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PubMed1993

Improved exercise test accuracy using discriminant function analysis and "recovery ST slope".

The objective of the study was to optimize the accuracy of the exercise test for predicting the presence of significant angiographic coronary artery disease. A retrospective analysis of stored digital exercise electrocardiographic data on 147 men who had undergone exercise testing and cardiac catheterization was performed. With significant coronary artery disease defined as > or = 70% stenosis, 95 patients had one or more vessel(s) diseased. None were receiving digoxin, had a myocardial infarction or previous coronary artery bypass graft, or exhibited left bundle branch block, left ventricular hypertrophy, Q waves, or ST depression on their resting electrocardiogram. Analysis was performed using the authors' averaging and measurement software at rest and at each 30 seconds throughout the exercise and recovery in leads II, V2, and V5. Discriminant function analysis was used to analyze pretest variables, as well as hemodynamic and electrocardiographic changes and symptoms during exercise. A discriminant function score was developed and compared to other treadmill scores. The setting was a 1,000 bed Veterans Affairs Medical Center (Long Beach, CA). Discriminant function analysis chose age, smoking status, presenting chest pain characteristics, and lead V5 ST slope in recovery to have independent power for separating those with and without coronary artery disease. A discriminant function score using these four variables was used to form a receiver operating characteristics curve (and derive receiver operating characteristics curve areas) for comparison to other exercise test methods and scores: (discriminant function score = .81; slope 3.5 minutes into recovery in lead V5 = .73; traditional ST amplitude method = .72; ST60/HR index (amplitude of ST depression 60 ms after the J point/delta heart rate) = .66; traditional ST amplitude/HR index (traditional method/delta heart rate) = .75; Hollenberg score = .68; Hollenberg areas only = .66; and ST integral = .66. Receiver operating characteristics curve analysis revealed a trend for the discriminant function score to be superior to all other measurements and scores. Recovery ST slope in lead V5 performed as well as or better than all other electrocardiographic criteria or treadmill scores except for the authors' discriminant function score.

Cardiac Catheterization↗
PubMed1998

The Effects of Sublingual Administration of Captopril on Parameters of Exercise Test and Neurohormonal Activation in Patients With Stable Angina Pectoris

A prospective randomized, double-blind, and placebo-controlled study was designed to investigate the effects of sublingual administration of captopril on the parameters of exercise test and neurohormonal activation in patients with stable angina pectoris. A total of 31 patients (28 male, 3 female; mean age 55.4 +/- 9.4 years) took part in the study. Coronary angiography and left ventriculography were performed in all cases and the patients were classified according to the ejection fraction (EF). Following sublingual placebo or 25 mg captopril, plasma levels of renin, angiotensin II, norepinephrine, and serum aldosterone levels were measured at rest and maximal exercise. test was performed. Hormone levels were remeasured immediately after the exercise. The same procedure was repeated the next day using captopril or placebo. Sublingual captopril administration increased the time to angina, the time to 1 mm ST depression, maximal exercise capacity, maximal exercise duration and decreased maximal ST depression, maximal systolic blood pressure, and maximal double product (p < 0.001-0.01). After the maximal exercise test following captopril, the % difference of angiotensin II, aldosterone, and norepinephrine levels was found to be significant lower and the % difference of the renin level was found to be significantly higher than those of placebo (p < 0.001). The effects of sublingual captopril on exercise parameters were additionally assessed in different left ventricular systolic function subgroups. The favorable effects were more prominent in cases with left ventricular systolic dysfunction. There were no adverse effects related to sublingual captopril use. As a result, sublingual administration of captopril improved the parameters of maximal exercise test and suppressed the neurohormonal activation during exercise. We suggest that sublingual captopril may be used effectively before planned daily activities in patients with stable angina pectoris.

Journal Article↗
PubMedDate not supplied

Evaluating pulmonary impairment: appropriate use of pulmonary function and exercise tests.

Pulmonary impairment in patients with occupational lung diseases can frequently be detected and quantified simply by measuring spirometric values (forced vital capacity, forced expiratory volume in 1 second), or single breath-diffusing capacity. When the results of such pulmonary function tests are equivocal or inconsistent with clinical symptoms, cardiopulmonary exercise testing provides helpful ancillary information. Published guidelines are available to assist in grading the severity of respiratory impairment based on pulmonary function and exercise testing.

Disability Evaluation↗
PubMed1987

Graded exercise testing and training after renal transplantation: a preliminary study.

Aerobic exercise training has been used as part of the treatment for a variety of chronic disorders, most notably cardiovascular disease. In order to determine the feasibility and utility of regular exercise after renal transplantation, the responses of 10 patients to graded exercise testing were compared before training (T1), immediately after a program of supervised exercise training (T2), and a mean of 2.2 years after completion of the supervised program (T3). Supervised exercise sessions began a mean of 17 days postoperatively and continued for a mean of 5.5 weeks. Patients were encouraged to continue regular unsupervised exercise thereafter. All patients easily tolerated the supervised exercise sessions, which consisted of treadmill walking and cycle ergometry. Exercise capacity improved 90% between T1 and T2 and an additional 12% between T2 and T3. On the average, patients achieved a normal exercise capacity by 8 weeks after transplantation. Of the 10 patients, 7 had continued regular exercise training at T3. The observed increase in aerobic exercise capacity was probably related to improved renal function, an increased hemoglobin concentration, and the surgical healing process as well as the exercise training. We conclude that supervised exercise training for selected patients after renal transplantation is feasible and worthwhile.

Adolescent↗
PubMed2005

Use of a multi-stage exercise test to assess the responsiveness of rate-adaptive pacemakers in dogs.

OBJECTIVES: To assess the ventricular rate response of rate-adaptive (VVIR) pacemakers in dogs using a multi-stage exercise test. METHODS: The rate-responsiveness of VVIR pacemakers was assessed in seven dogs with complete atrioventricular (AV) block and implanted with various models of pulse generators (six motion sensors and one automatic dual-sensor rate-response pacemaker). Response activity was assessed with a multi-stage exercise test on a treadmill. Atrial and ventricular rate were analysed retrospectively at the end of the test and the AV ratio was calculated after each minute of exercise. RESULTS: During exercise, the mean (sd) AV ratio recorded in all paced dogs was 1.7 (0.5) (expected physiological ratio 1.0), although a variety of individual performances was observed. A poor response (AV ratio 2.8 [0.2]) was obtained with the automatic dual-sensor pacemaker, suggesting that this type of rate-responsive device may not be indicated for implantation in dogs with complete AV block. The overall AV ratio for the six dogs implanted with motion sensors was 1.4 (0.2), showing a better performance of these pacemakers during exercise. CLINICAL SIGNIFICANCE: This multi-stage exercise test represents an easy and repeatable method for assessing the accuracy of rate-responsive sensors and offers valuable information for the correct setting of VVIR pacemakers in dogs.

Animals↗
PubMedDate not supplied

Relationship between the Minnesota Living With Heart Failure Questionnaire and key ventilatory expired gas measures during exercise testing in patients with heart failure.

PURPOSE: This study assessed the relationship between the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) and key ventilatory expired gas measures during a symptom-limited exercise test in the heart failure (HF) population. Specifically, is there evidence to indicate that perceived quality of life (QOL) influences exercise performance independent of physiologic function in the HF population? METHODS: Thirty-one subjects (21 male/10 female), diagnosed with compensated HF, underwent exercise testing and completed the MLWHFQ. Mean age and left ventricular ejection fraction were 52.8 years and 27.2%, respectively. Partial correlation, controlling for age and sex, assessed the relationship between MLWHFQ (overall and subscores) and key ventilatory expired gas measures. Intraclass correlation coefficient (ICC) analysis was used to determine reliability of the MLWHFQ. RESULTS: MLWHQ overall score (mean = 38.9, median = 36.0), physical subscore (mean = 14.8, median = 16.0), and psychosocial/symptomatology subscore (mean = 24.1, median = 19.0), were significantly correlated (P < or =.05) with peak oxygen consumption (VO2). The relationship between MLWHFQ and the minute ventilation-carbon dioxide production (VE/VCO2) slope was, however, not significant. ICC analysis revealed high reliability (0.95) for the MLWHFQ. CONCLUSIONS: The MLWHFQ demonstrates a significant relationship with peak VO2, a measure whose validity is dependent upon subject effort. VE/VCO2 slope, which is independent of subject effort and therefore potentially a better predictor of true physiologic function, does not appear to have a relationship with perceived QOL. These findings have implications for how the MLWHFQ is assessed, related to an exercise test, and used during clinical practice.

Adult↗
PubMed1984

Ineligibility for predischarge exercise testing after myocardial infarction in the elderly: implications for prognosis.

This study describes the clinical profile and prognosis of elderly patients not eligible for predischarge exercise testing. The database consisted of 133 patients 55-64 years of age, and 111 patients older than 64 years of age who survived an acute myocardial infarction. Follow-up was one year. In the younger age group, 24 (18%) patients were unable to perform the test, in contrast to 63 (57%) of the elderly subjects. In these two groups, one-year mortality rates were 13% and 37%, compared with 6% and 4% for the respective patients eligible for stress testing. Clinical profile and radionuclide ejection fraction between ineligible patients in both age groups were similar. Ejection fraction measurement was the best predictor of late mortality in those patients who did not have an exercise test. It is concluded that ineligibility for predischarge exercise test identifies a high-risk group, especially in patients older than 64 years of age.

Aged↗
PubMed1988

Exercise stress testing.

Exercise stress testing is used widely to evaluate the presence and extent of anatomic disease and the prognosis when significant disease has been defined. Indications for diagnostic testing include elevated blood pressure, palpitations, and chest pain. Functional testing is used to assess progression of cardiac disease, cardiac status following therapy, and physical capacity. Exercise testing must be applied to an appropriately selected group of patients. The indications, contraindications, types, results, and complications of exercise testing are presented.

Coronary Disease↗
PubMed2000

Clinical importance of risk factors and exercise testing for prediction of significant coronary artery stenosis in women recovering from unstable coronary artery disease: the Stockholm Female Coronary Risk Study.

BACKGROUND: The objectives of this study were to investigate the relation between coronary risk factors, exercise testing parameters, and the presence of angiographically significant coronary artery disease (CAD) (> or =50% luminal stenosis) in female patients previously hospitalized for an acute CAD event. METHODS AND RESULTS: All women younger than age 66 years in the greater Stockholm area in Sweden who were hospitalized for acute coronary syndromes during a 3-year period were recruited. Besides collection of clinical parameters, coronary angiography and a symptom-limited exercise test were performed in 228 patients 3 to 6 months after the index hospitalization. The mean age was 56 +/- 7 years. Angiographically nonsignificant CAD (stenosis <50%) was verified in 37% of the patients; significant CAD was found in 63%. The clinical parameters that showed the strongest relation with the presence of significant CAD after adjusting for age were history of myocardial infarction (odds ratio [OR] 4.91, 95% confidence interval [CI] 2.35 to 7.49), history of diabetes mellitus (OR 3.83, 95% CI 1.63 to 14.31), serum high-density lipoprotein cholesterol <1.4 mmol/L (OR 2.11, 95% CI 1. 20 to 3.72), and waist-to-hip ratio >0.85 (OR 1.78, 95% CI 1.02 to 3. 10). A low exercise capacity and associated low change of rate-pressure product from rest to peak exercise were the only exercise testing parameters that were significantly related to angiographically verified significant CAD (<90% of the predicted maximal work capacity adjusted for age and weight, OR 1.91, 95% CI 1. 04 to 3.50). CONCLUSIONS: In female patients recovering from unstable CAD, exercise capacity was the only exercise testing parameter of value in the prediction of significant CAD. The consideration of certain clinical characteristics and coronary risk factors offer better or complementary information when deciding on further coronary assessment.

Adult↗
PubMed1981

Diagnostic quantification of CASS (coronary artery surgery study) clinical and exercise test results in determining presence and extent of coronary artery disease. A multivariate approach.

Multivariate linear discriminant function analysis on maximal exercise treadmill and angiographic data from 500 men with definite angina, 584 men with probable angina and 267 men with nonspecific chest pain identified independent predictors of presence and extent of coronary disease. We used the discriminant function to develop a clinical risk index and a clinical and exercise risk index for each patient subset. Probability curves were generated to predict the presence and extent of coronary disease. In definite angina cases, exercise testing provided more diagnostic information than clinical data alone. However, in the 10% of cases with the smallest risk indexes, half of the patients had coronary disease and one-quarter had multivessel disease. In men with probable angina, exercise testing added substantially more diagnostic information than clinical data. The probability of multivessel disease was reduced to less than 10% for 30% of patients with probable angina, an important diagnostic contribution. Exercise testing in men with nonspecific chest pain was of limited value because disease prevalence was already low.

Angina Pectoris↗
PubMed1987

Treadmill exercise test and ambulatory measures in panic attacks.

Treadmill exercise test performance and ambulatory heart rate and activity patterns of 40 patients with panic attacks were compared with 20 age-matched controls (control group 1) and 20 nonexercising controls (control group 2). All patients underwent a symptom-limited exercise stress test. Panic attack patients and control group 1 wore an ambulatory heart rate/activity monitor for up to 3 days. Panic patients had a significantly higher heart rate at 4 and 6 METS than either control group. The max METS were 11.2 +/- 2.3, 13.5 +/- 2.3 and 11.2 +/- 1.8 for the panic attack patients and control groups 1 and 2, respectively. One panic patient had ischemia on the treadmill at 12 METS. Panic patients had a significantly higher standing heart rate than controls. Furthermore, 11 of 39 panic patients had tachycardia on standing compared with 3 of 40 controls. Panic attack patients had higher wake and sleep heart rates than control group 1, but the differences were not significant. These results are consistent with autonomic dysfunction in panic patients but may also be due to differences in physical conditioning. The treadmill can be useful for reassuring patients and for identifying the rare patient with ischemia on exercise.

Adult↗
PubMed1999

Usefulness of measurement of plasma atrial natriuretic peptide levels in exercise testing of patients with coronary heart disease.

Atrial natriuretic peptide secretion on exercise testing may be exaggerated by left ventricular dysfunction due to multivessel coronary disease rather than by scintigraphically detectable myocardial ischemia. The measurement of plasma atrial natriuretic peptide levels during exercise test may provide additional information regarding the severity of coronary heart disease.

Aged↗
PubMedDate not supplied

[CoQ10 blood levels and erythrocyte concentration of GSH in ischemic heart patients during exercise test (effects of vitamin E)].

During exercise there is an increase of oxygen consumption with production of superoxide anion. Tocopherols and ubiquinones are intrinsic lipid components involved in antioxidant protection and also glutathione reduced is an important water soluble antioxidant. The authors take into consideration 28 patients with ischemic heart disease coming in a rehabilitation center. In a group of 14 of them we studied the effects on the exercise ergonometer test of administration of 1200 mg of tocopherol on the behaviour of ubiquinone plasmatic levels and GSH. In this group CoQ10 after exercise increase significantly (0.762 SD 0.134 g/ml before vs 0.827 SD 0.89 after). GSH doesn't increase after (2.5 SD 0.459 mM/l vs 2.492 SD 0.457). In the group of patients without tocopherol after exercise CoQ10 decrease significantly (-39%) and also GSH has the same behaviour (-15%). Our study shows that the administration of tocopherol prevents lipoperoxidation occurring during exercise test.

Adult↗
PubMed1979

Prognostic value of exercise testing soon after myocardial infarction.

The prognostic value of a limited treadmill exercises test performed one day before hospital discharge after acute myocardial infarction was studied in 210 consecutive patients who had no over heart failure and had been free of chest pain for at least four days. No complications occurred. During a one-year follow-up period 28 of 43 patients (65 per cent) who had chest pain during the test reported angina, as compared with 60 of 167 (36 per cent) who had no chest pain during test (P less than 0.001). The one-year mortality rates were 2.1 per cent (three of 146) in patients without changes in the S-T segment during exercise and 27 per cent (17 of 64) in those with depression of the S-T segment (P less than 0.001). Sudden death occurred in one of 146 (0.7 per cent) patients who showed no change in the S-T segment and in 10 of 64 (16 per cent) with depression of the segment (P less than 0.001). Thus, a limited treadmill exercise test performed before hospital discharge after acute myocardial infarction is safe and can predict mortality in the subsequent year.

Adult↗
PubMed1985

Direct estimation of cardiac reserve through analysis of relation between oxygen consumption and heart rate during exercise testing.

In order to elucidate fundamental relationship between exercise and cardiac reserve, we investigated the parameters of regression equation (VO2 = A X HR + B) between oxygen consumption (VO2 ml/kg/min) and heart rate (HR) during exercise test (Bruce). 62 male children were divided into 3 groups based on history and clinical evaluation. HR related linearly with VO2 (average r = 0.967, range 0.90-0.993). Both of the parameters A and [B] were significantly high in Athlete (A = 0.465 +/- 0.043, [B] = 36 +/- 6.07), low in Failed (0.297 +/- 0.055, 17.4 +/- 6.1) and middle in Ordinary group (0.366 +/- 0.078, 23.5 +/- 8.6) (p less than 0.005). Based on our result of linear VO2-HR relation, and on the previously reported studies that cardiac output linearly and consistently relates with VO2, we considered the meaning of the parameters as follows; A determines the possible maximum stroke volume (SV), and B determines the HR where SV reaches plateau. In conclusion, since the SV is considered as a measure of cardiac function, measuring the parameters of VO2-HR relation allows us to isolate cardiac functional reserve through the exercise tolerance test.

Adolescent↗
PubMed1991

Exercise testing and training in patients with peripheral vascular disease and lower extremity amputation.

Patients with peripheral vascular disease have a high risk of coronary artery disease. The risk is even greater when the peripheral vascular disease leads to lower extremity amputation. Exercise testing using lower extremity exercise has been the "gold standard" for screening for coronary artery disease, but many patients with peripheral vascular disease and those with amputations have difficulty doing this type of exercise. Arm exercise ergometry has been shown to be a safe and effective alternative for the detection of coronary artery disease in patients who cannot do leg exercise. This test has also been used to determine safe exercise levels and may be able to predict the ultimate level of prosthetic use in amputees. Exercise training with arm ergometry also improves cardiovascular efficiency and upper body strength in poorly conditioned patients. Studies are needed to appreciate fully the role of exercise testing and training in the recovery of these patients after amputation.

Amputation, Surgical↗
PubMed1990

Routine exercise testing to detect coronary artery disease in patients with atherosclerotic vascular disease.

The ability of patients with peripheral vascular disease to perform exercise studies on a conventional treadmill is often hampered by claudication, amputation, ischemic ulceration or rest pain. This study was undertaken to investigate the use of the arm ergometer in these patients. Eighty-three patients admitted with peripheral vascular or carotid artery disease were subjected to electrocardiographic-monitored exercise testing, using both the arm ergometer and conventional treadmill, where possible. Coronary arteriography was performed consecutively on 32 of these patients to establish a control group from which the sensitivity, specificity and predictive accuracy of both methods of exercise testing could be calculated. Nineteen of the 70 arm ergometry tests and 22 of the 48 treadmill tests were positive. Nineteen of the patients with a positive test using either of the methods were asymptomatic for cardiac disease. All five patients who developed cardiac events during surgery had positive exercise tests, preoperatively. The sensitivity of arm ergometry in detecting coronary artery disease was 45.5% and the specificity 100%, while the figures for treadmill testing were 82.4% and 83.3%, respectively. The combined sensitivity for the two tests was 81.8% and the specificity 87.5%. Using a combination of these two tests thus provided a highly specific and adequately sensitive means of detecting the presence of coronary artery disease in patients presenting for peripheral vascular surgery.

Adult↗
PubMed1999

Is the shortening of the QTc interval in Q-wave leads showing ST segment shift during exercise testing a new ECG marker of myocardial ischemia and viability in patients with previous anterior myocardial infarction?

PURPOSE: To evaluate whether the shortening of the QTc-interval, measured in Q-wave leads showing ST segment elevation during exercise testing may be a marker of stress-induced transmural ischemia (and indirectly of myocardial viability) in the infarct zone in patients with prior Q-wave anterior myocardial infarction. METHODS: We evaluated 15 consecutive patients (Group A) with previous anterior myocardial infarction presenting these peculiarities: 1) ST segment elevation over Q waves during exercise testing; 2) critical (> 75%) stenosis of LAD; 3) evidence by echocardiography and stress-redistribution-reinjection 201thallium myocardial scintigraphy (SRR201TIMS) of viable myocardium in the infarct zone (akinetic segments with normal echo-reflectivity plus > 7 mm end-diastolic wall thickness and significant 201thallium redistribution after reinjection). The study control group (Group B) consisted of 15 patients with previous myocardial infarction, critical stenosis of LAD and evidence of scarring by imaging techniques (increased echo-reflectivity associated with an end-diastolic wall thickness < 6 mm and no 201thallium redistribution in infarcted areas). The QTc interval was measured at rest and at peak stress in all leads, and particularly in infarct-related leads showing ST-T changes, and the lead-by-lead fractional difference percentage between the QTc intervals (delta QTc) was calculated. The delta QTc was measured again during exercise testing in 11 patients from Group A (Group A1) who showed significant contractility recovery three months after complete myocardial revascularization. A delta QTc shortening < -10% was considered "significant". RESULTS: In 14/15 patients from Group A, a significant delta QTc shortening was measured, while in 14/15 patients from Group B no significant delta QTc shortening was detected (sensitivity = 93.3%; specificity = 93.3%) (p < 0.0001). The mean delta QTc in Group A was -18.1 +/- 8.5%; the mean delta QTc in Group B was -4.2 +/- 7.8% (p < 0.0001). No patient from Group A1 showed a significant delta QTc shortening in Q-wave leads (mean delta QTc group A1 = +6.9 +/- 14.8%). CONCLUSIONS: delta QTc shortening in infarct-related leads during exercise testing is a simple ECG marker of transmural ischemia and, indirectly, of myocardial-viability. This sign is no more evident after myocardial revascularization and may be useful in identifying "hibernating-myocardium".

Aged↗