Arm Exercise versus Other Stress Test Modalities for Clinical Outcome Prediction

手臂锻炼与其他压力测试方式的临床结果预测

• 批准号: 8586876
• 负责人: Wade Hampton Martin
• 金额: --
• 依托单位: ST. LOUIS VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-10-01 至 2015-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8586876
• 关键词: Address; American; Amputation; Blood Pressure; Cardiac; Cardiac Catheterization Procedures; Cardiovascular system; Cessation of life; Characteristics; Clinical; Coronary; Data; Databases; Defect; Diagnostic; Dilatation - action; Dipyridamole; Dose; Electrocardiographic Finding; Electronics; Equipment; Exercise; Exercise stress test; Expenditure; Foot joint structure; Goals; Gold; Health; Heart Rate; Hospitalization; Hospitals; Human Resources; Image; Information Systems; Injury; Investigation; Knee; Laboratories; Leg; Lower Extremity; Measures; Medical center; Modality; Modeling; Myocardial Infarction; Myocardial perfusion; Myopathy; Nature; Outcome; Outcome Measure; Patients; Perfusion; Pharmaceutical Preparations; Physiological; Predictive Value; Probability; Publishing; Radiation; Receiver Operator Characteristics; Records; Recovery; Regression Analysis; Research; Resources; Rest; Scanning; Spinal Cord; Stress; Stress Tests; Subgroup; Symptoms; System; Test Result; Time; United States; United States Department of Veterans Affairs; Veterans; arm; arthropathies; claudication; combat; computerized; cost; demographics; disability; follow-up; hemodynamics; mortality; prognostic; public health relevance; response; time interval

DESCRIPTION (provided by applicant): Treadmill exercise capacity and hemodynamic, symptomatic, and electrocardiographic (ECG) responses to leg exercise are powerful predictors of all-cause mortality and other important measures of health outcome but none of this information is available for patients who undergo pharmacologic stress tests because of lower extremity disabilities such as amputations, knee or other arthropathies, myopathies, claudication, spinal cord, or combat injuries. The major hypothesis of this project is that composite findings of arm ergometer exercise ECG stress testing, with selective myocardial perfusion imaging (MPI) in a subset of patients such as those with highly abnormal resting ECGs or blunted hemodynamic responses, provides prognostic, clinical, and diagnostic information equivalent to non-selective pharmacologic MPI at a fraction of the cost, time expenditure, radiation exposure, and institutional equipment and personnel resource requirements in patients who cannot perform adequate lower extremity exercise. To investigate this hypothesis, we propose the following specific aims and objectives: Aim # 1 Objective # 1 is to compile data on demographics, baseline clinical characteristics, medications, stress test and MPI responses to stress, and subsequent clinical outcome in a computerized research database obtained from electronic records of approximately 5800 unique veterans who underwent 360 arm ergometer, over 2000 dipyridamole, and 3400 treadmill stress tests performed on patients at the St. Louis Veterans Administration Medical Center between 1997 and 2002. Objective # 2 is to determine by univariate and multivariate Cox regression analyses, Kaplan-Meier curves, and Wald G2 models, which exercise capacity, hemodynamic, symptomatic, ECG and MPI responses to arm ergometer, dipyridamole and treadmill stress tests independently predict survival or all-cause mortality, subsequent myocardial infarction (MI), or coronary revascularization alone and in combination, after adjustment for demographic, clinical, and medication variables, during follow-up to an endpoint of death or 12/31/2009. Objective # 3 is to compare the prognostic value of a model of independently predictive arm ergometer ECG stress test variables with dipyridamole MPI, treadmill ECG, arm ergometer and treadmill ECG plus MPI results, using receiver operator characteristic (ROC) curve analyses, for prediction of clinical outcome. Aim # 2 The goal is to develop a simple scoring system, analogous to the Duke Treadmill Score, to best prognosticate death and MI from independently predictive arm ergometer ECG stress test variables. Aim # 3 Objective # 1 is to stratify subgroups of patients in the above data base with a highly abnormal baseline ECG, blunted hemodynamic responses to stress, an abnormal stress ECG or low exercise capacity, for whom it is hypothesized that MPI information might be most beneficial for incremental prognostication of outcome. Objective # 2 is to investigate the independent incremental prognostic value of MPI in these subgroups and compare the incremental value of MPI for prediction of outcome in the various subgroups of veterans using Cox regression and G2 analyses. PUBLIC HEALTH RELEVANCE: Approximately 132,000 veterans underwent cardiac imaging stress tests in Veterans Administration (VA) hospitals in 2007 and nearly 9 million Americans a year perform such studies in the United States as a whole at a cost of more than 10 billion dollars. Because of previous combat injuries, amputations, leg or foot joint, spinal cord, circulatory and other lower extremity disabilities, 20-40% of such patients are evaluated with pharmacologic rather than leg exercise stress tests, precluding access to the powerful prognostic data available from exercise tests for prediction of survival and other health outcome measures. To address this deficiency, in the present project we propose to continue our previous published investigations of arm exercise as an alternative to pharmacologic or treadmill exercise testing in veterans with lower extremity disabilities.

描述（由申请人提供）： 跑步机运动能力以及腿部运动的血流动力学、症状和心电图 (ECG) 反应是全因死亡率和其他重要健康结果指标的有力预测因素，但对于因截肢、膝关节或其他关节病、肌病、跛行、脊髓或战斗损伤等下肢残疾而接受药物应激测试的患者来说，这些信息均不可用。该项目的主要假设是，手臂测力计运动心电图压力测试的综合结果，以及对一部分患者（例如静息心电图高度异常或血流动力学反应迟钝的患者）进行选择性心肌灌注成像（MPI）的综合结果，可以提供与非选择性药理 MPI 相当的预后、临床和诊断信息，而成本、时间消耗、辐射仅为一小部分。 无法进行足够下肢运动的患者的暴露、机构设备和人员资源需求。为了研究这一假设，我们提出以下具体目的和目标： 目标#1 目标#1 是在计算机化研究数据库中汇编有关人口统计学、基线临床特征、药物、压力测试和 MPI 对压力反应以及后续临床结果的数据，该数据库从约 5800 名独特退伍军人的电子记录中获得，这些退伍军人接受了 360 次手臂测力计、超过 2000 次双嘧达莫和 3400 次跑步机压力 1997 年至 2002 年间在圣路易斯退伍军人管理局医疗中心对患者进行的测试。目标#2 是通过单变量和多变量 Cox 回归分析、Kaplan-Meier 曲线和 Wald G2 模型来确定运动能力、血流动力学、症状、心电图和 MPI 对手臂测力计、双嘧达莫和跑步机压力测试的反应独立预测生存或全因死亡率， 在对死亡终点或 2009 年 12 月 31 日的随访期间，在对人口、临床和药物变量进行调整后，随后发生心肌梗死 (MI) 或单独或联合冠状动脉血运重建。 目标 3 是使用受试者操作特征 (ROC) 曲线分析，比较独立预测手臂测力计 ECG 压力测试变量模型与双嘧达莫 MPI、跑步机 ECG、手臂测力计和跑步机 ECG 加 MPI 结果的预后价值，以预测临床结果。 目标#2 目标是开发一个简单的评分系统，类似于杜克跑步机评分，通过独立预测的手臂测力计心电图压力测试变量来最好地预测死亡和心梗。 目标#3 目标#1 是对上述数据库中基线心电图高度异常、对压力的血流动力学反应迟钝、压力心电图异常或运动能力低的患者亚组进行分层，假设 MPI 信息可能对增量预后预测最有利。 目标#2是调查这些亚组中 MPI 的独立增量预后价值，并使用 Cox 回归和 G2 分析比较 MPI 对退伍军人各个亚组结果预测的增量值。 公共卫生相关性： 2007年，大约132,000名退伍军人在退伍军人管理局(VA)医院接受了心脏成像压力测试，每年有近900万美国人在美国进行此类研究，花费超过100亿美元。由于之前曾遭受过战斗伤害、截肢、腿部或足部关节、脊髓、循环系统和其他下肢残疾，20-40%的此类患者接受了药物而不是腿部运动压力测试的评估，从而无法从运动测试中获得强大的预后数据来预测生存和其他健康结果指标。为了解决这一缺陷，在本项目中，我们建议继续之前发表的手臂运动研究，作为下肢残疾退伍军人药物或跑步机运动测试的替代方案。