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PubMed1990

Assessment of post-infarction jeopardized myocardium by vasodilation--thallium-201 tomography: impact on risk stratification.

For the purpose of risk stratification 80 consecutive patients (mean age 58 +/- 7 years) with a chest pain syndrome after documented myocardial infarction underwent tomographic vasodilation-redistribution thallium-201 perfusion imaging, using 0.56 mg kg-1 intravenous dipyridamole. Tomograms were analysed for size and location of reversible and fixed perfusion defects and correlated to angiographic characteristics, left ventricular ejection fraction and wall motion, collateral status and 1-year prognosis, as measured by cardiac events within 12 months. No serious side-effects were noted with the diagnostic use of intravenous dipyridamole. According to the perfusion pattern three subgroups of post-infarction patients were identified: (1) by ischaemia at a distance with redistribution in non-infarct related territories (n = 48); (2) by peri-infarctional ischaemia with redistribution in the territory of the 'infarct artery' (n = 9); and (3) by exclusively fixed defects without redistribution (n = 23). Ischaemia at a distance was associated with a larger reversible defect than peri-infarctional ischaemia (P less than 0.05) and the pattern without redistribution (P less than 0.005); the fixed defect size, however, was similar in all three subgroups. In addition, the severity of coronary artery disease (Gensini score and number of diseased vessels) and the degree of collateralization was higher in the presence of a redistribution pattern (P less than 0.05), although no significant differences in global and regional function were noted as a function of thallium-201 redistribution.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1984

Early risk stratification using clinical findings in patients with acute myocardial infarction.

The value of non-invasive, clinical variables in predicting short-term outcome after acute myocardial infarction has been prospectively studied using multivariate analysis in a learning population of 1724 patients and a validation sample of 588 cases. Early risk stratification of CCU mortality could be made with 89.4% accuracy by using 7 simple clinical variables (Killip class, systolic blood pressure, heart rate, age, intraventricular conduction disturbance, localization of infarction and obesity index) recorded on admission. A discriminant function formula could also be constructed resulting in a maximal classification of 89.3% and predictive values of 91.8% and 77.9%, respectively, for 28-day survival and early death prediction in the learning population. Accuracy figures dropped only slightly (1 to 5%) in the independent test set. Predictions could be made with a high degree of accuracy, especially in the upper and lower ranges of the discriminant risk score. This investigation demonstrates that a fairly good estimation of prognosis can be made by means of discriminant analysis of clinical findings gathered routinely in most CCU's.

Aged↗
PubMed1988

Improved risk stratification in patients with coronary artery disease. Application of a survival function using continuous exercise and angiographic variables.

Assessment of prognosis plays an important role in the management of patients with CAD. The objective of the study was to improve risk stratification in patients with known coronary angiographic findings. We analyzed the prognostic importance of 13 angiographic, exercise, and clinical variables in 1183 medically treated patients with documented CAD. Five-year actuarial survival rate (5-YSR) was 87%. Multivariate analysis with the proportional hazards regression model revealed four continuous and one discrete variable to be of independent prognostic importance (chi 2 value): cardiac output at the highest work load (COmax) (chi 2 = 80.7); coronary score (chi 2 = 18.6); heart volume by X-ray (chi 2 = 14.7); maximal pulmonary wedge pressure during exercise (chi 2 = 5.3), and history of myocardial infarction (chi 2 = 4.8). Inclusion of these variables in the survival function according to the regression model resulted in excellent prediction of 5-YSR, e.g. in the patients with three-vessel disease (N = 399): actuarial 5-YSR was 80%, calculated 81%. Patients with three-vessel disease and COmax greater than 11.21 min-1 (N = 188) had an actuarial 5-YSR of 88%, calculated 89%; if COmax was less than 11.21 min-1 the actuarial 5-YSR was 71%, calculated 70%. Patients with three-vessel disease from an independent cohort of surgically treated patients (N = 507) had a calculated 5-YSR under an assumed medical regimen of 77%.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1988

The effects of an aromatase inhibitor and a 5 alpha-reductase inhibitor upon the occurrence of polyovular follicles, persistent anovulation, and permanent vaginal stratification in mice treated neonatally with testosterone.

Female C57BL/Tw mice were given 5 daily injection of 20 micrograms testosterone (T), 100 micrograms 4-hydroxy-4-androstene-3, 17-dione (4-HA), 100 micrograms 6-methylene-4-pregnene-3, 20-dione (6-MP), 4-HA + 6-MP, T + 4-HA, T + 6-MP, and T + 4-HA + 6-MP starting on the day of birth. The animals were ovariectomized at 30 days or 90 days of age and were killed at 150 days. The incidence of polyovular follicles (PF) at 30 days of age was significantly increased by neonatal treatment with T. By contrast, the PF incidence was significantly reduced by injections of 4-HA given simultaneously with T. Neonatally T- or T + 6-MP-treated 90-day-old mice had ovaries containing follicles and hypertrophied interstitial cells but no corpora lutea. By contrast, T + 4-HA (64%)- and T + 4-HA + 6-MP (82%)-treated mice had ovaries with corpora lutea. In the T + 4-HA + 6-MP (82%)-treated mice had ovaries with corpora lutea. In the T + 4-HA + 6-MP-treated, 150-day-old, ovariectomized mice, the number of mice showing vaginal epithelial stratification was significantly decreased as compared with T-treated mice. There were no significant differences in the number of layers, thickness, and mitotic rate of vaginal epithelium of T-treated mice compared with mice treated with T + 4-HA, T + 6-MP, or T + 4-HA + 6-MP. The present results indicate that development of PF and persistent anovulation are due to the direct action of estrogen (E) derived from T upon neonatal ovarian follicles and the neonatal hypothalamo-hypophysial system, and that T itself can induce ovary-independent vaginal changes, although 5 alpha-reduced androgen and estrogen derived from T seem to be more effective in this regard.

5-alpha Reductase Inhibitors↗
PubMed2003

T wave alternans for ventricular arrhythmia risk stratification.

Sudden cardiac death remains one of the leading causes of death in western societies. Accordingly, the ability to identify patients at high risk of sudden cardiac death is important so that appropriate treatments can be used efficiently. Recently, T wave alternans (TWA) has emerged as a promising new test for such risk stratification. TWA is a heart rate-dependent measure of arrhythmia vulnerability, with maximal predictive accuracy at sustained, regular heart rates of 100 to 120 bpm. In the clinical setting, these conditions may be achieved by either exercise or atrial pacing. TWA has been shown to predict inducibility of ventricular tachycardia with programmed stimulation and also spontaneous arrhythmic events. TWA has been successfully applied to diverse populations, including patients with coronary artery disease, nonischemic cardiomyopathy, congestive heart failure, and implantable defibrillators. Despite these encouraging results, the role of TWA to guide clinical therapy still needs to be elucidated better.

Anti-Arrhythmia Agents↗
PubMed2003

New frontiers in risk stratification using stress myocardial perfusion single photon emission computed tomography.

PURPOSE OF REVIEW: The purpose of this review is to review the recent published literature since 2002 for studies using stress myocardial perfusion single photon emission computed tomography for determination of the prognostic value of testing. RECENT FINDINGS: A series of manuscripts dealing with myocardial perfusion single photon emission computed tomography have been published over the past 2 years that have altered a number of the most basic concepts defining risk stratification. These studies may have redefined the manner in which noninvasive stress imaging results will be interpreted and applied. SUMMARY: Recent studies have expanded the understanding of how stress myocardial perfusion single photon emission computed tomography is helpful in the identification of risk, enhanced the means of identifying risk, and improved its use as a means to identify optimal posttest treatment.

Angioplasty, Balloon, Coronary↗
PubMed1992

Exact stratification of person-years.

This paper describes methods for the exact assignment of person-years of follow-up to strata of time-dependent factors. It reviews methods applicable to variables that directly measure the passing of time and that increase in step with follow-up (monotonic time factors), and it extends their use to nonmonotonic time factors. When the same categorization scheme is used for all time factors (for example, 5-year categories), the follow-up period consists of segments whose length and position in time are predictable. A new exact method presented here uses this property to improve the efficiency of computations. The new method is generally faster than a method previously described. Finally, the paper outlines a method of exact person-year stratification that is applicable to all time-dependent factors.

Computer Simulation↗
PubMed2003

Comparison of plasma fibrinogen by Clauss, prothrombin time-derived, and immunonephelometric assays in a general population: implications for risk stratification by thirds of fibrinogen.

There is strong evidence from meta-analyses of prospective epidemiological studies that increasing plasma fibrinogen levels are associated with increasing risk of ischaemic heart disease. It has been suggested that categorization of plasma fibrinogen by thirds of the population distribution be added to cardiovascular risk prediction equations. However, the heterogeneity of plasma fibrinogen and the resulting discrepancies between commonly performed assays may lead to differences in both mean levels and distributions, and in categorizations of populations by thirds. We therefore compared three commonly performed routine fibrinogen assays in a random population sample of 1373 men and women aged 25-64 years in the fourth World Health Organization MONICA survey in north Glasgow. The two assays of clottable fibrinogen (von Clauss and prothrombin time derived) showed similar mean values and distributions, whereas the immunonephelometric assay showed lower mean values. There was significant disagreement between all three assays in categorization of thirds of population fibrinogen distribution (kappa statistic, 0.64 von Clauss versus prothrombin time derived, 0.46 von Clauss versus immunonephelometric, and 0.51 prothrombin time derived versus immunonephelometric). We conclude that further standardization of plasma fibrinogen assays is desirable for ischaemic heart disease risk stratification, and that further studies of the causes and clinical significance of discrepancies between fibrinogen assays in the general population are indicated.

Adult↗
PubMed1999

Reliability and limitations of echocardiographic measurement of left ventricular mass for risk stratification and follow-up in single patients: the RES trial. Working Group on Heart and Hypertension of the Italian Society of Hypertension. Reliability of M-mode Echocardiographic Studies.

OBJECTIVE: To investigate the clinical reliability of repeated measurements of left ventricular mass in a single patient. DESIGN: We used test-retest reliability analysis, within-class correlation and interval of agreement measures. METHODS: Two M-mode tracings (three consecutive cycles) were recorded in the same session and 3-10 days apart (5+/-2 days; mean +/- SD) in 261 participants (age 45+/-13 years, body mass index 24.7+/-3.6 kg/m2; 131 hypertensive and 130 normotensive; 50% of each group women) in 16 centres in Italy. The two tracings were read by two observers in each centre, after classification by a three-order quality score (1 = poor, 2 = sufficient, 3 = optimal). RESULTS: The average quality score was 2.11+/-0.71 (21% poor, 50% sufficient, 29% optimal). Left ventricular mass values ranged from 56 to 419 g (170+/-61 g). On the same day, within-observer 90% interval of agreement between tracing 1 and tracing 2 was -28 to +22 g (-17 to +11% of tracing 1). For day-to-day test-retest within-observer variability (average three cycles), the 90% interval of agreement was -30 to +35 g (-18 to +18%). This variability decreased to -13 to +12% at the 80% interval of agreement and -12 to +11% at the 75% interval of agreement. The 90% interval of agreement of test- retest between-observer variability was -26 to 30 g (-19 to +15%). A negligible regression toward the mean was identified. Categorical consistency of retest in the identification of hypertensive patients with left ventricular hypertrophy, classified in the first study, was 87% (k = 0.87). CONCLUSIONS: Measurement of left ventricular mass in single patients allows reliable risk stratification on the basis of the presence of left ventricular hypertrophy. The probability of a true change in left ventricular mass over time is maximized for a single-reader difference greater than 18% of the initial value, although differences of 10-13% might also have clinical relevance.

Adolescent↗
PubMed2002

Survey on treatment of hypertension and implementation of World Health Organization/International Society of Hypertension risk stratification in primary care in Belgium.

OBJECTIVE: To gain insight into the prevalence, treatment and control of hypertension and into the implementation of the 1999 World Health Organization/International Society of Hypertension guidelines for the management of hypertension in general practice in Belgium. DESIGN: A prospective cross-sectional survey. SETTING: Primary care. METHODS: Participating physicians enrolled the first 15 men, at least 55 years old, who visited the surgery, measured their blood pressure with a validated automatic device and recorded data on age, medical history, drug utilization, cardiovascular risk factors and target organ damage. Patients were considered to have hypertension when systolic blood pressure was >or= 140 mmHg, diastolic blood pressure was >or= 90 mmHg or when they were under antihypertensive therapy. RESULTS: Among 3761 evaluable patients, 74% were considered to be hypertensive, 80% of whom were treated with antihypertensive drugs. Blood pressure was under control in 38% of the treated patients and in 31% of all hypertensives. Among the 1316 hypertensive patients in whom risk stratification was possible, 47, 56 and 86% of the patients in, respectively, the medium, high and very high risk groups were treated with antihypertensive drugs. Among the treated patients, 46, 37 and 31%, respectively, had reached goal pressure. Within each risk category, patients were treated more frequently when baseline blood pressure was higher. Logistic regression analysis revealed that hypertension grade and level of risk contributed independently to the odds of being treated. CONCLUSIONS: The results indicate that a large number of older hypertensive men are treated with antihypertensive drugs in primary care, but that the goal blood pressure is not reached in a substantial number of patients due to undertreatment. Furthermore, whereas patients at higher risk are treated more frequently than patients at lower risk, blood pressure itself remains an important factor for the initiation of antihypertensive drug therapy within each risk category.

Age Factors↗
PubMed2003

Stratification of outcome for surgically treated unruptured intracranial aneurysms.

OBJECT: The combination of low anticipated rupture rates for many unruptured aneurysms, better delineation of treatment risks, and the availability of alternative modalities of treatment have led to heightened scrutiny of the surgical management of unruptured intracranial aneurysms. Most reports to date have provided aggregate data concerning surgical treatment risks. This study was performed to better delineate risk estimates for the surgical treatment of patients with unruptured intracranial aneurysms according to a patient's risk profile with regard to age, aneurysm location, and aneurysm size. METHODS: We studied 493 patients who were treated with surgical clipping of 604 unruptured saccular aneurysms. Information regarding aneurysm size, location, patient age, and 6-month or greater outcome were gathered prospectively from 1992 to 1999. Multivariate analysis was performed to identify independent risk factors for outcome. On the basis of the model, risk stratification curves were generated. RESULTS: In our series, the mean patient age was 53 years, and the mean lesion size was 8.8 mm. Lesion locations included the internal carotid artery (n = 259, 43%), the middle cerebral artery (n = 174, 28%), the anterior cerebral artery (n = 99, 17%), and the vertebrobasilar artery (n = 67, 11%). Multivariate analysis revealed that aneurysm size (beta = 0.122, P < 0.001), patient age (beta = 0.0308, P < 0.05), and vertebrobasilar location (beta = 1.37, P = 0.0080) were independently associated with high risk of poor outcome or death. CONCLUSION: Small aneurysms in the anterior circulation in young patients carry a very low treatment risk (approximately 1%), and treatment in elderly individuals (ages 70 years and older) with large lesions (greater than 10 mm), carries a significant risk of poor outcome (5% in the anterior circulation, 15% in the posterior circulation). The nomograms generated by this study should be particularly useful in discussing with patients the risks and benefits of surgical treatment of unruptured aneurysms.

Adult↗
PubMed2005

Combining different biochemical markers of myocardial ischemia does not improve risk stratification in chest pain patients compared to troponin I alone.

OBJECTIVE: Early evaluation of patients with chest pain is important not only for the detection of acute myocardial infarction (AMI) but also for identification of patients at high risk for future cardiac events. A multimarker strategy applying results of early measurements of different biochemical markers of cardiac necrosis in combination may improve risk prediction in chest pain patients. METHODS: Rapid measurements of troponin I (TnI), creatine kinase MB and myoglobin were performed in 191 consecutive patients with chest pain and a non-diagnostic electrocardiogram for AMI. The prognostic value of these markers and different multimarker strategies was evaluated and compared. RESULTS: Ten (5.2%) patients died during follow-up, which for eight (4.2%) patients was due to cardiac causes. Myocardial reinfarctions occurred in 17 (6.8%) patients. TnI was most predictive for cardiac mortality (TnI>or=0.1 microg/l, 10.7% event rate compared with TnI<0.1 microg/l, 0%, P<0.001) and myocardial reinfarction (14.9% compared with 1.7%, P<0.001). The other markers and multimarker strategies had a lower capacity for predicting adverse events apart from myoglobin and the combination of TnI or myoglobin regarding the endpoint of total mortality. CONCLUSION: The combinations of different markers were prognostically non-superior compared to TnI, which thus, should be preferred as a biochemical marker for risk stratification in patients with chest pain.

Aged↗
PubMed1998

Association between functional psychosis and expanded CAG/CTG repeats is not explained by health stratification.

A number of studies have reported an association between large CAG/CTG repeats and both schizophrenia and bipolar disorder. Recently, we reported an inverse correlation between CAG/CTG repeat size and age in a health-selected population, raising the possibility that selection of control groups for physical health was a confounding factor in our previous association studies. We investigated this by health-selection of patients with schizophrenia and bipolar disorder. The maximum CAG/CTG repeat size remained significantly larger in probands with functional psychosis compared with control individuals, and in probands with a diagnosis of schizophrenia compared with control individuals. The number of probands in the healthy bipolar group was small, and although on average this group also had longer CAG/CTG repeats than control individuals, this failed to reach statistical significance. Our findings do not support the notion that the original results with psychosis as a whole, and schizophrenia specifically, are attributable to a stratification effect consequent on health selection. Nevertheless, we are unable formally to reject the hypothesis that the previously observed difference between bipolar probands and control individuals is the result of this phenomenon.

Bipolar Disorder↗
PubMedDate not supplied

Risk stratification and primary prevention of sudden cardiac death: sudden death prevention.

The initial challenge in primary prevention of sudden cardiac death (SCD) lies in identifying those at greatest risk, before the index event. Ventricular fibrillation is the leading cause of SCD; however, many clinical conditions predispose fatal ventricular dysrhythmias. In patients with structural heart disease, left ventricular dysfunction is the strongest predictor of SCD. Noninvasive markers such as nonsustained ventricular tachycardia, delayed potentials, decreased heart rate variability and baroreflex sensitivity, and repolarization alternans are further observed to assess risk in ischemic cardiomyopathy; however, most of these markers have poor positive predictive value and lack specificity. The electrophysiologic study has strong positive predictive value, but remains a costly and invasive method for risk stratification. In patients with normal hearts, genetic predisposition may identify patients at risk but clinical markers are not readily recognized. The implantable loop recorder is a useful tool in detecting dysrhythmic causes of syncope and identifying patients at risk for SCD.

Adult↗
PubMed2006

Combined assessment of left ventricular perfusion and function by gated single-photon emission computed tomography for the risk stratification of high-risk hypertensive patients.

OBJECTIVE: This study was aimed at verifying whether combined information on left ventricular perfusion and function by electrocardiogram-gated single-photon emission computed tomography (SPECT) retains its known prognostic value in patients with systemic hypertension. METHODS: A total of 415 hypertensive patients underwent rest and stress (exercise in 278 and dipyridamole in 137) gated 99mTc-sestamibi SPECT and prospective follow-up for the composite endpoint of death and acute coronary syndrome. Patients undergoing revascularization were censored. The individual effect of clinical and stress imaging data on outcome was evaluated by Cox regression analysis. Model validation was performed using bootstrap methods adjusted by the degree of optimism in estimates. Survival analysis was performed using the product-limit Kaplan-Meier method. RESULTS: During a median follow-up of 24 months, 12 cardiac deaths and 32 acute coronary syndromes occurred. After adjusting for the most significant covariates, age [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.02-2.57], diabetes (HR 7.51, 95% CI 1.61-35.2), summed stress score (HR 2.06, 95% CI 1.07-4), and peak end-systolic volume (HR 3.62, 95% CI 1.35-9.69) were multivariable predictors of outcome. The normal perfusion pattern was associated with a low event rate independently of peak end-systolic volume. Conversely, in the case of moderate to severe perfusion abnormalities, a peak end-systolic volume greater than 74 ml was able to identify an increased risk of adverse outcome. Moreover, peak end-systolic volume was significantly higher among patients who died of a cardiac cause compared with those with different outcomes. CONCLUSION: A combined assessment of left ventricular perfusion and function by gated SPECT significantly improves risk stratification in hypertensive patients.

Aged↗
PubMed2006

Inappropriate left ventricular mass: Reliability and limitations of echocardiographic measurement for risk stratification and follow-up in single patients.

BACKGROUND: The appropriateness of left ventricular (LV) mass to cardiac workload may be calculated by the ratio of observed LV mass to the value predicted for an individual's sex, height, and stroke work at rest. OBJECTIVE: To investigate test-retest reproducibility of observed/predicted LV mass in a single patient. DESIGN AND METHODS: We measured intraclass correlation and interval of agreement between two M-mode tracings, recorded both at the same session and 3-10 days apart in 200 participants (45 +/- 13 years, body mass index 25 +/- 4 kg/m; 99 hypertensive and 101 normotensive; 50% of each group were women) in 16 centres in Italy. Tracings were read by two observers in each centre. RESULTS: The values of observed/predicted LV mass value ranged from 40.78 to 215.50%. On the same day, the within-observer 90% interval of agreement between tracings 1 and 2 was -23 to +20%. For day-to-day test-retest within-observer variability (average three cycles), the 90% interval of agreement of the observed/predicted LV mass was -30 to +32%. The 90% interval of agreement of test-retest between-observer variability was -25 to +25%. The categorical consistency of retest in the identification of subjects with appropriate LV mass, classified in the first study (i.e. > 73% and < 128%), was 90% (k = 0.87). CONCLUSION: Measurement of the appropriateness of LV mass in single patients allows acceptable risk stratification, with a coefficient of consistency similar to that reported for LV mass. The probability of a true change (90% chance) in observed/predicted LV mass over time is maximized for a single-reader difference greater than 22%, although lesser differences might also have clinical relevance.

Adult↗
PubMed2003

Time trends in clinical risk stratification for prostate cancer: implications for outcomes (data from CaPSURE).

PURPOSE: Many instruments designed to predict prostate cancer risk use a combination of clinical T stage, biopsy Gleason score and serum prostate specific antigen (PSA). We designed a study to characterize time trends in these parameters and their impact on patient risk stratification. MATERIALS AND METHODS: Data were abstracted from CaPSURE (Cancer of the Prostate Strategic Urological Research Endeavor), a disease registry of 8,685 men with prostate cancer. The 6,260 men diagnosed since 1989 who had complete clinical information reported were categorized into low, intermediate or high risk groups based on established parameters for T stage, Gleason score and PSA. RESULTS: Between 1989 to 1990 and 2001 to 2002 the proportion of patients presenting with high, intermediate and low risk disease changed from 40.9%, 28.0% and 31.2% to 14.8%, 37.5% and 47.7%, respectively (p <0.0001). The incidence of T1 tumors increased from 16.7% to 48.5% and that of T3-4 tumors decreased from 11.8% to 3.5%, respectively (p <0.0001). The incidence of Gleason 2 to 6 tumors decreased from 77.1% to 66.4%, while that of Gleason 7 tumors increased from 12.9% to 24.8%, respectively (p = 0.0030). PSA levels 10 ng/ml or less increased from 43.6% to 77.7%, respectively, while PSA 10 to 20 and greater than 20 ng/ml decreased accordingly (p <0.0001). These trends were mirrored in subset analysis of black patients. CONCLUSIONS: A significant downward risk migration has occurred over time. Gleason score is now more likely and PSA less likely than previously to drive risk assignment. This shift is most likely attributable to changes in practice patterns with respect to screening and pathological grading. These changes should be considered when applying nomograms derived from earlier datasets to contemporary cases.

Adenocarcinoma↗
PubMed2005

Postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma based on a validated prognostic nomogram and risk group stratification system.

PURPOSE: We created an evidence based postoperative surveillance protocol for patients with localized and locally advanced renal cell carcinoma (RCC) based on a risk group stratification system. MATERIALS AND METHODS: 559 patients undergoing surgery for localized and ocally advanced RCC were stratified into low risk (LR), intermediate risk (IR) and high risk (HR) groups based on the University of California-Los Angeles Integrated Staging System (UISS). Tumor recurrences were identified and categorized according to time and location. RESULTS: Patients with localized disease had a lower 5-year recurrence rate than patients with locally advanced (nodal) disease (27.6% vs 64%, p <0.0001). Patients in the LR, IR, and HR groups following nephrectomy demonstrated 5-year recurrence-free rates of 90.4%, 61.8%, and 41.9%, respectively (p <0.0001), and median times to recurrence of 28.9, 17.8 and 9.5 months, respectively (p <0.0001). Chest and abdomen recurrences comprised of 75% and 37.5%, 77.4% and 58.1%, and 45.2% and 67.7% of recurrences in the LR, IR and HR groups, respectively. In patients with node positive disease, chest and abdomen comprised of 58.8% and 76.5% of recurrences, respectively. Patients undergoing partial nephrectomy did not demonstrate a greater rate of local or distant recurrence compared with patients undergoing radical nephrectomy. CONCLUSIONS: Significant differences in incidence and time to recurrence following surgical resection for RCC mandates unique surveillance protocols for patients in each of the UISS risk groups. LR group patients should be followed for at least 5 years, whereas IR and HR group patients require longer surveillance. HR group patients require more stringent abdominal surveillance, whereas LR group patients should emphasize the chest. Patients with nodal disease also require stringent followup. Patients undergoing partial nephrectomy for localized disease can be followed according to the same UISS risk group based protocol.

Adult↗