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PubMed1977

Exercise testing in the diagnosis of coronary heart disease: a perspective.

The methods of assessing the diagnostic usefulness of exercise testing in detecting coronary obstructive disease are examined. The limitations of long-term clinical follow-up and coronary angiography as standards for the determination of disease are described as are the effects of test methodology, criteria for positivity, prevalence of disease in the study population, reliability of the standard and recognition of false positive and false negative results in determining reliability of such testing. High values were found for sensitivity and specificity for exercise testing of patients with coronary artery disease referred for consultation to medical center cardiology services. Maximal exercise testing and consideration of symptomatic and hemodynamic as well as electrocardiographic criteria for identification of myocardial ischemia are helpful in improving reliability. Diagnostic accuracy is greatly enhanced by recognition of known causes for false positive and false negative results.

Angina Pectoris↗
PubMed1998

Dipyridamole stress echocardiography and exercise testing for risk stratification after uncomplicated myocardial infarction.

BACKGROUND: Risk stratification for subsequent cardiac events after an acute infarction can be obtained by exercise testing or dipyridamole stress echocardiography. It remains to be determined whether these modalities are equivalent and provide incremental information on top of clinical evaluation. The aim of our study was to compare the prognostic information obtained early after an acute uncomplicated myocardial infarction of high dose dipyridamole coupled with echocardiography (stress echo) or maximal symptom-limited exercise testing. METHODS AND RESULTS: Ninety patients underwent dipyridamole stress echo and exercise testing at a mean +/- SD of 9 +/- 4 days after admission for acute uncomplicated first myocardial infarction. All patients were prospectively followed for 22 +/- 16 months. There were 9 hard events (3 cardiac deaths and 6 acute myocardial infarctions) and 12 soft events due to post MI angina (6 angioplasty and 6 bypass surgery procedures). Univariate predictor of hard events was rest-stress wall motion score index variation (p = 0.009); univariate predictors of all events (hard + soft) were: positive exercise testing (p = 0.001), positive stress echo (p = 0.001), rest-stress wall motion score index variation (p = 0.002), extent of ischemia at echo (p = 0.008). Multivariate analysis by Cox selected a non-Q wave infarction and rest-stress wall motion score index variation as predictors of death or reinfarction (overall chi-square for the model 12.2, p = 0.0022). CONCLUSIONS: Stress echo is superior to ergometric variables for predicting events after uncomplicated myocardial infarction.

Aged↗
PubMed1981

Predictive value of early postmyocardial infarction modified treadmill exercise testing in multivessel coronary artery disease detection.

We evaluated 57 patients with modified treadmill exercise testing and angiography early post-infarction (MI) to determine the predictive value of ST segment depression, angina, and an inadequate blood pressure response for multivessel coronary artery disease (MVCAD). ST segment depression alone identified MVCAD stenoses (greater than or equal to 70% diameter narrowing in two or more vessels) with sensitivity 54%, specificity 75%, and accuracy 60%. When ST segment depression and angina were considered a positive treadmill test result, a significant improvement in sensitivity (88%, p less than 0.01) and accuracy (82%, p less than 0.05) for MVCAD was observed. An inadequate blood pressure response was associated with MVCAD (12 of 13 patients) and a significantly reduced average left ventricular (LV) ejection fraction of 39 plus or minus 13% compared to 58 plus or minus 14% for patients without this treadmill abnormality (p less than 0.01). Therefore, we conclude that (1) ST segment depression and angina on early post-MI modified treadmill exercise testing are superior predictors of MVCAD compared to ST segment depression alone and (2) an inadequate blood pressure response during modified exercise testing early following MI is observed in patients with MVCAD and reduced LV performance.

Adult↗
PubMed1981

Limited exercise testing soon after myocardial infarction. Correlation with early coronary and left ventricular angiography.

Forty-eight patients within 3 weeks of myocardial infarction underwent both limited treadmill graded exercise testing and coronary and left ventricular angiography. Nineteen (90%) of 21 patients with positive exercise tests (greater than or equal to 1 mm ST depression, angina, or both) had multivessel coronary artery disease. In the 27 patients with negative exercise test results, 15 (55%) had multivessel disease, 11 (41%) had single-vessel disease, and one (4%) had no coronary stenosis. Exercise-induced ST segment elevation occurred in 24 patients and predicted a significantly lower ejection fraction and higher angiographic abnormally contracting segment size. Patients experiencing angina during or after exercise had a significantly shorter 2-year survival (54% +/- 21%) than patients without exercise-induced angina (97% +/- 3%) (p less than 0.03). Thus limited exercise testing postinfarction is useful in evaluating the presence of multivessel coronary artery disease and left ventricular dysfunction and predicting long-term survival.

Adult↗
PubMed2001

Ten-year mortality rate in relation to observations at a bicycle exercise test in patients with a suspected or confirmed ischemic event but no or only minor myocardial damage: influence of subsequent revascularization.

AIM: Our purpose was to describe symptoms and electrocardiographic findings at a bicycle exercise test 4 weeks after hospitalization for a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis and its relationship to long-term prognosis and subsequent revascularization. METHODS: In all patients a symptom-limited bicycle exercise test was performed 4 weeks after discharge from the hospital. The total mortality rate over 10 years was registered. RESULTS: In all, 770 patients participated in the evaluation. The median age was 63 years, and 34% were women. The most frequent reason for stopping the exercise test was fatigue (69%) followed by dyspnea (33%) and angina pectoris (15%). Angina pectoris was observed in 24% of the patients. ST-segment depression >or=1 mm was observed in 50% and ST-segment depression >or=2 mm was observed in 15% of the patients. The 10-year mortality rate in patients with ST-segment depression >or=2 mm was 24.7%, in patients with ST-segment depression 1.0 to 1.9 mm 33.5%, and in patients with ST-segment depression <1 mm 26.9% (not significant [NS]). Patients with symptoms of angina pectoris had a 10-year mortality rate of 29.4% compared with 27.9% among patients without such symptoms (NS). Patients who had either a drop in systolic blood pressure or failure to raise systolic blood pressure (13%) had a 10-year mortality rate of 36.2% compared with 27.2% among patients without such signs (NS). However, there was a significant association between maximum exercise capacity (in watts) and mortality (P < .0001): 53.8% in the lowest quartile (30-70 W) and 10.2% in the highest (>120 w). When clinical history was considered simultaneously, a low exercise capacity remained as a strong independent predictor of death together with age and a history of either acute myocardial infarction, smoking, or diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted only with angina pectoris and prognosis; thus patients who had angina during the exercise test had a worse prognosis than those without if they were not being revascularized. CONCLUSION: Among patients hospitalized with a suspected or confirmed acute ischemic event but either no or only minor myocardial necrosis, we found the maximum working capacity at a symptom-limited bicycle exercise test to be independently associated with the long-term prognosis but not other signs of myocardial ischemia. Further predictors for long-term prognosis were age, a history of acute myocardial infarction, current smoking, and diabetes mellitus. Mechanical revascularization during the subsequent 5 years interacted with the influence of symptoms of angina during test and prognosis.

Aged↗
PubMed1983

Exercise testing in pulmonary sarcoidosis.

The variable natural history of sarcoidosis and the toxicity of corticosteroids result in many clinical situations where there is controversy concerning the need for treatment. Progressive incremental testing is an excellent method to identify physiologic mechanisms responsible for exercise limitation. It is therefore ideal to determine if subjective symptoms such as dyspnea are due to cardiac abnormalities, pulmonary abnormalities, or poor physical conditioning. Thirty-one patients with sarcoidosis underwent progressive incremental exercise testing. Four of 14 asymptomatic patients and eight of 17 symptomatic patients demonstrated pulmonary abnormalities which potentially limited exercise tolerance. These consisted of an abnormal respiratory pattern or gas exchange abnormalities, or both. Patients with completely normal routine pulmonary function studies almost always performed normally with exercise. Symptomatic patients with multiple abnormalities on routine pulmonary function studies invariably demonstrated a pulmonary limitation on exercise testing. Patients with one or two abnormalities on routine pulmonary function studies, regardless of the presence or absence of parenchymal infiltrates, required exercise testing to determine if symptoms were due to physiologically significant abnormalities of the respiratory system. The important variables necessary to be measured, arterial desaturation and an abnormal respiratory pattern, can be measured noninvasively with a minimum of equipment.

Adrenal Cortex Hormones↗
PubMed1985

Prognostic value of symptom limited exercise testing in men with a high prevalence of coronary artery disease.

In order to evaluate the independent prognostic information provided by exercise testing in populations with a high prevalence of coronary artery disease, survival rates were calculated with the life table method in 372 men, mean age 48 years, referred for coronary arteriography. The prevalence of angiographic coronary artery disease was 82%. During a mean follow-up of 29 months (1 to 8 years), 32 patients died and 27 patients had a nonfatal event (acute infarction or hospitalization for disabling angina). Both the history (presence or absence of typical angina pectoris or of a previous myocardial infarction) and the exercise test results (abnormal if angina and/or ST segment changes greater or equal to 0.1 mV occurred) had a significant prognostic value for the 5 year survival rate (P less than 0.001). In patients with a positive history, the 5 year cumulative survival rate was 76% if the exercise test was abnormal versus 94% if it was normal (P less than 0.001). The following 8 noninvasive and 2 invasive variables were submitted to a Cox regression analysis: age, typical angina pectoris, previous myocardial infarction, maximal heart rate and workload, maximal ST segment depression and elevation, angina pectoris during exercise testing, number of diseased vessels, and wall motion score on contrast ventriculography. By univariate analysis, the age and the maximal workload reached during exercise were the only noninvasive predictive variables for survival or cardiac events (P less than 0.05). By multivariate analysis, and combining all noninvasive and invasive variables, survival was predicted by the wall motion score, the presence or absence of 3 vessel disease, and age.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1979

Limitations of exercise testing in critical left coronary artery disease.

Exercise testing was evaluated in 51 patients with critical left coronary artery disease (LCA) documented by coronary arteriography within two weeks of their bicycle ergometer (26 patients) or treadmill (25 patients) electrocardiographic study. Adequate tests, as defined by the patient having reached 85% of predicted maximum heart rate, were achieved in only 16 patients on the ergometer (62%) and in 21 (84%) on the treadmill. Nevertheless mean maximum double product (220 vs 232) and mean exercise time (4.6 min vs 5.0 min.) were similar (p:NS). The sensitivity for ergometry and treadmill testing was 75 and 62% respectively. If however we include those negative studies in which for various reasons patients were unable to achieve 85% of their predicted maximal heart rate (i.e., inadequate studies), sensitivity was only 46 and 52% respectively. Thus a sizable group of patients with critical LCA disease cannot adequately perform exercise tests especially on the ergometer; and over half of all such patients studied will be found for one reason or another to respond negatively, regardless of exercise protocol.

Blood Pressure↗
PubMed1989

[A case of chronic obstructive pulmonary disease associated with central alveolar hypoventilation diagnosed by exercise test].

We report a case of chronic obstructive pulmonary disease associated with central alveolar hypoventilation diagnosed by exercise test. A 61-year-old man with chronic obstructive pulmonary disease was admitted to our hospital because of respiratory failure caused by bacterial pneumonia. After recovery from pneumonia, we examined his functional ventilatory response to incremental exercise. Exercise was discontinued because of his maximal target heart rate, and there was no complaint of dyspnea throughout the exercise test. Although the patient had enough ventilatory reserve during exercise (VEmax/MVV = 50%), there was a marked progressive retention of carbon dioxide disproportionate to the extent of his air flow obstruction. Moreover the patient was able to reduce the carbon dioxide tension to a subnormal level by voluntary hyperventilation, and his ventilatory response to carbon dioxide and mouth occlusion pressure at rest was significantly diminished as compared with normal subjects. These findings suggest that this patient has several features compatible with central alveolar hypoventilation. Exercise test was useful for the diagnosis as well as exercise prescription because the patient could develop dangerous hypoxemia without alarming symptoms like dyspnea.

Exercise Test↗
PubMed1997

Treadmill testing for evaluation of claudication: comparison of constant-load and graded-exercise tests.

OBJECTIVES: To compare the correlation and practicability of single-stage vs. graded treadmill protocols in the assessment of the absolute claudication distance (ACD). DESIGN: Randomized open study. MATERIAL AND METHODS: In 52 patients with peripheral arterial occlusive disease, the ACD on treadmill at 3 km/h and 12% grade (constant-load test = C-test) ranged form 50 to 400 m. The C-test and the graded-exercise test (walking on the treadmill at 3 km/h and 0% gradient for 3 min, with subsequent increase in gradient of 3.5% every 3 min = G-test) were carried out at random on the same day under standardized conditions. RESULTS: The ACD was higher in the G-test than in the C-test (360.4 +/- 208.8m vs. 166.5 +/- 93.6m; p < 0.001). The coefficients of variation were very similar (57.9% and 56.2%, respectively). In the subgroup of patients with an ACD of between 100 m and 150 m, a large difference was found both for the coefficient of variation (58.6% G-test, 9.6% C-test) and for the standard deviation (339.8 +/- 199.0m and 133.1 +/- 12.8m, respectively). CONCLUSIONS: For the assessment of the ACD in patients with severe claudication the C-test would seem to be more suitable than the G-test.

Exercise Test↗
PubMed1989

The role of exercise testing in screening for coronary artery disease.

PURPOSE: To predict the effects of using exercise testing to screen healthy persons for coronary artery disease. DATA IDENTIFICATION: The publications of the Coronary Artery Surgery Study were the principal sources of data for the cost-effectiveness analysis; we also used data from the Veterans Administration Cooperative Study of stable angina and the publications of the European Coronary Surgery Study Group. STUDY SELECTION: We used studies that provided the data that our decision model required--life expectancy and probabilities of outcomes in persons who have or do not have coronary artery disease. DATA EXTRACTION: We did not use a structured method for abstracting data. We tested the susceptibility of our conclusions to poor quality of data by substituting a wide range of values for a variable in the decision model, and by calculating life expectancy and costs if screening was used routinely or not used. RESULTS OF DATA SYNTHESIS: We assumed that persons with an abnormal exercise test would have arteriography and that persons with severe coronary artery disease would have bypass surgery. When there were no suitable published data for the model, we made assumptions that favored screening. The model predicts that screening would increase the life expectancy of 60-year-old men at average risk by at most 12 days. Sixty-year-old men with no risk factors for coronary artery disease would derive less benefit, as would women and younger men. CONCLUSIONS: The effect of exercise testing is too small to justify doing this procedure routinely in healthy persons. If coronary bypass surgery is found to prolong life in asymptomatic persons as much as it does in angina pectoris, screening older men with risk factors for coronary artery disease may prove to be worthwhile.

Coronary Disease↗
PubMed2006

Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise.

OBJECTIVES/HYPOTHESIS: To assess the diagnostic feasibility and patient acceptance of a new developed diagnostic test for exercise induced upper airway flow limitation. STUDY DESIGN: Clinical case control study including evaluation of contemporary ergo-spirometry and laryngoscopy continuously performed during exercise. METHODS: Twelve nonsymptomatic controls and four young females with documented dyspnea and noisy breathing during exercise were studied. All subjects exercised to exhaustion on a treadmill while attached to a fully equipped ergo-spirometry unit and a fiberoptic laryngoscope linked to a video camera and a sound recorder. RESULTS: The test situation was well tolerated. Two control subjects had a minor inspiratory synchronous medial motion of the aryepiglottic folds without limitation of laryngeal airflow. In the four symptomatic subjects, exercise induced inspiratory synchronous medial motion of the dorsal part of the aryepiglottic folds as well as vocal cord adduction and inspiratory stridor was demonstrated. CONCLUSION: The continuous laryngoscopy exercise test was easy to perform, well tolerated, and can be implemented in future diagnostic work-up programs of laryngeal dysfunction.

Adolescent↗
PubMed1997

[Prediction of 6-year prognosis for cardiac event by thallium-201 single-photon emission computed tomography (SPECT) with treadmill exercise test].

To examine thallium-201 single-photon emission computed tomography (SPECT) with a treadmill exercise test can predict the long-term prognosis of patients with coronary artery disease, 95 patients (71 men, 24 women) who underwent a treadmill exercise test with thallium-201 SPECT from April to December 1986 were followed for 6 years. Three short-axis slices at the apical, mid- and basal-level were selected, and each slice was divided into eight segments. Each segment count was assigned a score according to the count range in the slice (score 0, count range 76-100%; 1, 51-75%; 2, 26-50%; 3, 1-25%; 4, 0%) by evaluating the mean value of the slice. The total T1 defect score of each segment in 3 slices was summed (sigma T1 defect score). The 'early sigma T1 defect score' was the sigma T1 defect score 5 min after treadmill exercise, and the 'late sigma T1 defect score' was sigma T1 defect score measured 4 h after treadmill exercise. Cardiac events occurred in 27 of the 95 patients: cardiac death 3; myocardial infarction 1; percutaneous transluminal angioplasty 16; coronary artery bypass graft 5; congestive heart failure 3. Univariate analysis showed that previous myocardial infarction (p < 0.01), exercise work load (p < 0.05), early sigma T1 defect score (p < 0.01) and late sigma T1 defect score (p < 0.01) were independent predictors of the prognosis. These results suggest that thallium-201 SPECT with the treadmill exercise test could be applicable and useful to predict long term prognosis.

Coronary Disease↗
PubMed1988

Value of New York Heart Association classification, radionuclide ventriculography, and cardiopulmonary exercise tests for selection of patients for congestive heart failure studies.

To evaluate the necessity of an objective cardiopulmonary exercise test in the selection procedure of patients for heart failure studies, 50 patients with congestive heart failure New York Heart Association (NYHA) class II and III and a left ventricular ejection fraction less than 40% were subjected to a cardiopulmonary exercise test. The results of the exercise test were compared with the independent clinical estimation of NYHA class and data of measurements obtained at rest. The NYHA classification separated the patients with a mild to moderate impairment of aerobic capacity from patients with a moderate to severe impairment of aerobic capacity very well, but 32% of the NYHA class II patients had a near normal aerobic capacity, and 29% of the NYHA class III patients had a very severe impairment of aerobic capacity, more compatible with NYHA class IV. Only data from exercise measurements showed differences between groups. The determination of maximal aerobic capacity for an objective assessment of patients' performance at exercise is necessary for a proper selection procedure of patients for heart failure studies.

Adult↗
PubMed2006

Heart rate response during exercise test and cardiovascular mortality in middle-aged men.

AIMS: The objective is to study whether a heart rate (HR) response during exercise test independently predicts cardiovascular disease (CVD) mortality. METHODS AND RESULTS: The subjects were a representative sample of 1378 men, 42-61 years of age, from eastern Finland with neither prior coronary heart disease (CHD) nor use of beta-blockers at baseline. HR was measured at rest and during a maximal, symptom-limited exercise test at 20, 40, 60, 80, and 100% of maximal workload. During an average follow-up of 11.4 years, there were 56 deaths due to CVD. The slope of HR increase during exercise test was steeper in survivors when compared with those who died due to CVD during follow-up (P<0.001), and the difference in the steepness of HR slope between the groups was the strongest at interval 40-100% (P<0.001). In Cox-multivariable models, maximal HR-HR at 40% workload as a continuous variable was inversely associated with CVD (P=0.04), CHD (P=0.004), and all-cause (P=0.002) mortality after adjustment for known risk factors for CVD death. CONCLUSION: By considering an HR response throughout an exercise test, we found that a blunted HR increase at 40-100% of maximal workload was associated with increased CVD mortality.

Adult↗
PubMed1994

Graded exercise testing following thrombolytic therapy for acute myocardial infarction: the importance of timing and infarct location. TPAT Study Group.

OBJECTIVES: To determine the influence of timing, infarct location and thrombolytic therapy on the electrocardiographic (ECG) response to exercise testing following acute myocardial infarction. DESIGN: Maximal treadmill exercise testing was performed on postinfarction day 8 and repeated on day 90 as part of a previously reported double-blind, placebo controlled study of recombinant tissue plasminogen activator (rt-PA) in acute myocardial infarction in which left ventricular function was the primary end-point. Patients were systematically evaluated for left ventricular function, myocardial perfusion and coronary anatomy. SETTING: Ten collaborating community and academic hospitals. PATIENTS: One hundred and fifteen patients, aged 20 to 75 years, with ischemic chest pain 30 mins or longer and ST elevation on ECG. Patients with cardiogenic shock, left bundle branch block, prior aortocoronary bypass surgery, recent percutaneous transluminal coronary angioplasty or standard contraindications to thrombolytic therapy were excluded. MAIN RESULTS: The analysis is confined to the 70 patients who underwent both exercise tests without intercurrent coronary revascularization. Peak rate-pressure product was greater on day 90 than on day 8 (mean difference +/- SE 2.2 +/- 0.6 x 10(3), P = 0.001), whereas 65% of patients had 1 mm or greater of exercise-induced ST shift on day 8 compared with 47% on day 90 (P = 0.025). Patients following anterior compared with inferior infarction were more likely to have exercise-induced ST elevation (54% versus 21%, P = 0.012) but less likely to have ST depression (29% versus 63%, P = 0.017) on day 8; results were directionally similar on day 90. Treatment with rt-PA, compared with placebo, did not influence exercise performance, the ECG response to exercise or the extent of inducible ischemia on thallium scintigraphy. CONCLUSIONS: Timing and infarct location are important modifiers of the ECG response to exercise testing following myocardial infarction. Thrombolytic therapy in these uncomplicated patients did not influence inducible ischemia.

Adult↗