Postexercise Electrocardiogram Research Articles

A Long-Term Evaluation of the Postexercise Electrocardiogram in the Prediction of Coronary Artery Disease.

s1 May 1968A Long-Term Evaluation of the Postexercise Electrocardiogram in the Prediction of Coronary Artery Disease.L. F. Parmley, M.D., F.A.C.P., T. W. Mattingly, M.D., F.A.C.P., J. A. Orbison, M.D., F.A.C.P.L. F. Parmley, M.D., F.A.C.P.Search for more papers by this author, T. W. Mattingly, M.D., F.A.C.P.Search for more papers by this author, J. A. Orbison, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-68-5-1160_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptIn 1952 a prospective study was initated at Walter Reed General Hospital to determine if a postexercise electrocardiogram stress test could detect latent coronary artery disease in the clinically normal individual. A retrospective study following extensive use of this exercise test in preceding years had established the electrocardiogram (EKG) criteria of ST segment straightening and depression of over 0.5 mm as indicative of myocardial ischemia and called "ischemic depression" (ID). T-wave changes and ST segment junctional depression were believed due to other than coronary artery disease and called "nonischemic depression" (NID). Three hundred male Army officers, 100 in each of... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Washington, D. C. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 May 1968Volume 68, Issue 5Page: 1160-1160KeywordsElectrocardiographyExerciseIschemiaProspective studiesRetrospective studiesStable coronary artery disease Issue Published: 1 May 1968 PDF DownloadLoading ...

The Electrocardiogram and Coronary Insufficiency

The exercise tolerance test is the most important of all widely employed office techniques for the detection and evaluation of coronary arteriosclerosis. A reliable sign of coronary insufficiency is the S-T segment abnormality occurring in the postexercise electrocardiogram indicating ischemia. The S-T segment shift refers to a horizontal flattening or sagging depression of the S-T segment induced by exercise. The depressions occur most often in lead V₄or similar apical leads. They are produced usually by an amount of exercise equivalent to the double Master "two-step" exercise test, persist for more than one minute after the cessation of exercise, and are seen more easily with the patient in the supine position. The test is only reliable when the patient has not received digitalis for three weeks or quinidine for 24 hours prior to the test, or when hypokalemia, hypocalcemia, or hyperventilation are not present. The test can be interpreted

Postexercise electrocardiogram in arteriosclerotic heart disease. Its value in diagnosis and prognosis

Postexercise electrocardiogram in arteriosclerotic heart disease. Its value in diagnosis and prognosis

Postexercise Electrocardiogram in Arteriosclerotic Heart Disease

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.

An electrocardiographic, anatomic, and metabolic study of zonal myocardial ischemia in coronary heart disease.

An integrated approach, utilizing cine coronary angiography, the standard 12-lead and post-exercise electrocardiograms, and regional myocardial lactate metabolism, is presented for detection of regional myocardial ischemia in patients with coronary heart disease. The normal electrocardiogram was of no predictive value and was present with extensive coronary disease and myocardial production of lactate. The abnormal electrocardiogram gave an accurate indication of a portion, but not all zones of ischemia. Multiple electrocardiographic abnormalities were invariably associated with severe coronary artery disease, although in most patients many more coronary lesions were present than electrocardiographic abnormalities. The regional lactate pattern was very helpful in localizing myocardial ischemia and significant coronary artery lesions. Regional lactate abnormalities may have a great practical value in the selection of patients for myocardial revascularization surgery and in their postoperative evaluation.

Correlation between coronary arteriography and the postexercise electrocardiogram

Seventy-five patients with chest pain were studied with a double Master exercise test (post-exercise electrocardiogram) and coronary cine-arteriography to determine the correlation between these two methods of indicating the presence and severity of coronary artery disease. In 33 patients, the description of the chest pain was not that of classic angina pectoris. In this group, coronary cinearteriography revealed no disease while 10 patients had a positive double Master exercise test. Forty-two patients had pain that was quite characteristic of angina pectoris. In this group, coronary artery disease was demonstrated in all patients by coronary cinearteriography while 24 of these patients had a negative Master test. Study of the coronary arteriograms showed no significant difference in the severity and distribution of the disease between patients with a positive postexercise electrocardiogram and those with a negative postexercise electrocardiogram. The incidence of demonstrable collateral channels was identical in both groups. Selective coronary arteriography has confirmed previous doubts regarding the diagnostic reliability of the postexercise electrocardiogram in the individual patient with chest pain.

Influence of stellate ganglion block on angina pectoris and the post-exercise electrocardiogram.

Influence of stellate ganglion block on angina pectoris and the post-exercise electrocardiogram.

Griseofulvin trial in angina

Eight patients were selected for a doubleblind griseofulvin trial in angina. Two of the patients showed significantly better results while receiving the drug than while on the placebo, and 6 of the 7 patients for whom the number of attacks was recorded had fewer attacks while on the drug than on the placebo. No side effects from the drug were found in any of the patients. Serum cholesterol was unaffected by the drug, and a favorable effect on the post-exercise electrocardiogram during the drug period was observed in only 1 of the 3 patients in whom the pretreatment electrocardiogram was positive on exercise. One could not really expect conclusive results from such a small number of patients, but these results may well justify the carrying out of further work on this subject.

The electrocardiogram during exercise. Its value in the diagnosis of angina pectoris.

The electrocardiogram after exercise has proved to be an extremely valuable tool in the diagnosis of coronary artery disease. However, it fails to record the events during the actual period of exercise at the time of the greatest stress on the circulation. Recent technics have enabled us to take the electrocardiogram during the period of exercise. Data presented indicate that the electrocardiogram taken during this period of exercise adds much to the information obtained in the postexercise electrocardiogram; at times, this information may be crucial in determining evidence of abnormalities in the exercise study. The tracings may be solely positive or more markedly positive during the period of exercise. Evidence of such changes would be helpful in diagnosis and in the early termination of the exercise test. It is our belief that the complete electrocardiographic exercise study should include tracings taken both during and after exercise, and the data obtained during both of these periods should be available for evaluation. Although the complete exercise test adds much to the diagnosis of coronary artery disease, the presence of a normal test does not necessarily exclude this state. Evaluation of the tracing taken during exercise is in its infancy. Much still needs to be done relative to (a) more adequate standardization of the type of exercise to suit the individual subject, (b) improvement of standardization of apparatus, (c) standardization of leads and their placement, and (d) more rigid standardization of criteria for normality and abnormality.

MONITORED AND POST-EXERCISE TWO-STEP TEST.

Silent coronary artery disease presents a problem of great magnitude, affecting an estimated 2 million persons or more yearly. The Master test is of great value in the detection of such asymptomatic, ischemic heart disease. On the basis of long-term studies in 800 patients, it was substantiated that a negative twostep test virtually excludes significant myocardial ischemia. The response may be considered positive when ischemic depression of the RS-T segment occurs, or when a j-type RS-T depression is characterized by both a prolonged systole (QT ratio abnormal) and a duration prolonged in relation to this systole (QX/QT abnormal). The experienced physician can usually interpret these electrocardiographic changes by visual inspection. Monitoring of the two-step test has research potential, but at present is not as sensitive as the post-exercise electrocardiogram.

STUDIES ON ELECTROCARDIOGRAM DURING EXERCISE.

Faithful electrocardiogram with stable base line is obtained during the exercise (Master's single two step test) without using radio-telemetering method but using cable connecting apparatus devised by us. Forty cases of coronary insufficiency and sixty normal subjects are tested here and the result obtained is that Master's criteria is applicable even in the electrocardiogram during the exercise. According to this method and criteria, positive findings are found in almost half number of patients with coronary insufficiency who are negative in postexercise electrocardiogram.

The Electrocardiogram during Exercise as Recorded by Radioelectrocardiography: Comparison with the Post-exercise Electrocardiogram (Master Two-step Test).

s1 April 1962The Electrocardiogram during Exercise as Recorded by Radioelectrocardiography: Comparison with the Post-exercise Electrocardiogram (Master Two-step Test).S. Bellet, M.D., F.A.C.P., S. Deliyiannis, M.D., M. Eliakim, M.D., E. Figallo, M.D.S. Bellet, M.D., F.A.C.P.Search for more papers by this author, S. Deliyiannis, M.D.Search for more papers by this author, M. Eliakim, M.D.Search for more papers by this author, E. Figallo, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-56-4-665_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptHitherto, the evaluation of the effects of exercise on the electrocardiogram has been limited chiefly to observations during the immediate post-exercise period. A new radio-electrocardiograph system, permitting recording close to the patient or at a distance of several hundred feet, was employed in this study. This system made possible the recording of electrocardiograms during various types of exercise, without interference and with a stable baseline. The electrocardiogram during and after the Master two-step test was examined for 200 normal subjects and 1000 patients with various types of myocardial abnormality. These included patients with hypertension, coronary insufficiency, and other cardiovascular disorders.... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Philadelphia, Pa. (CI) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 April 1962Volume 56, Issue 4Page: 665-665KeywordsCardiovascular therapyElectrocardiographyExerciseHypertension Issue Published: 1 April 1962 PDF downloadLoading ...

The postexercise electrocardiogram ∗: Its value in the diagnosis and prognosis of coronary arterial disease

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.

Errors encountered in records of the postexercise electrocardiogram

Errors encountered in records of the postexercise electrocardiogram

The electrocardiogram during exercise as recorded by radioelectrocardiography: Comparison with the postexercise electrocardiogram (Master two-step test) ∗

The electrocardiogram during the standard Master two-step test was studied and compared with the postexercise tracings in a total of 296 subjects. A radioelectrocardiograph system based on the principle of broadcasting the electrocardiogram was used. The records obtained with this method show a steady baseline. In addition the method permits the taking of records during various forms of activity performed far from the recording apparatus. The changes during exercise in 127 apparently healthy persons below the age of forty years consisted of a decrease of the amplitude of the T wave to complete flattening (54 per cent), S-T segment depression of the junction type (13 per cent), occasional ischemic S-T segment depression (4 per cent) or T wave inversion (3 per cent) and occasional extrasystoles. Only one subject had persistent ischemic S-T segment depression. The following criteria for abnormality were used: appearance or increase of an ischemic S-T segment depression over 1 mm.; elevation of an isoelectric or previously depressed S-T segment over 1 mm. of the control; T wave inversion; reversion of a negative T wave to an upright position; marked changes in the contour of the QRS complex; or appearance of multiple extrasystoles. Sixty-six patients with hypertensive and/or arteriosclerotic cardiovascular disease with normal resting electrocardiograms or evidence of mild left ventricular hypertrophy showed the following electrocardiographic changes during and after exercise: 19.5 per cent had probably or definitely abnormal records only or chiefly during exercise; 9 per cent had changes only or chiefly after exercise; and 6 per cent had equal changes during and after exercise. Eighty-one patients with hypertensive and/or arteriosclerotic cardiovascular disease with abnormal resting electrocardiograms (ST-T changes in one or more leads) showed the following changes during and after exercise: 33 per cent had abnormalities only or chiefly during exercise; 11 per cent only or chiefly after exercise; and 13 per cent both during and after exercise. Of thirty-eight patients with symptomatic coronary artery disease (included in the 147 patients with hypertensive-arteriosclerotic cardiovascular disease), six had changes only or chiefly during exercise and nine both during and after exercise. Of twenty-two patients with miscellaneous (primarily noncardiac) diseases, seven had abnormalities during exercise and only three after exercise. It is concluded that the electrocardiogram during exercise is an extremely valuable adjunct in the detection of myocardial disease since the information obtained during this period is often unavailable or inadequately shown in the postexercise period.

Physiologic Evaluation of Angina Pectoris

Electrocardiographic and ballistocardiographic observations have been the only objective methods easily available for assessment of the state of the coronary circulation. As has been pointed out, however, these methods give only indirect information concerning the hemodynamic status and functional adequacy of the coronary circulation. The extensive pathologic studies of the coronary arteries in angina pectoris”2 have demonstrated that these vessels seldom show a single vascular disturbance, but more often, demonstrate diffuse involvement of the entire coronary vascular tree leading to increased large vessel resistance to blood flow. Physiological principles have been applied to the understanding of other cardiac problems, particularly valvular, congenital and constrictive heart disease and congestive heart failure. They have led to the development of objective hemodynamic methods of evaluation which would appear to be of value for the coronary circulation as well. We have attempted such an approach. Our findings are based on a correlative clinical, electrocardiographic and cardiac catheterization study of 43 patients. Coronary sinus catheterization was performed and coronary blood flow measured by the nitrous oxide technique’ as modified by Goodale and Hackel.4 Diastolic coronary vascular resistance was calculated.5 The group of 43 patients was subdivided as follows: Group 1 was the normal group, composed of 10 patients with negative histories, physical examinations and resting and post-exercise electrocardiograms. Group 2 was the abnormal group, composed of 23 patIents with typical angina pectoris and positive electrocardiographic examinations. Group 3 was designated the unknown group, composed of 10 patients, all of whom complained of atypical chest pain, and In whom the resting and exercise electrocardiograms were negative or equivocal. Three of these patients had left ventricular hypertrophy secondary to aortlc valve disease. The open columns in Figure 1 summarize the results of resting studies performed in normals, in patients with coronary artery disease and in those with increased left ventricular work. Coronary flow was essentially the same in all three groups; in the coronary group it was actually 19 per cent above normal. Diastolic coronary vascular resistance, which encompasses coronary inflow time as well as perfusion pressure, is perhaps the most useful index of the cross-sectional area of the coronary vascular bed. Again, no difference was found among these groups. In a recent report evaluating internal mammary ligation for angina pectoris, nitrous oxide flows were performed at rest. The authors found no difference in values before and after ligation, and therefore, concluded

Evaluation of type and degree of change in postexercise electrocardiogram in detecting coronary artery disease.

SummaryIschemic ST segment depression after exercise is due usually to coronary atherosclerosis and insufficiency. Our data suggest that type and degree of ischemic ST segment depression after exercise reflects the severity of the coronary disease. The results of this investigation indicate also that ST junction depression is a normal response to exercise.