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Increased Risk of Death from Cardiac Causes and Other Causes in Patients with Self-Reported Dyspnea

November 18, 2005

By Jennifer Tartaglia M.S. and Asher Kimchi M.D.

Los Angeles, CA - There are several clinical variables that are used to evaluate prognosis in known or suspected coronary artery disease patients. Dyspnea is a common symptom that may indicate subclinical left ventricular dysfunction or pulmonary disorders, and may be equivalent to the symptom of exertional angina. Aiden Abidov, M.D., Ph.D., et al. from Cedars-Sinai Medical Center in Los Angeles, CA studied the incremental prognostic value of symptom categories in predicting the risk of death in patients who underwent myocardial-perfusion single-photon-emission computed tomography (SPECT) during stress and at rest. Their study, published in the November 3, 2005 issue of The New England Journal of Medicine shows that in a large cohort of patients, those who self-reported dyspnea, identified a subgroup of asymptomatic patients who were at an increased risk of death from cardiac and noncardiac causes.

Though dyspnea, fatigue, and palpitations are somatic symptoms that may be associated with coronary artery disease, there have been limited studies predicting the risk of cardiac events in patients having these symptoms. In this study Abidov et al evaluated consecutive patients with no known cardiomyopathy or valvular disease who were subjected to myocardial-perfusion SPECT with exercise-induced stress or vasodilator-induced stress. Patients were divided into five groups based on their self-reported symptoms of chest pain and dyspnea at the time of testing (asymptomatic, nonanginal chest pain, atypical angina, typical angina, and dyspnea). All patients were prospectively enrolled in a registry, and follow-up data was collected for a minimum of one year after testing.

Of 17,991 patients who had myocardial-perfusion SPECT, 11,888 (66.1%) had exercise-induced stress and 6103 (33.9%) had vasodilator-induced stress. During the follow-up time (mean SD = 2.7 1.7 years), 786 patients without known coronary artery disease died, 224 of cardiac causes; and 720 patients with apparent coronary artery disease died, 347 of cardiac causes. Dyspnea seemed to be an independent and incremental predictor of death on multivariable analysis, since the hazard ratios for death from cardiac causes in patients with dyspnea with and without known coronary artery disease were 1.9 (95 percent confidence interval, 1.5 to 2.4) and 2.9 (95 percent confidence interval, 1.7-5.1) respectively. There was a substantially higher risk of death from cardiac and non-cardiac causes in patients with dyspnea than in those with other or no symptoms (P<0.001). Myocardial-perfusion SPECT of the study participants found that there was a higher rate of left ventricular enlargement in patients with dyspnea than the other four categories of patients. Patients with dyspnea also had higher rates of atrial fibrillation and left ventricular hypertrophy on electrocardiography (P<0.05).

The results of the study indicate that increased rates of death from cardiac causes and death from any cause exist in patients with dyspnea, both with and without known coronary artery disease. Among patients without known coronary artery disease, patients with dyspnea had four times the risk of death from cardiac causes than asymptomatic patients and at least twice the risk of patients with typical angina. Consequently, the authors of this study suggest that it may be beneficial to include an evaluation of dyspnea in the clinical assessment of patients referred for cardiac stress testing and in the algorithms used to assess prognosis of coronary artery disease.

Co-authors: Alan Rozanski, M.D., Rory Hachamovitch, M.D., Sean W. Hayes, M.D., Fatma Aboul-Enein, M.D., Ishac Cohen, Ph.D., John D. Friedman, M.D., Guido Germano, Ph.D., and Daniel S. Berman, M.D.


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