Barlera, Simona

Franzosi, MariaGrazia

Giordano, Amerigo

Maggioni, Aldo P.

Turazza, Fablo

Villella, Alessandro

Villella, Massimo

Elsevier - Publisher Connector 

330A ABSTRACTS- Oral JACC February 1996 
4:30 
[~3" -~ Proonostle Sig,amcance of  Double Product und 
Inad'eCNete Double Prod.uct Respon_se.to M_ax..Imal 
Symptom-Limited Exerc/s? ._~tress.. Testing Al~.r L 
Myocardial !n~rot ion in 6~e~ PaUenlHI lreal[eO wnn 
Thrombolytlc Agents 
Mansimo Vitlella, Alessandro Vitiolla, $imona Barlera, Ameflgo Glordano, 
MadaGrazle Franzosi, Ndo R Maggioni, Fable Turn_ :".'n; GISSI-2 
Investigators. GISSI Coordinating Centre, ANMCO and M. Negri Institute, 
Italy 
The Double Product (DP), the product of heart rate and systolic blood pres- 
sure at the end of exercise stress testing (ET) allows to estimate the myocar- 
dial oxygen uptake. 
The aim of the study was to evaluate if this parameter san provide different 
prngnostlo Information on AMI survivors treated with thrombelyttc agents. 
Of 10,219 patients (pts) randomized In GISSI-2 study discharged alive with 
confirmed rnyocardial infarction 6,296 pedormed maximal symptom-limited 
ET. In the remaining 3,923 pts ET was not performed for cardiac or non- 
cardiac contraindicotions. All the tots were given thrombotytic therapy in 
the acute phase of MI. The independent prognostic value of the DP was 
assessed by Cox ~1 In tiv" ~,n-51 pts (99.3%) for whom 6 month mortality 
and retnferction data ware .~vailable. The distribution of OP was evaluated 
according to the receiver operator characteristic (ROC) analysis to choose 
the best discrimlnsting vague. The value of DP with the highest sensitivity and 
specificity was 21,700. The DP was higher than 21,700 in 3,944 pts (63%) 
(Group 1); equal or Inferior to 21,700 in 2,283 pts (36%) (Group 2); unknown 
In 24 pts due to missing data. 
Results on 6-month mortality are reported In the table. 
Group I Group 2 RRCOx 95% GI 
Mortality % O.S 2.0 2.00 1.26-.,3.18 
In conclusion a poor DP response to maxima[ ET ls an Independent 
predlntor of C--menfh mortality in survivors of MI treated with thrombolytic 
agents. 
4:45 
F~- ]  Exercise Testing Rapid Triage Emergency for of 
Room Pallente With Chest Pain 
Howard K. Newhouse, David G. DiMattia, Mark A. Menagus, Ronald 
H. Wharton. Menteflore Medical Center, Bronx, NY 
Rapid and cost-efficient evaluation of patients presenting to the emergency 
room (ER) with chest pain (CP) is important. A protocol was established for 
Immediate maximal exerdsa stress (EX) testing of pts without ECG evidence 
of acute Ischemla, at the discretion of the ER physfclan. Pts with known 
CAD, age • 65, or unlnterpmtabte EX ECG due to LVH, BBB, or Digoxin 
were excluded. Telephone follow-up was performed at 6 months. 
56 pte undemmnt EX test < 24 hrs after ER ardval. Mean age was 46, 
and 65% were female. CP was 5% typical, 32% atypical, and 63% non- 
anginal. An adequate test endpolnt was achieved In 9~% (mean 9 METS, 
92% PMHR). Horizontal ST deprsssion >_. 1 mm occurred In 3 pts (5"/0). There 
were no complications from testing. 
Fallow.up was available In 96%. Two of 3 pts with positive EX ECG were 
admitted and had angtngraphio CAD. All pts with a normal EX ECG were 
discharged from the ER; none had death, MI, or documented CAD at follow- 
up. Of pts with normal EX ECG, 37% continued to report CP, including 10% 
with reoJrrenf ER visits. 
In conclusion, early EX testing Is safe and effective for the triage of pte 
presenting to the ER with chest pain. Despite negative tests and a benign 
prognosis, persistent symptoms and recurmnf ER visits were h~quant sng- 
gasting that further evaluation and treatment after ER discharge is important. 
Variations in Cardiovascular Care: 
Imp l i ca t ions  on  Costs  and  Appropr ia teness  
Wednesday, March 27, 1996, 4:00 p .m. -5 :00  p.m. 
Orange County  Convent ion Center, Room 224C 
4:00 
I~- I  Reglonul Vadatlons Treatment Costs  and In 
Resource Utllizctlon mr Uncomplicated Acute 
Myocardial  Infarction (UMI) 
Eric L. Eissnstein, L Kdstin Newby, J. David Knight, Laslee J. Shaw, Robert 
M. Califf, Edc J. Topoi, Daniel 8. Mark. Duke Unlversfly Medical Center, 
Durham, NO 
Previous analysis of GUSTO-I data found regional variation in cardiac proce- 
dura use despite similarities in disease characteristics. We used the 22,043 
GUSTO-I patients for whom we had resource utilization data and a set of 
validated clinical cdteda to identity UMI patients by region and to compute 
their hospital and physician costs. We found differences in UMI rates (range 
46°/=--59%) and in the use of resources (room and procedure). The New Eng- 
land and Pacific regions had similar total costs for UMI but had algnitlcant 
differences in mean length of stay (LOS, 9.1 vs. 7.5 days) and in percent of 
total costs that were procedures (% Proc, 22=/0 vs. 32%). 
Region % UMI Complicated Un¢omplic~lled 
LOS Cost LOS Cost % Proc 
New Engl 52 11.3 23,226 9.1 13.877 22 
Mid Atlantic 53 11.9 25,971 10.4 17,383 26 
S Atlantic 54 10.7 24,735 8.8 16,268 35 
EN Central 52 10.5 24,962 9.0 16,663 33 
S Centre! 59 10.8 28,346 8.6 15,798 36 
WN Central 46 9.8 24,423 8.1 15,089 32 
Mountain 52 9.5 24,0:7 7.9 15,180 35 
Padfla 58 8.9 21,743 7.5 13,748 32 
Condus/on. Regional differences in resource use for UMI suggest the 
potential for significant cost savings through case management. 
4:15 
~ '~7 British laterventionlste bat  Not General  
Cardiologiste Mirror US Practice: AppllcaUon of  the 
Unlvemlty of  Maryland Revesculorisat lon 
Appropriateness Scoring System at the UK National 
Cardiac Centre 
Redney H. Stables. Th~ Royal Brompton Hospital, London, England 
Them has been much interest in the development of scodng systems to 
evaluate the sppropdatensss of coronary revasculerisation by PTCA and 
CABG. The University of Maryland RAS system has proven a practical tool 
for this purpose and, when compared to the more complex RAND expo~ 
panel ratings end AOC/AHA guldallnes, was the only Index to predict cllnisal 
outcome. At the UK national centre we have examined the allocation of pa- 
tients with single vessel comnen] disease (SVD) to PTCA or medical therapy 
and demonstrated that, in a cohort prospectively Identified from a consecutive 
ssdss of 2000 diagrmstic atheter procedures, interventional cardiologists (I) 
were more than twtco as likely to recommend PTOA than their non-hlvesivo 
colleagues (N). No patients were allocated to CABG. Cardiologist disposition 
was a powerful and independent predictor of .treabllent a lan .  The RAS 
methodology was applied to examine this vedation in practice. 
Conc/us/ons: The RAS system can ha applied in a UK ssffing. In the 
management of SVD, British Intenmntianists practice in line with its recom- 
mendations ~nd there Is little evidence that they are performing significant 
numbers of inappropriate ixocodures. In confxast it appears that general 
cardiologists fall to reco~ PTCA In a significant proportion {46%) of 
patients when the RAS suggests that mvssc~ladsa~n Is ledlsatsd. 
% Of all p4tJwlts when PTCA is: I N 
Not Indtmlted and Not Per/staled 26% 24% 
Not Indicated and Peffocmed 10% 2% 
I~at=:l sad Nol ~ 0% 
Indicated e~d Pe~m~ed 64% 28% 


Prognostic significance of double product and inadequate double product response to maximal symptom-limited exercise stress testing after myocardial infarction in 6,296 patients treated with thrombolytic agents 

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Prognostic significance of double product and inadequate double product response to maximal symptom-limited exercise stress testing after myocardial infarction in 6,296 patients treated with thrombolytic agents

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