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PubMed1983

Serum creatine kinase and creatine kinase MB isoenzyme responses of post-infarction patients after a graded exercise test.

The response of total creatine kinase (CK) and the creatine kinase isoenzyme (CK MB) was studied in 22 male post-infarction patients (three to six months after myocardial infarction) after a functional graded exercise test, before entering a rehabilitation programme. Eleven subjects (group A) completed the test without developing significant electrocardiographic abnormalities. Eleven subjects (group B) showed changes that necessitated premature termination of the test. No significant differences were observed before the functional graded exercise test between the groups in serum concentration of CK, CK MB, and the percentage of CK MB to CK (MB/ CK%). The two groups were significantly different (p less than 0.01) 24 hours after the graded exercise test in CK MB and MB/CK%, but not in CK. In group B, CK and CK MB rose significantly after the graded exercise test (p less than 0.05) as did MB/CK% (p less than 0.01). In group A only CK showed a significant rise (p less than 0.05). It is probable that increases in CK MB after exercise arise from myocardial tissue efflux, reflecting reversible ischaemia. It is concluded from this study that CK MB appears to be a specific indicator of myocardial ischaemia and could, therefore, be of significant assistance in the clinical and functional assessment of the post-infarction patient.

Clinical Enzyme Tests↗

PubMed1982

Accurate detection of coronary heart disease by new exercise test.

The ability of a new exercise test accurately to detect the presence and severity of coronary heart disease has been examined in 206 patients with anginal pain, including patients on beta blockers or with concomitant cardiac lesions. From recordings of 13 electrocardiographic leads during exercise, the maximal rate of progression of ST segment depression relative to increased in heart rate (maximal ST/HR slope) was obtained and used as an index of myocardial ischaemia. The maximal ST/HR slope and results of coronary arteriography were independently obtained and the two sets of data compared the ranges of the maximal ST/HR slopes in the 38 patients with no significant disease, 49 with single vessel, 75 with double vessel, and 44 patients with triple vessel disease were different from each other and there was no overlap in the data between adjacent groups; there were no false positive, false negative, or indeterminate results. It is concluded that the maximal ST/HR slope can be used reliably to predict the presence of absence and severity of coronary heart disease in individual patients presenting with anginal pain in a hospital population.

Adrenergic beta-Antagonists↗

PubMed1994

Behind the scenes of cardiopulmonary exercise testing.

The benefits and advantages of automated systems for cardiopulmonary exercise testing are well appreciated. Overenthusiasm and overconfidence in computer "black box" generated information, however, has resulted in inadequate attention to important issues related to quality control. The objective of this article is to provide basic and practical information related to equipment, methodology, conduct of the test, and quality control that will help assure clinically reliable results. The authors elaborate on the most widely applied methodologies and current criteria and guidelines of exercise testing.

Anaerobic Threshold↗

PubMed2003

Usefulness of exercise test in selected patients coming to the emergency department for acute chest pain.

BACKGROUND: The management of patients with acute chest pain is a common and difficult challenge for clinicians. In our emergency department (ED) a systematic protocol that involves the use of the exercise test for the management of patients with chest pain of suspected cardiac origin is presently running. The aim of the present study was to evaluate the feasibility of such a test in this setting, in terms of the safety and satisfactory follow-up of these patients discharged home. METHODS: Patients with chest pain lasting < or = 24 hours, aged > 18 years, without a history of trauma or of any other evident medical cause of chest pain and without high-risk characteristics were included in the present study. These patients, defined as low-risk patients for acute coronary events on admission, were evaluated in the ED area and submitted to serial ECG and blood sampling for the determination of the creatine kinase-MB mass and troponin I serum levels on admission and at 6 and 12 hours after admission. A symptom-limited maximal exercise was performed in the patients with a negative clinical observation and typical chest pain or atypical chest pain but multiple coronary risk factors. RESULTS: In the year 2000, 1370 patients were evaluated in the ED for chest pain. In 150 (11%) an exercise test was performed. The test was positive in 24 patients (16%). The criteria for a positive test were only clinical in 3 patients, only ECG in 13 patients, and both in 8 patients. Inconclusive tests were observed in 27 patients (18%) and the test was negative in 99 patients (66%). There were no complications during the exercise test. At a median follow-up of 237 days (range 11-443 days), 11 clinical events were recorded (4 acute coronary syndromes and 7 revascularization procedures). Patients with a non-negative exercise test had a significantly shorter event-free survival (p < 0.005). CONCLUSIONS: The exercise test performed in selected patients coming to the ED with acute chest pain is safe and useful for further risk assessment.

Acute Disease↗

PubMed1997

The reproducibility of the Bruce protocol exercise test for the determination of aerobic capacity in older women.

The reproducibility of the Bruce exercise test protocol for the determination of maximal aerobic activity was evaluated in sedentary older women. Seventeen women between the ages of 51 and 68 yr performed five maximal graded exercise tests to volitional fatigue on a treadmill. VO2max (mL.kg-1.min-1) values averaged 27.5 +/- 1.1; 28.3 +/- 1.3; 28.4 +/- 1.3; 29.6 +/- 1.5; and 28.2 +/- 1.4 for trials 1-5, respectively, and were not significantly different. Criteria for a plateau in VO2 at the point of exhaustion were met in 21 out of 85 tests (25%). The mean coefficient of variation VO2max for the subjects for the 5 tests was 6.5% (range, 2.0-14%). Pearson's correlation coefficients for the study variables were significant, indicating good agreement between repeated tests (r2: between 0.70 to 0.89). Although there were no significant differences among the mean VO2max values in the 5 trials, 11 subjects had a 1.0 ml.kg-1.min-1 or greater increase in the VO2max from test 1 to test 2, and only 6 subjects had no change or a decrease in VO2max. The mean difference between T2 and T3 was lower (T1 vs T2: 0.8 mL.kg-1.min-1, T2 vs T3: 0.1 mL.kg-1.min-1) indicating slightly better agreement between the second and third set. Estimates of the between and within subject variance revealed a low within subject variance (4.2 (mL.kg-1.min-1)2) compared to the between subject variance (22.1 (mL.kg-1.min-1)2). This study demonstrates that a commonly used exercise testing protocol generates highly reproducible measurements of VO2max in women between 51 and 68 yr. The mean differences between tests and the high level of agreement between repeated tests suggests that a single measurement of VO2max can be performed to assess functional aerobic capacity in this population.

Aged↗

PubMed1996

[Arrhythmia in patients with hypertrophic cardiomyopathy during an exercise test with 24-hour Holter monitoring].

Thirty patients with hypertrophic cardiomyopathy (HCM), (20 men and 10 women, age 16-55, mean 37 +/- 8 years) underwent exercise test done on bicycle twice to estimate effort tolerance before drugs. In all patients a 24-hour ekg Holter monitoring was also performed. During exercise test heart rhythm disturbances were noticed in 2 patients (7%). One had a 2-second sinus arrest, in the other ventricular bigeminity was observed. Twenty two patients (79%) had rhythm or conduction disturbances in Holter monitoring. In 2 (7%) rhythm generation and conduction abnormalities, in 7 (23%)-supraventricular and in 13 (43%)-ventricular arrhythmia. Ten of them (33%) had Lown class IVa and IVb arrhythmia. In conclusion we suggest that exercise test done on bicycle ergometer is a safe method to estimate effort tolerance in patients with HCM and usually does not induce rhythm disturbances. Holter monitoring is more effective than exercise test in revealing cardiac arrhythmia.

Adolescent↗

PubMed1990

Application of a standardised treadmill exercise test for clinical evaluation of fitness in 10 thoroughbred racehorses.

Clinical exercise stress testing is an important diagnostic tool for evaluating exercise intolerance and degree of fitness in human athletes. The purpose of this paper was to describe the methodology necessary to perform a clinical exercise test and report the results of performance evaluations on 10 Thoroughbred racehorses using this test. The test utilised an open flow gas analysis system for ease of use with untrained horses and a fast time response lactate analyser for rapid data analysis. Exercise test measurements used to evaluate fitness included peak oxygen consumption (mean VO2peak = 161.9 +/- 12.9 ml/kg/min), peak heart rate (mean HRpeak = 232 +/- 10 b/m), peak venous blood lactate concentration (mean LAC peak = 15.2 +/- 5.8 mmol/l), peak packed cell volume (mean PCV peak = 0.64 +/- 0.3 l/l) and the maximum number of steps completed (mean STEPmax = 8.7 +/- 0.5 steps). The relationship between these exercise test measurements with velocity and time post exercise was also evaluated. Change in serum creatine kinase levels resulting from exercise test were minimal (mean delta SCK = 72 +/- 53 u/l).

Animals↗

PubMed1986

Diagnostic value of R wave amplitude changes during exercise testing after myocardial infarction.

To determine the diagnostic value of R wave amplitude changes occurring during exercise testing after myocardial infarction, exercise ECG's and coronary angiograms were reviewed in 76 postinfarction patients and in 40 patients with normal coronary arteries. During exercise, an increase in R wave amplitude (mean: + 2.7 +/- 1.3 mm) was observed in the postinfarction patients, significantly different (P less than 0.001) from the decrease (mean: - 2.6 +/- 1.1 mm) observed in the group with normal coronary arteries. Although this change increased with the number of diseased coronary arteries, the difference between 1-vessel and multi- or 3-vessel disease was not significant. Extension of infarct size from one to more akinetic segments on the left ventricular angiogram was associated with a significant (P less than 0.001) increase of the R wave amplitude change during exercise (mean: + 1.6 +/- 1.1 vs 3.3 +/- 1.3 mm). It is concluded that the abnormal increase in R wave amplitude observed during exercise testing after myocardial infarction is more strongly related to infarct size then to the number of diseased coronary arteries. Furthermore exercise induced R wave amplitude changes have no diagnostic value in the prediction of multi- or 3-vessel disease in postinfarction patients.

Angiocardiography↗

PubMed1979

The prognostic significance of serial exercise testing after myocardial infarction.

Serial treadmill exercise testing (mean 5.5 tests/patient) was used to evaluate the prognosis of 200 males (mean age 53 years) without clinical heart failure or unstable angina pectoris 3 weeks after acute myocardial infarction (MI). Exercise-induced ischemic ST-segment depression greater than or equal to 0.2 mV 3 weeks after MI was significantly more prevalent in patients with subsequent cardiac arrest (100%) or coronary artery bypass graft surgery (64%) than in patients without subsequent events within 2 years of infarction (35%) (p less than 0.05). Exercise-induced ventricular arrhythmia on multiple tests 5-52 weeks after MI was more prevalent in patients with recurrent myocardial infarction (90%) than in patients without subsequent events (47%) (p less than 0.001). By contrast, exercise-induced ventricular arrhythmia on a single test at 3 weeks was a less powerful predictor of subsequent cardiac events. Exercise-induced ischemia 3 weeks after MI predicted early fatal events, while ventricular arrhythmia on serial testing predicted later nonfatal events.

Adult↗

PubMed2001

Using baseline respiratory function data to optimize cycle exercise test duration.

BACKGROUND: It is often difficult to select an appropriate workload increment for progressive cycle exercise tests in order to achieve optimal test duration (8-12 min). We hypothesize that baseline respiratory function can be systematically used to select appropriate workload increment to optimize test duration in patients referred to the clinical laboratory. METHODOLOGY: One hundred and eighty consecutive exercise tests (with increments of 15 W/min) were retrospectively assessed. Using regression analysis, an equation was generated that predicts the work rate increment that would provide exercise duration of 8-12 min. The validity of this equation was tested prospectively in 231 consecutive tests performed with the calculated workload increment rounded to the nearest 5 watts (W). RESULTS: The best regression equation was: workload increment (W/min)=1.94 x FEV1 (L) + 0.63 x TLCO (mmol/min per kPa) - 0.07 x age + 1.94 x gender (male=1, female=0) + 4.12 (r=0.85, P < 0.0001). Using this equation allowed selection of the most appropriate workload increment in 79% of tests and reduced the number of tests of non-optimal duration from 72% (for a fixed increment of 15 W/min) to 38%. CONCLUSIONS: Utilization of this regression equation allows standardization in the selection of workload increment, and reduces the number of cycle exercise tests of inadequate duration.

Algorithms↗

PubMed2000

Prognostic significance of cardiopulmonary exercise testing for 10-year survival in patients with mild to moderate heart failure.

Although a number of studies have investigated the prognostic significance of exercise variables, they have focused only on short-term prognosis in relatively severe heart failure. This study was carried out to determine whether the indices obtained during cardiopulmonary exercise testing have prognostic significance during a 10-year follow-up in mild to moderate heart failure. Three hundred and sixty-four consecutive patients with cardiac disease performed 4 min of 20-W warm-up, followed by a symptom-limited incremental exercise test on a cycle ergometer. In addition to the measurements of peak oxygen uptake (VO2) and gas exchange (anaerobic) threshold, the time constant of VO2 kinetics during the onset of warm-up exercise was calculated using a single exponential equation. Data on mortality were available for follow-up in 260 patients. After 3,331+/-610 days of follow-up, 29 cardiovascular-related deaths occurred. The time constant of VO2 in the nonsurvivors was 76.7+/-43.3 s and was significantly prolonged compared with that of survivors (55.3+/-30.6 s, p=0.001). Peak VO2 and gas exchange threshold were both significantly lower in nonsurvivors than in survivors. Kaplan-Meier survival curves for 10 years of follow-up demonstrated a survival rate of 89.0% for patients with a normal VO2 time constant (< 80 s) and 71.7% for those with a longer time constant (> or = 80 s), showing a significant difference in survival (p=0.0028). Respiratory gas parameters obtained during exercise testing, particularly the time constant of VO2 kinetics, were found to be useful for predicting long-term prognosis in patients with chronic heart failure. These results suggest that cardiopulmonary exercise testing could be more applicable in ambulatory patients with minimal symptoms or minimal functional impairment.

Actuarial Analysis↗

PubMed1995

Exaggerated atrial repolarization waves as a predictor of false positive exercise tests in an unselected population.

The authors previously postulated that a markedly downsloping PR-segment might be a marker for exaggerated atrial repolarization waves and demonstrated PR-segment appearance to be an independent predictor of a false positive exercise test. This study was conducted to determine the sensitivity, specificity, and predictive value of markedly downsloping PR-segments for predicting false positive exercise tests. The study group consisted of 82 consecutive patients with a positive exercise test (> or = 1.0 mm horizontal ST depression) and a normal resting electrocardiogram. Tests were predicted to be false positive based on previously defined criteria: (1) markedly downsloping PR-segments in two or more of leads II, III, and aVF and (2) exercise duration 4 minutes or longer. Patients were then classified according to available clinical information (coronary angiography and radionuclide stress testing) into true positive (due to myocardial ischemia, n = 62) and false positive (n = 20) groups. The sensitivity, specificity, and predictive value of the PR-segment/exercise duration criterion for predicting a false positive test were 70, 74, and 47%, respectively. Patients with false positive tests also had higher heart rates (158 +/- 16 vs 136 +/- 20 beats/min, P < .001) and less frequent chest pain (15 vs 46%, P = .017) during the exercise test. Patients with false positive exercise tests can be recognized by the achievement of a high peak exercise heart rate, the absence of exercise-induced chest pain, and the appearance of markedly downsloping PR-segments in the inferior leads.

Atrial Function↗

PubMed1987

Value of the treadmill exercise test in asymptomatic and minimally symptomatic patients with chronic severe aortic regurgitation.

The value of the graded treadmill exercise test was assessed in 19 asymptomatic and minimally symptomatic (13 NYHA class I and 6 NYHA class II) male patients with chronic severe aortic regurgitation. It was observed that, in 2 patients who showed significant ST segment depression at peak exercise, the total exercise duration was significantly shorter (P less than 0.001) than in the patients not showing such changes. During left ventricular and aortic root angiography (in both patients) and selective left coronary angiography (in one of them), ST segment changes similar to those seen during exercise testing were observed. The mean rise in left ventricular end-diastolic pressure after injection of contrast material was significantly more (P less than 0.001) in these 2 patients compared to the other 17 patients. Both patients had normal resting M-mode echocardiographic parameters. It is concluded that ST segment depression on exercise testing and reduced exercise capacity are indicants of exercise-induced left ventricular dysfunction in asymptomatic and minimally symptomatic patients with chronic severe aortic regurgitation. Furthermore, it is suggested that this simple and cheap test can be used for serial evaluation of such patients in the absence of the facility of radionuclide cineangiography.

Adolescent↗

PubMed1995

[Usefulness of early exercise test after anterior infarction in the diagnosis of multivessel disease].

OBJECTIVE: The aim of the present study was to determine the reliability of early exercise test to detect multivessel disease in survivors of an uncomplicated first anterior Q-wave myocardial infarction. METHODS: Among 100 consecutive patients 64 (aged 55 +/- 10 years) were included in the study. Thirty-four patients (53.1%) received thrombolytic therapy and this was considered successful, by means of non-invasive criteria, in 24 patients (37.5%). A standard symptom-limited exercise test, 11-15 days after myocardial infarction, and coronary arteriography, < 72 hours later, were performed in all patients. RESULTS: On exercise test 6 (9.3%) patients developed significant ST segment depression, 48 (75%) significant ST segment elevation, 5 (7.8%) ST depression in inferior leads together with ST elevation in anterior leads and 3 (4.6%) angina. Of the 18 patients with multivessel disease 5 (27.8%) developed ST depression, 10 (55.5%) ST elevation, 1 (5.5%) ST depression in inferior leads together with ST elevation in anterior leads and 1 (5.5%) angina. CONCLUSIONS: Our study indicates that ST depression in a symptom-limited exercise test performed early after an anterior Q-wave acute myocardial infarction is unusual and has low sensitivity (27.8%) to detect multivessel disease. ST elevation is the more common finding in this test (75%) and has no relation with the severity of CAD.

Adult↗

PubMed1997

Exercise testing in the preoperative evaluation of patients with bronchogenic carcinoma.

The aim of this study was to evaluate which parameters of preoperative spirometry and cardiopulmonary exercise test are the best predictors of postoperative morbidity and mortality in patients with bronchogenic carcinoma. Ninety seven patients were prospectively and consecutively examined. All patients had preoperative maximal exercise test and dynamic spirometry. Postoperative complications and causes of death were registered. Logistic regression was used and models explaining the relationship between preoperative variables and postoperative complications and deaths were constructed. We found significant differences in preoperative maximal workload and carbon dioxide output between groups, with and without cardiopulmonary-related complications, but not in spirometry variables. Logistic regression showed maximal workload to be the only predictor of cardiopulmonary complications. Maximal oxygen uptake was predictive of cardiopulmonary deaths. Maximal oxygen uptake and forced expiratory volume were predictive of postoperative complications. A maximal oxygen uptake <50% predicted was associated with high risk of death from cardiopulmonary causes. Kaplan-Meier survival curves showed that maximal oxygen uptake was correlated to long-term survival, while spirometric variables were not. Exercise testing can be used in the preoperative evaluation of patients with nonmetastatic bronchogenic carcinoma. A combination of the results of variables from spirometry and exercise testing is proposed to be used as a preoperative criterion for operability.

Carcinoma, Bronchogenic↗

PubMed1986

Exercise testing in patients with heart disease.

Exercise tests performed in the clinic give important qualitative and quantitative information. Psychological scaling of main symptoms is most valuable to define a patient's incapacitation and maximal performance. In pharmacological testing this is of utmost importance, particularly in patients with angina pectoris or heart failure. In chronic heart failure there is a poor correlation between the maximal working capacity and the performance of the heart.

Angina Pectoris↗

PubMed1998

Cardiopulmonary exercise testing identifies low risk patients with heart failure and severely impaired exercise capacity considered for heart transplantation.

OBJECTIVES: The 3-year survival rates of 500 patients with congestive heart failure (CHF) referred for heart transplantation were assessed to evaluate the clinical and exercise variables most useful for estimating prognostic risk. BACKGROUND: Detailed prognostic risk stratification of patients with a peak exercise oxygen consumption (VO2) < or = 14 ml/min per kg to identify lower risk patient subsets has been limited in earlier series by relatively small sample size. METHODS: Cardiopulmonary exercise testing was performed in 500 patients with CHF referred for heart transplantation; 154 (31%) had a peak exercise VO2 < or = 14 ml/min per kg. Univariate and multivariate analyses were performed to identify the 3-year prognostic risk. RESULTS: The 55% 3-year survival rate of the 77 patients with a peak exercise VO2 < or = 14 ml/min per kg unable to reach a peak exercise systolic blood pressure (SBP) of 120 mm Hg was significantly lower than the 83% survival rate in the 74 patients able to reach this exercise blood pressure (p = 0.004). Multivariate analysis revealed that peak exercise SBP (p = 0.0005) and percent predicted peak VO2 < or = 50% (p = 0.04) were the two most important predictors for the combined end point of death or listing as Status 1. CONCLUSIONS: Peak exercise SBP and percent predicted peak exercise VO2 are two inexpensive and easily measured noninvasive variables that can be used to further prognostically risk stratify ambulatory patients with CHF referred for heart transplantation with a peak exercise VO2 < or = 14 ml/min per kg.

Adult↗

PubMed1989

Risk stratification in patients with first non-Q wave infarction: limited value of the early low level exercise test after uncomplicated infarcts. The Multicenter Post-Infarction Research Group.

Risk stratification using clinical and historical variables plus early low level exercise testing was performed in 141 patients with a first non-Q wave myocardial infarction. The 111 patients who performed the exercise test had a 3.6% cardiac mortality rate in the first year compared with 13.3% in the 30 patients who could not exercise (p = 0.063), and a 1 year incidence rate of recurrent cardiac events (cardiac death or recurrent nonfatal myocardial infarction) of 10.8% compared with 23.3% (p = 0.127). Patients who developed ischemia (ST depression or angina) during the test had an increased incidence of cardiac events in the year after the infarction (odds ratio greater than 3, p less than 0.05). When patients were subgrouped by the presence or absence of pulmonary congestion, the discriminatory value of the exercise test was seen to reside primarily in the cohort with pulmonary congestion. For example, ST depression during exercise in this group identified patients with a 71% incidence of cardiac events in the year after the infarction compared with 5.3% for those without ST depression (odds ratio 45, p = 0.002). In the patients without pulmonary congestion, the exercise test had no discriminatory value. It is concluded that early low level exercise testing has a limited role after an uncomplicated non-Q wave infarction, but is useful in patients with clinical markers of higher risk.

Electrocardiography↗