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To the Editor: Dr Nishime and colleagues¹ recently reported that heart rate recovery (HRR) of less than 12 beats per minute in the first minute following exercise predicted all-cause mortality in patients undergoing exercise stress testing. They also found that HRR and the Duke treadmill exercise score (DTES) independently predicted all-cause mortality in these patients. The authors state that all-cause mortality is an "objective and unbiased end point," unlike cardiac mortality. Nevertheless, since patients are usually referred for exercise testing to assess cardiac symptoms and risk of coronary events, the study would have been far more clinically useful if the cardiac-specific end points of cardiac death and nonfatal infarction had been reported.

Myocardial perfusion single-photon emission computed tomography (SPECT) imaging also predicts cardiac death,² but would not be expected to predict noncardiac death. Because patients with low coronary risk are more likely to die of noncardiac causes, neither cardiac SPECT . . . [Full Text of this Article]

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