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PubMedDate not supplied

Prognostic value of exercise tests in male veterans with chronic coronary artery disease.

PURPOSE: The authors evaluate the prognostic value of treadmill testing in a large consecutive series of patients with chronic coronary artery disease. Exercise testing is widely performed, but analyses of the prognostic value of test results have largely concentrated on patients referred for the diagnosis of coronary artery disease, patients after an acute coronary event or procedure, or patients with congestive heart failure. METHODS: All patients referred for evaluation at two university-affiliated Veterans Affairs Medical Centers who underwent exercise treadmill tests for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security Death Index after a mean 5.8-year follow-up. Patients without established heart disease and those with congestive heart failure were excluded, leaving the target population of those with a history myocardial infarction or coronary intervention. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. All-cause mortality was used as the endpoint for follow-up. Standard survival analysis was performed including Kaplan Meier curves and the Cox Hazard Model. RESULTS: Of the 1,473 patients with coronary artery disease who had exercise testing, 273 (19%) patients had a revascularization procedure (Revascularization group); 813 (55%) had a history of myocardial infarction, diagnostic Q waves (MI group), or both; and 387 (26%) had a history of myocardial infarction or Q wave and revascularization (Combined group). Mean age of the patients was 61.8 +/- 9 years. A total of 401 deaths occurred during a mean follow-up of 5.8 years with an annual mortality rate of 4.5%. Only two variables, age and maximal exercise capacity, were independently and statistically associated with time to death in all three groups and were the strongest predictors of all cause mortality. CONCLUSION: A simple score based on METs, age, and history of myocardial infarction or diagnostic Q waves can stratify prognosis in patients with chronic coronary artery disease. The score enabled the identification of a group at low risk (32% of the cohort) with an annual mortality rate of 2%, a group at intermediate risk (42% of the cohort) with an annual mortality rate of about 4%, and a group at high risk (26% of the cohort) with an average annual mortality rate of approximately 7%.

Age Factors↗
PubMed2004

Factors affecting ST depression during cardiopulmonary exercise testing in patients with mitral stenosis without significant coronary lesions.

Symptom-limited cardiopulmonary exercise testing was performed in 37 patients with mitral stenosis (MS) without significant coronary artery stenosis to evaluate factors affecting ST depression in exercise electrocardiograms. The degree of ST depression was not associated with gender or exercise tolerance. The incidence of significant ST depression was higher in the patients receiving than in those not receiving digitalis (P < 0.05). In addition, the patients with atrial fibrillation and a higher heart rate response were more likely to have a high prevalence of significant ST depression than those with sinus rhythm and a lower response (P < 0.05). We concluded that atrial fibrillation, a higher maximum heart rate, and oral digitalis administration were involved in ST depression during exercise testing in patients with mitral stenosis without coronary heart disease.

Anti-Arrhythmia Agents↗
PubMed1978

The "false negative" treadmill exercise test and left ventricular dysfunction.

One hundred and fifteen consecutive symptomatic patients undergoing graded exercise testing, selective coronary angiography and left ventriculography were retrospectively evaluated. The sensitivity, specificity, and false negative response rates of the exercise tests were 79%, 81%, and 21%, respectively. Although the magnitude of a positive ST-segment response was related to more extensive vascular disease, the frequency of false negative responses was nearly identical in patients with single, double, or triple vessel disease (22%, 21%, 19%). Analysis of the false negative group demonstrated significant ventriculographic and hemodynamic abnormalities when compared to the true positive responders. Five out of six patients with the most serious motion disorders in the study fell into the false negative group. There were no significant differences in the extent, distribution and severity of vascular involvement, or in the development of collateral circulation in the two groups. However, occluded vessels supplied abnormal ventricular segments more frequently in the false negative group (88% vs 38%); the absence of an "ischemic response" and the presence of segments of abnormal myocardium may be related. Left ventricular dysfunction appears to be an important reason for a false negative response to exercise.

Angiography↗
PubMed1987

Exercise testing after surgical repair of coarctation of the aorta.

After repair of coarctation, exercise testing was performed in 20 patients with an isolated coarctation (group I) and in 26 with additional congenital cardiac malformations (group II). Ages at time of operation were significantly different in both groups (7.9 +/- 6.0 years in group I; 4.6 +/- 3.8 years in group II; p less than or equal to 0.01). Simultaneous blood pressures were obtained from upper and lower limbs at rest and after exercise. There was no significant difference regarding the systolic blood pressures at rest (122.5 +/- 15.6 mmHg in group I versus 119 +/- 15.8 mmHg in group II). Seven (14%) of the patients were hypertensive; five of them had blood pressure gradients between arms and legs of 15-45 mmHg. But the gradients at rest were found to be significantly different in both groups (9.0 +/- 10.5 mmHg in group I; 18.5 +/- 16.1 mmHg in group II; p less than or equal to 0.05). Six patients, all in group II, had gradients greater than or equal to 30 mmHg at rest. After exercise there were no significant differences in systolic blood pressure and gradients in both groups. Values for blood pressures and gradients at rest and after exercise showed a positive correlation (blood pressure r = 0.76, p less than or equal to 0.001; gradient r = 0.44, p less than or equal to 0.01). Thus exercise testing can provide valuable information about blood pressure and gradient changes during physical activity, but angiography is required to reveal restenosis or residual stenosis.

Adolescent↗
PubMed1981

Early exercise test in the assessment of long-term prognosis after acute myocardial infarction.

Subjective maximal exercise test was performed in 317 patients in the third week after an acute myocardial infarction (AMI); 78% of the total AMI population could be tested. The long-term survival was assessed on the basis of data from the exercise test. The average follow-up time was 5.7 years. Mortality increased significantly among patients with major ventricular arrhythmias and among those with a small increase in the pressure rate product (dPRP) from rest to maximal exercise. Patients with arrhythmias and those with a low dPRP constituted a high-risk group of 165 patients (52%). The probability of 5-year survival was 0.551 in this group vs. 0.783 in the others (p less than 0.001). The death rate was higher in the high-risk group than in the other patients throughout the whole observation period.

Aged↗
PubMed1981

Treadmill exercise tests predischarge and six weeks post-myocardial infarction to detect abnormalities of known prognostic value.

We evaluated 89 patients with predischarge and 6-week post-myocardial infarction treadmill exercise tests to determine the importance of doing repeat tests to identify abnormalities of known prognostic value, and assess the individual variability of treadmill abnormality responses. Nineteen patients (21%) completed only a predischarge exercise test, nine of whom experienced an early cardiac event precluding repeat testing. All nine had a prognostically important treadmill abnormality during the predischarge test. Electrocardiographic ST segment depression was highly reproducible between the early and 6-week tests (k = 0.968). However, angina, inadequate blood pressure response, and ventricular arrhythmias showed limited reproducibility (k = 0.344, 0.50, and 0.166, respectively) and substantial individual variability. Thus, we concluded that: a predischarge treadmill exercise test is important for determining the immediate short-term prognosis of patients after myocardial infarction; and ST segment depression is highly reproducible, whereas other treadmill abnormality responses show substantial variability between the predischarge and 6-week tests.

Adult↗
PubMed1993

Prevalence and significance of transient--predominantly asymptomatic--myocardial ischemia on Holter monitoring in unstable angina pectoris, and correlation with exercise test and thallium-201 myocardial perfusion imaging.

The prevalence and clinical significance of transient myocardial ischemia was evaluated prospectively in 43 patients with a clinical diagnosis of unstable angina. Continuous 2-channel Holter electrocardiographic monitoring was begun < 24 hours after admission. In 3,558 hours of recordings (mean 83 +/- 20 hours/patient), there were 1,671 episodes of transient ischemia; > 90% were asymptomatic. All patients but 1 had at least 1 episode of transient ischemia. Twenty-two patients (group 1) had a total ischemic duration of > or = 30 minutes/day, whereas 21 patients (group 2) had a total ischemic duration of < 30 minutes/day. A predischarge symptom-limited exercise test was performed in 40 of these patients after medical stabilization and 39 patients underwent exercise thallium-201 imaging, an average of 3 days after the exercise test. During a follow-up period of 39.9 +/- 9 months (range 28 to 49), 4 patients developed myocardial infarction and 22 required revascularization because of medically refractory angina. There were significantly more patients with total cardiac events (myocardial infarction or a need for revascularization) in group 1 than in group 2 (p < 0.05). Among patients undergoing an exercise test and exercise thallium-201 imaging, a positive exercise electrocardiogram and the presence of a reversible thallium-201 perfusion defect were also significant predictors of subsequent cardiac events (p < 0.05 and p < 0.001, respectively). The results of the Holter recordings did not add significantly more prognostic information.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1994

Validation of the sensormedics (S2900Z) metabolic cart for pediatric exercise testing.

The accuracy of many microprocessor controlled exercise testing systems has not been established, particularly for testing children. A metabolic cart (Sensormedics S2900Z) was validated against a reference system (Douglas bag) in children. The systems were tested using 10 active, healthy children (age 11.6 +/- 2.3 yrs) during physiological steady state at two exercise intensities, submaximal walking and running. Eight children performed a high ventilatory flow (HVF) protocol, running for 11 min. All 10 performed a low ventilatory flow (LVF) protocol, walking for 11 min. In both, gas samples were measured after 6 to 7 and 10 to 11 min into the Douglas bag, and after 8 to 9 min by the test system. There was minimal evidence of bias for VO2 at either ventilation rate. Greater variability was noted for FeCO2 and VCO2. In conclusion, the Sensormedics S2900Z appears to be adequate for testing children.

Bias↗
PubMed1999

Assessment of cardiac risk before aortic reconstruction: noninvasive work-up using clinical examination, exercise testing, and dobutamine stress echocardiography versus routine coronary arteriography.

In this prospective study we evaluated the efficacy of a battery of noninvasive tests including clinical evaluation (CE), exercise testing (ET), and dobutamine stress echocardiography (DSE) for assessment of cardiac risk in 90 patients indicated for aortic reconstruction. As the gold-standard reference technique, coronary arteriography was performed in each patient after noninvasive evaluation. The sensitivity of CE was low (61%). ET proved to be more sensitive (71.4%) and highly specific (95.8%) but feasibility (77%) and diagnostic accuracy (42%) were low. DSE demonstrated acceptable sensitivity (78%) and specificity (75.5%) with high feasibility (94.5%) and diagnostic accuracy (100%). None of the four patients with false negative ET results and only one of seven with false-negative DSE required coronary bypass. On the basis of these findings we conclude that a combination of CE and ET with DES, if necessary, can reliably assess cardiac risk before aortic reconstruction. Noninvasive assessment is a reliable alternative to routine coronary arteriography.

Adrenergic beta-Agonists↗
PubMedDate not supplied

[Coronary spasm during exercise test (author's transl)].

We thought chest pain associated with ST segment elevation during exercise test in patients with not significant coronary lesions could be related to coronary spasm. Three patients with mild coronary obstructive lesions underwent coronary arteriography during exercise test. In two patients this hypotesis was supported by angiographic documentation of the coronary spasm.

Angina Pectoris↗
PubMed1995

Left ventricular performance during exercise testing in patients with silent and symptomatic myocardial ischemia.

We compared cardiohemodynamic response to dynamic exercise in 32 patients with exercise-induced silent or symptomatic myocardial ischemia. All patients had coronary artery disease without prior myocardial infarction and left ventricular hypertrophy. Patients underwent supine leg-exercise testing and received right heart catheterization. All patients exhibited ischemic ST-segment depression on electrocardiogram during exercise testing. They were classified retrospectively into two groups according to the absence (n = 10, group 1) or presence (n = 22, group 2) of chest pain induced by exercise. There was no significant difference between groups in the magnitude of peak ST-segment depression. Pulmonary artery wedge pressure at peak exercise was significantly lower (p < 0.01), and the cardiac index was significantly higher (p < 0.01), in group 1 versus group 2. Our results indicate that exercise-induced left ventricular dysfunction is less severe in patients with silent myocardial ischemia than in those with symptomatic ischemia.

Adult↗
PubMed1999

Meta-analysis of exercise testing to detect coronary artery disease in women.

To determine the accuracy of the exercise electrocardiogram (ECG), exercise thallium, and exercise echocardiogram (echo) for the diagnosis of coronary artery disease in women, English language studies published between 1966 and 1995 were identified through a MEDLINE search. Studies that contained data on at least 50 women who underwent both an exercise test and coronary angiography were examined. Studies were reviewed for sensitivity, specificity, and methodologic characteristics by 2 independent reviewers. Nineteen studies met the inclusion criteria for exercise electrocardiography, 5 studies for exercise thallium, and 3 studies for exercise echo. The exercise ECG had a weighted mean sensitivity, specificity, and a likelihood ratio (LR) of 0.61 (95% confidence intervals 0.54 to 0.68), 0.70 (0.64 to 0.75), (+) LR 2.25 (1.84 to 2.66), (-) LR 0.55 (0.47 to 0.62), respectively. The exercise thallium had a weighted mean sensitivity, specificity, and LRs of 0.78 (0.72 to 0.83), 0.64 (0.51 to 0.77), (+) LR 2.87 (1.0 to 4.96), (-) LR 0.36 (0.27 to 0.45). The exercise echo had a weighted mean sensitivity, specificity, and LRs of 0.86 (0.75 to 0.96), 0.79 (0.72 to 0.86), (+) LR 4.29 (2.93 to 5.65), (-) LR 0.18 (0.05 to 0.31). Thallium subset analysis revealed that studies using planar imaging were more specific than those using tomographic imaging. Thus, currently available exercise tests are only moderately sensitive and specific for the diagnosis of coronary artery disease in women.

Coronary Angiography↗
PubMed1985

Isometric exercise test for predicting gestational hypertension.

One hundred normotensive young primigravidas underwent an isometric handgrip exercise test between 28 and 32 weeks of gestation. The same individual performed the tests and the results were withheld from the physician taking care of the patient. The study demonstrates a sensitivity of 81% and a specificity of 96.5%. These results demonstrate a reliable predictive ability of this simple exercise test for gestational hypertension.

Exercise Test↗
PubMed1992

Usefulness of exercise-induced ST-segment depression in the inferior leads during exercise testing as a marker for coronary artery disease.

Multiple lead systems are shown to have a higher sensitivity than that of single leads for detecting coronary artery disease (CAD) during exercise testing, but the value of ST-segment depression isolated to the inferior leads is questionable. To ascertain the diagnostic accuracy of inferior limb lead II compared with that of precordial lead V5, a retrospective analysis of 173 men was performed (108 in a training population and 65 in a validation cohort). All patients had a standard exercise test and underwent diagnostic coronary angiography within 15 days of the exercise test (range 1 to 65). Sixty-three patients had greater than or equal to 1 coronary stenoses greater than or equal to 70%, or left main lesion greater than or equal to 50%, whereas 45 patients in the training population did not. Exclusion criteria were female sex, left ventricular hypertrophy, left bundle branch block or resting ST-segment depression on the baseline electrocardiogram, previous myocardial infarction or revascularization procedures, and any significant valvular or congenital heart disease. Lead V5 had a better combination of sensitivity (65%) and specificity (84%) (chi-square = 24.11; p less than 0.001) than that of lead II (sensitivity 71%, specificity 44%) (chi-square = 2.25; p = 0.13) at a single cut point, and this improved specificity was substantial (95% confidence interval for observed difference 22 to 58%). Receiver-operating characteristic curve analysis also revealed that lead V5 (area = 0.759) was markedly superior to lead II (area = 0.582) over multiple cut points (z = 3.032; 2p = 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2004

Exercise testing in children -- what works, what doesn't, and where to go?

Exercise testing is a valuable tool in the assessment of healthy children and those with a chronic disease. However, especially for testing small children modified equipment is required. The choice of the exercise protocol and the outcome variables depends mainly on the reason for conducting the test. Future developments in pediatric exercise testing will focus on testing protocols designed to accommodate the specific biology and behavior of children. A further focus will be on the development of norms based on appropriate scaling techniques.

Child↗
PubMedDate not supplied

Exercise testing early after myocardial infarction: historic perspective and current uses.

Exercise testing performed earlier than six weeks post-MI is accepted as "standard" medical practice. Although both heart rate-limited and symptom-limited exercise protocols are used with nearly equal frequency, the latter appears more valuable because the prognostic yield is greater without sacrificing patient safety. Treadmill or cycle ergometers are the preferred modes of testing because of higher exercise work loads imposed and increased sensitivity and specificity of results. The physiologic exercise responses to graded work loads among these acute MI survivors include a mean maximal heart rate range of 118 to 136 beats/min, a peak systolic blood pressure between 137 and 170 mmHg, a mean peak double product from 16,000 to 22,400, and a mean maximal work load between 4.8 and 7.0 METS. Exercise findings which are most clinically useful are greater than 1 mm ST segment depression from rest level, presence of angina pectoris during exercise, decrease in systolic blood pressure with increasing work, presence of complex or frequent VEBs, and exercise tolerance less than 4 METS. These exercise findings identify, in recent post-MI survivors, groups of patients that have significantly different estimated future cardiac morbidity and mortality rates. The most consistent indices of multi-vessel coronary heart disease are ST segment depression, angina pectoris, and poor exercise tolerance. The most important role of stress testing in this period post-MI is identification of individuals who urgently need evaluation for coronary bypass surgery. In addition to risk stratification, exercise testing provides valuable information regarding exercise prescription for cardiac rehabilitation, direct psychologic benefit for resuming an active lifestyle, and motivation for exercise participation. Although safety of the early post-MI stress test has not been systematically studied, reports from individual studies indicated low morbidity and mortality. Attesting to this is the frequency with which it is performed as a routine office procedure. Finally, there has been a growing use of this procedure not only among cardiologists but also among internists and family practice physicians.

Angina Pectoris↗
PubMed1995

Additional value of thallium-201 SPECT to a conventional exercise test for the identification of severe coronary lesions after an episode of unstable coronary artery disease.

The additional value of thallium-201 SPECT to a conventional exercise test for the identification of patients with severe coronary lesions was evaluated in 170 men, one month after an episode of unstable coronary artery disease. Severe coronary lesions at coronary angiography--defined as three vessel disease, left main stenosis or proximal left anterior descending artery stenosis as part of two vessel disease--were observed in 45.9%. In the SPECT image, the left ventricular myocardium was divided into nine segments and each segment was classified as either normal (= 0), reduced uptake (= 1) or uptake defect (= 2). The sum of gradings in all segments post-exercise was denoted "SPECT score". The patients were divided into nine different groups regarding ST-depression during exercise (no ST-depression, ST-depression in 1-2 leads or > or = 3 leads) and "SPECT score" (no SPECT score, 1-3 scores or > or = 4 scores). Severe coronary lesions were, in 68% identified by SPECT score > or = 4 and in 65% by ST-depression in > or = 1 lead at exercise test. The specificity for identification of severe coronary lesions was, for both tests, 65%. SPECT score > or = 4 and/or ST-depression in > or = 3 leads identified 82% of the patients with severe coronary lesions with a specificity of 63%. Furthermore, SPECT score > or = 3 identified more patients with isolated proximal left anterior descending artery stenosis than ST-depression alone at exercise test.

Adult↗
PubMed1993

Prediction of cardiovascular death by means of clinical and exercise test variables in patients selected for cardiac catheterization.

The objective of this report is the development of a population-specific prediction rule based on clinical and exercise test data that would estimate the risk of cardiovascular death in patients selected for cardiac catheterization. Prospective data and follow-up information were obtained from patients who underwent cardiac catheterization soon after clinical assessment and exercise testing. Males (n = 588) referred for evaluation of coronary heart disease from 1984 to 1990 were selected after exclusion of patients with significant valvular heart disease and patients with prior cardiac surgery. Half had a prior myocardial infarction and half complained of typical angina pectoris. All patients performed a treadmill test and were selected for clinical reasons to undergo coronary angiography within 3 months. Over a mean follow-up period of 2.5 years (+/- 1.4 years), there were 39 cardiovascular deaths and 45 nonfatal myocardial infarctions. The Cox proportional hazards model demonstrated the following characteristics to be statistically significant independent predictors of time until cardiovascular death: history of congestive heart failure (hazards ratio of 4), ST depression on the resting ECG (hazards ratio of 3), and a drop in systolic blood pressure below the resting value during exercise (hazards ratio of 5). Exercise-induced ST depression was not associated with either death or nonfatal myocardial infarction. A simple score based on one item of clinical information (history of congestive heart failure), a resting ECG finding (ST depression), and an exercise test response (exertional hypotension) stratified our patients for 4 years after testing from 75% with a low risk (annual cardiac mortality rate of 1%), 17% with a moderate risk (annual mortality rate of 7%), and 1% with a high risk (annual cardiac mortality rate of 12%, with a hazards ratio of 20 and 95% confidence interval from 6 to 70X). It was concluded that the variables available from the usual noninvasive workup of patients with known or suspected coronary artery disease enable prediction of risk of cardiovascular death. Three quarters of those usually undergoing cardiac catheterization can be identified by simple noninvasive variables as being at such low risk that invasive intervention is unlikely to improve prognosis.

Aged↗