ECG Stress Test Research Articles

Receipt of American Heart Association-Recommended Preconception Health Care Among Privately Insured Women With Congenital Heart Defects, 2007-2013.

BackgroundOur objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation.Methods and ResultsUsing 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for ≥11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid‐stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac‐related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association–recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception (P<0.05 for all). In 9.0% of pregnancies, ≥1 prescriptions for US Food and Drug Administration category D or X cardiac‐related medications were filled in the year before conception.ConclusionsA low percentage of women with CHD received American Heart Association–recommended preconception health care in the year before conception.

Cardiac Exercise Stress Testing: A Safe Tool to Design an Individualized Physical Exercise Training Plan for Older Adults

IntroductionIn the United States about 10% of premature mortality is associated with insufficient physical activity. New 2018 Physical Activity Guidelines (PAG) were announced recently but it is unclear how these guidelines will be implemented in the general population. Recommending an individualized training plan in elderly patients is challenging. Cardiac stress tests are primarily used to evaluate potential underlying cardiovascular disease but can also be used to assess cardiorespiratory fitness (CRT). We hypothesized that treadmill cardiac exercise stress testing in older adults will be safe and useful to initiate an exercise training plan.MethodsWe retrospectively investigated ECG treadmill test results conducted at the Center for Ambulatory Rehabilitation Graz (ZARG), Austria. The Austrian cardiac rehabilitation program consists of three phases; phase I begins during the hospital stay, and phase II (6 weeks, 4 times/week) as well as phase III (up to 13 months, 2 times/week) are conducted in ambulatory cardiac rehabilitation centers and a home‐based training recommended every day of the week. Patients participating in phase II and phase III rehabilitation underwent initial screening and subjects with aortic stenosis, low systolic output (EF% &lt; 45), and dyspnea at rest (NYHA Class IV) were excluded. Male and female patients age 65y–75y (n= 3006) and 75y–90y (n= 2493) were included. The ECG stress test training protocol was conducted, heart rate (HR) monitored continuously, and the HR threshold (HRT) calculated from the whole HR curve over time. We further documented body weight, height, body mass index, resting HR, maximal HR, resting/baseline as well as maximal systolic and diastolic blood pressure, calculated VO2Max, 50Watt HR, 100‐Watt HR, max Watt, and Watt/kg.ResultsBaseline bicycle ergometer exercise was performed until perceived exertion. Protocols used were 10W/10W increments per min (~90% of patients) or 20W/20W/1min (~10% of patients). Treadmill exercise tolerance testing was well tolerated by male and female patients of all ages (total n=5499). No differences between “maximal training capacity (Max Watt)” were found in male and female patients. Further, no difference in exercise capacity was found between the 65–75‐year (n= 3006) and 75–90‐year (n= 2493) age groups due to a wide range of individual exercise capacity amongst all participants. A personal training plan was compiled based on 70% of maximal performance. Patients were encouraged to achieve optimal training heart rates for 30 minutes daily and advised to perform muscle strengthening twice per week.ConclusionTreadmill exercise stress testing in older adults is safe and of great value to implement a home‐based personalized endurance exercise program. Since a direct link between CRT and early mortality has been shown, our data suggest that cardiac exercise stress testing should be routinely performed, not only to document and monitor cardiovascular disease, but also to prescribe a detailed, safe, individual, and home‐based exercise plan to achieve the new 2018 PAG.Support or Funding InformationNoneThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Myocardial ischemia in patients with hypertrophic cardiomyopathy

Authors present is comprehensive clinical and instrumental evaluation of patients with HCM with myocardial ischemia. 104 patients (38.4% of men) with HCM were examined, mean age 58.2±14.7. The examination included risk factors assessment for CAD, ECG, Echo, stress ECG test, 24-hour ECG monitoring. In the presence of myocardial ischemia, CAG (n=66) and MSCT of the coronary arteries (CA) (n=4) were performed. All patients were split up on 2 groups: I - 70 HCM patients with myocardial ischemia, 67.3%, and II (the control group) - 34 HCM patients without myocardial ischemia, 32.7%. The group I was divided on 2 subgroups: 1 - 29 patients with coronary atherosclerosis (41.4%), 2 - 41 patient without coronary atherosclerosis (58.6%). Age (p=0.046), family history (p=0.037), higher systolic and diastolic arterial pressure, long-term arterial hypertension (p<0.05) were determined as significant risk factors for CAD. Smaller diameter of LAD (p=0.008), higher LV mass index, greater LV diastolic function disorder (p<0.05) were detected in group 2 compared to group II. The decrease in myocardial perfusion (MBG scale) was associated with high LV mass index and cardiac arrhythmias. The frequency of concomitant coronary atherosclerosis among HCM patients with myocardial ischemia was determined as 41.4%. Analysis of traditional risk factors for CAD in patients with HCM revealed the strong relation to age, aggravated by a family history of CAD, blood pressure level and duration of hypertension. Smaller diameter of LAD, higher LV mass index, greater LV diastolic function disorder were observed in HCM patients with myocardial ischemia without CAD.

Audit of a Cardiac Screening Policy for Elite Australian Cricketers

Background: Cricket Australia implemented a policy recommending players undertake cardiac screening. This is consistent with other sports, and aims to prevent sudden cardiac arrest/death (SCA/D). Screening involved a history and physical, and resting 12-lead electrocardiogram (ECG), with follow-up tests conducted if indicated. Aims: To assess policy compliance, including the number/completeness of follow-up tests, and to document/analyse ECG findings. Methods: Audit (February 1, 2019) examined screening reports for the previous 5 years for players in all Australian Cricket state squads, male and female, including junior players aged ≥16. Data were extracted from a database with complete records for all players. The audit analysed which players had been screened, signed waivers opting out, required follow-up tests, and whether follow-up was complete. ECGs were reviewed according to the International criteria. Where a player required follow-up, their file was checked. Results: 648/670 (97%) players had been screened at the time of audit, with 1% opting out. In terms of follow-up: 5% required echocardiogram, 2% required ECG stress test, 1% required other interventions, no players required cardiac MRI. No players were excluded from sport, no SCA/D occurred during the period. Compliance was high amongst all squads (>95%). ECG analysis suggested cricket is a sport of moderate cardiac demands, with benign athlete heart changes common but abnormal ECGs uncommon. Conclusions: Initial audit of a cardiac screening program in elite Australian cricketers found excellent compliance with 97% of players screened. A small proportion required follow-up testing and no player was excluded from sport due to a cardiac problem.

Usefulness, timing and modality of ECG stress testing after myocardial revascularization

Myocardial revascularization in patients with stable ischemic heart disease aims at eliminating myocardial ischemia, in order to (i) relieve anginal symptoms; (ii) improve functional capacity; and, possibly, (iii) improve prognosis. Given that ischemic recurrences are relatively common in patients undergoing myocardial revascularization, an appropriate follow-up is needed as part of a secondary prevention program. Stress testing can be here useful to: (i) detect residual or recurrent ischemia/angina; (ii) define functional capacity in order to establish physical aerobic training individualized programs; (iii) stratify prognosis. These goals can in large part be achieved by the ECG stress test, by far the cheapest, the easiest to perform and the most accessible test among those proposed so far, particularly compared with other imaging stress test modalities. There is, however, considerable discrepancy among scientific society recommendations on the use, timing and methods of ECG stress testing and of stress testing in general after revascularization. In addition to the diversity of recommendations, the use of stress tests in general is extremely variable in current clinical practice.This review aims therefore at revisiting principles, advantages and limitations of the ECG stress test and of stress tests in general in revascularized patients, highlighting recent developments of the ECG stress technique. This should also aim at issuing new recommendations to avoid the inappropriate prescription of expensive and more cumbersome techniques, to be reserved only to a second-tier diagnostic level and in a minority of cases.

Coronary atherosclerosis in apparently healthy master athletes discovered during pre-PARTECIPATION screening. Role of coronary CT angiography (CCTA)

BackgroundPre-participation screening (PPS) of athletes aged over 35 years (master athletes, MA) is a major concern in Sports Cardiology. In this population, sports-related sudden cardiac death is rare but usually due to coronary atherosclerosis (CA). Coronary CT Angiography (CCTA) has changed the approach to diagnosis/management of CA, but its role in this context still needs to be assessed. Methods and resultsWe retrospectively examined 167 MA who underwent CCTA in our hospital since 2006, analyzing symptoms, stress-test ECG, cardiovascular risk profiles (SCORE) and CCTA findings.Among the whole enrolled population, 153 (91.6%) MA underwent CCTA for equivocal/positive stress-test ECG with/without symptoms, 13 (7.8%) just for clinical symptoms, 1 (0.6%) for the family history. The CCTA showed the presence of CA in 69 MA (41.3%), congenital coronary anomalies (anomalous origin or deep myocardial bridge) in 8 (4.8%), both in 7 (4.2%). A negative CCTA was observed in 83 MA (49.7%).The risk-SCORE (age, hypertension, hypercholesterolemia, smoking) was a good indicator for the presence of moderate/severe CA on CCTA. However, mild/moderate CA was present in 17.8% of MA clinically stratified at a low risk-SCORE. ConclusionWhile coronary angiography is more indicated in athletes with positive stress-test ECG and high clinical risk, the CCTA may be useful in the evaluation of MA with an abnormal stress test ECG and/or clinical symptoms engaged in competitive sports with a high cardiovascular involvement. Age, gender, presence of symptoms and clinical risk-SCORE assessment may help sports physicians and cardiologists to decide whether to request a CCTA or not.

Ectopic overexpression of Kir6.1 in the mouse heart impacts on the life expectancy

We recently reported the reduced ATP-sensitive potassium (KATP) channel activities in the transgenic mouse heart overexpressing the vascular type KATP channel pore-forming subunit (Kir6.1). Although dysfunction of cardiac KATP channel has been nominated as a cause of cardiomyopathy in human, these transgenic mice looked normal as wild-type (WT) during the experiment period (~20 weeks). Extended observation period revealed unexpected deaths beginning from 30 weeks and about 50% of the transgenic mice died by 55 weeks. Surface ECG recordings from the transgenic mice at rest demonstrated the normal sinus rhythm and the regular ECG complex as well as the control WT mice except for prolonged QT interval. However, the stress ECG test with noradrenaline revealed abnormal intraventricular conduction delay and arrhythmogeneity in the transgenic mouse. Fibrotic changes in the heart tissue were remarkable in aged transgenic mice, and the cardiac fibrosis developed progressively at least from the age of 30 weeks. Gene expression analyses revealed the differentiation of cardiac fibroblasts to myofibroblasts with elevated cytokine expressions was initiated way in advance before the fibrotic changes and the upregulation of BNP in the ventricle. In sum, Kir6.1TG mice provide an electro-pathological disease concept originated from KATP channel dysfunction.

ECG stress-tests and single-photon emission computed tomography with 99MTC-MIBI in rest and in combination with physical activity stress-test in diagnostics of coronary disease in rheumatoid arthritis

ECG stress-tests and single-photon emission computed tomography with 99MTC-MIBI in rest and in combination with physical activity stress-test in diagnostics of coronary disease in rheumatoid arthritis

Elevated high‐sensitive troponin T in negative stress test individuals

The exercise ECG stress test (EST) is still the first step of work-up in intermediate risk patients in many clinical scenarios. High-sensitive cardiac troponin T (hs-cTnT) elevation is related to future cardiovascular events in the general population and in patients with ischaemic heart disease. The relation between these 2 tests is not well described. A total of 2780 participants from the Tel-Aviv Medical Center Inflammation Survey cohort (mean age 49 years, 79% men) were analysed. Multiple physiologic and metabolic parameters including hs-cTnT were collected. All participants completed an EST manually reviewed by a cardiologist. A positive EST was documented in 224 subjects (8%). The majority (91%) of participants with hs-cTnT levels of 5-14 ng/L had a negative EST as well as 89.3% of subjects with levels >14 ng/L. The proportion of subjects with a positive EST and detectable hs-cTnT levels (>5 ng/L) was not significantly greater compared to those with a negative EST (53.1% vs 46.2%, respectively, P = .09). Among subjects referred for EST as part of an annual health survey, we found no significant association between EST results to hs-cTnT detection.

Coronary computed tomography angiography, ECG stress test and nuclear imaging as sources of false-positive results in the detection of coronary artery disease.

Coronary computed tomography angiography, ECG stress test and nuclear imaging as sources of false-positive results in the detection of coronary artery disease.

Aortic stiffness improves the prediction of both diagnosis and severity of coronary artery disease

Elective coronography presents low diagnostic yield for obstructive coronary artery disease (CAD). Better strategies for CAD screening are required to reduce unnecessary invasive procedures. We aim to determine whether non-invasive aortic stiffness assessment improves diagnostic accuracy of CAD screening by reducing the number of false-positive results of cardiac stress test. A cross-sectional study was conducted from January 2013 to September 2014 in our medical center. Electrocardiogram (ECG) stress test coupled with nuclear imaging was performed in 367 consecutive patients routinely followed-up, for myocardial ischemia screening. Aortic pulse wave velocity (PWV) was assessed by applanation tonometry in overall population. Forty-two patients underwent elective coronography because of ischemia. Theoretical PWV was calculated according to age, blood pressure and gender. Results were expressed as an index ([measured PWV-theoretical PWV]/theoretical PWV) for each patient. Ten patients presented with obstructive CAD, 16 patients had non-obstructive CAD and 16 patients had normal coronary angiography. PWV index and severity of CAD were positively correlated ( P = 0.001). All patient with obstructive CAD had positive PWV index. When considering retrospectively PWV index, false positive results of cardiac stress test were significantly reduced ( P < 0.001). Twenty-three procedures may have been avoided in the present study cohort ( Fig. 1 ). The salient finding of this study was that, in patients with known or suspected CAD, routinely followed-up, aortic PWV index may be considered as clinically useful to reduce the rate of unnecessary invasive angiographies. The clinical relevance of this individualized decision approach should be confirmed in a large-scale study. Prospective studies shall have the potential to further evaluate PWV index as a marker of CAD.

Aortic stiffness improves the prediction of both diagnosis and severity of coronary artery disease.

Elective coronography has low diagnostic yield for obstructive coronary artery disease (CAD). We aim to determine whether non-invasive aortic stiffness assessment improves diagnostic accuracy of CAD screening by reducing the number of false-positive results from the cardiac stress test. A cross-sectional study was conducted from January 2013 to September 2014 in our medical center. Electrocardiogram (ECG) stress test coupled with nuclear imaging was performed in 367 consecutive patients routinely followed for myocardial ischemia screening. Aortic pulse wave velocity (PWV) was assessed by applanation tonometry in the overall population. Forty-two patients underwent elective coronography because of ischemia. Theoretical PWV was calculated according to age, blood pressure and gender. The results were expressed as an index ((measured PWV-theoretical PWV)/theoretical PWV) for each patient. Ten patients presented with obstructive CAD, 16 patients had non-obstructive CAD and 16 patients had normal coronary angiography. PWV index and severity of CAD were positively correlated (P=0.001). All patients with obstructive CAD had a positive PWV index. When considering the PWV index retrospectively, the false positive results of cardiac stress test were significantly reduced (P<0.001). Twenty-three procedures may have been avoided in the present study cohort. The salient finding of this study was that in patients with known or suspected CAD, routinely followed aortic PWV index may be considered clinically useful for reducing the rate of unnecessary invasive angiographies. The clinical relevance of this individualized decision approach should be confirmed in a large-scale study. Prospective studies have the potential to evaluate the PWV index as a marker of CAD.

Anomalous origin of coronary arteries from the "wrong" sinus in athletes: Diagnosis and management strategies.

Although anomalous origin of left (AOLCA) and right coronary artery (AORCA) from the wrong sinus may cause sudden death (SD) in athletes, early diagnosis and management of these anomalies are still challenging. We analysed clinical/instrumental profiles of athletes identified with AOLCA/AORCA focusing our attention on diagnosis, management and follow-up. We report 23 athletes (17 males, mean age 27±17yrs.), 6 with AOLCA and 17 with AORCA. Diagnosis was made by trans-thoracic echocardiography (TTE) in 21/23(91%). Symptoms were present only in 10(41%). Only 3 had an abnormal rest-ECG and 9(39%) an abnormal stress test ECG (3 ST-depression, 4 ventricular arrhythmias, 1 supraventricular arrhythmias, 1 rate-dependent left-bundle-branch-block). Anatomy of the anomalous coronary artery showed no significant correlation with clinical presentation, except for a tendency to higher occurrence of proximal hypoplasia in symptomatic athletes (83% vs 40%, p=0.09). All athletes were disqualified from competitive-sports and advised to avoid strenuous effort. Surgery was recommended to all athletes with AOLCA and 6 with AORCA, but only 6 underwent surgery. No major cardiac events or ischemic symptoms/signs occurred during a mean follow-up of 65±70months. Early diagnosis of AOLCA/AORCA in athletes is feasible by TTE. Typical symptoms/signs of myocardial ischemia are present only in one third of cases thus underlying the need of a high index of clinical suspicion to achieve the diagnosis. After exercise restriction, none had major cardiac events or ischemia symptoms/signs recurrence. There was no correlation between anatomical characteristics and clinical presentation with the possible exception of coronary hypoplasia.

PP.24.07] AGENESIS OF RIGHT CORONARY ARTERY DIAGNOSED IN A 48 YEAR-OLD WOMAN

Objective: The presence of a single coronary artery pathology is very rare, the reported incidence of this anomaly among patients who received angiography being between 0.6 to 1.3%. The association of this disease with other conditions which increases the degree of myocardial ischemia gives unsatisfactory long-term prognosis. Design and method: Case presentation. A 48-year-old woman, overweight, presented with daytime sleepiness and palpitations. Physical examination did not show significant findings.Results: Laboratory investigations, ECG, chest radiography and cardiac ultrasound were normal. Epworth questionnaire score was 12 points. Holter ECG: 134 ventricular extrasystoles. Sleep apnea syndrome was suspected and cardiorespiratory polygraphy was performed, which showed severe obstructive sleep apnea. Continuous positive airway pressure (CPAP) and beta blockers therapy was started, but the patient continued to have palpitations. An electrocardiogram (ECG) stress test was performed, with Bruce protocol. Exercise ECG was positive for ischemia, the patient complaining of chest pain. Coronarography was done, which revealed the agenesis of the right coronary artery, with normal epicardial coronary arteries. CT angiography confirmed the absence of the right coronary artery, its territory being vascularized by the terminal branch of circumflex artery, extended in the right atrioventricular groove (Panel A, B, C, D). Conclusions: Conclusions. Long term prognosis of this patient is not favorable, due to agenesis of the right coronary artery associated with severe sleep apnea syndrome. Sleep apnea syndrome is a known aggravating factor for myocardial ischemia and a risk factor for sudden cardiac death during sleep.

Myocardial bridging as one of the causes of atypical chest pain in young women

IntroductionMyocardial bridging is congenital anomaly which usually has benign prognosis but there are also reports suggesting that it can be associated with ischemic clinical syndromes presenting with chest pain. Coronary computed tomography angiography is a well-established method for detecting myocardial bridging. However, clinical significance of this anomaly still remains unclear.MethodsWe studied 977 patients who presented with recurrent typical or atypical chest pain in outpatient clinic. All patients have undergone detailed clinical examination, ECG stress testing and coronary computed tomography angiography.ResultsHighest positive prediction for having myocardial bridging was for patients presenting with atypical chest pain with negative ECG stress test and who were younger women.ConclusionCoronary computed tomography angiography may be preferable method for evaluation of chest pain in younger women presenting with atypical chest pain.

Diagnostic value of ST-segment deviations during cardiac exercise stress testing: Systematic comparison of different ECG leads and time-points

BackgroundExercise ECG stress testing is the most widely available method for evaluation of patients with suspected myocardial ischemia. Its major limitation is the relatively poor accuracy of ST-segment changes regarding ischemia detection. Little is known about the optimal method to assess ST-deviations. MethodsA total of 1558 consecutive patients undergoing bicycle exercise stress myocardial perfusion imaging (MPI) were enrolled. Presence of inducible myocardial ischemia was adjudicated using MPI results. The diagnostic value of ST-deviations for detection of exercise-induced myocardial ischemia was systematically analyzed 1) for each individual lead, 2) at three different intervals after the J-point (J+40ms, J+60ms, J+80ms), and 3) at different time points during the test (baseline, maximal workload, 2min into recovery). ResultsExercise-induced ischemia was detected in 481 (31%) patients. The diagnostic accuracy of ST-deviations was highest at +80ms after the J-point, and at 2min into recovery. At this point, ST-amplitude showed an AUC of 0.63 (95% CI 0.59–0.66) for the best-performing lead I. The combination of ST-amplitude and ST-slope in lead I did not increase the AUC. Lead I reached a sensitivity of 37% and a specificity of 83%, with similar sensitivity to manual ECG analysis (34%, p=0.31) but lower specificity (90%, p<0.001). ConclusionWhen using ECG stress testing for evaluation of patients with suspected myocardial ischemia, the diagnostic accuracy of ST-deviations is highest when evaluated at +80ms after the J-point, and at 2min into recovery.

Association between lipid profile and silent coronary artery disease in south Indian patients with type 2 diabetes mellitus

Background: The patients with type 2 diabetes have an increased prevalence of lipid abnormalities (Dyslipidemia). Early diagnosis of diabetic patients with silent CAD and dyslipidemia can reduce the morbidity and mortality for cardiovascular death. The objective of the present study is to assess the prevalence of silent coronary disease among south Indian type-2 diabetic patients without cardiovascular symptoms and association between lipid profile and silent coronary disease among them. Methods: 100 Type 2 diabetes mellitus patients (65 males and 35 females) of age 40-80 years attending the OPD of Sri Siddhartha Medical College, Tumakuru, Karnataka, India were enrolled in this study. The Serum samples were analysed for fasting blood glucose (FBS), post prandial blood glucose (PPBS), HbA1c, and lipid profile. The patients were classified into CAD and Non CAD groups based on ECG changes and stress test. Results were analysed SPSS 16.0 software. Results: The study revealed that 46% of our study population had silent CAD. The prevalence of dyslipidemia was found higher in males than females in both study groups. CAD group patients had significantly higher levels of serum total cholesterol, triglycerides, LDL- cholesterol and low HDL - cholesterol compared to Non CAD group. Conclusions: Dyslipidemia is indicating the strong association with silent CAD in type 2 diabetes mellitus. It is also advisable to have a screening ECG for silent CAD at the time of diagnosis or during the follow-up period in type 2 diabetes.

ECG stress test induced atrial ischemia in a patient with old inferior myocardial infarction due to a distal coronary artery lesion.

ECG stress test induced atrial ischemia in a patient with old inferior myocardial infarction due to a distal coronary artery lesion.

The Relation of Arm Exercise Peak Heart Rate to Stress Test Results and Outcome.

Arm exercise is an alternative to pharmacologic stress testing for >50% of patients unable to perform treadmill exercise, but no data exist regarding the effect of attained peak arm exercise heart rate on test sensitivity. Thus, the purpose of this investigation was to characterize the relationship of peak arm exercise heart rate responses to abnormal stress test findings, coronary revascularization, and mortality in patients unable to perform leg exercise. From 1997 until 2002, arm cycle ergometer stress tests were performed in 443 consecutive veterans age 64.1 yr (11.0 yr) (mean (SD)), of whom 253 also underwent myocardial perfusion imaging (MPI). Patients were categorized by frequency distributions of quartiles of percentage age-predicted peak heart rate (APPHR), heart rate reserve (HRR), and peak heart rate-systolic blood pressure product (PRPP). Exercise-induced ST-segment depression, abnormal MPI findings, coronary revascularization, and 12.0-yr (1.3 yr) Kaplan-Meier all-cause and cardiovascular mortality plots were then characterized by quartiles of APPHR, HRR, and PRPP. A reduced frequency of abnormal arm exercise ECG results was associated only with the lowest quartile of APPHR (≤69%) and HRR (≤43%), whereas higher frequency of abnormal MPI findings exhibited an inverse relationship trend with lower APPHR (P = 0.10) and HRR (P = 0.12). There was a strong inverse association of APPHR, HRR, and PRPP with all-cause (all P ≤ 0.01) and cardiovascular (P < 0.05) mortality. The frequency of coronary revascularization was unrelated to APPHR or HRR. Arm exercise ECG stress test sensitivity is only reduced at ≤69% APPHR or ≤43% HRR, whereas arm exercise MPI sensitivity and referral for coronary revascularization after arm exercise stress testing are not adversely affected by even a severely blunted peak heart rate. However, both all-cause mortality and cardiovascular mortality are strongly and inversely related to APPHR and HRR.

ST segment/heart rate hysteresis improves the diagnostic accuracy of ECG stress test for coronary artery disease in patients with left ventricular hypertrophy.

The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients. In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis. We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the 'neutral' receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score. Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy.