The Prognosis of an Abnormal Electrocardiographic Stress Test
TL;DR: These relatively insensitive but highly specific and reproducible ECG criteria accurately identify men with clinically silent but far-advanced coronary atherosclerosis, attested by the poor prognosis of an abnormal response.
Abstract: Treadmill walking for 10 min at 3 mph against a 5% grade has been used as an electrocardiographic (ECG) stress test as part of a prospective epidemiologic study of 2,437 men. From 1953 through 1966, 22,223 tests have been done without untoward event. The criteria of an abnormal postexercise ECG were ischemic flattening or coving of the S-T segment, T-wave changes consistent with focal left ventricular epicardial ischemia, and paroxysmal left bundle-branch block. Of the 2,003 men exercised two or more times, 264 developed some manifestation of ischemic heart disease (IHD) and in 75 (30%) this was an abnormal ECG response to exercise. They had higher blood pressures and were more often heavy smokers than normal responders. Body weight and serum cholesterol were similar in the two groups. Over the next 5 years there was an 85% probability that these abnormal responders would develop angina pectoris or experience a myocardial infarction. These relatively insensitive but highly specific and reproducible ECG cr...
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TL;DR: No major innovations are required to identify candidates for coronary disease and to estimate their risk, but there is much to learn about motivating changes in behavior to control risk factors.
Abstract: Epidemiologic investigations have provided a portrait of the potential candidate for coronary heart disease. This is important because studies of the evolution of coronary disease in the general population reveal that it is a common disease that frequently attacks without warning, can be silent in its most dangerous form and can present with sudden death as the first symptom. Progress in identifyin- persons in jeopardy and the factors needing correction makes it theoretically possible to interrupt the chain of factors that eventuate in this disease. Coronary disease does not really begin with crushing chest pain, pulmonary edema, shock, angina or ventricular fibrillation, but rather with more subtle signs like a poor coronary risk profile. The risk factors can be treated quantitatively as ingredients of a cardiovascular risk profile and their joint effect estimated. An efficient practicable set of variables for this purpose is a casual blood test for cholesterol and sugar, a blood pressure determination, an electrocardiogram and a cigarette smoking history. With this set of variables the risk of coronary heart diseases can be estimated over a 30-fold range and 10 percent of the asymptomatic population identified in whom 25 percent of the coronary disease, 40 percent of the occlusive peripheral arterial disease and 50 percent of the strokes and congestive heart failure will evolve. The periodic use of the electrocardiogram at rest and after exercise in persons with a poor risk profile can demonstrate persons with asymptomatic ischemic cardiomyopathy due to advanced coronary artery disease. Most cases of angina pectoris or myocardial infarction represent medical failures; the conditions should have been detected years earlier for preventive management. About 30 percent of patients with infraction will shortly experience new angina, have an annual death rate of 4 percent and a fourfold increased risk of sudden death. Reinfarction will occur at an annual rate of 6 percent, and half the recurrences will be fatal. Congestive heart failure must be expected at 10 times and strokes at 5 times the rate found in the general population. Although no major innovations are required to identify candidates for coronary disease and to estimate their risk, we have much to learn about motivating changes in behavior to control risk factors. Approaches to prevention of coronary heart disease include public health measures to alter the ecology in favor of cardiovascular health, preventive medicine directed at highly vulnerable candidates and hygienic measures initiated by an informed public in its own behalf.
451 citations
TL;DR: It is concluded that attention to configuration, time of onset, and duration of ischemic ST depression aids both in assessing the validity of exercise responses in diagnosing coronary artery disease and in delineating patients with advanced coronary obstruction.
Abstract: The configuration, time of onset, and duration of depressed ST segments during and after treadmill exercise testing were evaluated in 269 patients with angiographically proven coronary artery disease and 141 normal subjects. The test specificity was 93% and sensitivity 64%, the latter being influenced by the type of ST response; false-positive responses were rare with depressed, downsloping STs (1 of 123, 1%), occurred more frequently with horizontal ST depression (9 of 60, 15%), and occurred commonly with slowly upsloping STs (15 of 47, 32%). Depressed downsloping STs, ischemic changes appearing in the first 3 minutes of exercise, and those persisting past 8 minutes in recovery were associated with 91%, 86%, and 90% prevalences of two- to three-vessel or main left coronary disease, respectively. It is concluded that attention to configuration, time of onset, and duration of ischemic ST depression aids both in assessing the validity of exercise responses in diagnosing coronary artery disease and in delineating patients with advanced coronary obstruction.
441 citations
TL;DR: The electrocardiographic response to exercise was compared with the results of coronary angiography in 89 patients with Type II hyperlipoproteinemia who had previous myocardial infarction or typical angina or both and the diagnostic usefulness of exercise Electrocardiography is limited.
Abstract: The electrocardiographic response to exercise was compared with the results of coronary angiography in 89 patients with Type II hyperlipoproteinemia who had previous myocardial infarction ...
307 citations
TL;DR: 'Controversy regarding the usefulness and role of exercise stress testing in a variety of clinical settings persists.
Abstract: ALTHOUGH EXERCISE STRESS TESTING FOR CARDIAC PATIENTS has been in use for nearly 50 years, widespread acceptance of the technique as an important diagnostic tool in cardiology has been accomplished only recently. This has occurred with the recognition that patients with cardiac disease, even in advanced degree, can perform exercise safely under controlled conditions, and that objective information regarding cardiac functional capacity and the presence or absence of myocardial ischemia can be determined. In addition, epidemiologic follow-up studies and correlative studies comparing exercise electrocardiographic findings with coronary arteriograms have provided documentation of the sensitivity and specificity of the test in patients with coronary artery disease. In spite of considerable scientific input into this field in the last ten years, controversy regarding the usefulness and role of exercise stress testing in a variety of clinical settings persists.' This review will consider those aspects of exercise testing most relevant to the practicing physician. Several comprehensive monographs dealing with various aspects of this field have been published recently.2-8 The reader is referred to these sources for technical details or further discussion of some of the material covered here.
259 citations
TL;DR: It is concluded that recent digitalis ingestion should not be considered a contraindication for exercise stress testing and the angiographic severity of coronary artery disease correlates strongly with the frequency of positive tests.
Abstract: Graded exercise stress tests performed on 650 consecutive patients with proven or suspected coronary disease undergoing evaluation by cardiac catheterization were correlated with clinical, hemodynamic, and angiographic findings. Among 451 patients with significant coronary stenosis, 332 (74%) had interpretable stress tests and 65% of these were positive (sensitivity). The rate of "false positives" was 8%. The clinical syndrome of typical angina identified significant coronary disease in 89% of the patients, and 58% of that group had a positive exercise test defined by objective electrocardiographic criteria. Patients were not eliminated from this study because of recent digitalis ingestion. Although a higher frequency of uninterpretable exercise tests was found in this group (40%), the test results reflected more severe coronary disease. None of the patients with "false positive" tests were taking digitalis. It is concluded that recent digitalis ingestion should not be considered a contraindication for ex...
247 citations
References
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30 Jun 2012
254 citations
TL;DR: Correlation with abnormalities in the coronary arteries of deceased persons who had had postexercise ischemic electrocardiographic changes indicate that, in general, ischeMIC S-T segment changes occur only when advanced and diffuse occlusive coronary disease is present.
Abstract: The results of long-term clinical follow-up evaluation and postmortem evaluation in a large series of patients, and in a smaller series of normal healthy persons who have had postexercise electrocardiograms, are briefly reviewed and summarized. The postexercise electrocardiogram with an ischemic S-T configuration has been found to be the only reliable electrocardiographic manifestation of coronary insufficiency. It has both diagnostic and prognostic value. The presence of electrocardiographic changes in either the resting or postexercise electrocardiogram should not be considered synonymous with organic coronary arterial disease, especially obstructive coronary atherosclerosis. Such changes have been observed in patients who have normal coronary arteries but in whom metabolic and hemodynamic abnormalities are associated with either severe anemia, electrolyte disorders, drug therapy, pulmonary and systemic hypertensive vascular disease, or obstructive valvular and vascular lesions with a low and fixed cardiac output. However, since obstructive coronary atherosclerosis is by far the most common cause of coronary insufficiency, its presence should be strongly considered as the cause of coronary insufficiency until proved otherwise. Correlation with abnormalities in the coronary arteries of deceased persons who had had postexercise ischemic electrocardiographic changes indicate that, in general, ischemic S-T segment changes occur only when advanced and diffuse occlusive coronary disease is present . This finding is in agreement with physiologic and radiologic correlations as made by others in living patients. Usually people who show such ischemic S-T changes have a poor prognosis and are sensitive to complicating factors, such as thrombosis or hemorrhage into sclerotic placques, which further compromise the coronary circulation. Sudden death or arrhythmic deaths in the early stages of an infarction are common. The interval between the initial finding of ischemic changes and death, however, was quite variable and a positive test result does not indicate a grave prognosis. After 10 years, 40 per cent of the subjects studied were still living. This finding indicates the type of coronary death which might be expected. The degree and severity of S-T depression are not important in diagnosis, but they do reflect to a significant degree the severity of the insufficiency and the prognosis of heart disease. Other postexercise electrocardiographic changes, such as isolated changes in T wave polarity and junctional RS-T depression with adequate precordial tracings, presented poor correlation with subsequent clinical coronary disease or coronary disease at autopsy. These changes are not considered useful in the diagnosis and prognosis of obstructive coronary disease. When coronary atherosclerosis was the only condition found at necropsy, neither lesser degrees of generalized occlusive disease nor complete occlusive lesions in an isolated vessel, either with or without myocardial infarction or fibrosis, was regularly associated with ischemic changes. Therefore, the absence of abnormal changes in a postexercise electrocardiogram does not exclude organic coronary disease. Such a finding may occur with a different type and a lesser degree of coronary disease which has been observed to provide a more favorable prognosis for longevity but not for the eventual development of significant clinical coronary disease.
167 citations
TL;DR: The results of a recently published comparative study between the double Master two-step test and the exercise on a treadmill, which was sufficiently long to achieve the steady state, show that the procedure was of short duration and did not permit the achievement of a steady state.
Abstract: THE electrocardiographic exercise test is a well established procedure in the diagnosis of coronary insufficiency. The method most widely used in America is the two-step test of Master.1 2 3 4 5 6 Master has standardized the exercise for the individual subject on the basis of sex, age and weight. One of the objections raised against the procedure was that the exercise was of short duration and did not permit the achievement of a steady state. However, the results of a recently published comparative study between the double Master two-step test and the exercise on a treadmill, which was sufficiently long to achieve the steady . . .
133 citations
TL;DR: Excerpt Diagnosis of heart disease is often complicated by the fact that objective evidence of organic disease cannot be obtained, and in many cases of coronary disease with angina pectoris, physical e...
Abstract: Excerpt Diagnosis of heart disease is often complicated by the fact that objective evidence of organic disease cannot be obtained. In many cases of coronary disease with angina pectoris, physical e...
111 citations
"The Prognosis of an Abnormal Electr..." refers background or methods in this paper
...It was, therefore, decided early in 1954 to require as evidence of induced acute coronary insufficiency one or more of the following: (1) flattening or downward inclination for 0....
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...The following categories have been excluded from analysis: (1) 97 men who were not exercised, mostly because of orthopedic disabilities; (2) 45 men with antecedent IHD (myocardial infarction, 23; angina pectoris, 22); and (3) 361 men with normal postexercise electrocardiograms who continued under surveillance but were...
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TL;DR: The postexercise electrocardiogram gave more reliable evidence of latent or silent coronary disease than did the medical history and no adverse effect resulted from the test.
Abstract: An evaluation of the electrocardiographic exercise test in the diagnosis and prognosis of latent arteriosclerotic heart disease was made using improved methods of performance and interpretation. The evaluation was based on 2,224 male applicants for life insurance given the test. A long-term follow-up of these cases disclosed: Ischemic ST segment depression after exercise is pathognomonic of coronary insufficiency for all practical purposes. The amount of ischemic ST depression indicates the degree of the insufficiency and the prognosis. Ischemic response involving multiple leads has a worse prognosis than that involving one lead. In the vast majority of cases, a nonischemic response—ST junction depression, negative response, or T-wave change—excludes latent coronary insufficiency of significant degree. Preexercise T-wave abnormality due to coronary disease is distinguished by an ischemic response. In this study, the postexercise electrocardiogram gave more reliable evidence of latent or silent coronary disease than did the medical history. No adverse effect resulted from the test.
107 citations