Prognostic Value of Exercise Echocardiography
in 2,632 Patients Ն65 Years of Age
Adelaide M. Arruda, MD, MS, Mini K. Das, MD, Veronique L. Roger, MD, MPH, FACC,
Kyle W. Klarich, MD, FACC, Douglas W. Mahoney, MS, Patricia A. Pellikka, MD, FACC
OBJECTIVES We sought to determine the prognostic value of exercise echocardiography in the elderly.
BACKGROUND Limited data exist regarding the prognostic value of exercise testing in the elderly, a
population which may be less able to exercise and is at increased risk of cardiac death.
METHODS Follow-up (2.9 Ϯ 1.7 years) was obtained in 2,632 patients Ն65 years who underwent
RESULTS There were 1,488 (56%) men and 1,144 (44%) women (age 72 Ϯ 5 years). The rest ejection
fraction was 56 Ϯ 9%. Rest wall motion abnormalities were present in 935 patients (36%).
The mean work load was 7.7 Ϯ 2.3 metabolic equivalents (METs) for men and 6.5 Ϯ 1.9
METs for women. New or worsening wall motion abnormalities developed with stress in
1,082 patients (41%). Cardiac events included cardiac death in 68 patients and nonfatal
myocardial infarction in 80 patients. The addition of the exercise electrocardiogram to the
clinical and rest echocardiographic model provided incremental information in predicting
both cardiac events (chi-square ϭ 77 to chi-square ϭ 86, p ϭ 0.003) and cardiac death
(chi-square ϭ 71 to chi-square ϭ 86, p Ͻ 0.0001). The addition of exercise echocardio-
graphic variables, especially the change in left ventricular end-systolic volume with exercise
and the exercise ejection fraction, further improved the model in terms of predicting cardiac
events (chi-square ϭ 86 to chi-square ϭ 108, p Ͻ 0.0001) and cardiac death (chi-square ϭ
86 to chi-square ϭ 99, p ϭ 0.004).
CONCLUSIONS Exercise echocardiography provides incremental prognostic information in patients Ն65 years
of age. The best model included clinical, exercise testing and exercise echocardiographic
variables. (J Am Coll Cardiol 2001;37:1036 –41) © 2001 by the American College of
It has been estimated that the proportion of the U.S.
population Ն65 years of age will increase progressively and,
in the year 2050, will comprise 79 million people (1). In the
elderly, the prevalence of coronary artery disease is high, and
cardiovascular disease is the leading cause of death. How-
ever, elderly patients may be less able to exercise (2), which
makes identiﬁcation of high risk patients more difﬁcult in
this age group.
Limited data on the prognostic value of exercise testing in
elderly patients are available (2). The purposes of the
present study were to determine the prognostic value of
exercise electrocardiography and exercise echocardiography
in patients Ն65 years of age and to assess the incremental
value of exercise electrocardiography and exercise echocar-
diography in predicting cardiac events in this population.
Patients. From January 1990 to December 1995, 6,420
patients were referred for clinically-indicated exercise echo-
cardiography. Of the patients, 234 (4%) had inadequate
echocardiographic images (no echocardiographic evidence
of ischemia and two or more segments not visualized), and
142 patients (2%) refused to participate in the study. Of the
remaining 6,044 patients, 2,716 were at least 65 years of age.
Follow-up data were obtained in 2,632 of these patients
(97%); these comprise the study group. No statistically
signiﬁcant differences were present in these patients, as
compared with patients without follow-up.
Exercise echocardiography. All patients underwent
symptom-limited treadmill exercise testing according to: 1)
the Bruce protocol in 2,181 (83%); 2) the Naughton
protocol in 259 (10%); and 3) the modiﬁed Bruce protocol
in 192 (7%). Work load was measured by metabolic equiv-
alents (METs). Two-dimensional echocardiographic im-
ages were obtained from the parasternal and apical windows
before and immediately after exercise (3).
Both quad-screen digitized and videotape-recorded im-
ages were used for interpretation of all studies (4). The
ejection fraction (EF) at rest was measured using a previ-
ously validated modiﬁcation of the method of Quinones et
al. (5) or by visual estimation (6); after exercise, it was
measured by visual estimation. Regional wall motion was
assessed semiquantitatively by an experienced echocardiog-
rapher (7) who had no knowledge of the clinical informa-
tion. Wall motion at rest and with exercise in each of 16
segments was scored 1 through 5 (8). The wall motion score
From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic
and Mayo Foundation, Rochester, Minnesota. Dr. Arruda was supported by grants
from the CAPES Foundation (Fundac¸a˜o Coordenac¸a˜o de Aperfeic¸oamento de
Pessoal de Nı´vel Superior), Brası´lia, Brazil, and from the Mayo Foundation.
Manuscript received June 5, 2000; revised manuscript received November 3, 2000,
accepted December 1, 2000.
Journal of the American College of Cardiology Vol. 37, No. 4, 2001
© 2001 by the American College of Cardiology ISSN 0735-1097/01/$20.00
Published by Elsevier Science Inc. PII S0735-1097(00)01214-6