The value of exercise tests in patients with abnormal resting electrocardiograms

Abstract

Resting int’racardiac pressures and cardiac output were normal. Response to exercise demonstrated an increase in st#roke volume and cardiac output by 370/,, and the left ventricular end-diastolic pressure increased only slightly, while the left vemricular dp/dt, increased moderately. It now appears possible to reverse episodes of acute rejection, if they are detected early, in the majority of cases. In our patients, no evidence of myocardial ischemia or late funct.ional impairment of the transplanted heart has been demonstrat.ed. The Value of Exercise Tests in Patients with Abnormal Resting Electrocardiograms PETER F. COHN, MD/HARVEY G. KEMP, MD and RICHARD GORLIN, MD, FACC Boston, Massachusetts To investigate the usefulness of exercise tests in patients with abnormal resting electrocardiograms, 60 subjects who had undergone selective coronary cinearteriography were exercised with the standard double Master’s two step test and their electrocardiographic responses compared with their coronary anatomy. These subjects were suspected clinically of having coronary artery disease uncomplicated by other forms of heart disease; they were not receiving digitalis or beta adrenergic blockers, and had resting electrocardiograms demonstrating stable minor or major ST-T abnormalities and/or evidence of old transmural myocardial infarction. Subjects presenting with conduction disturbances and arrhythmias in the resting electrocardiogram were not included in this study. The exercise tests were interpreted as positive when the S-T segment showed an initial or further depression of at least 1 mm. No negative tests were included if post-exercise heart rate was less than 110 beats/min. Result,s are as follows : 44 Patients 16 Patients With Coronary Without Coronary Artery Disease Artery Disease Master’s test positive 35 (30%) 4 (25%) Master’s test negative 9 (20%) I2 (75%) ConverseIy, of the subjects with positive tests, 90% had anatomic coronary artery disease ; of the group with negative tests, 500/, had coronary artery disease. Subjects with three vessel disease had 90% positivity; those with two vessel disease, 75% positivity; and those with one vessel disease, 0%. Of the subjects with S-T segment depression of 2 mm or more, 96 percent had anatomic coronary artery disease. The anterior zonal leads were clearly more sensitive than the inferior ones in showing electrocardiographic abnormalit,ies. No fatalities or serious complications were observed. Abnormal Heart Sounds and Apexcardiographic A Waves in Patients with Coronary Artery Disease PETER F. COHN, MDjPANTEL S. VOKONAS, MD/RICHARD WILLIAMS, MD MICHAEL V. HERMAN, MD and RICHARD GORLIN. MD, FACC Boston, Massachusetts Despite numerous reports of an increased incidence of abnormal heart sounds and apexcardiographic A waves in patients wit,h coronary artery disease, correlations of these clinical findings with both hemodynamic and anatomic data have been lacking. Forty subjects underwent cardiac catheterization, selective coronary cinearteriography and left ventriculography, and were found to have coronary artery disease uncomplicated by other forms of heart disease. They were also studied with the phonocardiogram (PCG) and/or apexcardiagram (ACG) to document the presence or absence of a third or fourth sound or abnormal A wave. Results are shown in the table at right. The vast majority of patients with abnormal PCG-ACG studies had either three vessel disease, abnormal ventriculograms or elevated left ventricular end-diastolic pressure. Conversely, no subject presenting with normal PCGACG studies had combined three vessel disease, abnormal left ventricular motion study, and elevated LVEDP. Of the three PCG-ACG parameters, the abnormal A wave was the most sensitive single index of an elevat,ed left ventricular end-diastolic pressure and of an abnormal ventriculogram, but was one third less reliable than all three parameters taken together. No accurate prediction of three vessel disease could be made from any single parameter. 22 Subjects 18 Subjects With Without PCGACG PCGACG Abnormalities Abnormalities Three vessel disease Abnormal ventriculogram Left ventricular end-diastolic pressure above 12 mm Hg All of the above Cardiac index below 3.0 liters/min 36% 34%