Advertisement

Trends in referral patterns, invasive management, and mortality in elderly patients referred for exercise stress testing

  • Alberto Bouzas-Mosquera
    Correspondence
    Corresponding author at: Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Hospital Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), As Xubias, 84. 15006. A Coruña, Spain. Tel.: +34 981178184; fax: +34 981178258.
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Jesús Peteiro
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Francisco J. Broullón
    Affiliations
    Departamento de Tecnologías de la Información, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Ramón Calviño-Santos
    Affiliations
    Unidad de Hemodinámica, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Víctor X. Mosquera
    Affiliations
    Servicio de Cirugía Cardiaca, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Cayetana Barbeito-Caamaño
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • José María Larrañaga-Moreira
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Nicolás Maneiro-Melón
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • Nemesio Álvarez-García
    Affiliations
    Unidad de Imagen y Función Cardíacas, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
  • José Manuel Vázquez-Rodríguez
    Affiliations
    Unidad de Hemodinámica, Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña (INIBIC), A Coruña, Spain
    Search for articles by this author
Published:September 17, 2015DOI:https://doi.org/10.1016/j.ejim.2015.08.016

      Highlights

      • We evaluated the temporal trends among older adults referred for exercise stress testing.
      • The probability of inducible myocardial ischemia declined over time.
      • The use of cardiac imaging and the rate of coronary revascularization increased gradually.
      • Survival rate at 1 year improved over time in these patients.

      Abstract

      Introduction

      Scarce data are available on the temporal patterns in clinical characteristics and outcomes of elderly patients referred for exercise stress testing. We aimed to assess the trends in baseline characteristics, tests results, referrals for invasive management, and mortality in these patients.

      Methods

      We evaluated 11,192 patients aged ≥65 years who were referred for exercise stress testing between January 1998 and December 2013. Calendar years were grouped into four quadrennia (1998–2001, 2002–2005, 2006–2009, and 2010–2013), and trends in clinical characteristics of the patients, type and results of the tests, referrals for invasive management, and mortality across the different periods were assessed.

      Results

      Despite a progressive decrease in the proportion of patients with non-interpretable baseline electrocardiograms or prior history of coronary artery disease, there was a gradual and marked increase in the use of cardiac imaging from 32.8% in 1998–2001 to 67.6% in 2010–2013 (p < 0.001). In addition, despite a gradual decline in the probability of positive exercise stress testing both without imaging (from 18.9 to 13.6%, p < 0.001) and with imaging assessment (from 40.2 to 29.7%, p < 0.001), the cumulative rate of coronary revascularization at 1 year increased (from 10.8 to 13.7%, p < 0.001). One-year mortality also decreased progressively from 3% to 1.6% (p < 0.001).

      Conclusions

      Among older adults referred for exercise stress testing, we observed a decline over time in the probability of inducible myocardial ischemia, an increase in the use of cardiac imaging and in the rate of coronary revascularization, and an improvement in the survival rate at 1 year.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Levi F.
        • Chatenoud L.
        • Bertuccio P.
        • Lucchini F.
        • Negri E.
        • La V.C.
        Mortality from cardiovascular and cerebrovascular diseases in Europe and other areas of the world: an update.
        Eur J Cardiovasc Prev Rehabil. 2009; 16: 333-350
        • Nichols M.
        • Townsend N.
        • Scarborough P.
        • Rayner M.
        Cardiovascular disease in Europe 2014: epidemiological update.
        Eur Heart J. 2014; 35: 2950-2959
        • O'Gara P.T.
        • Kushner F.G.
        • Ascheim D.D.
        • Casey Jr., D.E.
        • Chung M.K.
        • de Lemos J.A.
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e78-e140
        • Anderson J.L.
        • Adams C.D.
        • Antman E.M.
        • Bridges C.R.
        • Califf R.M.
        • Casey Jr., D.E.
        • et al.
        2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2013; 61: e179-e347
        • Fihn S.D.
        • Gardin J.M.
        • Abrams J.
        • Berra K.
        • Blankenship J.C.
        • Dallas A.P.
        • et al.
        2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2012; 60: e44-e164
        • Lucas F.L.
        • DeLorenzo M.A.
        • Siewers A.E.
        • Wennberg D.E.
        Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993–2001.
        Circulation. 2006; 113: 374-379
        • Alter D.A.
        • Stukel T.A.
        • Newman A.
        Proliferation of cardiac technology in Canada: a challenge to the sustainability of Medicare.
        Circulation. 2006; 113: 380-387
        • Patel M.R.
        • Peterson E.D.
        • Dai D.
        • Brennan J.M.
        • Redberg R.F.
        • Anderson H.V.
        • et al.
        Low diagnostic yield of elective coronary angiography.
        N Engl J Med. 2010; 362: 886-895
        • Jedrzkiewicz S.
        • Goodman S.G.
        • Yan R.T.
        • Welsh R.C.
        • Kornder J.
        • DeYoung J.P.
        • et al.
        Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification.
        Can J Cardiol. 2009; 25: e370-e376
        • Diamond G.A.
        A clinically relevant classification of chest discomfort.
        J Am Coll Cardiol. 1983; 1: 574-575
        • Bouzas-Mosquera A.
        • Peteiro J.
        • Broullon F.J.
        • Mendez E.
        • Barge-Caballero G.
        • Lopez-Perez M.
        • et al.
        Impact of electrocardiographic interpretability on outcome in patients referred for stress testing.
        Eur J Clin Invest. 2012; 42: 541-547
        • Bouzas-Mosquera A.
        • Peteiro J.
        • Alvarez-Garcia N.
        • Broullon F.J.
        • Mosquera V.X.
        • Garcia-Bueno L.
        • et al.
        Prediction of mortality and major cardiac events by exercise echocardiography in patients with normal exercise electrocardiographic testing.
        J Am Coll Cardiol. 2009; 53: 1981-1990
        • Peteiro J.
        • Bouzas-Mosquera A.
        • Broullon F.J.
        • Garcia-Campos A.
        • Pazos P.
        • Castro-Beiras A.
        Prognostic value of peak and post-exercise treadmill exercise echocardiography in patients with known or suspected coronary artery disease.
        Eur Heart J. 2010; 31: 187-195
        • Cuzick J.
        A Wilcoxon-type test for trend.
        Stat Med. 1985; 4: 87-90
        • Kwok J.M.
        • Miller T.D.
        • Hodge D.O.
        • Gibbons R.J.
        Prognostic value of the Duke treadmill score in the elderly.
        J Am Coll Cardiol. 2002; 39: 1475-1481
        • Bouzas-Mosquera A.
        • Peteiro J.
        • Broullon F.J.
        • Alvarez-Garcia N.
        • Mendez E.
        • Perez A.
        • et al.
        Value of exercise echocardiography for predicting mortality in elderly patients.
        Eur J Clin Invest. 2010; 40: 1122-1130
        • Ladapo J.A.
        • Blecker S.
        • Douglas P.S.
        Physician decision making and trends in the use of cardiac stress testing in the United States: an analysis of repeated cross-sectional data.
        Ann Intern Med. 2014; 161: 482-490
        • Rozanski A.
        • Gransar H.
        • Hayes S.W.
        • Min J.
        • Friedman J.D.
        • Thomson L.E.
        • et al.
        Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009.
        J Am Coll Cardiol. 2013; 61: 1054-1065
        • Bouzas-Mosquera A.
        • Peteiro J.
        • Broullon F.J.
        • Calvino-Santos R.
        • Mosquera V.X.
        • Sanchez-Fernandez G.
        • et al.
        Temporal changes in the use and results of exercise echocardiography.
        Eur Heart J Cardiovasc Imaging. 2015; https://doi.org/10.1093/ehjci/jev068
        • Viana-Tejedor A.
        • Loughlin G.
        • Fernandez-Aviles F.
        • Bueno H.
        Temporal trends in the use of reperfusion therapy and outcomes in elderly patients with first ST elevation myocardial infarction.
        Eur Heart J Acute Cardiovasc Care. 2015; https://doi.org/10.1177/2048872614565928
        • Khera S.
        • Kolte D.
        • Palaniswamy C.
        • Mujib M.
        • Aronow W.S.
        • Singh T.
        • et al.
        ST-elevation myocardial infarction in the elderly—temporal trends in incidence, utilization of percutaneous coronary intervention and outcomes in the United States.
        Int J Cardiol. 2013; 168: 3683-3690
        • Steg P.G.
        • James S.K.
        • Atar D.
        • Badano L.P.
        • Blomstrom-Lundqvist C.
        • Borger M.A.
        • et al.
        ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.
        Eur Heart J. 2012; 33: 2569-2619
        • Page M.
        • Doucet M.
        • Eisenberg M.J.
        • Behlouli H.
        • Pilote L.
        Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly.
        CMAJ. 2010; 182: 1415-1420
        • Lewis W.R.
        • Ellrodt A.G.
        • Peterson E.
        • Hernandez A.F.
        • LaBresh K.A.
        • Cannon C.P.
        • et al.
        Trends in the use of evidence-based treatments for coronary artery disease among women and the elderly: findings from the get with the guidelines quality-improvement program.
        Circ Cardiovasc Qual Outcomes. 2009; 2: 633-641
        • Pellikka P.A.
        • Nagueh S.F.
        • Elhendy A.A.
        • Kuehl C.A.
        • Sawada S.G.
        American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography.
        J Am Soc Echocardiogr. 2007; 20: 1021-1041
        • Poldermans D.
        • Fioretti P.M.
        • Boersma E.
        • Thomson I.R.
        • Cornel J.H.
        • ten Cate F.J.
        • et al.
        Dobutamine-atropine stress echocardiography in elderly patients unable to perform an exercise test. Hemodynamic characteristics, safety, and prognostic value.
        Arch Intern Med. 1994; 154: 2681-2686
        • Goraya T.Y.
        • Jacobsen S.J.
        • Pellikka P.A.
        • Miller T.D.
        • Khan A.
        • Weston S.A.
        • et al.
        Prognostic value of treadmill exercise testing in elderly persons.
        Ann Intern Med. 2000; 132: 862-870
        • Gharacholou S.M.
        • Pellikka P.A.
        Trends in noninvasive testing for coronary artery disease: less exercise, less information.
        Am J Med. 2015; 128: 5-7
        • Lauer M.S.
        The “exercise” part of exercise echocardiography.
        J Am Coll Cardiol. 2002; 39: 1353-1355
        • Safavi K.C.
        • Li S.X.
        • Dharmarajan K.
        • Venkatesh A.K.
        • Strait K.M.
        • Lin H.
        • et al.
        Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes.
        JAMA Intern Med. 2014; 174: 546-553