New tests to assess lung function. Exercise testing in pulmonary evaluation: rationale, methods and the normal respiratory response to exercise.
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Submaximal exercise testing after unstable angina.
Sixty-one consecutive men, mean age 56 years, who fulfilled criteria for unstable angina and who responded to medical therapy, underwent submaximal exercise testing prior to hospital discharge and at least 3 days after their last episode of angina. Forty-two patients were receiving propranolol at the time of exercise. Submaximal exercise was targeted to 120 beats/minute and strict criteria for the premature termination of each study were followed. Follow-up data were available on 55 patients post-discharge over a period of 6 to 36 weeks. No patient suffered recurrence of unstable angina or myocardial infarction due to the exercise test. Exercise was prematurely terminated by an ischemic response (chest pain and/or ST segment changes) in 34 patients (56%) and by leg fatigue in 13 patients (21%). Only five patients had exercise-induced ventricular ectopic activity, four of whom were not receiving propranolol. Nine patients achieved the target heart rate. Exercise-induced abnormal electrocardiographic changes predicted the postdischarge recurrence of episodes of unstable angina (p less than 0.05). Comparison of predischarge submaximal exercise data with postdischarge maximal exercise shows that recovery in cardiovascular function after unstable angina occurs soon after stabilization and prior to the submaximal test.
Adult↗
Significance of ST-segment depression with R-wave amplitude decrease on exercise testing.
A retrospective evaluation was performed of patients who underwent exercise tests and angiography and 50 ambulatory normal subjects who underwent only exercise testing. We found that when deltaST depression of 0.5 mm was combined with deltaR-wave decrease of 1 mm, the sensitivity and specificity were improved.
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The role of exercise testing in the identification of patients with silent myocardial ischemia.
At present, the role of exercise testing in asymptomatic individuals is limited, and the test should be applied only selectively. Regardless of this, the popularity of wellness programs and the widespread use of exercise testing in asymptomatic groups continue. The preceding discussion presents some guidelines to help improve on the diagnostic accuracy of exercise testing in all patients, with special emphasis on its use in asymptomatic individuals.
Adult↗
A four-minute submaximal constant work rate exercise test to assess cardiovascular functional class in chronic heart failure.
To develop a submaximal constant work rate exercise test able to grade cardiovascular dysfunction in patients with chronic heart failure, 80 patients and 59 control subjects performed a symptom-limited incremental exercise test and a constant work rate exercise test at a fixed work rate (50 W for 4 minutes). The time constant of VO2 at the start of constant work rate exercise and time for gas exchange ratio (respiratory exchange ratio) to equal 1 were independent predictors of cardiovascular functional class and correctly classified the functional class in 89 +/- 9% and 83 +/- 11% of patients, respectively.
Cardiac Output, Low↗
[Value of Holter monitoring and the electrocardiographic exercise test in the diagnosis of silent ischemia after myocardial infarction].
In 75 patients 24-hour ecg monitoring value was compared with exercise test in diagnostics of postinfarction silent ischemia. Results compatibility of both comparing examinations was 79% with regard to only painless ischemia (p less than 0.001) and 91% to both estimated painless or painful episodes (p less than 0.001). Painless ischemia was observed during ecg Holter monitoring and exercise test respectively in 39% and 35% of examined patients (NS) and/or with the angina respectively in 44% and 53% (p less than 0.01). 24-hour ecg monitoring and exercise test are of a comparable value in diagnosis of postinfarction silent ischemia, whereas in diagnostics of jointly estimated painless or painful ischemia the exercise test is a more sensitive examination than ecg Holter monitoring.
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Update on exercise stress testing.
Exercise stress testing is an important diagnostic tool for the evaluation of suspected or known cardiac disease. In 2002, the American College of Cardiology (ACC) and the American Heart Association (AHA) revised their guidelines for exercise testing. Ten categories from the ACC/ AHA 1997 guidelines were modified: ST heart rate adjustment, unstable angina, older patients, acute coronary syndromes, chest pain centers, acute myocardial infarction, asymptomatic patients, valvular heart disease, rhythm disturbances, and hypertension. Adjustment of the ST heart rate can identify myocardial ischemia in asymptomatic patients with elevated cardiac risk. Intermediate- and low-risk patients with unstable angina, acute coronary syndromes, or chest pain should undergo exercise stress testing when clinically stable. Provided they are stable, patients who have had acute myocardial infarction can undergo a submaximal exercise test before discharge or a symptom-limited exercise stress test any time after two to three weeks have elapsed. In asymptomatic patients with cardiac risk factors, the exercise stress test may provide valuable prognostic information. Aortic regurgitation is the only valvular heart disorder in which there is significant evidence that exercise stress testing is useful in management decisions. The stress test also can be used in older patients to identify the presence of coronary artery disease. However, because of other comorbidities, a pharmacologic stress test may be necessary. Exercise stress testing can help physicians successfully evaluate arrhythmia in patients with syncope. The exercise stress test also can help identify patients at risk of developing hypertension if they show an abnormal hypertensive response to exercise.
Age Factors↗
Predictive accuracy of coronary artery calcification and abnormal exercise test for coronary artery disease in asymptomatic men.
To determine the predictive accuracy of fluoroscopically detected coronary artery calcification (CAC) and a positive submaximal exercise test, 129 asymptomatic men were screened; 13 had both coronary artery calcification and positive exercise test (greater than or equal to 1.0 mm ST-segment depression). These 13 men were studied at coronary arteriography. They had a mean age of 44 years (range 41-56 years); none had history or symptoms of heat disease and all had normal resting ECGs at entry. CAC was detected in one artery in 10 men, in two arteries in two men, and in three arteries in one man. Coronary artery disease (CAD) was considered clinically significant if any major coronary branch was narrowed > 50%. Coronary arteriography revealed 12 men with clinically significant CAD (one-vessel CAD in four, two-vessel CAD in five and three-vessel CAD in three men) and one man with minor one-vessel CAD. The predictive accuracy was 100% for minor CAD and 92% for clinically significant CAD. The location of CAC and CAD correlated, but the absence of CAC did not rule out the presence of CAD at coronary arteriography. Furthermore, CAC did not indicate the location of the highest stenotic (most occlusive) lesions seen at arteriography. Follow-up for the 13 patients was 36 months; three patients developed typical angina and one patient developed a transmural myocardial infarction. This study suggests that the predictive accuracy of CAC and a positive exercise test in the middle-aged non-hyperlipidemic asymptomatic male is very high (100% for CAD and 92% for clinically significant CAD) and that CAC and a positive exercise test predict an early appearance of angina or myocardial infarction in previously asymptomatic men.
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Changes in serum concentrations of markers of myocardial injury following treadmill exercise testing in patients with suspected ischaemic heart disease.
BACKGROUND: The treadmill exercise test (TEST) is frequently used in patients with suspected ischaemic heart disease to establish a diagnosis and estimate future risk. However, its predictive value is poor. We aimed to investigate whether measurement of biochemical markers of myocardial injury could improve the diagnostic value of the procedure. MATERIAL AND METHODS: Twenty-four subjects with suspected acute coronary syndrome underwent a treadmill exercise stress test. Of these 13 had had a previous myocardial infarction and two had a past history of coronary artery bypass grafting. Nine subjects were found to be positive for coronary ischaemia during the treadmill test. Serum cardiac markers (total creatine kinase [CK], CK-MB, Troponin I and Troponin T) were measured pre-TEST, and 0, 1, 2, 4, 8 and 24 hours following the treadmill test. RESULTS: Total CK remained within the reference range for all subjects and showed no significant rise. However, mean serum concentrations of CK-MB were significantly higher than pre-test values at 2 hours (p < 0.03) following treadmill exercise testing in subjects who had a positive exercise stress test, but not in those with a negative test. In the subjects with a positive stress test, CK-MB levels returned to pre-Test value by 24 hours. Levels of neither serum troponin I, nor troponin T altered significantly at any point. CONCLUSION: The measurement of CK-MB, but not cardiac troponins may add to the diagnostic utility of the TEST.
Angina Pectoris↗
[Silent myocardial ischemia in diabetics--by treadmill exercise testing].
We examined silent myocardial ischemia in diabetics by treadmill exercise testing. There were 28 diabetic men and 64 diabetic woman without angina, with a mean age of 59 +/- 11 years. Symptom-limited treadmill exercise testing was performed, and we used the electrocardiogram during exercise and immediately after exercise for judgement. ST segment depression was defined as positive if there was at least 0.1 mV of ST depression 80 ms from the J point. It was defined as negative if max heart rate (HR) was more than 80% of target HR and there was no significant ST depression. It was defined as equivocal if there was no significant ST depression but max HR was less than 80% of target HR. In 92 diabetics, 21 patients (23%) showed positive ST depression, 35 (38%) showed negative ST depression, 36 (39%) showed equivocal ST depression. In 56 diabetics exclusive of treadmill equivocal patients, 38% of patients showed positive ST depression. Treadmill positive diabetics had a significantly higher rate of smokers, patients with hypertension, and a higher triglyceride level as compared with treadmill negative diabetics. Coronary arteriography, which was performed in six treadmill positive diabetics, revealed coronary stenosis of more than 75% in four patients.
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Systolic blood pressure response to exercise testing is related to the risk of acute myocardial infarction in middle-aged men.
BACKGROUND: We assessed the association of systolic blood pressure response to exercise with the risk of an acute myocardial infarction. DESIGN: We conducted a population-based follow-up study. METHODS: This study was based on 1731 middle-aged men without history of coronary heart disease who underwent a cycle ergometer exercise test. Systolic blood pressure was measured every 2 min during a cycle ergometer exercise test in 1731 men followed for 12.7 years on average. A total of 188 acute myocardial infarctions were observed. RESULTS: The total change in systolic blood pressure, the slope of the rise in systolic blood pressure per minute and maximal systolic blood pressure during exercise in quintiles were related to the risk of acute myocardial infarction. Maximal systolic blood pressure of over 230 mmHg was associated with a 2.47 [95% confidence interval (CI) 1.46-4.18] fold risk of acute myocardial infarction, after adjustment for age, other risk factors including the use of antihypertensive medications and systolic blood pressure at rest. Among men with elevated systolic blood pressure at rest, the relative risk for an acute myocardial infarction was 4.31 (95% CI 2.04-9.07) times higher for those who had a steep slope of systolic blood pressure rise (>9.4 mmHg per min of exercise) as compared with those who had a more gradual rise in systolic blood pressure. CONCLUSIONS: Both rate and levels of rise in systolic blood pressure during a progressive exercise test were risk predictors for acute myocardial infarction. These measurements provide an incremental predictive value for an acute myocardial infarction to elevated resting systolic blood pressure, emphasizing the importance of regular blood pressure measurements during exercise testing.
Antihypertensive Agents↗
A comparison of dipyridamole-thallium imaging and exercise testing in the prediction of postoperative cardiac complications in patients requiring arterial reconstruction.
The individual and combined predictive values of dipyridamole-thallium imaging and exercise testing were compared in a prospective study of 70 patients who had abdominal aortic aneurysms or aortoiliac occlusive disease that required surgical repair. All patients were evaluated clinically by the same cardiologist and had exercise stress testing and dipyridamole-thallium imaging before admission for surgery. Ten patients were excluded from the study because they had evidence of severe ischemia when tested (ST segment depression greater than 2 mm on exercise testing, severe multivessel disease on thallium imaging). The remaining 60 patients were operated on (abdominal aortic aneurysm repair, 40; aortobifemoral repair, 17; femorofemoral graft, 3). The test results were withheld from the surgeon, anesthetist, and cardiologist before surgery. A total of 22 patients experienced major cardiac complications postoperatively (acute pulmonary edema, 17; acute myocardial, infarction, 5; cardiac death, 2). Thallium imaging showed myocardial ischemia in 31/60 patients. Exercise testing was positive (greater than or equal to 1 mm ST segment depression) in 10/60 patients. Dipyridamole-thallium imaging with a high sensitivity and reasonable specificity is the initial test of choice. Exercise testing is a poor screening test because of its low sensitivity. The combination of the two tests gives the highest positive predictive value and the greatest likelihood ratio. Thus patients assessed initially and found to have positive thallium scan results may be further stratified by exercise testing.
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[Evaluation of clinical parameters and myocardial perfusion scintigraphy findings in patients with suspected coronary artery disease, abnormal resting electrocardiogram, and noninterpretable exercise test].
UNLABELLED: The aim of this work was to estimate the impact of clinical variables on predicting stress myocardial perfusion abnormalities in patients with suspected coronary artery disease, abnormal resting electrocardiogram, and noninterpretable exercise test. MATERIAL AND METHODS: The clinical variables and stress myocardial perfusion data were analyzed in 370 patients (157 males and 213 females) with suspected coronary artery disease and abnormal resting electrocardiogram. All patients underwent (99m)Tc-methoxyisobutylisonitrile (MIBI) scintigraphy following a one-day protocol (stress-rest). The bicycle exercise test was considered noninterpretable when the age-predicted peak heart rate was not achieved, and ischemic signs were not detected. RESULTS: One hundred sixty (43.2%) patients had noninterpretable bicycle exercise test. Pathological stress myocardial perfusion defects (reversible and fixed) were more often present in patients with noninterpretable than in patients with informative exercise test (63.1 and 50.0%, respectively, p<0.01). Univariate analysis showed that reversible perfusion defects were more frequent in men than in women (p<0.00001, odds ratio 9.6), in patients with pre-existing left bundle-branch block (p<0.02, odds ratio 3.4), and in cases when sufficient working capacity (> or =150 W) was achieved (p<0.05, odds ratio 2.1). CONCLUSION: The myocardial perfusion defects were registered in 63.1% of patients with suspected coronary artery disease, abnormal resting electrocardiogram, and noninterpretable exercise test. The probability of reversible perfusion defects was higher in male patients, in patients with pre-existing left bundle-branch block and with sufficient working capacity (> or =150 W).
Aged↗
Exercise test in Parkinson's disease.
UNLABELLED: In this study we assessed cardiovascular performance and metabolic response after an exercise test in Parkinsonian patients (PD patients). METHODS: 15 PD patients (10 male, 5 female; mean age:63 +/- 6.17 y; mean weight: 72.2 +/- 9.5 kg) and 15 sex, age (mean: 63.8 +/- 5.38 y), and weight-(mean: 72.2 +/- 8.69 kg) matched controls performed an exercise test using a cycle ergometer and a ramp protocol. All patients and control subjects underwent a heart rate variability test prior to the exercise test. At rest and at the end of each interval blood pressure (BP) and capillary lactate samples were taken. Heart rate was monitored continuously. RESULTS: The heart rate variability tests were abnormal in Parkinson's patients. All patients and control subjects achieved an intensity level of 75 watts, 12/15 PD patients managed 100 watts, and 7/15 PD patients managed 150 watts. 12/15 control subjects performed at an intensity level of 125 Watts and 9/15 at an intensity level of 150 Watts. There was no statistically significant difference in heart rate increase but there was a tendency to lower lactate levels at high intensity levels in PD patients. PD patients had a statistically lower systolic BP at 75, 100, 125, and 150 watts. CONCLUSION: We did not find striking differences in cardiovascular adaptation to physical work in PD patients and we propose, therefore, that it should be possible to improve cardiovascular endurance in PD patients. Previously, reports have suggested respiratory chain impairment in Parkinson's disease and poor endurance performance. However, our results do not support a clinically relevant impairment of the respiratory chain.
Blood Pressure↗
Comparison of the ST/heart rate slope with the modified Bruce exercise test in the detection of coronary artery disease.
The rate of depression of the ST segment with increasing heart rate (HR) during exercise has been claimed to predict the extent of coronary artery disease (CAD). To determine whether the maximal ST/HR slope is better than the Bruce treadmill exercise test for predicting the presence of CAD, the maximal ST segment/HR slope was calculated in 81 patients and compared with the results of a standard 12-lead exercise test. In 21 patients (26%), the ST/HR slope could not be calculated. In 60 patients with ST/HR slope values, the extent of CAD was predicted in 24 patients (40%). The sensitivity and specificity of the ST/HR slope in predicting the presence of CAD in the 60 patients with slope values were 91% and 27%, respectively. The sensitivity and specificity of the modified Bruce treadmill exercise test in the 81 patients were 81% and 64%, respectively. Thus, the use of the ST/HR slope does not provide additional information that cannot be obtained using the standard Bruce exercise test.
Adult↗
The spectrum of exercise test and angiographic correlations in myocardial revascularization surgery.
Maximal exercise tests and angiographic evaluations were obtained in a group of patients before and after myocardial revascularization. Patients were classified on the basis of angiography and operative records. Two primary groups of 33 patients with complete revascularization and 95 patients with postoperative residual ischemia were studied. The residual ischemia subgroups included patients with partial revascularization, progressive coronary atherosclerosis, or graft failure. Patients with complete revascularization had statistically significant improvements in work capacity, maximal heart rate, maximal rate-pressure products, abnormal exercise electrocardiograms, exercise-induced angina pectoris, and atrial gallop sounds. A spectrum of lesser improvements in these measurements was observed in the subgroups with residual ischemia. Total graft failure resulted in no significant improvements in exercise-test parameters. Maximal stress tests provide a useful adjunct to routine clinical follow-up of myocardial revascularization patients. Myocardial revascularization is associated with significant patient palliation as determined by serial stress testing.
Angina Pectoris↗
Poor reproducibility of exercise test in assessment of claudication.
To assess reproducibility of the exercise test in intermittent claudication, a prospective, comparative, randomized study was undertaken. Ten patients with stable intermittent claudication of ischaemic origin were exercised on a flat surface (0-Ex), with 12% steady inclination (12-Ex) and with progressively increasing inclination (p-Ex) in a random order during three different sessions. The ankle-brachial index (ABI) at rest and after exercise (rABI, exABI), initial and maximum walking distance (IWD, MWD) and metabolic equivalent (MET) were obtained as the main outcome measures. The results were analysed using intraindividual coefficients of variation (CVs) and standard deviations (SDs). The ABI values of the worst extremity were used in evaluation of results. Reproducibility of the exercise ABI appeared to be good, especially during progressively increasing exercise, the mean CV being 9 +/- 5%. The best mean CV was observed during p-Ex (16% +/- 14%) for maximum walking distance. The mean CV for initial walking distances ranged from 30% to 54%. Treadmill exercise testing to measure walking distances is highly inaccurate and the value of exercise on the flat treadmill should be questioned. Graded exercise appeared to be the most reproducible in this respect. The ABI after exercise, however, was a reliable single parameter when assessing arterial insufficiency causing decreased walking capacity.
Aged↗
The value of exercise testing in patients with coronary artery spasm.
To analyze the usefulness of a single exercise test to predict the presence of fixed obstructive coronary artery disease in patients with active coronary spasm, 91 consecutive patients with angiographically proven symptomatic coronary artery spasm who had performed a symptom-limited exercise test within the week before diagnostic coronary angiography were studied. Coronary angiography revealed significant coronary obstructions in 61 patients (67%). According to the type of angina, the prevalence of significant coronary stenosis was 53% for patients with angina at rest, 68% for those with effort angina, and 92% for those with mixed angina. Exercise-induced ST segment elevation was present in eight patients (9%), ST segment depression was seen in 37 patients (41%), and no ST abnormalities in 46 (50%). There was not a significant relationship between the ST segment response to exercise and the clinical variables assessed except for coronary anatomy. Abnormal exercise test results were significantly more frequent in patients with significant coronary obstructions than in those without significant coronary occlusions (62% versus 23%; p less than 0.01). ST elevation was not useful to predict the presence of fixed coronary lesions. However, ST depression strongly suggested the presence of underlying coronary lesions with a sensitivity of 54%, a specificity of 87%, and a positive predictive value of 89%. Using this criterion, 65% of the patients were correctly classified. The results indicate that despite the functional component of ischemia in patients with coronary spasm, ST segment depression with exercise is still a highly specific sign with a high positive predictive value for the presence of significant coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)
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