We assessed the relation of abnormal predischarge non-invasive test results to outcomes
in postmyocardial infarction patients. We included series published from 1980 to 1995
containing only myocardial infarction patients, enrolling most patients after 1980,
testing within 6 weeks of infarction, having follow-up rates > 80%, and having 2 x
2 frequency outcome rates for test results, that were the latest of multiple reports.
Sensitivity, specificity, and predictive values were calculated for test results for
1-year outcomes (cardiac death, cardiac death or reinfarction). Univariable and summary
odds were calculated for test results. Reports (n = 54) included a total of 19,874
patients and were primarily retrospective (76%) and small series (35% of reports included
< 5 deaths). One-year mortality ranged from 2.5% for pharmacologic stress echocardiography
to 9.3% for exercise radionuclide angiography. Positive predictive values for most
noninvasive risk markers were < 0.10 for cardiac death and < 0.20 for death or reinfarction.
Electrocardiographic, symptomatic, and scintigraphic risk markers of ischemia (ST-segment
depression, angina, a reversible defect) were less sensitive (< or = 44%) for identifying
morbid and fatal outcomes than markers of left ventricular dysfunction or heart failure
(exercise duration, impaired systolic blood pressure response, and peak left ventricular
ejection fraction). The positive predictive value of predischarge noninvasive testing
is low. Markers of left ventricular dysfunction appear to be better predictors than
markers of ischemia. Limitations of the literature-small samples and widely varying
event rates-impede our ability to discern the accuracy of pre-discharge noninvasive
testing. More rigorous, controlled trials are required to elucidate the relative value
of these tests for risk stratification.