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Performance and Interpretation of Office Exercise Stress Testing. Prim Care 2021; 48:627-643. [PMID: 34752274 DOI: 10.1016/j.pop.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In an era where cardiovascular disease continues to increase in prevalence, chest pain is a commonly encountered complaint in the outpatient setting. Clinicians are often tasked with the challenge of selecting the most appropriate screening tool in the evaluation of a patient with suspected coronary artery disease. With proper consideration of indications and contraindications, exercise electrocardiogram (ECG) stress testing is an accessible, cost-conscious, and validated outpatient diagnostic modality for predicting coronary artery disease.
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Geluk CA, Dikkers R, Kors JA, Tio RA, Slart RHJA, Vliegenthart R, Hillege HL, Willems TP, de Jong PE, van Gilst WH, Oudkerk M, Zijlstra F. Measurement of coronary calcium scores or exercise testing as initial screening tool in asymptomatic subjects with ST-T changes on the resting ECG: an evaluation study. BMC Cardiovasc Disord 2007; 7:19. [PMID: 17629903 PMCID: PMC1959245 DOI: 10.1186/1471-2261-7-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 07/13/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Asymptomatic subjects at intermediate coronary risk may need diagnostic testing for risk stratification. Both measurement of coronary calcium scores and exercise testing are well established tests for this purpose. However, it is not clear which test should be preferred as initial diagnostic test. We evaluated the prevalence of documented coronary artery disease (CAD) according to calcium scores and exercise test results. METHODS Asymptomatic subjects with ST-T changes on a rest ECG were selected from the population based PREVEND cohort study and underwent measurement of calcium scores by electron beam tomography and exercise testing. With calcium scores > or =10 or a positive exercise test, myocardial perfusion imaging (MPS) or coronary angiography (CAG) was recommended. The primary endpoint was documented obstructive CAD (>/=50% stenosis). RESULTS Of 153 subjects included, 149 subjects completed the study protocol. Calcium scores > or =400, 100-399, 10-99 and <10 were found in 16, 29, 18 and 86 subjects and the primary endpoint was present in 11 (69%), 12 (41%), 0 (0%) and 1 (1%) subjects, respectively. A positive, nondiagnostic and negative exercise test was present in 33, 27 and 89 subjects and the primary endpoint was present in 13 (39%), 5 (19%) and 6 (7%) subjects, respectively. Receiver operator characteristics analysis showed that the area under the curve, as measure of diagnostic yield, of 0.91 (95% CI 0.84-0.97) for calcium scores was superior to 0.74 (95% CI 0.64-0.83) for exercise testing (p = 0.004). CONCLUSION Measurement of coronary calcium scores is an appropriate initial non-invasive test in asymptomatic subjects at increased coronary risk.
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Affiliation(s)
- Christiane A Geluk
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Riksta Dikkers
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jan A Kors
- Department of Medical Informatics, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - René A Tio
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Riemer HJA Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Rozemarijn Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Hans L Hillege
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Tineke P Willems
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Paul E de Jong
- Departement of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Wiek H van Gilst
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, The Netherlands
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Matthijs Oudkerk
- Department of Radiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, The Netherlands
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Abstract
Exercise stress testing is a non-invasive, safe and affordable screening test for coronary artery disease (CAD), provided there is careful patient selection for better predictive value. Patients at moderate risk for CAD are best served with this kind of screening, with the exception of females during their reproductive period, when a high incidence of false positive results has been reported. Patients with a high pretest probability for CAD should undergo stress testing combined with cardiac imaging or cardiac catheterization directly. Data from the test, other than ECG changes, should be taken into consideration when interpreting the exercise stress test since it has a strong prognostic value, i.e. workload, heart rate rise and recovery and blood pressure changes. Only a low-level exercise stress test can be performed early post myocardial infarction (first week), and a full exercise test should be delayed 4 to 6 weeks post uncomplicated myocardial infarction. The ECG interpretation with myocardial perfusion imaging follows the same criteria, but the sensitivity is much lower and the specificity is high enough to overrule the imaging part.
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Affiliation(s)
- Suleiman M Kharabsheh
- Department of Cardiovascular Disease, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
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Abstract
Chest pain units provide an important alternative to traditional hospital admission for patients who present to the emergency department with symptoms compatible with acute coronary syndrome and a normal or inconclusive initial evaluation. Although patient subgroups such as women, diabetics, those with established coronary artery disease,and those with symptoms related to stimulant use present unique challenges,management in a chest pain unit appears to be appropriate in these populations. Judicious application of accelerated diagnostic protocols and current testing methods can promote safe, accurate, and cost-effective risk stratification of special populations to identify patients who can be safely discharged and patients who require hospital admission for further evaluation.
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Affiliation(s)
- Deborah B Diercks
- Department of Emergency Medicine, University of California School of Medicine (Davis) and Medical Center, Sacramento, CA 95817, USA.
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Munagala VK, Guduguntla V, Kasravi B, Cummings G, Gardin JM. Use of atropine in patients with chronotropic incompetence and poor exercise capacity during treadmill stress testing. Am Heart J 2003; 145:1046-50. [PMID: 12796761 DOI: 10.1016/s0002-8703(02)94703-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treadmill stress testing (TMST) is a valuable diagnostic test for ischemic heart disease. However, the inability to achieve the target heart rate because of either chronotropic incompetence or poor exercise capacity is a major limitation to its utility. We evaluated the usefulness of atropine in decreasing the number of tests with inconclusive results in patients with a poor chronotropic response or exercise capacity during TMST. METHODS The study comprised 126 patients undergoing TMST. In subjects experiencing fatigue at submaximal exercise, atropine was administered in doses of 0.5 mg per minute until the test conclusion (positive test results or target heart rate achieved) or until a maximum dose of 2 mg was administered. RESULTS Thirty-three of the 126 patients (26%) required atropine (mean dose, 1 mg) during the study; 23 of the 33 patients (70%) proceeded to achieve their target heart rate (n = 17) or positive test results (n = 6). The mean increase in heart rate after atropine administration was 25 beats/min (range 3-53 beats/min). Atropine was required in 39% of patients receiving beta-blockers, versus 21% of patients not receiving beta-blockers (P =.02). Among patients receiving atropine, a conclusive test was achieved significantly more often in patients not receiving beta-blockers (94% vs 46%, P =.01). No adverse events were associated with the use of atropine. Atropine administration resulted in conclusive tests more often in subjects with poor chronotropic response than in subjects with poor exercise capacity (78% vs33%, P = <.001). CONCLUSION The use of atropine as an adjunct to standard TMST can help decrease the number of inconclusive tests, even in patients taking beta-blockers. Larger studies are warranted to further define the role of atropine in diagnostic TMST.
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Affiliation(s)
- Vijaya K Munagala
- Division of Cardiology, St. John Hospital and Medical Center, Detroit, MI 48236, USA
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Tobin D, Thow M. The 10 m Shuttle Walk Test with Holter Monitoring: an objective outcome measure for cardiac rehabilitation. ACTA ACUST UNITED AC 1999. [DOI: 10.1016/s1362-3265(99)80028-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Do D, Marcus R, Froelicher V, Janosi A, West J, Atwood JE, Myers J, Chilton R, Froning J. Predicting severe angiographic coronary artery disease using computerization of clinical and exercise test data. Chest 1998; 114:1437-45. [PMID: 9824025 DOI: 10.1378/chest.114.5.1437] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Currently the standard exercise test is shifting from being a tool for the cardiologist to utilization by the nonspecialist. This change could be facilitated by computerization similar to the interpretation programs available for the resting ECG. Therefore, we sought to determine if computerization of both exercise ECG measurements and prediction equations can substitute for visual analysis performed by cardiologists to predict which patients have severe angiographic coronary artery disease. We performed a retrospective analysis of consecutive patients referred for evaluation of possible or known coronary artery disease who underwent both exercise testing with digital recording of their exercise ECGs and coronary angiography at two university-affiliated Veteran's Affairs medical centers and a Hungarian hospital. There were 2,385 consecutive male patients with complete data who had exercise tests between 1987 and 1997. Measurements included clinical and exercise test data, and visual interpretation of the ECG paper tracings and > 100 computed measurements from the digitized ECG recordings and compilation of angiographic data from clinical reports. The computer measurements had similar diagnostic power compared with visual interpretation. Computerized ECG measurements from maximal exercise or recovery were equivalent or superior to all other measurements. Prediction equations applied by computer were only able to correctly classify two or three more patients out of 100 tested than ECG measurements alone. beta-Blockers had no effect on test characteristics while ST depression on the resting ECG decreased specificity. By setting probability limits using the scores from the equations, the population was divided into high-, intermediate-, and low-probability groups. A strategy using further testing in the intermediate group resulted in 86% sensitivity and 85% specificity for identifying patients with severe coronary disease. We conclude that computerized exercise ST measurements are comparable to visual ST measurements by a cardiologist and computerized scores only minimally improved the discriminatory power of the test. However, using these scores in a stratification algorithm allows the nonspecialist physician to improve the discriminatory characteristics of the standard exercise test even when resting ST depression is present. Computerization permitted accurate identification of patients with severe coronary disease who require referral.
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Affiliation(s)
- D Do
- University of Texas in San Antonio, USA
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Atwood JE, Do D, Froelicher V, Chilton R, Dennis C, Froning J, Janosi A, Mortara D, Myers J. Can computerization of the exercise test replace the cardiologist? Am Heart J 1998; 136:543-52. [PMID: 9736150 DOI: 10.1016/s0002-8703(98)70233-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The type of practitioners who use the standard exercise test is changing. Once a tool of the cardiologist, the standard exercise test is now being performed by internists and other noncardiologists. Because this change could be facilitated by computerization similar to the computerized interpretation programs available for the resting electrocardiograph (ECG), we performed this analysis. A secondary aim was to demonstrate the effects of medication status and resting ECG abnormalities on test diagnostic characteristics because these factors affect utility of the exercise test by the generalist. METHODS AND RESULTS A retrospective analysis was performed of consecutive patients referred at 2 university-affiliated Veteran's Affairs Medical Centers and a Hungarian Hospital for evaluation of chest pain and possible ischemic heart disease. There were 1384 consecutive male patients without a prior myocardial infarction with complete data who had exercise tests and coronary angiography between 1987 and 1997. Measurements included clinical, exercise test data, and visual interpretation of the ECG recordings as well as more than 100 computed measurements from the digitized ECG recordings and compilation of angiographic data from clinical reports. The computer measurements had similar diagnostic power compared with visual interpretation. Computerized measurements from maximal exercise or recovery were equivalent or superior to all other measurements. Prediction equations applied by computer were superior to single ECG measurements. Beta-blockers had no effect on test characteristics, whereas resting ST depression was associated with decreased specificity and increased sensitivity. CONCLUSIONS Computerized exercise ST measurements are comparable to visual ST measurements by a cardiologist; computerized scores that included clinical and exercise test results exhibited the greatest diagnostic power. Applying scores with a computer allows the practicing physician to improve the diagnostic characteristics of the standard exercise test. This approach is successful even when there is resting ST depression, thus lessening the need for more expensive nuclear or imaging studies.
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Affiliation(s)
- J E Atwood
- Cardiology Division at the Veterans Affairs Palo Alto Health Care System, Calif 94304, USA
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Do D, West JA, Morise A, Atwood JE, Froelicher V. An agreement approach to predict severe angiographic coronary artery disease with clinical and exercise test data. Am Heart J 1997; 134:672-9. [PMID: 9351734 DOI: 10.1016/s0002-8703(97)70050-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To demonstrate that an agreement approach to applying equations on the basis of clinical and exercise test variables is an accurate, self-calibrating, and cost-efficient method for predicting severe coronary artery disease in clinical populations. DESIGN Retrospective analysis of consecutive patients with complete data from exercise testing and coronary angiography referred for evaluation of possible coronary artery disease. After developing an equation in a training set, this equation and two other equations developed by other investigators were validated in a test set. The study was performed at two university-affiliated Veteran's Affairs medical centers. PATIENTS 1080 consecutive men studied between 1985 and 1995 who had coronary angiography within 3 months of the treadmill test. The population was randomly divided into a training set of 701 patients and a test set of 379 patients. Patients with previous coronary artery bypass surgery, valvular heart disease, marked degrees of resting ST depression, and left bundle branch block were excluded. MEASUREMENTS Recording of clinical and exercise test data along with visual interpretation of the electrocardiogram recordings on standardized forms and abstraction of visually interpreted angiographic data from clinical catheterization reports. RESULTS Simple clinical and exercise test variables improved the standard application of exercise-induced ST criteria for predicting severe coronary artery disease. By setting probability thresholds for severe disease of <20% and >40% for the three prediction equations, the agreement approach divided the test set into three groups: low risk (patients with all three equations predicting <21% probability of severe coronary disease), no agreement, and high risk (all three equations with >39% probability) for severe coronary artery disease. Because the patients in the no agreement group would be sent for further testing and would eventually be correctly classified, the sensitivity of the agreement approach was 89% and the specificity was 96%. The agreement approach appeared to be unaffected by disease prevalence, missing data, variable definitions, or even angiographic criteria. CONCLUSIONS Requiring diagnosis of severe coronary disease to be dependent on agreement between these three equations has made them likely to function in all clinical populations. The agreement approach should be an efficient method for the evaluation of populations with varying prevalence of coronary artery disease, limiting the use of more expensive noninvasive and invasive testing to patients with a higher probability of left main or triple-vessel coronary artery disease. This approach provides a strategy that can be applied by inputting the results of basic clinical assessment into a programmable calculator or a computer to assist the practitioner in deciding when further evaluation is appropriate, thus assuring patients access to subspecialty care.
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Affiliation(s)
- D Do
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, CA 94304, USA
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Do D, West JA, Morise A, Atwood E, Froelicher V. A consensus approach to diagnosing coronary artery disease based on clinical and exercise test data. Chest 1997; 111:1742-9. [PMID: 9187202 DOI: 10.1378/chest.111.6.1742] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To demonstrate that a consensus approach for combining prediction equations based on clinical and exercise test variables derived from different populations can stratify patients referred for possible coronary artery disease (CAD) into low-, intermediate-, and high-risk groups. DESIGN Retrospective analysis of consecutive patients with complete data from exercise testing and coronary angiography referred for evaluation of possible CAD. After derivation of a logistic equation in our own training set of patients, this equation, along with two other equations developed independently by other investigators, was validated in a test set. The validation strategy for the consensus approach included the following: (1) calculation of probability scores for each patient using each logistic equation independently; (2) determination of probability thresholds in the training set to divide the patients into three groups-low risk (prevalence CAD <5%), intermediate risk (5 to 70%), and high risk (>70% prevalence of CAD); (3) using agreement among at least two of three of the prediction equations to generate "consensus" for each patient; and (4) application of the consensus approach thresholds to the test set of patients. SETTINGS Two university-affiliated Veteran's Affairs medical centers. PATIENTS We studied 718 consecutive men between 1985 and 1995 who had coronary angiography within 3 months of an exercise treadmill test for suspected CAD. The population was randomly divided into a training set of 429 patients and a test set of 289 patients. Patients with previous myocardial infarction or coronary artery bypass surgery, valvular heart disease, left bundle branch block, or any Q waves present on their resting ECG were excluded from the study. MEASUREMENTS Recording of clinical and exercise test data along with visual interpretation of the ECG recordings on standardized forms and abstraction of visually interpreted angiographic data from clinical catheterization reports. RESULTS We demonstrated that by using simple clinical and exercise test variables, we could improve on the standard use of ECG criteria during exercise testing for diagnosing CAD. Using the consensus approach divided the test set into populations with low, intermediate, and high risk for CAD. Since the patients in the intermediate group would be sent for further testing and would eventually be correctly classified, the sensitivity of the consensus approach is 94% and the specificity is 92%. The consensus approach controls for varying disease prevalence, missing data, inconsistency in variable definition, and varying angiographic criterion for stenosis severity. The percent of correct diagnoses increased from the 67% for standard exercise ECG analysis and from the 80% for multivariable predictive equations alone to >90% correct diagnoses for the consensus approach. CONCLUSIONS The consensus approach has made population-specific logistic regression equations portable to other populations. Excellent diagnostic characteristics can be obtained using simple data and measurements. The consensus approach is best applied utilizing a programmable calculator or a computer program to simplify the process of calculating the probability of CAD using the three equations.
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Affiliation(s)
- D Do
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Stanford University, Calif 94304, USA
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Okin PM, Kligfield P. Heart rate adjustment of ST segment depression and performance of the exercise electrocardiogram: a critical evaluation. J Am Coll Cardiol 1995; 25:1726-35. [PMID: 7759730 DOI: 10.1016/0735-1097(95)00085-i] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Analysis of the rate-related change in exercise-induced ST segment depression using the exercise ST segment/heart rate slope and ST segment/heart rate index can improve the accuracy of the exercise electrocardiogram (ECG) for the identification of patients with coronary artery disease, recognition of patients with anatomically or functionally severe coronary obstruction and detection of patients at increased risk for future coronary events. These methods provide a more physiologic approach to analysis of the ST segment response to exercise by adjusting the apparent severity of ischemia for the corresponding increase in myocardial oxygen demand, which in turn can be linearly related to increasing heart rate. Solid-angle theory provides a model for the linear relation of ST segment depression to heart rate during exercise and a framework for understanding the relation of the ST segment/heart rate slope to the presence and extent of coronary artery disease. False positive and false negative test results of the heart rate-adjusted methods are well known in selected populations and require further clarification. Application of these methods is also highly dependent on the type of exercise protocol, number of ECG leads examined, timing of ST segment measurement relative to the J point and accuracy and precision of ST segment measurement. These methodologic details have been an important limitation to test application when traditional protocols and measurement procedures are required. When applied with attention to required details, the heart rate-adjusted methods can improve the usefulness of the exercise ECG in a range of clinically relevant populations.
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Affiliation(s)
- P M Okin
- Department of Medicine, New York Hospital-Cornell Medical Center, New York 10021, USA
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Stevenson RN, Umachandran V, Ranjadayalan K, Roberts RH, Timmis AD. Early exercise testing after treatment with thrombolytic drugs for acute myocardial infarction: importance of reciprocal ST segment depression. BMJ (CLINICAL RESEARCH ED.) 1994; 308:1189-92. [PMID: 8180533 PMCID: PMC2540068 DOI: 10.1136/bmj.308.6938.1189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To investigate the clinical importance of reciprocal ST depression induced by exercise testing early after acute myocardial infarction in patients treated with thrombolysis. DESIGN Prospective observational study. SETTING District general hospital in London. SUBJECTS 202 patients (170 men) aged 33-69 with acute myocardial infarction treated with thrombolysis. MAIN OUTCOME MEASURES All patients underwent exercise testing and coronary arteriography. ST depression induced by exercise was classified as either reciprocal (associated with ST elevation) or isolated (occurring on its own). The relation between reciprocal ST depression and the following end points was studied: characteristics of the infarct, left ventricular ejection fraction, extent of coronary artery disease on arteriography, and presence of angina induced by exercise. RESULTS Reciprocal ST depression occurred almost exclusively in Q wave infarctions and was associated with a lower overall ejection fraction than isolated ST depression. It tended to be associated with persistent occlusion of the coronary artery related to the infarct and did not indicate remote ischaemia due to multivessel coronary disease. Unlike isolated ST depression, reciprocal ST depression was not associated with angina induced by exercise. CONCLUSIONS Reciprocal ST depression induced by exercise is usually associated with extensive Q wave infarctions and persistent occlusion of the artery related to the infarct. It does not seem to indicate reversible ischaemia and should not be used as a non-invasive marker of multivessel disease in the assessment of requirements for further investigation soon after acute myocardial infarction.
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Kligfield P, Okin PM, Goldberg HL. Value and limitations of heart rate-adjusted ST segment depression criteria for the identification of anatomically severe coronary obstruction: test performance in relation to method of rate correction, definition of extent of disease, and beta-blockade. Am Heart J 1993; 125:1262-8. [PMID: 8097611 DOI: 10.1016/0002-8703(93)90993-j] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Performance of the linear regression-based ST/HR (heart rate) slope, the simple ST/HR index, and ST segment depression alone for the identification of anatomically severe coronary obstruction was examined in relation to the definition of the extent of disease and the presence or absence of beta-blockade during treadmill exercise using the Cornell protocol in 172 catheterized patients. Whether severe disease was defined by three-vessel obstruction, by Gensini scores partitioned at 35 or at 48, or by Duke jeopardy scores exceeding 6, the 83% to 100% sensitivities of an ST/HR slope criterion of 6.0 microV/beat/min were each significantly higher than the corresponding 65% to 80% sensitivities of 150 microV of ST segment depression closely matched specificities. The ST/HR slope was significantly more sensitive than a simple ST/HR index criterion of 3.4 microV/beat/min for detection of high Gensini scores, but despite consistently intermediate performance trends, in no case did sensitivity of the simple ST/HR index criterion significantly exceed that of ST depression alone. Each method performed better and with comparable sensitivity in patients not receiving beta-blockers. In contrast, the 82% to 100% sensitivities of the ST/HR slope for identification of severe disease were significantly higher than the 63% to 77% sensitivities of ST depression in patients taking beta-blocking drugs; however, simple heart rate adjustment using the ST/HR index had intermediate performance that in no case was significantly more sensitive than ST segment depression alone.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P Kligfield
- Department of Medicine, New York Hospital-Cornell Medical Center, NY 10021
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Ribisl PM, Liu J, Mousa I, Herbert WG, Miranda CP, Froning JN, Froelicher VF. Comparison of computer ST criteria for diagnosis of severe coronary artery disease. Am J Cardiol 1993; 71:546-51. [PMID: 8094938 DOI: 10.1016/0002-9149(93)90509-b] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To determine which computer ST criteria are superior for predicting patterns and severity of coronary artery disease during exercise testing, 230 male veterans were studied who had both coronary angiography and a treadmill exercise test. Significant (p < or = 0.05) differences in computer-scored ST criteria were observed among patients with progressively increasing disease severity. Three-vessel/left main disease produced responses significantly different from 1- and 2-vessel disease or those with < 70% occlusion. Discriminant function analysis revealed that horizontal or downsloping ST depression measured at the J junction during exercise or recovery, or both, was the most powerful predictor of severe disease. With use of a cut point of 0.075 mV ST depression, horizontal or downsloping ST depression alone yielded a sensitivity of 50% (95% confidence interval = 35 to 65%) and specificity of 71% for prediction of severe disease; the only additional variable that added significantly to the prediction was exercise capacity, which improved sensitivity to 57% (95% confidence interval = 41 to 72%) with no change in specificity. Measurements of ST amplitude at the J junction and at 60 ms after the J point without slope considered and other scores, including the Treadmill Exercise Score, ST Integral, and ST/heart rate index, had a lower but comparable predictive accuracy when compared with horizontal or downsloping ST depression. Prediction of coronary artery disease severity can be achieved using computerized electrocardiographic measurements obtained during exercise testing. The most powerful marker for severe coronary artery disease is the amount of horizontal or downsloping ST-segment depression during exercise or recovery, or both, a measurement that stimulates the traditional visual approach.
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Affiliation(s)
- P M Ribisl
- Cardiology Department, Long Beach Veterans Affairs Medical Center, California
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