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PubMedDate not supplied

Review of studies using multivariable analysis of clinical and exercise test data to predict angiographic coronary artery disease.

Multivariable analysis of clinical and exercise test variables has the potential to become both a useful tool for assisting in the diagnosis of coronary artery disease and reducing the cost of evaluating patients with suspected coronary disease. Managed care and capitation require that tests such as the exercise test or its replacements, be used only when they can accurately and reliably identify which patients need medications, counseling, or further evaluation or intervention. The replacements for the standard exercise electrocardiogram test require expensive equipment and personnel, and their incremental value is currently being evaluated. Because general practitioners are to function as gatekeepers and decide which patients must be referred to the cardiologist, they will need to use the basic tools they have available (ie, history, physical exam, and the exercise test) in an optimal fashion. However, the discriminating power of the variables from the medical history and exercise test remains unclear because of inadequate study design and differences in study populations. There is a need for further evaluation of these routinely obtained variables to improve the accuracy of prediction algorithms especially in women. Of paramount concern is the need to avoid workup bias by having patients agree to testing before the decision for angiography is made. The portability and reliability of these equations must be shown because access to specialized care must be safeguarded. By reviewing the available studies considering clinical and exercise test variables to predict coronary angiographic findings, we have attempted to provide guidelines and recommendations for a more uniform approach to this endeavor in future investigations. Hopefully, the next generation of multivariable equations will be robust and portable, and empower the clinician to assure the cardiac patient access to appropriate cardiac care.

Coronary Angiography↗
PubMed1988

Short term reproducibility of exercise testing in patients with ST segment elevation and different responses to the dipyridamole test.

The short term reproducibility of exercise testing in 25 patients who had exercise induced ST segment elevation without baseline regional asynergy or a previous myocardial infarction, who had different responses to the dipyridamole test, was assessed. The patients performed a dipyridamole echocardiography test and a second exercise stress test. All underwent coronary arteriography. Seventeen patients had transient regional asynergy after dipyridamole (group 1) and either ST segment elevation (14 patients) or depression (three patients); a second group of eight had no asynergy and no electrocardiographic changes (group 2). The repeated exercise stress test was positive in 16 of the 17 patients of group 1 (11 with ST elevation and five with ST depression) and in two patients of group 2 (both had ST depression and one had coronary artery disease). The dipyridamole echocardiography test was positive in 17 of the 19 patients with coronary artery disease and was negative in all six patients without coronary artery disease. The repeated exercise stress test was positive in 17 of the 19 patients with coronary artery disease and in one patient without. The dipyridamole echocardiography test and a repeated exercise stress test, but not a single exercise stress test, identified coronary artery disease causing exercise induced ST segment elevation.

Adult↗
PubMed2000

Early symptom-limited exercise test for risk stratification in post menopausal women with unstable coronary artery disease. FRISC study group. Fragmin during Instability in Coronary Artery Disease.

AIMS: The exercise test is considered less reliable in women than in men both for diagnostic and prognostic purposes. The value, however, of the exercise test might vary with the population that is examined, the way the test is performed and which exercise test variables are taken into consideration in the analysis. The aim of the study was to evaluate an early symptom-limited exercise test as a tool for risk stratification in women with unstable coronary artery disease admitted to the coronary care unit. METHODS AND RESULTS: Of the 543 women in the FRISC I study, 395 stabilized on medical treatment and performed a symptom-limited exercise test 5-8 days after inclusion. Sixteen patients with a cardiac event before the scheduled exercise test were excluded. During the 6 months follow-up 17% of the women who did not perform the exercise test and 9% of the 395 women who did, died or had a myocardial infarction (P<0.01). Multivariate stepwise logistic regression analysis was performed to assess the value of clinical variables and findings at the predischarge exercise test to predict cardiac events. Based on the exercise test results three risk groups were identified with an event rate of 19%, 9% and 1%, respectively. The exercise test was better than any of the tested clinical variables in predicting cardiac events. CONCLUSION: Women with unstable coronary artery disease who do not stabilize within a few days have a high event rate early during follow-up. For women who are medically stabilized, considering not only variables like ST depression and chest pain but also parameters reflecting the cardiac performance such as maximal workload and increase in rate-pressure product, an early symptom-limited exercise test is a good predictor of future cardiac events.

Aged↗
PubMed1980

Observations on exercise testing and coronary arteriography.

Exercise tests were performed on 551 patients with a clinical diagnosis of coronary artery disease during their admission for angiography. A computer-generated index (CI, 0-100%) was used to describe the coronary anatomy, and additional data on left ventricular contraction abnormalities were recorded. Significant correlations exist between exercise performance and angina grade, coronary pathology, left ventricular function, and prognosis.

Angina Pectoris↗
PubMed1994

Performing the exercise test.

With proper training, exercise testing is a useful diagnostic procedure for the primary care physician in the outpatient as well as the inpatient setting. By careful pretest evaluation, one is able to study patients safely and to obtain both diagnostic and prognostic information concerning the risk for cardiovascular disease.

Exercise Test↗
PubMed1982

Exercise testing early after myocardial infarction. Risks and benefits.

Submaximal exercise testing in the early weeks following myocardial infarction appears to be safe in selected patient groups. Potential benefits of such testing includes: (1) promotion of patient self-confidence, (2) determination of post-hospital exercise prescription, (3) detection of arrhythmias, and (4) determination of post-hospital prognosis. However, the practical value of the apparent psychologic benefits and of the exercise prescription information in a patient not participating in formal exercise rehabilitation therapy is unclear. Detection of potentially important arrhythmias appears to be more adequately effected with 24-hour ambulatory electrocardiography, and detection of such arrhythmias appears to add relatively little prognostic information to that available from exercise electrocardiographic S-T analysis, or from resting radionuclide ejection fraction. Nonetheless, exercise-induced S-T segment depression can provide potentially useful prognostic information regarding morbid or fatal events during the year after infarction. Moreover, recent data suggest that exercise-induced angina and/or S-T segment depression can aid importantly in the noninvasive determination of the anatomic extent of coronary artery disease. The additional benefit or radionuclide cineangiographic determination of left ventricular function during exercise and of thallium 201 scintigraphic determination of myocardial perfusion during stress remain to be defined, although both approaches appear to provide important prognostic information. However, despite the potential benefits of exercise testing, in the absence of clinical trials of available therapy in the "high risk" patient defined by exercise testing, there remains an ill-defined relationship between the information available from exercise testing and the results of management decisions based on this information.

Angina Pectoris↗
PubMed1990

Methodology and repeatability of a standardised treadmill exercise test for clinical evaluation of fitness in horses.

This paper describes the methodology necessary to perform a clinical exercise test and the expected variability in an individual horse's exercise test measurements based on comparing the results of two repetitions of the test with six horses. The exercise test measurements were obtained with an open flow respiratory gas analysis system, fast time response lactate analyser and an on-board heart rate monitor during an incremental inclined treadmill exercise test. With the exception of peak venous lactate concentration (LACpeak), the results indicate that the mean variability in peak oxygen consumption (VO2peak) peak carbon dioxide production (VCO2peak), peak respiratory exchange ratio (Rpeak), peak heart rate (HRpeak), peak packed cell volume (PCVpeak), peak total plasma protein (TPPpeak) and the maximum number of steps completed during the exercise test (STEPmax) was less than 5 per cent. Variation in the regression analysis of VO2, VCO2 and HR versus velocity was also less than 5 per cent. Slightly higher variation was recorded for LAC and R. Mean variation in the regression analysis of PCV and TPP versus velocity was more than 16 per cent. Mean variation for all of the post exercise test measurements was less than 10 per cent at 1, 5 and 15 mins post exercise. Therefore, the results obtained during a single exercise test are a reliable assessment of a horse's metabolic capability.

Animals↗
PubMed1998

Improvement in the mechanical efficiency of walking: an explanation for the "placebo effect" seen during repeated exercise testing of patients with heart failure. Duke University Clinical Cardiology Studies (DUCCS) Exercise Group.

To determine the mechanism responsible for the "placebo effect" seen during serial exercise testing of patients with heart failure, we examined metabolic variables for 81 patients who underwent five baseline exercise tests as part of a multicenter drug trial. The patients were 50 men and 31 women with a mean ejection fraction of 30.1% and a mean age of 69 years. From test 1 to 2, the exercise time increased from 419 +/- 140 to 462 +/- 130 seconds before it reached a plateau over the next three tests. Metabolic measurements at test 1 and test 3 revealed no change in peak oxygen consumption ( 1119 +/- 376 to 1105 +/- 346 ml/min). Maximum heart rate, systolic blood pressure, ventilation, and respiratory exchange ratio also were unchanged. The onset of the anaerobic threshold was delayed from 211 +/- 81 to 238 +/- 93 seconds, but there was no change in oxygen consumption at the anaerobic threshold (810 +/- 222 to 795 +/- 220 ml/min). At a predetermined submaximal level, oxygen consumption, ventilation, and respiratory exchange ratio all decreased to a statistically significant degree. These results indicate that a rapid increase in the mechanical efficiency of walking contributes to the placebo effect among patients with heart failure during serial exercise testing and is independent of changes in conditioning or motivation.

Aged↗
PubMed1991

Usefulness of ambulatory silent myocardial ischemia added to the prognostic value of exercise test parameters in predicting risk of cardiac death in patients with stable angina pectoris and exercise-induced myocardial ischemia.

The prognostic significance of ambulatory silent ischemia detected by Holter monitoring during daily life was prospectively evaluated and compared with several exercise test parameters in 86 patients with stable angina and positive exercise tests. Forty-seven patients (group 1) had no evidence of ischemia and 39 (group 2) had 1 or more episodes of silent ischemia during the monitoring period. During mean follow-up of 24 +/- 8 months there were only 2 cardiac deaths (nonsudden) in group 1 (4% mortality) compared with 9 (3 sudden and 6 nonsudden) in group 2 (23% mortality). Kaplan-Meier actuarial analysis revealed worse survival (p less than 0.008) for patients in group 2. The Cox regression analysis of clinical variables, electrocardiographic and exercise parameters, angiographic data and Holter monitoring results revealed silent ischemia during daily life as the most powerful predictor of cardiac mortality (p = 0.003). These results demonstrate that in patients with chronic stable angina and abnormal exercise tests, ambulatory ischemia detected by Holter monitoring provides significant additional prognostic information to that derived from evaluation of exercise test parameters alone.

Actuarial Analysis↗
PubMed2006

Actual clinical practice of exercise testing in consecutive patients after non-ST-elevation myocardial infarction: results of the acute coronary syndromes registry.

BACKGROUND: Exercise testing has been advocated for risk stratification and determination of therapeutic strategies after acute myocardial infarction. Frequency and therapeutic impact of exercise testing after non-ST-elevation myocardial infarction (NSTEMI) in actual clinical practice, however, is not known. METHODS AND RESULTS: From the German acute coronary syndrome (ACOS) registry patients with acute NSTEMI (n = 5281) were evaluated: 20.8% of patients (1097/5281) had predischarge exercise testing, and from these tests 33.5% (367/1097) were positive. The strongest predictors for renunciation of predischarge exercise testing were ejection fraction under 40%, age over 70 years and stroke history. In-hospital coronary angiographies or percutaneous coronary interventions were not associated with a lower rate of exercise testing. During 1-year follow-up all-cause mortality was 13.6% in patients without and 5.1% in patients with exercise test respectively (P < 0.0001). In patients with positive exercise test 1-year mortality was 6.5%, in patients with negative exercise test 4.4% (P = 0.13). During follow-up no significant difference was found in the rate of coronary revascularizations between patients either with positive or negative exercise tests. Furthermore, no significant difference was found in the rate of death and revascularizations comparing different groups of exercise capacity. CONCLUSIONS: After NSTEMI in Germany the majority of patients do not get predischarge exercise testing, although this group appears to be of special risk for fatality during follow-up. Furthermore, in actual clinical practice, neither exercise induced signs of ischemia nor exercise capacity have a significant impact on the rate of revascularization procedures during follow-up.

Angioplasty, Balloon, Coronary↗
PubMed1987

Ventricular extrasystolic arrhythmias in exercise testing. II. Haemodynamic correlations.

Exercise testing (ET) has been used for assessing the arrhythmogenic tendency of myocardium in patients (pts) with coronary heart disease. It has been suggested that coronary patients with left ventricular (LV) dyssynergy are prone to present ventricular extrasystolic arrhythmia (VA) during ET. We studied the functional status of the LV in a group of 25 coronary patients who presented VA during ET (Group A), and compared the results with a group of 87 patients without VA during ET (Group B). No statistically significant difference was found between the two groups in end-diastolic pressure, ejection fraction, and extent of dyssynergy of the LV. Furthermore, no significant difference was noted in the extent of development of the collateral circulation.

Blood Pressure↗
PubMed1995

The prognostic value of exercise testing early after myocardial infarction in patients treated with thrombolytics.

Exercise testing early post AMI was evaluated as a predictor of reinfarction in patients treated with thrombolytics. AMI patients exercise-tested prior to discharge were included in the study (n = 178). The patients were followed for 2.9 +/- 0.9 years (mean +/- 1 SD) for the development of new cardiac events defined as cardiac death or reinfarction. Cox regression analysis of clinical and exercise test variables showed that there was significant predictive value of treating heart failure with drugs from two or more therapeutic groups (P < 0.001; hazard ratio 9.4 (3.1-28.2) (estimate and 95% confidence interval)), such as those with a previous history of myocardial infarction (P = 0.001; hazard ratio 4.0 (1.7-9.6)) and of significant ST depression (P = 0.029; hazard ratio 2.5 (1.1-5.7)). Significant ST depression could be substituted by the delta ST/delta HR index (P = 0.042; hazard ratio 2.8 (1.2-6.8)). The exercise test had independent but limited prognostic value in AMI patients treated with thrombolytics. The delta ST/delta HR index did not improve the predictive value of the exercise test.

Aged↗
PubMed1990

[An unexpected complication of exercise testing].

A male patient 40 years of age died after diagnostic exercise testing for stable exercise induced angina, which had existed for two months. The ECG prior to the stress was normal and there had been no signs of unstable angina. The exercise test was discontinued at a load of 120 Watts because of angina without significant ECG changes. Subsequently shock developed with widening of the QRS complex. Immediate coronary angiography revealed an occluded main stem of the left coronary artery. Although recanalisation was achieved, the patient died. The risks of exercise testing and the appropriate precautions are discussed. Laboratories for stress testing of patients with suspected coronary diseases should be located in a hospital with facilities for coronary care.

Adult↗
PubMed2000

The effects of oxitropium bromide on exercise performance in patients with stable chronic obstructive pulmonary disease. A comparison of three different exercise tests.

The purpose of the present study was to compare the characteristics of three different exercise tests in evaluating the effects of oxitropium bromide on exercise performance. Thirty-eight males with stable chronic obstructive pulmonary disease (COPD) (FEV(1) = 40.8 +/- 16.5% predicted; mean +/- SD) completed randomized, double-blind, placebo-controlled, crossover studies for each exercise test. The exercise tests were performed 60 min after the inhalation of either oxitropium bromide 400 microg or placebo. The patients performed 6-min walking tests (6MWT) on Days 1 and 2, progressive cycle ergometry (PCE) on Days 3 and 4, and cycle endurance tests at 80% of the maximal workload of PCE on Days 5 and 6. Spirometry was conducted before and at 45 and 90 min after the inhalation. Oxitropium bromide significantly increased FEV(1) as compared with placebo. Oxitropium bromide increased the endurance time significantly, by 19% (p < 0.001), and caused a small but significant increase in the 6-min walking distance by 1% (p < 0.05), but induced no significant increase in maximal oxygen consumption (V O(2)max) in PCE. The responses in these three exercise tests were different, and we conclude that the endurance test was the most sensitive in detecting the effects of inhaled anticholinergic agents on exercise performance in patients with stable COPD. An endurance procedure may be performed to detect clinical changes in evaluating the effects of oxitropium bromide on exercise performance.

Administration, Inhalation↗
PubMed1977

[Value of the exercise test after aortocoronary bypass].

The 100 patients who underwent an exercise test and a follow-up coronary arteriogram at a mean interval of 10.1 months after an aorto-coronary bypass had suffered preoperatively from incapacitating angina 50%), a threatened infarction syndrome (35%), or Prinzmetal's angina (15%). The majority had a single bypass graft (72%), but 28% had two or three grafts. The exercise test was positive 39 times, negative 51 times, and indeterminate in 10. Correlation with the clinical picture shows that 27% of the patients in functional category I had a positive exercise test. Correlation with coronary arteriography shows that a positive test is reliable evidence for a defect or occlusion of the graft. On the other hand, a negative exercise test is a less reliable indicator of a good result. No instances of positive exercise tests were found when there was complete alleviation of the coronary condition.

Adult↗
PubMedDate not supplied

Exercise testing: uses and limitations considering recent studies.

Accurate use and interpretation of exercise test results depend on an understanding of physiologic principles, meticulous attention to proper methodology, and realization of the appropriate applications and limitations of testing. Understanding the relationship between myocardial and ventilatory oxygen consumption and exercise test variables will aid in the diagnosis and prognostic evaluation. Use of proper methodology in preparing the patient, performing the examination, and interpreting the results is critical to obtaining the maximum information with maximum safety for each individual patient. Improvements in methodology including the use of the Borg scale to estimate individual effort, abandonment of the predicted maximum heart rate, and the increased use of ventilatory oxygen uptake measurements should be applied. Exercise capacity should not be reported in total time but rather as the VO2 or MET equivalent of the workload achieved. This permits the comparison of the results of many different exercise testing protocols. The most useful exercise ECG variable for the diagnosis of coronary artery disease remains the ST segment shift. Unfortunately, it is not as helpful in localizing myocardial ischemia. Diagnostic accuracy can be improved by adjusting ST depressions for exercise-induced heart rate increase. Accuracy can be further increased by combining ECG, clinical, and radionuclide variables in probabilistic formulas that retain the independent diagnostic information from each variable and accurately predict disease probability. To avoid errors in clinical decision making, care must be used to insure that the mathematical formula used was derived from a population of patients that is similar to those being tested. The clinical applications for exercise testing include diagnosis of patients with chest pain syndromes, determination of disease severity, and prognosis in patients with known coronary artery disease, evaluation of arrhythmias, screening of asymptomatic patients, and evaluation of medical, surgical, and angioplastic therapy for coronary disease. In spite of studies involving thousands of patients, controversy exists regarding the diagnostic power of exercise testing. The large differences in reported accuracies are largely due to methodologic problems that have been encountered by various investigators. Clinicians should be made aware of these problems when reading the literature on ECG and radionuclide exercise testing. Such awareness will help them understand the limitations of these noninvasive procedures.(ABSTRACT TRUNCATED AT 400 WORDS)

Electrocardiography↗