaluation of suspected CAD provide additional
prognostic information. Models developed using clinically relevant
combinations of test results obtained from different patient populations
are frequently able to predict absolute levels of survival in unrelated but
similar samples.
ARTICLES
Independent and incremental prognostic value of tests performed in hierarchical order to evaluate patients with suspected coronary artery disease. Validation of models based on these tests
Department of Medicine, University of Virginia School of Medicine, Charlottesville.
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