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(Circulation. 2005;112:1566-1572.)
© 2005 American Heart Association, Inc.

Epidemiology

Enhanced Risk Assessment in Asymptomatic Individuals With Exercise Testing and Framingham Risk Scores

From the Center for Cardiovascular Disease Prevention, Divisions of Preventive Medicine and Cardiovascular Medicine (S.M.), Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass; Division of Cardiology (R.F.R.), Department of Medicine, University of California, San Francisco, San Francisco, Calif; Department of Epidemiology (A.R.S.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Md; and Ciccarone Preventive Cardiology Center (R.S.B.), Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Md.

Correspondence to Samia Mora, MD, MHS, Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital, 900 Commonwealth Ave E, Boston, MA 02215. E-mail smora2{at}partners.org

Received February 14, 2005; revision received June 16, 2005; accepted June 24, 2005.

Background— National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines recommend the use of Framingham risk scores (FRS) for cardiovascular assessment of asymptomatic individuals. We hypothesized that risk prediction could be improved with 2 non-ECG exercise test measures, exercise capacity (metabolic equivalents, or METs) and heart rate recovery (HRR).

Methods and Results— An asymptomatic cohort with baseline treadmill tests (n=6126; 46% women, FRS <20%) was followed up prospectively for 20 years. Individuals with low (median or less) HRR or METs experienced 91% of all cardiovascular disease (CVD) deaths (225/246). After FRS adjustment, low HRR and METs individually were highly significant predictors of CVD death, but low HRR and METs together were associated with substantially higher risk (adjusted hazard ratio compared with high HRR/high METs for women 8.51, 95% CI 3.65 to 19.84; for men, 3.53, 95% CI 2.03 to 6.15; P<0.001 for both). At 10-year follow-up, FRS-adjusted CVD death risk associated with low HRR/low METs was less than at 20 years but remained significant (women 3.83, 95% CI 1.09 to 13.47, and men 2.70, 95% CI 1.11 to 6.55). The application of HRR/METs information to FRS assessment identified those at high risk (>0.5% annual CVD mortality) in half of women with FRS 6% to 9% and 10% to 19% and just under half of men with FRS 10% to 19%. Low HRR/low METs was also associated with an increased relative risk of CVD death in individuals with low-risk FRS (FRS <6% in women and <10% in men), but absolute CVD mortality rates were low in this subgroup.

Conclusions— Exercise testing may be a useful adjunct for clinical risk assessment in asymptomatic women with FRS 6% to 19% and men with FRS 10% to 19%.

Key Words: exercise • prevention • prognosis • risk factors