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PubMed1984

Role of exercise testing early after myocardial infarction in identifying candidates for coronary surgery.

It has been suggested that ST depression in lead V5 or equivalent on early exercise testing after acute myocardial infarction predicts a high risk of death. To evaluate exercise testing and radionuclide ventriculography in this context 103 consecutive patients with myocardial infarction who were able to undertake a limited exercise test before discharge from hospital were exercised and underwent gated blood pool scanning. No serious complications resulted from exercise testing. Twenty nine patients developed ST depression in lead V5, 19 had exertional hypotension, 31 developed a heart rate of greater than or equal to 130 beats/min, and 15 had complex ventricular arrhythmias. Death during the first year after discharge from hospital was associated with exertional hypotension (p less than 0.001) and a heart rate on exercise testing of greater than or equal to 130 beats/min (p less than 0.05); these two variables identified all nine deaths. Inability to complete the exercise protocol for any reason was also predictive of death (p less than 0.01). Ventricular arrhythmias and ST depression in lead V5 induced by exercise were not significantly associated with an increased risk of death. The mean (SD) radionuclide ejection fraction in the patients who died was 29 (16%) compared with 43 (11)% in the patients who survived (p less than 0.001). ST changes on exercise testing after myocardial infarction appear to be less predictive of later complications than haemodynamic signs, which may indicate left ventricular damage rather than ischaemia.

Adult↗
PubMed1994

[Exercise test in patients with pulmonary diseases].

To assess the clinical utility of a ramp exercise test in patients with pulmonary diseases, the gas exchange variables from normal volunteers and patients with pulmonary diseases during ramp exercise were compared to those during steady-state exercise. Measurements during ramp exercise could titrate the extent of the patients' maximal exercise as well as the adequate performance of parameters in gas exchange coupling. There were no significant differences in the four variables achieved between the two exercises. These gas exchange variables during ramp exercise made it possible to predict the exercise-limiting factors for patients with COPD and pulmonary fibrosis. Furthermore, a ramp exercise test could be performed safely even in patients with severe lung diseases and required a shorter period than a steady state exercise test. Thus, a ramp exercise test is thought to be useful in the evaluation of patients with pulmonary diseases.

Evaluation Studies as Topic↗
PubMed2006

Evaluation of a specific activity questionnaire to predict mortality in men referred for exercise testing.

BACKGROUND: A self-administered symptom questionnaire developed at our institution (Veterans Specific Activity Questionnaire [VSAQ]) is routinely used to estimate a patient's exercise capacity to individualize the exercise test in accordance with current guidelines. This study was performed to evaluate the association of the VSAQ with all-cause mortality. METHODS: The VSAQ was administered to 1185 consecutive male patients (mean age 58 +/- 12 years) referred for exercise testing for clinical reasons. The VSAQ is designed to determine which specific daily activities are associated with cardiovascular symptoms (fatigue, chest pain, or shortness of breath) to provide an estimate of exercise tolerance (in metabolic equivalents [METs]) before exercise testing. Patients were classified into 1 of 3 groups according to VSAQ score: <5 METs, 5 to 8 METs, and >8 METs. The association between exercise capacity estimated by the VSAQ, other clinical and exercise test variables, and all-cause mortality was assessed by Cox proportional hazards. The mean follow-up period was 4.5 +/- 2.9 years. RESULTS: There were a total of 132 deaths during the follow-up period, resulting in an average annual mortality of 2.7%. In a multivariate analysis including clinical risk factors and exercise test variables, age-adjusted predictors of mortality, in rank order, were the VSAQ score in METs, history of chronic heart failure, history of smoking, and diabetes (for VSAQ: hazard ratio [HR] 0.90, 95% CI 0.83-0.98; for chronic heart failure: HR 2.67; 95% CI 1.51-4.72; for smoking: HR 1.74, 95% CI 1.18-2.57; and for diabetes: HR 1.84, 95% CI 1.15-2.95). Expressed in tertiles, age-adjusted relative risks for the VSAQ were 1.0, 0.54, and 0.22 (P for trend <.001). Each 1-MET increase in the VSAQ conferred a 10% survival benefit. CONCLUSIONS: A simple self-administered symptom questionnaire strongly and independently predicted all-cause mortality. The VSAQ is a useful adjunct to clinical and exercise test data for stratifying risk in patients undergoing exercise testing for clinical reasons.

Aged↗
PubMed1985

Combined cardiac cinefluoroscopy, exercise testing and ambulatory ST-segment monitoring in the diagnosis of coronary artery disease; a report of 104 symptomatic patients.

To enhance diagnostic accuracy in coronary artery disease, cardiac cinefluoroscopy for the detection of coronary artery calcification was combined with exercise test and ambulatory ST-segment monitoring in 104 symptomatic patients before they underwent coronary angiography. In 44 patients with typical angina the combination of the three noninvasive tests and the exercise test alone both detected 92% of subjects with clinically important coronary artery disease. In 60 patients with atypical angina, the combination of the three noninvasive tests screened 77% of the subjects with clinically important coronary artery disease versus 43% after exercise test only (P less than 0.001). The exercise electrocardiogram was false negative in a substantial number of patients with atypical angina due to the presence of a good coronary reserve or to a daily circadian variation in the tone of the coronary arteries. Under these circumstances, cardiac cinefluoroscopy gave additional anatomic information to the physiological assessment of ischemia provided by the exercise test and ambulatory ST-segment monitoring. Our study suggests that the combination of cardiac cinefluoroscopy with other noninvasive tests may be particularly useful in screening atypically symptomatic populations.

Adult↗
PubMed2002

The prognostic value of body mass index and standard exercise testing in male veterans with congestive heart failure.

OBJECTIVE: To evaluate the prognostic characteristics of body mass index (BMI) and standard exercise test variables in a consecutive series of patients with mild to moderate congestive heart failure (CHF) referred for standard exercise tests. BACKGROUND: Controversy exists regarding the prognostic importance of BMI, etiology, and exercise test variables in patients with CHF. METHODS: All patients referred for evaluation at two university-affiliated Veterans Affairs Medical Centers who underwent treadmill tests for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security Death Index after a mean 6 years follow-up. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. Survival analysis was performed using all-cause mortality as the endpoint for follow-up. RESULTS: A total of 522 patients with a history and clinical findings of CHF underwent exercise testing. Forty-two percent died during the follow-up period, for an average annual mortality of 6.7%. Cox proportional hazards model chose peak metabolic equivalents (METs), BMI, age, and ischemic etiology in rank order as independently and significantly associated with time to death. A score based on these variables classified patients into low (2% annual mortality), medium (5.2%), and high-risk groups (7% annual mortality). CONCLUSION: Standard exercise testing and BMI can be used to estimate prognosis in outpatients with heart failure. A score incorporating METs, BMI, age, and etiology efficiently stratified these patients. BMI was chosen by the survival analysis, confirming its surprising inverse relationship to prognosis in CHF patients (i.e., heavier patients do better).

Aerospace Medicine↗
PubMed1988

Prospective evaluation of clinical assessment, exercise testing and signal-averaged electrocardiogram in predicting outcome after acute myocardial infarction.

The relative value of exercise testing, late potentials and simple clinical assessment in predicting ischemic and arrhythmic events during follow-up after acute myocardial infarction (AMI) was investigated prospectively in a population of 176 consecutive patients surviving to 7 days after AMI. During 15 +/- 9 (range 3 to 24) months of follow-up, there were 23 ischemic events (2 fatal reinfarctions, 6 nonfatal reinfarctions and 16 patients who underwent coronary artery bypass grafting, 1 after reinfarction) and 11 arrhythmic events (7 symptomatic ventricular tachycardias and 4 sudden cardiac deaths). Stepwise multiple regression analysis showed that out of 11 variables, including exercise testing, late potentials and clinical data, exercise testing was the only independent variable predicting the occurrence of ischemic events (p less than 0.05 not including coronary artery bypass grafting and p less than 0.002 including it). Arrhythmic events were predicted, in order of importance, by Killip class (p less than 0.05), late potentials (p less than 0.005), previous AMI (p less than 0.009), occurrence of in-hospital complications (p less than 0.005) and non-Q-wave AMI (p less than 0.02). The presence of late potentials provided independent prognostic information from the Killip class and the result of exercise testing in predicting both arrhythmic and ischemic events. Exercise testing, late potentials and clinical assessment provide complementary prognostic information in postinfarction patients.

Adult↗
PubMed1981

Pre-discharge exercise testing involving weight carrying after myocardial infarction.

Exercise testing involving weight carrying was undertaken on 36 consecutive men under the age of 70 years at a mean of 12.2 days after myocardial infarction before their discharge from hospital. The test consisted of four stages: walking for 3 minutes at 5.3 km/h, carrying a 13.6 kg weight for 3 min at a speed of 4.4 km/h, holding a 22.7 kg weight with the arm flexed for 1 min and carrying the 22.7 kg weight for 1 min at a speed of 2.6 km/h. Twenty-four (66 percent) men completed all four stages during which mean maximal heart rate and systolic blood pressure were 143/min and 166 mmHg respectively. No test was discontinued because of arrhythmias and complex ventricular arrhythmias occurred in only one man. On subsequent maximal treadmill testing on 32 of these subjects at a mean of 7.2 weeks post-infarction, significantly more of those completing the pre-discharge test achieved an average work capacity for their age. As a result of this study, we believe that exercise testing of this type involving weight carrying can be helpful in the management of patients convalescing after myocardial infarction.

Adult↗
PubMed2006

Exercise test in the inter-attack period of thyrotoxic periodic paralysis: a useful diagnostic tool.

Exercise test was reported to be useful for some patients with periodic paralysis. We report here the results of exercise test in three cases of thyrotoxic periodic paralysis, for whom the exercise test was all positive. Exercise test could be one of the diagnostic tools in the "inter-attack" state of the probable cases with thyrotoxic periodic paralysis. However, the case number of this study is small and larger-scale studies may be warranted in the future.

Action Potentials↗
PubMed1995

Prognostic significance of maximal exercise testing after myocardial infarction treated with thrombolytic agents: the GISSI-2 data-base. Gruppo Italiano per lo Studio della Sopravvivenza Nell'Infarto.

Exercise testing helped in diagnosing postinfarction patients in the prethrombolytic era. Over the past decade acute myocardial infarction treatment has changed because of new thrombolytic therapies and consequently, the value of exercise testing is under debate. The GISSI-2 database allowed us to reevaluate the prognostic role of exercise testing in thrombolysed patients. The exercise test was performed in 6296 patients, on average 28 days after randomisation. The test was not performed in 3923 patients because of contraindications. The test was judged positive for residual ischaemia in 26% of the patients, negative in 38%, and non-diagnostic in 36%. Among the patients with a positive stress test result, 33% had symptoms, whereas 67% had silent myocardial ischaemia. The mortality rate was 7.1% among patients who did not have an exercise test and 1.7% [correction of 7.1%] for those with a positive test, 0.9% for those who had a negative test, and 1.3% for those who did not have a diagnostic test. In the adjusted analysis, symptomatic induced ischaemia, submaximal positive result, low work capacity, and abnormal systolic blood pressure were independent predictors of 6-month mortality (relative risks [RR] 2.54, 95% CI 1.27-5.08, 2.28, 1.17-4.45, 2.05, 1.23-3.42, and 1.86, 1.05-3.31, respectively). However, when these factors were tested simultaneously, only symptomatic induced ischaemia and low work capacity were confirmed as independent predictors of mortality (RR Cox 2.07, 95% CI 1.02-4.23 and 1.78, 1.06-2.99, respectively). Patients with a normal exercise response have an excellent medium-term prognosis and do not need further investigation. However, more evaluation should be devoted to the patients who cannot undergo exercise testing, because the potential to influence outcome appears to be much greater.

Aged↗
PubMed1990

Diagnostic accuracy of radionuclide techniques in patients with equivocal electrocardiographic exercise testing.

The aim of the present study was to evaluate the yield of radionuclide studies for the diagnosis of coronary artery disease (coronary artery narrowing greater than 50%) in a prospective series of 73 patients with thoracic pain and equivocal electrocardiographic stress testing. In the study population, the prevalence of coronary artery disease was 51%. The sensitivity, specificity, diagnostic accuracy and the post-test probability difference curves according to the Bayes' theorem were calculated for 201-thallium exercise testing and radionuclide exercise equilibrium ventriculography. For the latter study the following criteria were considered: (1) increase in left ventricular ejection fraction less than 5%; (2) the criterion proposed by Rozanski; (3) decrease in regional ejection fraction; and (4) abnormalities in phase and amplitude analysis (Fourier). 201-thallium exercise testing was the most sensitive (97%) and accurate (86%) study. Radionuclide ventriculography sensitivity was always lower for any criterion, although its best result was for evaluation of regional ejection fraction (85%). The most specific study was Fourier analysis (97%), although its sensitivity was low (42%). The application of Bayes' theorem to these results shows that the highest post-test probability difference values were achieved with 201-thallium exercise testing for prevalences higher than 40% and with Fourier analysis for lower prevalences.

Adult↗
PubMed1999

Ambient temperature and relative humidity influenced packed cell volume, total plasma protein and other variables in horses during an incremental submaximal field exercise test.

Thermoregulation may limit exercise performance under hot and humid conditions. This study compared heart rate (HR), respiratory rate (RR), rectal temperature (Tr), packed cell volume (PCV) and total plasma protein concentration (TPP) during a submaximal incremental field exercise test under high vs. low ambient temperature and relative humidity. Ten horses were tested 3 times in summer (July) and 3 times in autumn (September). Heart rate was measured continuously, the other variables at rest and immediately after 4 min at 3.5, 4.5 and 7.0 m/s, separated by 3 min rest intervals, and after 5 and 10 min recovery. Data for all variables were significantly greater during exercise and recovery in the hot vs. cool conditions, respectively: after 4 min at 7.0 m/s, HR was 135+/-1 and 123+/-1/min (P<0.0001), Tr was 39.0+/-0.06 and 38.0+/-0.05 degrees C (P<0.0001), RR was 99+/-3 and 50+/-3/min (P<0.0001), PCV was 48.8+/-0.06 and 42.1+/-0.3% (P<0.0001) and TPP was 7.7+/-0.14 and 7.6+/-0.12 g/l (P = 0.026). These data reflect the thermal burden during submaximal exercise under hot conditions in the field. The greater relative PCV increase in the heat probably conferred a thermoregulatory advantage and reflected a greater circulating red cell volume increase rather than a decrease of plasma volume. This study illustrates how differences in environmental conditions can affect assessment of exercise responses and how these factors must be considered in monitoring progress during fitness and acclimatisation regimes in the field.

Animals↗
PubMed2003

A QRS score versus ST-segment changes during exercise testing: which is the most reliable ischaemic marker after myocardial revascularisation?

BACKGROUND: The diagnostic ability of exercise testing based on ST-segment changes is low for the detection of restenosis after percutaneous transluminal coronary angioplasty (PTCA) or ischaemia after bypass surgery (CABG). The aim of this study was to improve the diagnostic accuracy of exercise testing in patients with a history of PTCA or CABG, with the implementation of a QRS score. METHODS: We studied 128 post-PTCA patients (aged 49 +/- 8 years) and 104 post-CABG patients (aged 54 +/- 8 years), who had either positive exercise tests with or without angina, or negative exercise tests with continuing angina-like symptoms, and underwent cardiac catheterisation. RESULTS: The univariate risk ratio of exercise-induced ST-segment deviation to detect restenosis was 3.05 (p = 0.005) and 0.83 (p = 0.690) in group A and group B patients, respectively. The univariate risk ratios of abnormal QRS score values to detect restenosis were 32.1 (p < 0.001) and 18.8 (p < 0.001) for group A and group B patients, respectively. The univariate risk ratios of the combination of exercise-induced ST-segment changes and of abnormal QRS score values to detect restenosis was 9.43 (p < 0.001) and 3.77 (p < 0.044) for group A and group B patients, respectively. The value of the area under the ROC curves is higher for the QRS score in group A patients, group B patients and for the whole study population. CONCLUSIONS: QRS score values significantly improve the diagnostic ability of ST-segment change-based exercise testing, for the assessment of restenosis after PTCA or ischaemia after CABG.

Adult↗
PubMedDate not supplied

[Value of the exercise test in asymptomatic myocardial ischemia].

To evaluate the predictive value of ischemic ST segment depression without associated chest pain during exercise testing, data were analyzed from 7305 studies. Two hundred thirty six patients were included in this study and were separated in 2 groups. Group A consisted of 169 patients without chest pain who, during exercise testing, showed a positive ST segment response (at least 1.5 mm of horizontal or downward ST segment depression for at least 0.08 second, compared with the resting baseline value), and Group B consisted of 67 patients who had both chest pain and a positive ST segment response. Selective coronary angiogram was performed on all patients. Each Group was separated into 3 sub-group according to the Cohn criteria: sub-group I (asymptomatic persons 8.3 vs 19.4%); sub-group II (patients with history of Myocardial Infarction 36.7% vs 19.4%); sub-group III (patients with chronic angina 55% vs 61.2%). The clinical characteristics, coronary risk factors, distribution of coronary artery disease, and exercise test response were similar in both groups. During treadmill exercise, the mean heart rate was 140.6 +/- 22 in group A versus 127.1 +/- 23 in the group B. The pressure-rate product was 2.4 +/- 0.8 versus 1.9 +/- 0.5, respectively (P less than or equal to 0.05). The predictive value for severe coronary artery disease of an exercise test in patients with asymptomatic ischemia was 77.5% as compared with 89.6% in the group with angina. This study confirms the high frequency of asymptomatic myocardial ischemia during exercise testing, compared with patients who had angina during exercise testing, with high percentage of prediction (77.5%) for coronary artery disease.

Aged↗
PubMed1991

Logistic discriminant analysis improves diagnostic accuracy of exercise testing for coronary artery disease in women.

BACKGROUND: Diagnostic accuracy of the exercise electrocardiogram in women has been shown to be limited for the detection of coronary artery disease. New diagnostic methods based on computer analysis of the exercise electrocardiogram and multivariate analysis have improved the diagnostic value of exercise testing in male subjects. The aim of the present study was to assess whether the diagnostic value of exercise testing can be enhanced in women by using multivariate analysis of exercise data. METHODS AND RESULTS: Between 1978 and 1984, 135 infarct-free women underwent exercise testing and coronary angiography. Significant coronary artery disease was present in 41% of the patients. In this first group, maximal exercise variables were submitted to a stepwise logistic analysis. Work load, heart rate, and ST60X were selected to build a diagnostic model. The model was tested in a second group of 115 catheterized women (significant coronary artery disease in 47%) and of 76 volunteers. We compared the present model with conventional analysis of the exercise electrocardiogram, with ST changes adjusted for heart rate, and with a previously described analysis. In both groups, sensitivity was better with the present model (66% and 70%) than by conventional (68% and 59%) and by the previously described analysis (57% and 44%) without a loss of specificity (85% and 93%). Receiver-operator characteristic curves showed also a better diagnostic accuracy with the present model. CONCLUSIONS: In women, logistic analysis of exercise variables improves the diagnostic value of exercise testing. It yields a significantly better sensitivity without a loss of specificity.

Coronary Disease↗
PubMed1999

Analysis of the results from an early low-level predischarge and late symptom-limited exercise tests and coronary angiographic examination in patients with uncomplicated myocardial infarction.

The aim of our study was to evaluate the prognostic value of an early predischarge and late symptom-limited exercise tests as opposed to the evidence from the coronary angiographic examination. Twenty patients with an uncomplicated myocardial infarction were studied with an early predischarge exercise test (14-21 days) and a following postdischarge late symptom-limited veloergometric test. All the patients underwent an exercise test designed according to the protocol of the International Health Organization. A coronary angiographic examination was carried out in all the studied patients. Thirteen of the patients were with two positive veloergometric tests and significant stenosis from the selective coronary angiography. Seven of the patients had two negative tests. Two of them did not have significant coronary stenosis from the angiografic assessment. Generally 40% of the patients undergoing late exercise test reached a higher workload. There was no significant difference between the results from an early predischarge and late symptom-limited veloergometric test. A higher physical work load reached during the late exercise test did not show an improved coronary blood flow. Positive early and late exercise tolerance tests proved significant coronary stenosis. A negative exercise test did not exclude significant coronary stenosis.

Coronary Angiography↗
PubMed1982

Exercise testing in the evaluation of coronary artery disease.

Exercise testing, after having established the indication (Tables 1 and 2) is not only an important method for detection of coronary artery disease, it also enables delineation of exercise capacity and permits assessment of medical and surgical treatment. A subnormal increase in heart rate or blood pressure, or even a decrease in blood pressure, during exercise may frequently be found in patients with known coronary artery disease or in those at high risk of developing subsequent coronary events. Downsloping ST segment depression is highly specific for the presence of coronary artery disease; the specificity of upsloping ST segment depression can be increased on requiring this pattern to consist of a 2 mm depression 0.08 s beyond the J point. Consideration of the QTc interval may also be useful in patients with upsloping ST segment depression. Marked ST segment depression and early onset of ST segment depression during exercise is related to increasing severity of the disease while the duration of ST segment depression bears no certain relevance. ST segment elevation may be associated with transmural myocardial ischemia, left ventricular aneurysm or variant angina. An increase in the R wave amplitude appears indicative of multiple vessel disease, while a reduction in septal Q wave amplitude is suggestive of left anterior descending coronary artery occlusion. The current concept of testing asymptomatic patients for coronary artery disease has low predictive value. Post-myocardial infarction exercise testing is an objective method for evaluation of prognosis and guiding management. In the assessment of the results of aorto-coronary bypass surgery, the finding of persistent angina and/or ST segment depression during exercise is indicative of residual ischemia; normalization of the exercise ECG in the presence of a high-level exercise capacity is usually associated with good coronary perfusion. In order to provide maximum diagnostic utility, exercise testing must take into consideration other clinical findings as well as the prevalence of disease in the respective population. With respect to the coronary angiographic findings as well as the incidence of coronary events, the predictive value of exercise testing may be notably increased on consideration of multiple clinical and exercise variables. The exercise test has evolved into a clinically important noninvasive method for the evaluation of the functional aspects of the heart.

Adult↗
PubMed1977

Comparison between regional myocardial blood flow measurements and results of exercise tests.

The relationship between regional myocardial blood flow and the results of exercise tests were evaluated in 54 patients, 40 of whom had angiographically demonstrated coronary artery disease (CAD) and 14 had normal angiograms. After 20 patients had 2-step tests, 20 had bicycle ergometry, and 14 had treadmill tests, regional myocardial specific blood flow (RMBF) at rest was determined by selective injections of xenon-133 into the left coronary artery and quadrantic washout measured with an Anger camera. RMBF (ml/min/100 gm, mean +/- SE) was significantly lower in patients with coronary artery disease (72 +/- 3) than in normals (91 +/- 7, p less than .05) but RMBF in 12 CAD patients with negative exercise tests (75 +/- 6) was similar to regional myocardial blood flow in 28 coronary artery disease patients with positive exercise tests (71 +/- 4). Degree of ST depression did not influence results. Although measurement of RMBF and exercise testing are both useful procedures in the evaluation of patients with CAD, the data in the present study indicate the RMBF measurements at rest cannot predict the result of the postexercise ECG and vice versa.

Coronary Angiography↗
PubMed2003

Modified exercise test in screening for mitochondrial myopathies--adjustment of workload in relation to muscle strength.

The aim of this study was to evaluate the usefulness of a modification of the bicycle ergometer test, the subanaerobic threshold exercise test (SATET), as a screening test for patients with mitochondrial myopathies. Since the original SATET is frequently found to be strenuous for weak patients, a new variable (relative muscle strength) was added to the workload formula. Plasma lactate levels were recorded at rest, then after 5 and 15 min of cycling on an ergometer, with constant workload. Nine patients with mitochondrial myopathy, 10 patients with other neuromuscular diseases and 9 healthy but sedentary volunteers undertook the test. An upper reference limit after exercise for plasma lactate was settled at 2.9 mmol/l. The modified SATET showed a sensitivity of 78% and a specificity compared to the healthy subjects of 100%. Compared to patients with other neuromuscular diseases, the specificity was lower (60%). All subjects completed the test without severe fatigue or pain.

Adult↗