Context: The usefulness of exercise stress test results and global cardiovascu lar risk systems for predicting all cause mortality in asymptomatic individuals seen in clinical settings is unclear. Objectives: To determine the validity for prediction of all cause mortality of the Framingham Risk Score and of a recent ly described European global scoring system Systematic Coronary Risk Evaluation (SCORE) for cardiovascular mortality among asymptomatic individuals evaluated in a clinical setting and to determine the potential prognostic value of exercise stress testing once these baseline risks are known. Design, Setting, and Partici pants: Prospective cohort study of 3554 asymptomatic adults between the ages of 50 and 75 years who underwent exercise stress testing as part of an executive he alth program between October 1990 and December 2002; participants were followed up for a mean of 8 years. Main Outcome Measures: Global risk based on the Framin gham Risk Score and the European SCORE. Prospectively recorded exercise stress t est result abnormalities included impaired physical fitness, abnormal heart rate recovery, ventricular ectopy, and ST segment abnormalities. The primary end po int was all cause mortality. Results: There were 114 deaths. The c index, whic h corresponds to receiver operating characteristic curve values, and the Akaike Information Criteria found that the European SCORE was superior to the Framingha m Risk Score in estimating global mortality risk. In a multivariable model, independent predictors of death were a higher SCORE (for 1%predicted increase in absolute risk, relative risk [RR], 1.07; 95%con fi dence interval [CI], 1.04-1.09; P< .001), impaired functional capacity (RR, 2 .9 5; 95%CI, 1.98-4.39; P< .001), and an abnormal heart rate recovery (RR, 1.59; 95%, 1.04-2.41; P=.03). ST segment depression did not predict mortality. Amon g patients in the highest tertile from the SCORE, an abnormal exercise stress te st result, defined as either impaired functional capacity or an abnormal heart r ate recovery, identified a mortality risk of more than 1%per year. Conclusion: Exercise stress testing when combined with the European global risk SCORE may be useful for stratifying risk in asymptomatic individuals in a comprehensive exec utive health screening program.
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