Electrocardiographic Exercise Stress Testing PDF

International Journal of Cardiology 116 (2007) 285 – 299
www.elsevier.com/locate/ijcard
Review
Electrocardiographic exercise stress testing:
An update beyond the ST segment
John P. Higgins a,⁎, Johanna A. Higgins b
a
Cardiac Stress Laboratory, Medicine-Harvard Medical School, VA Boston Healthcare System, Boston, MA 02132, United States
b
Department of Anesthesia, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, United States
Received 19 December 2005; received in revised form 31 March 2006; accepted 13 April 2006
Available online 11 July 2006
Abstract
Routine exercise testing is frequently ordered to evaluate a patient's cardiovascular performance. The test is more direct and less
expensive than imaging technology, and derives valuable information. New variables such as dyspnea and heart rate recovery, as well as
integrated scores, provide incremental value to conventional analysis of exercise-induced angina or electrocardiographic changes.
Considerations relating to test accuracy in women need to be weighed. This paper seeks to make physicians aware of the current status of the
test, and improve their understanding of and ability to integrate new variables and scores to more effectively manage their patients.
© 2006 Elsevier Ireland Ltd. All rights reserved.
Keywords: Stress testing; Treadmill testing; Gender; Score
1. Introduction 2. Normal versus abnormal tests
This paper provides an update on the accuracy and value 2.1. Defining the abnormal test result
of the electrocardiographic exercise testing in cardiovascular
disease. Common exercise modalities used are treadmill The exercise test is considered abnormal if any of the
exercise test (TET) in North America and Australasia, and following occur:
stationary bicycle ergometer in Europe. There are advantages
and disadvantages to both modalities; experience and • Stress electrocardiogram (ECG) ST-segment depression
familiarity on both the patient and provider are also major (during and/or after exercise): >= 0.10 mV (1 mm)
factors [1]. Our objectives are first to review abnormal test horizontal or downsloping ST-segment depression, with
results. Patients in special circumstances undergoing the test the PR segment as the isoelectric baseline of the ECG.
are discussed. Gender differences affecting accuracy are The amount (mm) of ST-segment depression is measured
highlighted. Then, newer exercise testing parameters such as 80 ms after the J point (the junction between the QRS and
chronotropic incompetence, heart rate recovery, functional the ST-segment), and must be present in at least 3
capacity, and integrated scores are detailed. consecutive beats in 2 or more contiguous ECG leads.
Note the leads in which the ST-segment depression occurs
Abbreviations: CAD, coronary artery disease; DTS, Duke Treadmill do not localize the ischemic region nor the coronary
Score; ECG, electrocardiogram; TET, treadmill exercise testing; HRR, heart arteries involved [2]. Possible mechanisms of ST-segment
rate recovery; METS, metabolic equivalents; MI, myocardial infarction. depression include changes in the myocardial cell
⁎ Corresponding author. Cardiac Stress Laboratory, VA Boston Healthcare
membrane potential produced by action potential duration
System, Cardiology Section, Nuclear Medicine, 2C-120, 1400 VFW
Parkway, Boston, MA 02132, United States. Tel.: +1 857 203 6830; fax:
changes in the ischemic region, as well as a spatial
+1 857 203 5602. gradient of the resting membrane potential between the
E-mail address: John.Higgins@va.gov (J.P. Higgins). normal and ischemic regions [3]. Less frequently
0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2006.04.047
286 J.P. Higgins, J.A. Higgins / International Journal of Cardiology 116 (2007) 285–299
> = 1 mm ST-segment elevation is certain leads are below rest standing value) reflects an inadequate augmenta-
considered abnormal (see below). The aforementioned tion of cardiac output (poor pump function, outflow tract
ECG changes may indicate underlying CAD; obstruction) and/or an abnormal reduction in systemic
• Chest pain that began either during and/or after exercise vascular resistance [10]. Conditions associated with exer-
that by description is consistent with the patients angina tional hypotension are multivessel and/or severe CAD,
or an anginal equivalent. Of patients with a positive cardiomyopathy, arrhythmias, medications (vasodilators,
exercise test, most will have significant ST-segment diuretics, and negative inotropic agents), hypovolemia,
changes, while only about a third will develop angina [4]. prolonged vigorous exercise, and left ventricular outflow
Experiencing typical angina during the treadmill stress tract obstruction (aortic stenosis, hypertrophic cardiomyo-
test generally correlates with a greater extent of ischemia pathy) [11,12]. History, physical, and echocardiography may
and underlying CAD, with the exception of diabetics help differentiate these various causes for exertional
whom are less likely to experience pain [5]; hypotension. In the case of severe CAD, an early (during
• The test was stopped prematurely due to complications. the first 5 min) hypotensive response associated with
symptoms or ST-segment depression correlates well with
2.2. Abnormal hemodynamic response during exercise severe CAD [13]. One study showed reversal of the
exertional hypotension response after successful coronary
Either heart rate or blood pressure or both may behave artery bypass graft surgery [14].
abnormally.
2.2.2.2. Too high. Exertional hypertension is present if the
2.2.1. Abnormal heart rate response peak systolic blood pressure is >= 210 mm Hg in men, or
190 mm Hg in women [15]. In non-hypertensives, exertional
2.2.1.1. Too slow (“chronotropic incompetence”). This is hypertension either at peak exercise or noted during the first
an inability to increase heart rate appropriately during 3 min in recovery is associated with an increased risk for
exercise to match the increasing exercise workload [6]. future sustained hypertension [16]. This response is more
Formal definitions include a failure to achieve 85% maximal common in the elderly, poorly controlled hypertensive
age-predicted heart rate or 100 beats per minute at maximal patients, and those who do not take their medications on
exercise workload; however, some authors advocate a test day. Exertional hypertension is associated with impaired
specified increase in heart rate per protocol stage [7]. Causes subendocardial blood flow and may lead to false positive ST-
of chronotropic incompetence include sick sinus syndrome, segment changes, even when the baseline ECG is normal
compensated congestive heart failure, medications, and [17]. In addition, men with a rise in systolic blood pressure
advanced age. In patients with congestive heart failure, it is > 20 mm Hg/min of exercise duration or whose systolic
probably due to postsynaptic desensitization of beta- blood pressure did not fall 2 min after exercise have a 5-fold
adrenergic receptors, reduced functional capacity, and other increased risk of stroke [18].
medication effects. Chronotropic incompetence indepen-
dently predicts death in patients regardless of whether they 2.3. Significance of ST-segment elevation
are taking beta-blockers or calcium-channel blockers [6,8].
One study of asymptomatic middle-aged men found that ST-segment elevation may be important depending on
inability to increase one's heart rate during exercise by which leads it occurs in. It is not significant for ischemia if it
89 beats per minute independently predicted risk of sudden occurs in leads aVR, V1, or any lead with a Q-wave. In the
cardiac death [9]. latter case, this finding may reflect wall-motion abnormal-
ities from an aneurysm and is associated with akinesis or
2.2.1.2. Too fast. A rapid increase in heart rate at low dyskinesis of the left ventricular wall, residual viability
levels of exercise can occur in patients who are decondi- within an infarcted area, or peri-infarct ischemia [19]. In
tioned, anemic, hyperthyroid, hypovolemic, cardiomyo- contrast, ST-segment elevation is significant for ischemia if it
pathic, or in atrial fibrillation; these individuals can also occurs in leads other than those mentioned above. The
have an abnormal slowing down during recovery. Further, a criteria for positivity are >= 0.10 mV (1 mm) horizontal or
patient may go into an arrhythmia and suddenly jump to a upsloping ST-segment elevation, measured 80 ms after the J
very fast heart rate. Because the heart rate reaches high point, and seen in 3 or more consecutive beats. Such
levels early on, total exercise time and capacity is usually exercise-induced ST-segment elevation signifies severe
limited [7]. transmural ischemia caused by either extensive and often
multivessel CAD, or coronary artery spasm as seen in
2.2.2. Abnormal blood pressure response Variant or Prinzmetal's angina [20]. In contrast to ST-
segment depression, ST-segment elevation does localize the
2.2.2.1. Too low. Abnormally low peak systolic blood ischemic region; further, the territory of ischemia is greater in
pressure (< 130 mm Hg) or exertional hypotension (fall in patients with exercise-induced ST-segment elevation than
systolic blood pressure during exercise of > = 10 mm Hg with ST-segment depression [21].
J.P. Higgins, J.A. Higgins / International Journal of Cardiology 116 (2007) 285–299 287
2.4. Accuracy of the test imbalance which can decrease blood flow to the subendo-
cardium [26]. In addition, certain clinical situations,
It should be noted that most published data on TET medications, sympathetic nerve stimulation, electrolyte
involves studies of men. With that said, the often quoted TET abnormalities, or metabolic changes may affect the ST-
sensitivity is 72% (range 45–92%) and specificity 77% segment at increasing heart rates resulting in false positive
(range 17–92%), but this is further complicated by the fact results [22,27–29].
that these numbers are based on studies with multiple cut Conditions associated with false positive TET's are listed
points for positivity and multiple biases [22,23]. When a in Table 1.
positive test was strictly defined as > =1 mm horizontal or
downsloping ST-segment depression, the sensitivity is about 2.6. Causes of a false negative TET
60% and specificity 90% [24]. To avert bias, one study
performed TET and cardiac catheterization on 814 con- A false negative TET is associated with male gender,
secutive male veterans presenting with chest pain. The TET single vessel disease, inability to achieve adequate workload,
sensitivity and specificity were 45% and 85% respectively medications which limit the myocardial workload with
for detecting CAD [25]. exercise or improve myocardial blood flow, and high clinical
probability of CAD [30,31]. If the goal is to maximize the
2.5. Causes of a false positive TET test sensitivity, medications which limit heart rate or blood
pressure should be withdrawn several weeks before the test.
A false positive TET means exercise-induced ST-segment However, this should only be done in consultation with the
depression in the absence of significant stenosis to the major patients primary care physician or cardiologist, and only if
epicardial coronary arteries. Such false positive results may deemed safe to do so. Conditions associated with false
be associated with conditions that lead to increased left negative results are listed in Table 1.
ventricular mass, pressure and/or volume overload, or
greater oxygen requirements, resulting in a supply demand 3. Special circumstances
3.1. Exercise electrocardiography after an acute coronary

Table 1
event
Causes of false positives and false negative tests
The current American College of Cardiology and
Conditions associated with false Conditions associated with false
positive exercise test negative exercise test American Heart Association guidelines recommend sub-
maximal or low-level stress testing as early as 3–5 days after
Aortic regurgitation Sub-maximal stress workload
Aortic stenosis (severe) Beta-adrenergic blocking agents an uncomplicated coronary event prior to discharge unless
Athletes heart Calcium-channel blocking agents the patient has undergone percutaneous coronary interven-
Digitalis Single vessel coronary artery disease tion or coronary artery bypass graft surgery and been fully
Estrogen use Male gender revascularized [32]. Maximal symptom limited stress-testing
Female gender Left bundle branch block
can be performed 30 days after the coronary event. The
Left bundle branch block Nitrates
Left ventricular hypertrophy Right bundle branch block submaximal exercise test is stopped when one of the
Heart failure (systolic or diastolic) High exercise diastolic blood following end points occurs:
pressure
Hypertrophic cardiomyopathy • A peak heart rate of 120 to 130 beats per minute or 70% of
Hypertension (severe or exertional)
the maximal predicted heart rate for age;
Hyperventilation
Hypokalemia (especially if taking • A peak work level of 5 metabolic equivalents;
diuretics) • Mild angina or dyspnea;
Hypoxia (severe) • Exercise-induced ST-segment depression of 2 mm or
Intraventricular conduction defects more;
Microvascular disease or vasospasm
• Exertional hypotension; or
Mitral regurgitation
Mitral valve prolapse • Three or more consecutive ventricular premature
Pectus excavatum contractions.
Postprandial changes (glucose
ingestion) Generally, if a patient can complete a stress test to an
Right bundle branch block
acceptable cardiovascular workload (5 or more metabolic
Supraventricular tachycardia
Syndrome X (especially younger equivalents) without any ECG changes, angina, hypotension,
women) significant ST-segment depression or frequent ventricular
Ventricular paced rhythm premature contractions, they are deemed low risk for a
Wolff–Parkinson–White syndrome recurrent cardiac event during the next year [33]. If the patient
Young age
has resting ECG abnormalities which preclude interpretation
of exercise-induced ischemia, the addition of nuclear imaging 3.3. Exercise electrocardiography after coronary artery
or echocardiography is suggested. bypass graft surgery
However, several groups have noted that it is safe to
perform a symptom-limited TET after an acute MI using the Usually one typically waits 2–3 months after surgery to
Bruce protocol 3 days after admission with a very low allow sternal healing and appropriate early rehabilitation
incidence of complications [34,35]. In fact, performing the before doing a symptom limited stress test. In those surgical
symptom limited exercise test soon after MI will identify patients with an abnormal baseline ECG which are
more patients with exercise-induced ST-segment depression nondiagnostic for ischemia, an imaging modality should be
or chest pain than the low level test, and in several studies added. Exercise-induced ischemic ST-segment depression
was equally safe [36,37]. A meta-analysis showed that if the may persist when incomplete revascularization is achieved,
predischarge TET is normal following an acute MI, there is a as well as in 5% of patients who have had complete
< 10% event rate at 1 year; if abnormal, the event rate revascularization [47,48]. The sensitivity as well as the
increased to 10–20% [38]. However, another study using prognostic value of the test is greater in the late period (5–
TET in conjunction with nuclear imaging showed that 10 years after coronary artery bypass graft surgery) than in
neither angina pectoris nor ST-segment depression during the early period (first year after surgery) [49].
the stress test was independently predictive for cardiac death
[39]. In fact, the most powerful predictor of subsequent 3.4. Exercise electrocardiography in risk assessment before
cardiac mortality was a lower ejection fraction at rest. noncardiac surgery
Functional capacity post-MI is also important, and the
ability to achieve an adequate cardiac workload (pressure- Exercise electrocardiography is useful to identify CAD in
rate product of >21,700) signifies good myocardial blood asymptomatic patients, especially in those who do not
supply and a favorable 6 month prognosis [40]. A recent exercise regularly, or to risk stratify patients with known
meta-analysis found that exercise capacity and blood CAD prior to noncardiac surgery. Findings which increase
pressure response to exercise were better predictors of future risk of perioperative cardiac events include marked exercise-
cardiac events following MI than exercise-induced electro- induced ST-segment depression or exercise-induced angina
cardiographic ischemia or angina [38]. at low workloads, poor exercise capacity (< 5 metabolic
equivalents), an abnormally low peak systolic blood pressure
3.2. Exercise electrocardiography after percutaneous cor- (< 130 mm Hg), or a fall in systolic blood pressure during
onary intervention exercise > 10 mm Hg below standing rest values [50]. In
addition, one can readily use a simple score such as the Lee
In patients who have undergone recent percutaneous index (calculated using the variables: high-risk type of
coronary intervention, recurrence of symptoms itself has low surgery, ischemic heart disease, congestive heart failure,
sensitivity and specificity for detecting restenosis and cerebrovascular disease, treatment with insulin, and serum
myocardial ischemia. Exercise testing may provide useful creatinine > 2.0 mg/dL) to further identify which stable
information on symptoms and functional capacity of the patients undergoing non-urgent major noncardiac surgery are
patient; however, a meta-analysis showed that TET alone has at a higher risk for complications [51].
a poor sensitivity (46%) and a moderate specificity (77%) for However, it is important to note that in practice, the
the identification of post-percutaneous coronary intervention non-invasive cardiac stress tests have a poor positive
restenosis [41]. The use of nuclear imaging increases the predictive value for identifying which patients will have a
sensitivity to 83% without affecting specificity [42]. In perioperative cardiac event, suggesting that perioperative
addition, TET with imaging adds incremental information MI's may not share the same pathophysiology as
(ejection fraction and wall motion) and helps localize the nonoperative MI's [52]. In addition, if a patient requires
region of ischemia and assist the interventionalist in a stress test yet is not able to walk due to arthritis or other
identifying the culprit lesion [43]. Importantly, symptom medical problem, they will likely require an alternative
limited stress testing the day after stent implantation is safe form of stress test such as a pharmacological nuclear or
[44]. In the first month post-percutaneous coronary inter- echocardiographic stress test.
vention, an abnormal TET may indicate inadequate inter- Further, in light of the considerable risk of coronary
vention or revascularization result, or a successful result with angiography and revascularization in high-risk patients, the
impaired coronary flow reserve in the site [45]. Thus for current approach is moving away from extensive non-
routine follow up in the asymptomatic patient, one should invasive preoperative risk stratification toward selective non-
wait 2–3 months after percutaneous coronary intervention invasive testing and aggressive pharmacological periopera-
before doing an TET with imaging to avoid false positive tive therapy [53]. Perioperative plaque stabilization by
results. A TET done after this time in an asymptomatic pharmacological means may be just as important in the
patient can help diagnose restenosis or new stenosis, prevention of perioperative MI as addressing the periopera-
document functional capacity, and aid in early identification tive myocardial oxygen supply–demand imbalance of
of patients at risk for subsequent events [46]. existing CAD [54]. Thus, those patients who are low risk
by TET should proceed to surgery without further cardio- – assess abnormal response to exercise in children with
vascular work up in most cases. cardiac, pulmonary, or other organ disorders (including
myocardial ischemia and arrhythmias)
3.5. Exercise electrocardiography in diabetic patients – assess efficacy of medical or surgical treatments
– assess functional capacity for recreational, athletic, and
Patient with diabetes mellitus have more frequent and vocational activities
severe CAD to such an extent that diabetes is now – evaluate prognosis
considered equivalent in risk to established CAD [55]. – establish baseline data for institution of cardiac,
Pertinent issues specific to diabetic patients undergoing pulmonary, or musculoskeletal rehabilitation.
exercise electrocardiography include [5]: • Protocols and modalities of stress must be adapted to the
age and size of the child, and normal values for most
• Similar diagnostic sensitivity and specificity of TET for variables measured will vary with age and often with sex.
identification of CAD in patients presenting with angina;
• Lower diagnostic accuracy in asymptomatic diabetics, 3.8. Patients with left ventricular hypertrophy (LVH) on
who may not manifest angina; their baseline ECG
• Reduced functional capacity is associated with increased
cardiac morbidity and mortality; and The TET is still sensitive (68% vs. 72%) but not as
• Abnormal heart rate recovery (described below) indepen- specific (69% vs. 77%) for detecting CAD [22]. Most
dently predicts cardiovascular and all-cause mortality in testing labs will require > =2 mm of ST-segment depression
diabetics, and is associated with increasing blood sugar in the presence of LVH by Sokalow-Lyon (voltage) criteria
levels. to report a significant ST-segment change [22]. In other
words, if the TET is normal (no ischemic ST-segment
3.6. Exercise electrocardiography in geriatric patients changes or angina), then the test result is negative.
However, if abnormal, it may or may not mean obstructive
Exercise electrocardiography is more challenging in the CAD, and one should consider additional testing with
elderly for several reasons including: imaging. The major reason for false positive ST-segment
changes is mild subendocardial ischemia secondary to
• More likely to have baseline ECG abnormality rendering concentric hypertrophy and microvessels, in the setting of
the ECG nondiagnostic [56]; relatively normal epicardial coronary arteries. Recently, one
• Less likely to achieve adequate and diagnostic exercise group showed that the ratio of early post-exercise systolic
workload due to arthritis, musculoskeletal disease, blood pressure to peak-exercise systolic blood pressure may
peripheral arterial disease, and reduced cardiopulmonary be diagnostically helpful in detecting CAD in patients with
reserve [57]; LVH with positive ST-segment depression during an
• In an older population with a high prevalence of CAD, a exercise test [62].
borderline exercise test is much more likely to indicate
real disease than in a low risk younger population. 3.9. Patients with a right bundle branch block on their
baseline ECG
In elderly patients able to exercise, workload achieved is
independently predictive of cardiac morbidity and mortality Patients with right bundle branch block typically have
[58,59]. For those patients with a nondiagnostic ECG or not wide “rabbit ear” QRS complexes and T wave inversion in
able to exercise or achieve an adequate workload, adjunctive leads V1–V3 on their baseline ECG, so exercise-induced ST-
imaging may determine the extent and severity of ischemia segment depression is nondiagnostic if it occurs in leads V1–
with more accuracy. V3 [22]. However, in the remaining leads, ST-segment
changes are diagnostic for ischemia, with the resulting
3.7. Exercise electrocardiography in pediatric patients sensitivity and specificity being similar to a patient with a
normal baseline ECG [63]. Thus it is still considered
Exercise electrocardiography in the pediatric population appropriate to perform exercise electrocardiography without
differs from adults in that [60,61]: imaging as an initial test in patients with right bundle branch
block [64].
• Most stress testing is to evaluate nonischemic heart
disease such as congenital heart defects or cardiomyo- 3.10. Exercising patients with aortic stenosis
pathies (CAD is rare), and so cardiopulmonary testing is
often performed; Symptomatic patients with moderate or severe aortic
• Common indications for testing include stenosis should not undergo an TET because of the concern
– evaluate signs/symptoms induced/aggravated by of precipitating cardiac arrest. However, asymptomatic
exercise patients with moderate to severe aortic stenosis (aortic
valve area 0.5 to 1.5 cm2 and/or mean gradients 18 to 64 mm skin and precordial ECG leads making it difficult to
Hg) can undergo a TET with reasonable safety (no fatalities interpret ST-segment changes.
reported if studies where patients were stopped at first sign of 5. Women have smaller coronary vessel size which may
symptoms, significant ischemic ST-segment changes, or reduce the maximal flow heterogeneity and potentially
hemodynamic abnormalities) [65]. An abnormal test may decrease the amount of ST-segment changes [75].
reveal symptoms in an “asymptomatic patient” or identify a
patient who needs closer follow up [65,66]. When exercising Women suited for a standard exercise electrocardiogram
aortic stenosis patients, be conservative with respect to are those with a normal resting ECG and a good exercise
stopping the test (usual indications) and also stop if the capacity. If the test is negative and they are considered low
patient develops exercise-induced bradycardia, a lack of risk patients (e.g. atypical history, good functional capacity,
expected increase in systolic blood pressure, or increasing normal hemodynamics), then no further cardiac testing such
ventricular ectopy. as cardiac catheterization is required. The TET does have a
high negative predictive value in women with a low pretest
4. Gender differences probability of CAD and a low-risk Duke Treadmill Score
(described below) [67]. In women with suspected CAD, the
4.1. Accuracy in women and who are best suited for the test diagnostic accuracy of the TET is enhanced by inclusion of
parameters such as exercise time to the traditional parameters
The sensitivity (61%) and specificity (69%) of the TET (ST-segment changes and angina development) [67]. How-
for detecting CAD in women using ST-segment changes or ever, women with intermediate or high-risk Duke Treadmill
exertional angina are significantly less than for men [67,68]. Score or those with baseline ECG abnormalities or those
In postmenopausal women, sensitivity to detect CAD is unable to exercise at a good workload should be referred for
even lower at 50–57% [69]. One large population-based an imaging stress test [67,76]. In addition, functional
cohort of 2994 asymptomatic women (pre and postmeno- capacity, integrative treadmill scores, and hemodynamic
pausal) followed for 20 years, found no difference in recovery from exercise independently predict morbidity and
cardiovascular death risk when stratified by exercise- mortality in women [77].
induced ST-segment depression or elevation [70]. However
low exercise capacity, low heart rate recovery (HRR), 5. Endpoints and recovery
inability to achieve target heart rate, and integrative scores
were independently associated with increased cardiovascu- 5.1. Achievement of appropriate workload level
lar and total mortality.
Possible reasons for the lower test accuracy in women An adequate workload during a study requires the patient
include: to achieve one of the following [22,78]:
1. Women have a lower exercise capacity (average 2 min 1. 85% of their maximal age-predicted heart rate i.e.
less) and achieve target heart rate less often than age- 0.85 × (220 − age of patient in years). This results in an
matched men [67]. Details on age-predicted exercise increase in coronary blood flow of 2–4-fold in non-
capacity in women have recently been published, and stenosed coronary arteries [79];
exercise capacity predicts survival among symptomatic 2. A pressure-rate product or double product of > 20,000,
and asymptomatic women [71]. Further, women present chosen because a pressure-rate product >20,000 results in
with manifestations of CAD at an older age then men and an increase in coronary blood flow of 2–3-fold in non-
thus unable to achieve as great a workload [72]. stenosed coronary arteries [80,81];
2. Women more often have resting ST-T changes and lower 3. An ischemic endpoint (i.e. reproduced patients usual
ECG voltage [67]. angina and they wish to stop or significant ischemic ST-
3. Estrogen can affect ST-segment changes and have a segment changes). Exercise-induced ischemic ECG
digoxin-like effect. Premenopausal women are more changes occur more frequently, and usually precede
likely to have false positive TET than postmenopausal onset of angina [82].
women, and false positive tests occur more frequently
when estrogen levels are high [73]. Thus in menstruating If a patient cannot reach any of these endpoints for
women, one should consider performing the TET in the whatever reason, the test's capacity for detecting significant
perimenstrual period when estrogen levels are low CAD is reduced [22].
[73,74]. Postmenopausal women taking oral estrogen
have an increase in false positive ischemic ST-segment 5.2. Premature termination of the test
depressions on TET [69].
4. During the exercise portion of the TET, women with Certain occurrences during the test should prompt one to
moderate sized breasts may get excessive ECG motion immediately stop the test and have the patient sit down and
artifact from the breasts pushing and pulling on adjacent recover. These include development of significant angina,
> 10 mm Hg fall in systolic blood pressure, central nervous 5.5.2. Recurrent or high grade ventricular ectopy
system symptoms, signs of decreased perfusion, ischemic Several studies involving men have confirmed that
ST-segment elevation > = 1.0 mm in leads without Q waves exercise-induced ventricular arrhythmias (defined as pre-
(other than V1 and aVR), ischemic ST-segment depression mature ventricular contractions > 10% of all ventricular
> =3.0 mm, equipment problems, request by patient to stop, depolarizations during any 30-s recording, or a run of three
or significant arrhythmia. or more premature ventricular contractions during exercise
or recovery) independently predict increased mortality
5.3. Exercise test events that portend a poor prognosis [9,86,87]. One study of 29,244 men and women (mean age
56 years; 70% men) who had been referred for TET (with no
Adverse findings during the TET which point to future history of heart failure, valve disease, or arrhythmia) found
cardiac morbidity and mortality include: frequent ventricular ectopy (> 7 premature ventricular
contractions/min, bigeminy, trigeminy, couplets, triplets,
1. Poor exercise capacity (< 5 metabolic equivalents); ventricular tachycardia, flutter, torsade, or fibrillation) during
2. Abnormally low peak systolic blood pressure (< 130 mm recovery but not during exercise was an independent
Hg) or a fall in systolic blood pressure during exercise of predictor of increased morbidity and mortality [88]. Despite
10 mm Hg or more below standing rest values; these studies, it remains unclear whether exercise-induced
3. Exercise-induced angina, especially at low workloads; frequent ventricular ectopy is an independent predictor or a
4. >= 2 mm of ischemic ST-segment depression at a low marker of underlying heart disease.
workload (< = Bruce stage 2 or heart rate < = 120 beats per
minute); 5.5.3. Heart rate recovery (HRR)
5. Early onset (Bruce stage 1) or prolonged duration During recovery, vagal reactivation results in increased
(> 5 min) ST-segment depression; parasympathetic tone and a decline in heart rate. This decline
6. Multiple leads (5 or more) with ST-segment depression; is blunted with decreased myocardial function and reduced
7. Exercise-induced ST-segment elevation (excluding aVR exercise capacity. Multiple investigators have confirmed that
or leads with Q waves); abnormal HRR, defined as failure of heart rate to decrease
8. Ventricular couplets, triplets, sustained (> 30 s) or 12 beats or more during the first minute after peak exercise
symptomatic ventricular tachycardia; (while the patient remains standing) independently predicts
9. Abnormal heart rate recovery [9,83]. an increased mortality in men and women [70,89]. Further,
the greater the fall in heart rate in the first minute of recovery,
5.4. Importance of recovery stage the lower the subsequent mortality [90]. An abnormal HRR
likely reflects decreased vagal reactivation, and has been
Often the recovery stage is the only time where directly related to abnormal heart rate variability and insulin
abnormalities manifest. Recovery continues until the patients resistance [91,92]. Patients with a HRR of less than 25 beats
heart rate, systolic blood pressure, and ECG have returned to per minute likely have autonomic imbalance; in one cohort
near baseline levels (usually within 9 min). In addition, of middle-aged men, this independently predicted sudden
because the patient is resting in recovery, the ECG has a good death [9]. Abnormalities in autonomic tone appear to be
baseline with minimal motion artifact. During recovery, amplified when sympathetic tone predominates and/or
patients can have major ischemic ECG changes even when parasympathetic (vagal) tone is diminished. Mechanistically,
the exercise portion appeared normal. Also, tachyarrhyth- sympathetic hyperactivity increases the cardiovascular work-
mias including ventricular tachycardia and paroxysmal atrial load, hemodynamic stress, while predisposing one to
fibrillation, or bradyarrhythmias such as second or third endothelial dysfunction, coronary artery spasm, left ventri-
degree heart block, can occur. cular hypertrophy, serious arrhythmias, stroke, and cardiac
mortality. In contrast, increased parasympathetic activity is
5.5. Key points on the recovery phase: protective against ischemia related dysrhythmias, and also
reduces heart rate and blood pressure [93].
5.5.1. ST-segment depression
Often, the optimum ECG is early in recovery, where the 5.5.4. Systolic blood pressure recovery
patient is still, and one gets the best baseline and best look at The systolic blood pressure should fall rapidly after
the ST-segments. Changes in recovery are just as significant cessation of exercise by more than 15% at 3 min after
for predicting risk for cardiac events (angina, MI, cardiac stopping; myocardial ischemia may delay this decline
death) as those that occur during exercise [84]. In addition to [62,94]. Various definitions of abnormal systolic blood
supply–demand induced ischemia, levels of neuropeptide Y, pressure recovery exist. For example, a 3 min recovery
a potent vasoconstrictor released with norepinephrine during systolic blood pressure of >90% of peak systolic blood
sympathetic activity, has been shown to correlate with the pressure, or a ratio of systolic blood pressure at 3 min reco-
degree and duration of ST-segment depression after exercise very to a systolic blood pressure at 1 min recovery > 1 [95].
in patients with CAD [85]. Abnormal systolic blood pressure recovery is significantly
associated with severe CAD (left main, 3 vessel disease, or 2 hemodynamic aspects of the TET that have prognostic
vessel disease with proximal left anterior descending artery value, including the Duke Treadmill Score (DTS), the VA/
involvement) [96]. Another study of 2336 Finnish men Froelicher Score, and others. Many labs use the DTS because
determined that a systolic blood pressure > 195 mm Hg after it:
exercise or a rise in systolic blood pressure of more than
10 mm Hg/min for 2 min after exercise was associated with 1. Uses 3 independent variables based on exercise
risk of future MI [94]. capacity and exercise ischemia;
2. Predicts all-cause mortality and cardiac event rates in
5.6. Exercise-induced bundle branch blocks patients aged 45 to 75 years with or without known
CAD [77,102–105];
Exercise-induced transient left bundle branch block 3. Correlates with severity of CAD and prognosis in both
occurs in about 0.4% of patients, renders the left bundle genders [104,106], and it appears more specific for
branch block portion of the ECG uninterpretable for detecting left main disease, three vessel disease and
ischemia, and in one series independently predicted a higher two vessel disease involving the proximal left anterior
rate of death and major cardiac events [97]. However, if descending artery [107];
ischemic ST-segment changes occur before or after the left 4. Is easy to calculate;
bundle branch block has resolved, the TET is still sensitive 5. Does not include maximal heart rate in its calculation,
for CAD. If a transient left bundle branch block develops at and thus provides incremental information on patients
lower heart rates < = 120 beats per minute or with classic not able to achieve an adequate heart rate;
angina, this may correlate with significant CAD (often 6. Is clinically relevant, and may prognosticate in cases
proximal stenosis of the left anterior descending artery) [98]. where the patients test is borderline by conventional
In contrast, if the left bundle branch block develops at rates criteria;
> 120 beats per minute it is more likely a rate-related 7. Is validated in men and women; though good at
phenomenon, and several studies have confirmed this to be excluding significant disease in women if normal, it
associated with normal coronary arteries [98,99]. may not stratify moderate- and high-risk women as
Exercise-induced transient right bundle branch block is well as men [108,109];
less common, occurring in about 0.1% of patients; a single 8. Performs well against other more cumbersome scores
study noted this was associated with CAD [98]. [110];
9. Provides incremental prognostic information to that
5.7. Supraventricular arrhythmias during the TET already provided by clinical information, ejection
fraction, and coronary anatomy;
Supraventricular arrhythmias (atrial premature beats, 10. May have a physiological basis: one study found it
atrial fibrillation, atrial flutter, supraventricular tachycardia) correlated with coronary flow reserve [79]; and
are commonly induced by exercise and seen in up to 10% of 11. Requires the patient undergo the standard Bruce
normals and in up to 25% of those with known or suspected Protocol Stress Test protocol, the commonest stress
CAD; they appear to be more common in patients with test protocol used worldwide.
underlying heart disease [100]. However, they are not
diagnostic for CAD, nor do they predict adverse long-term The DTS is calculated as follows: DTS = (exercise time in
cardiovascular outcomes [101]. minutes) − (5 × maximal exercise-induced ST-segment devia-
tion in millimeters) − (4 × exercise angina; with 0 = none,
6. Scores, functional capacity, and new developments 1 = nonlimiting, 2 = exercise limiting angina). The DTS is
then classified into risk as follows: Low-risk >= 5, Moderate-
6.1. Integrated treadmill scores risk −10 to +4, and High-risk < =− 11.
In a study of patients of average age 50 years, classification
There are various scores that can be calculated based on by DTS and extent/severity of CAD and cardiovascular
traditional results as well as on other functional and mortality by gender is shown in Table 2 [111–113]. As can be
Table 2
Duke Treadmill Test Score and coronary artery stenosis and cardiovascular mortality by gender in symptomatic patients
Risk category Significant coronary 3 vessel disease Annual Significant 3 vessel disease Annual
based on Duke stenosisa: men or left main cardiovascular coronary or left main cardiovascular
Treadmill Score disease: men mortality: men stenosis: women disease: women mortality: women
Low risk 47% 11% 0.3–0.9% 19% 4% 0.5–0.6%
Moderate risk 82% 39% 1.3–2.9% 35% 12% 1.0–1.1%
High risk 98% 72% 5.3–8.3% 89% 46% 1.8–2.0%
a
Significant coronary artery disease (>=1 vessel with >=50% stenosis).
noted, CAD was more prevalent in men of all risk groups; men or women classified as low risk by DTS have an excellent
however, amount and severity of disease increased from low- prognosis, and further evaluation is generally unnecessary; in
risk to high-risk in both genders. There is a higher morality by contrast, high-risk patients have a worse prognosis and one
all risk groups in men than in women [111–113]. For mortality, should consider further cardiac evaluation and action such as
the DTS appears to better risk stratify men than women. Yet, cardiac catheterization for them [4].
Table 3
Advantages, disadvantages, and accuracy of various stress testing-imaging modalities
Stress Advantages Disadvantages Specificity mean Specificity mean Ref.
testing-imaging percent (range) percent (range)
modality for detection of for detection of
coronary artery coronary artery
disease disease
Exercise Standard assessment of ischemia, Sensitivity and specificity lower than 72% (45–92%) 77% (17–92%) [22,23]
electrocardiography functional capacity, heart rate most other stress imaging techniques;
recovery, hemodynamic response; accuracy decreased if patient unable
accurate if baseline electrocardiogram to achieve adequate workload; does
is interpretable; standardized not localize area or extent of
protocols; cheap. ischemia; lower specificity if
baseline electrocardiogram
abnormalities, digoxin use, and in
women.
Exercise myocardial Standard assessment of ischemia, Long test (about 3 h); radiation 87% (75–88%) 64% (60–94%) [137,138]
perfusion imaging functional capacity, heart rate exposure; expensive equipment and
recovery, hemodynamic response; nuclear hot lab required; artifacts
accurate evaluation of extent of from equipment and patient factors
coronary disease (semi-automated can affect accuracy (e.g. breast
computer quantification); prognostic; attenuation, left bundle branch
reproducible; obtain left ventricular block); expensive.
size and ejection fraction; assesses
myocardial viability.
Pharmacologic Accurate evaluation of coronary No evaluation of functional capacity 89% (75–90%) 70% (65–90%) [137,139]
(adenosine or artery disease in patients unable to or hemodynamic response to exercise;
persantine) exercise (e.g. patients with peripheralexercise electrocardiographic changes
myocardial arterial disease requiring preoperativeless accurate than with exercise
perfusion imaging risk assessment); more accurate in (however when changes occur
evaluation of patients with left bundlegenerally signify more severe
branch block; accurate evaluation of coronary artery disease); difficult to
extent of coronary disease gauge if patient experience true
(semi-automated computer angina; contraindicated if patient
quantification); prognostic; hypotensive, have high grade heart
reproducible; obtain left ventricular block, severe bronchospastic airways
size and ejection fraction; assesses disease; reduced specificity in
myocardial viability. patients with permanent pacemaker;
expensive.
Exercise Evaluates cardiac anatomy and Interpretation difficult when resting 85% (71–97%) 77% (70–100%) [138,140,141]
echocardiography function, chamber size, wall thickness wall motion abnormalities are present;
and valvular function; results suboptimal images decrease accuracy;
available immediately; portable; accuracy is dependent upon operator
shorter test than myocardial perfusion and physician experience
imaging. (interpretation subjective); modestly
expensive.
Dobutamine Evaluates cardiac anatomy and No evaluation of functional capacity 80% (70–96%) 84% (62–93%) [23,139–141]
echocardiography function, chamber size, wall thickness or hemodynamic response to exercise;
and valvular function; accurate in exercise electrocardiographic changes
patients with baseline left bundle less accurate than with exercise;
branch block; shorter test than interpretation difficult when resting
myocardial perfusion imaging; wall motion abnormalities are present;
assesses myocardial viability. suboptimal images decrease accuracy;
accuracy is operator and machine
dependent; labor intensive;
dobutamine may cause significant
ventricular arrhythmias; modestly
expensive.
6.2. Importance of functional capacity and metabolic CAD. The choice of which imaging modality to use should
equivalents be a combination of availability, familiarity, and local
expertise. The advantages, disadvantages, sensitivity, and
The metabolic equivalent (MET) is a unit of resting specificity of these imaging modalities against TET are
oxygen uptake which measures energy expenditure; 1 MET shown in Table 3.
equals 3.5 mL oxygen uptake/kg/min i.e. the amount of
oxygen taken up each minute while you sit reading this 6.4. Role of treadmill exercise test in cardiac rehabilitation
paper. Maximum MET values are usually attained between and exercise prescription
ages 15 and 30, and progressively decrease thereafter. The
number of METs one can achieve is proportional to the Cardiac rehabilitation in patients with CAD results in a
maximal coronary flow reserve [114]. substantial reduction in morbidity and all-cause mortality
In studies of men and women referred for exercise [121]. Exercise stress testing can be used to risk stratify
testing, determination of exercise capacity in METs is a patients prior to starting an exercise program into four
more powerful predictor of mortality than other estab- classes per the American Heart Association guidelines
lished risk factors for cardiovascular disease [83,89,115]. [122]:
Patients with CAD who achieve 10 METs or more have
an excellent prognosis regardless of the angiographic • Class A — healthy individuals with no increased risk;
findings [116]. In contrast, poor functional capacity in • Class B — patients with stable CAD at low risk from
patients with known CAD or prior MI (inability to attain 5 vigorous exercise;
METs) is associated with an increased risk of cardiac • Class C — patients with complicated CAD at high risk
events [117]. Peripheral vascular endothelial function from vigorous exercise; and
correlates with exercise capacity in both genders, even • Class D — patients with unstable CAD who should not
in the absence of CAD [118]. Impaired functional capacity exercise.
and abnormal HRR appear to be strongly and indepen-
dently associated with lower socioeconomic status [119]. Exercise stress testing can also be used as an initial
Major or sudden reductions in a patients functional exercise prescription and also intermittently to monitor
capacity (or MET level) is a red flag and should trigger the patients functional capacity. Prescriptions for an
further evaluation. exercise program usually include mode, frequency,
duration, and intensity of exercise [123]. A typical
6.3. Performance of the treadmill exercise test against outpatient cardiac rehabilitation program consists of
stress-imaging tests weekly exercise electrocardiography sessions for
12 weeks, allowing the development of an individualized
A stress test is often combined with an imaging modality exercise prescription that is safe and effective. The
in the following specific situations [120]: program should not only improve the patients exercise
capacity, but will also bolster confidence and psycholo-
1. Resting ECG abnormalities that render them uninter- gical well-being, allow counseling on risk factor mod-
pretable for exercise-induced ischemic ST-segment ification, and also establish a long term exercise
changes. This includes left bundle branch block, elec- maintenance program [124].
tronically paced rhythm, >1 mm ST-segment depression
or elevation in two or more leads, pre-excitation
syndromes;
2. Inability to exercise adequately to give meaningful results Table 4
on routine stress electrocardiography; and Traditional and new diagnostic variables in exercise treadmill test
3. Patients with angina and a history of revascularization
Phase of test Traditional variables New variables
where it is important to localize the territory of ischemia
Exercise ST-segment depression Maximal exercise capacity
for possible future intervention.
ST-segment elevation Abnormal heart-rate response
(chronotropic incompetence,
The most common combination stress and imaging rapid response)
modalities are: Angina pectoris Abnormal blood-pressure response
(exertional hypotension,
exertional hypertension)
1. Stress (exercise or pharmacologic) myocardial perfusion
Ventricular arrhythmia
imaging; Duke Treadmill Score
2. Stress (exercise or dobutamine) echocardiography. Dyspnea
Recovery ST-segment depression Abnormal heart-rate recovery
The sensitivity of exercise electrocardiography is lower ST-segment elevation Abnormal blood-pressure recovery
Angina pectoris Ventricular arrhythmia
than that of stress imaging for identification of patient with
6.5. Recent developments in stress testing testing for diagnostic and prognostic purposes. However,
due to the lower accuracy of the standard TET in women,
Ongoing research into stress testing has lead to following when suspicion for CAD is higher, additional imaging
recent developments: (nuclear or stress-echocardiography) is warranted. In both
genders, a substantial functional capacity is associated with a
1. Self-reported dyspnea in patients referred for cardiac good prognosis, and other novel variables and scores can
stress testing increases risk of death from cardiac and help stratify risk, and so should be a integral part of the TET
noncardiac causes, and provides incremental information report (see Table 4).
to the exercise test result [125].
2. Generalized vascular disease predicts exercise perfor- References
mance. Arterial compliance of the lower extremities
independently predicts treadmill time in patients with a [1] ATS/ACCP. Statement on cardiopulmonary exercise testing. Am J
Respir Crit Care Med 2003;167(2):211–77.
wide range of cardiovascular risk but without overt CAD
[2] Kafka H, Leach AJ, Fitzgibbon GM. Exercise echocardiography after
[126]. coronary artery bypass surgery: correlation with coronary angiogra-
3. Generalized inflammation may predict performance. phy. J Am Coll Cardiol 1995;25(5):1019–23.
Exercise capacity is inversely related to C-reactive protein [3] Aslanidi OV, Clayton RH, Lambert JL, Holden AV. Dynamical and
levels [127]. Circulating endothelin-1 levels correlate cellular electrophysiological mechanisms of ECG changes during
ischaemia. J Theor Biol 2005;237(4):369–81 [Electronic publication
with coronary flow reserve and time of onset of chest pain
2005 Jun 24].
with exercise [128]. [4] Marwick TH, Case C, Vasey C, Allen S, Short L, Thomas JD.
4. New stress modalities including psychological and Prediction of mortality by exercise echocardiography: a strategy for
mental stress such as a 3-min mental arithmetic task are combination with the Duke Treadmill Score. Circulation 2001;103
noting that mental stress-induced ischemia typically (21):2566–71.
[5] Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with
occurs without pain; this research may shed light on the
diabetes mellitus: diagnostic and prognostic value. Circulation
role of emotional factors in acute coronary syndrome and 2006;113(4):583–92.
sudden cardiac death [129,130]. [6] Lauer MS, Francis GS, Okin PM, Pashkow FJ, Snader CE, Marwick
5. Newer variables with prognostic value such as functional TH. Impaired chronotropic response to exercise stress testing as a
capacity, HRR, systolic blood pressure recovery, and DTS predictor of mortality. JAMA 1999;281(6):524–9.
[7] Tavel ME. Stress testing in cardiac evaluation: current concepts with
likely have different normal ranges depending on which
emphasis on the ECG. Chest 2001;119(3):907–25.
stress modality (treadmill vs. bicycle) is utilized [131]. [8] Khan MN, Pothier CE, Lauer MS. Chronotropic incompetence as a
6. New adjusted variables and indices may improve predictor of death among patients with normal electrograms taking
accuracy of the exercise ECG test. Beta blockers (metoprolol or atenolol). Am J Cardiol 2005;96
7. Heart rate-adjusted ST-segment depression analysis and (9):1328–33 [Electronic publication 2005 Sep 15].
[9] Jouven X, Empana JP, Schwartz PJ, Desnos M, Courbon D,
stress recovery index may further improve accuracy of the
Ducimetiere P. Heart-rate profile during exercise as a predictor of
exercise ECG test [132,133]. sudden death. N Engl J Med 2005;352(19):1951–8.
8. New scores such as the Athens QRS score may improve [10] Rehman A, Zalos G, Andrews NP, Mulcahy D, Quyyumi AA. Blood
overall test accuracy [134]. In addition, scores developed pressure changes during transient myocardial ischemia: insights into
for use in the elderly (age >= 75 years) are being validated mechanisms. J Am Coll Cardiol 1997;30(5):1249–55.
[11] Lele SS, Scalia G, Thomson H, et al. Mechanism of exercise
[135]. Complex computer algorithm scores that utilize
hypotension in patients with ischemic heart disease. Role of
patient risk factors and medical history and integrate this neurocardiogenically mediated vasodilation. Circulation 1994;90
information with test variables and data sets improve the (6):2701–9.
TET accuracy [136]. [12] Kim JJ, Lee CW, Park SW, et al. Improvement in exercise capacity
and exercise blood pressure response after transcoronary alcohol
ablation therapy of septal hypertrophy in hypertrophic cardiomyo-
7. Conclusions
pathy. Am J Cardiol 1999;83(8):1220–3.
[13] Watson G, Mechling E, Ewy GA. Clinical significance of early vs late
Looking at traditional variables measured on a stress test hypotensive blood pressure response to treadmill exercise. Arch
in new ways is proving important diagnostically and Intern Med 1992;152(5):1005–8.
prognostically in patients undergoing exercise stress testing. [14] Li WI, Riggins RC, Anderson RP. Reversal of exertional
hypotension after coronary bypass grafting. Am J Cardiol 1979;44
Exercise electrocardiography has an improved accuracy and
(4):607–11.
is more clinically relevant when multiple risk parameters [15] Campbell L, Marwick TH, Pashkow FJ, Snader CE, Lauer MS.
(ST-segment deviation, chest pain, exercise time, heart rate Usefulness of an exaggerated systolic blood pressure response to
recovery, blood pressure recovery, ventricular arrhythmia) exercise in predicting myocardial perfusion defects in known or
are incorporated into the final test result. These variables, suspected coronary artery disease. Am J Cardiol 1999;84(11):
1304–10.
and new integrative scores based upon them, are important
[16] Nakashima M, Miura K, Kido T, et al. Exercise blood pressure in
indicators of current cardiovascular status and also predict young adults as a predictor of future blood pressure: a 12-year follow-
future morbidity and mortality. Most male patients with a up of medical school graduates. J Hum Hypertens 2004;18
normal resting ECG can undergo standard treadmill exercise (11):815–21.
[17] Chang HJ, Chung J, Choi SY, et al. Endothelial dysfunction in [35] DeBusk RF, Haskell W. Symptom-limited vs heart-rate-limited
patients with exaggerated blood pressure response during treadmill exercise testing soon after myocardial infarction. Circulation
test. Clin Cardiol 2004;27(7):421–5. 1980;61(4):738–43.
[18] Kurl S, Laukkanen JA, Rauramaa R, Lakka TA, Sivenius J, Salonen [36] Jensen-Urstad K, Samad BA, Bouvier F, et al. Prognostic value of
JT. Systolic blood pressure response to exercise stress test and risk of symptom limited versus low level exercise stress test before discharge
stroke. Stroke 2001;32(9):2036–41. in patients with myocardial infarction treated with thrombolytics.
[19] Gussak I, Wright RS, Kopecky SL, Hammill SC. Exercise-induced Heart 1999;82(2):199–203.
ST segment elevation in Q wave leads in postinfarction patients: [37] Juneau M, Colles P, Theroux P, et al. Symptom-limited versus low
defining its meaning and utility in today's practice. Cardiology level exercise testing before hospital discharge after myocardial
2000;93(4):205–9. infarction. J Am Coll Cardiol 1992;20(4):927–33.
[20] Gallik DM, Mahmarian JJ, Verani MS. Therapeutic significance of [38] Shaw LJ, Peterson ED, Kesler K, Hasselblad V, Califf RM. A
exercise-induced ST-segment elevation in patients without previous metaanalysis of predischarge risk stratification after acute myocardial
myocardial infarction. Am J Cardiol 1993;72(1):1–7. infarction with stress electrocardiographic, myocardial perfusion,
[21] Mark DB, Hlatky MA, Lee KL, Harrell Jr FE, Califf RM, Pryor DB. and ventricular function imaging. Am J Cardiol 1996;78(12):
Localizing coronary artery obstructions with the exercise treadmill 1327–37.
test. Ann Intern Med 1987;106(1):53–5. [39] Gosselink AT, Liem AL, Reiffers S, Zijlstra F. Prognostic value of
[22] Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline predischarge radionuclide ventriculography at rest and exercise after
update for exercise testing: summary article. A report of the American acute myocardial infarction treated with thrombolytic therapy or
College of Cardiology/American Heart Association Task Force on primary coronary angioplasty. The Zwolle Myocardial Infarction
Practice Guidelines (Committee to Update the 1997 Exercise Testing Study Group. Clin Cardiol 1998;21(4):254–60.
Guidelines). J Am Coll Cardiol 2002;40(8):1531–40. [40] Villella M, Villella A, Barlera S, Franzosi MG, Maggioni AP.
[23] San Roman JA, Vilacosta I, Castillo JA, et al. Selection of the optimal Prognostic significance of double product and inadequate double
stress test for the diagnosis of coronary artery disease. Heart 1998;80 product response to maximal symptom-limited exercise stress testing
(4):370–6. after myocardial infarction in 6296 patients treated with thrombolytic
[24] Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST agents. GISSI-2 Investigators. Grupo Italiano per lo Studio della
depression in the diagnosis of coronary artery disease. A meta- Sopravvivenza nell-Infarto Miocardico. Am Heart J 1999;137
analysis. Circulation 1989;80(1):87–98. (3):443–52.
[25] Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardio- [41] Garzon PP, Eisenberg MJ. Functional testing for the detection of
graphic exercise test in a population with reduced workup bias: restenosis after percutaneous transluminal coronary angioplasty: a
diagnostic performance, computerized interpretation, and multi- meta-analysis. Can J Cardiol 2001;17(1):41–8.
variable prediction. Veterans Affairs Cooperative Study in Health [42] Dori G, Denekamp Y, Fishman S, Bitterman H. Exercise stress
Services #016 (QUEXTA) Study Group. Quantitative Exercise testing, myocardial perfusion imaging and stress echocardiography
Testing and Angiography. Ann Intern Med 1998;128(12 Pt for detecting restenosis after successful percutaneous transluminal
1):965–74. coronary angioplasty: a review of performance. J Intern Med
[26] Duncker DJ, Merkus D. Regulation of coronary blood flow. Effect of 2003;253(3):253–62.
coronary artery stenosis. Arch Mal Coeur Vaiss 2004;97(12): [43] Beregi JP, Bauters C, McFadden EP, Quandalle P, Bertrand ME,
1244–50. Lablanche JM. Exercise-induced ST-segment depression in patients
[27] Pigozzi F, Spataro A, Alabiso A, et al. Role of exercise stress test in without restenosis after coronary angioplasty. Relation to preproce-
master athletes. Br J Sports Med 2005;39(8):527–31. dural impaired left ventricular function. Circulation 1994;90(1):
[28] Shin JH, Shiota T, Kim YJ, et al. False-positive exercise 148–55.
echocardiograms: impact of sex and blood pressure response. Am [44] Roffi M, Wenaweser P, Windecker S, et al. Early exercise after
Heart J 2003;146(5):914–9. coronary stenting is safe. J Am Coll Cardiol 2003;42(9):1569–73.
[29] Gronke S, Schmidt M, Schwinger RH. Typical angina and [45] Ferrari M, Schnell B, Werner GS, Figulla HR. Safety of deferring
normal coronary arteriogram. Dtsch Med Wochenschr 2005;130 angioplasty in patients with normal coronary flow velocity reserve. J
(15):942–5. Am Coll Cardiol 1999;33(1):82–7.
[30] Lewandowski M, Szwed H, Kowalik I, et al. Is application of [46] Eisenberg MJ, Schechter D, Lefkovits J, et al. Utility of routine
electrocardiographic exercise test always useful in the diagnosis of functional testing after percutaneous transluminal coronary angio-
coronary artery disease? Advantages and limitations of this method. plasty: results from the ROSETTA registry. J Invasive Cardiol
Pol Arch Med Wewn 2001;105(6):483–94. 2004;16(6):318–22.
[31] Yamagishi H, Yoshiyama M, Shirai N, Akioka K, Takeuchi K, [47] Parisi AF, Folland ED, Hartigan P. A comparison of angioplasty with
Yoshikawa J. Protective effect of high diastolic blood pressure during medical therapy in the treatment of single-vessel coronary artery
exercise against exercise-induced myocardial ischemia. Am Heart J disease. Veterans Affairs ACME Investigators. N Engl J Med 1992;
2005;150(4):790–5. 326(1):10–6.
[32] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines [48] Bourassa MG, Pepine CJ, Forman SA, et al. Asymptomatic Cardiac
for the management of patients with ST-elevation myocardial Ischemia Pilot (ACIP) study: effects of coronary angioplasty and
infarction-executive summary: a report of the American College of coronary artery bypass graft surgery on recurrent angina and
Cardiology/American Heart Association Task Force on Practice ischemia. The ACIP investigators. J Am Coll Cardiol 1995;26
Guidelines (Writing Committee to Revise the 1999 Guidelines for the (3):606–14.
Management of Patients with Acute Myocardial Infarction). Circula- [49] Weiner DA, Ryan TJ, Parsons L, et al. Prevalence and prognostic
tion 2004;110(5):588–636. significance of silent and symptomatic ischemia after coronary bypass
[33] Dominguez H, Torp-Pedersen C, Koeber L, Rask-Madsen C. surgery: a report from the Coronary Artery Surgery Study (CASS)
Prognostic value of exercise testing in a cohort of patients followed randomized population. J Am Coll Cardiol 1991;18(2):343–8.
for 15 years after acute myocardial infarction. Eur Heart J 2001;22 [50] Maddox TM. Preoperative cardiovascular evaluation for noncardiac
(4):300–6. surgery. Mt Sinai J Med 2005;72(3):185–92.
[34] Senaratne MP, Smith G, Gulamhusein SS. Feasibility and safety of [51] Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and
early exercise testing using the Bruce protocol after acute myocardial prospective validation of a simple index for prediction of cardiac risk
infarction. J Am Coll Cardiol 2000;35(5):1212–20. of major noncardiac surgery. Circulation 1999;100(10):1043–9.
[52] Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. follow-up of the lipid research clinics prevalence study. JAMA
Perioperative cardiac events in patients undergoing noncardiac 2003;290(12):1600–7.
surgery: a review of the magnitude of the problem, the pathophysiol- [71] Gulati M, Black HR, Shaw LJ, et al. The prognostic value of a
ogy of the events and methods to estimate and communicate risk. nomogram for exercise capacity in women. N Engl J Med 2005;353
CMAJ 2005;173(6):627–34. (5):468–75.
[53] Wesorick DH, Eagle KA. The preoperative cardiovascular evaluation [72] Wenger NK. Clinical characteristics of coronary heart disease in
of the intermediate-risk patient: new data, changing strategies. Am J women: emphasis on gender differences. Cardiovasc Res 2002;53
Med 2005;118(12):1413. (3):558–67.
[54] Priebe HJ. Perioperative myocardial infarction—aetiology and [73] Lloyd GW, Patel NR, McGing E, Cooper AF, Brennand-Roper D,
prevention. Br J Anaesth 2005;95(1):3–19 [Electronic publication Jackson G. Does angina vary with the menstrual cycle in women with
2005 Jan 21]. premenopausal coronary artery disease? Heart 2000;84(2):189–92.
[55] Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality [74] Henzlova MJ, Croft LB, Diamond JA. Effect of hormone replacement
from coronary heart disease in subjects with type 2 diabetes and in therapy on the electrocardiographic response to exercise. J Nucl
nondiabetic subjects with and without prior myocardial infarction. N Cardiol 2002;9(4):385–7.
Engl J Med 1998;339(4):229–34. [75] Cerqueira MD. Diagnostic testing strategies for coronary artery
[56] Molander U, Dey DK, Sundh V, Steen B. ECG abnormalities in the disease: special issues related to gender. Am J Cardiol 1995;75
elderly: prevalence, time and generation trends and association with (11):52D–60D.
mortality. Aging Clin Exp Res 2003;15(6):488–93. [76] Shaw LJ, Olson MB, Kip K, et al. The value of estimated functional
[57] Fleischmann KE. Noninvasive cardiac testing in the geriatric patient. capacity in estimating outcome: results from the NHBLI-Sponsored
Am J Geriatr Cardiol 2003;12(1):28–32. Women's Ischemia Syndrome Evaluation (WISE) Study. J Am Coll
[58] Goraya TY, Jacobsen SJ, Pellikka PA, et al. Prognostic value of Cardiol 2006;47(3 Suppl):S36–43.
treadmill exercise testing in elderly persons. Ann Intern Med [77] Gulati M, Arnsdorf MF, Shaw LJ, et al. Prognostic value of the Duke
2000;132(11):862–70. Treadmill Score in asymptomatic women. Am J Cardiol 2005;96
[59] Spin JM, Prakash M, Froelicher VF, et al. The prognostic value of (3):369–75.
exercise testing in elderly men. Am J Med 2002;112(6):453–9. [78] Guidelines for cardiac exercise testing. ESC working group on
[60] Paridon SM, Alpert BS, Boas SR, et al. Clinical stress testing in the exercise physiology, physiopathology and electrocardiography. Eur
pediatric age group. A statement from the American Heart Heart J 1993;14(7):969–88.
Association Council on Cardiovascular Disease in the Young, [79] Youn HJ, Park CS, Moon KW, et al. Relation between Duke
Committee on Atherosclerosis, Hypertension, and Obesity in Youth. Treadmill Score and coronary flow reserve using transesophageal
Circulation 2006;27:27. Doppler echocardiography in patients with microvascular angina. Int
[61] Rodgers GP, Ayanian JZ, Balady G, et al. American College of J Cardiol 2005;98(3):403–8.
Cardiology/American Heart Association Clinical Competence state- [80] Jagathesan R, Kaufmann PA, Rosen SD, et al. Assessment of the
ment on stress testing. A report of the American College of long-term reproducibility of baseline and dobutamine-induced
Cardiology/American Heart Association/American College of Phy- myocardial blood flow in patients with stable coronary artery disease.
sicians-American Society of Internal Medicine Task Force on Clinical J Nucl Med 2005;46(2):212–9.
Competence. Circulation 2000;102(14):1726–38. [81] Driggers DA, Marchant D. Maximizing the exercise stress test.
[62] Yamada K, Hirai M, Abe K, et al. Diagnostic usefulness of Critical factors that enhances its validity. Postgrad Med 1999;105
postexercise systolic blood pressure response for detection of (5):53–7 [60].
coronary artery disease in patients with echocardiographic left [82] McCance AJ, Forfar JC. Selective enhancement of the cardiac
ventricular hypertrophy. Can J Cardiol 2004;20(7):705–11. sympathetic response to exercise by anginal chest pain in humans.
[63] Mammana C, Cox ID, Azzarelli S, et al. Diagnostic value of exercise Circulation 1989;80(6):1642–51.
electrocardiography for predicting a positive scintigraphic test in [83] Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE.
patients with complete right bundle branch block. Cardiologia Exercise capacity and mortality among men referred for exercise
1999;44(8):727–34. testing. N Engl J Med 2002;346(11):793–801.
[64] Yen RS, Miranda C, Froelicher VF. Diagnostic and prognostic [84] Lanza GA, Mustilli M, Sestito A, Infusino F, Sgueglia GA, Crea F.
accuracy of the exercise electrocardiogram in patients with preexist- Diagnostic and prognostic value of ST segment depression limited to
ing right bundle branch block. Am Heart J 1994;127(6):1521–5. the recovery phase of exercise stress test. Heart 2004;90(12):
[65] Das P, Rimington H, Chambers J. Exercise testing to stratify risk in 1417–21.
aortic stenosis. Eur Heart J 2005;8:8. [85] Gullestad L, Jorgensen B, Bjuro T, et al. Postexercise ischemia is
[66] Baumgartner H. Management of asymptomatic aortic stenosis: how associated with increased neuropeptide Y in patients with coronary
helpful is exercise testing? Eur Heart J 2005;13:13. artery disease. Circulation 2000;102(9):987–93.
[67] Mieres JH, Shaw LJ, Arai A, et al. Role of noninvasive testing in the [86] Beckerman J, Mathur A, Stahr S, Myers J, Chun S, Froelicher V.
clinical evaluation of women with suspected coronary artery disease: Exercise-induced ventricular arrhythmias and cardiovascular death.
consensus statement from the Cardiac Imaging Committee, Council Ann Noninvasive Electrocardiol 2005;10(1):47–52.
on Clinical Cardiology, and the Cardiovascular Imaging and [87] Morshedi-Meibodi A, Evans JC, Levy D, Larson MG, Vasan RS.
Intervention Committee, Council on Cardiovascular Radiology and Clinical correlates and prognostic significance of exercise-induced
Intervention, American Heart Association. Circulation 2005;111 ventricular premature beats in the community: the Framingham Heart
(5):682–96 [Electronic publication 2005 Feb 1]. Study. Circulation 2004;109(20):2417–22 [Electronic publication
[68] Hoilund-Carlsen PF, Johansen A, Christensen HW, et al. Usefulness 2004 May 17].
of the exercise electrocardiogram in diagnosing ischemic or coronary [88] Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent
heart disease in patients with chest pain. Am J Cardiol 2005;95 ventricular ectopy after exercise as a predictor of death. N Engl J
(1):96–9. Med 2003;348(9):781–90.
[69] Bokhari S, Bergmann SR. The effect of estrogen compared to [89] Messinger-Rapport B, Pothier Snader CE, Blackstone EH, Yu D,
estrogen plus progesterone on the exercise electrocardiogram. J Am Lauer MS. Value of exercise capacity and heart rate recovery in older
Coll Cardiol 2002;40(6):1092–6. people. J Am Geriatr Soc 2003;51(1):63–8.
[70] Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict [90] Morshedi-Meibodi A, Larson MG, Levy D, O'Donnell CJ, Vasan RS.
cardiovascular and all-cause death in asymptomatic women: a 20-year Heart rate recovery after treadmill exercise testing and risk of
cardiovascular disease events (The Framingham Heart Study). Am J [110] Fearon WF, Gauri AJ, Myers J, Raxwal VK, Atwood JE, Froelicher
Cardiol 2002;90(8):848–52. VF. A comparison of treadmill scores to diagnose coronary artery
[91] Panzer C, Lauer MS, Brieke A, Blackstone E, Hoogwerf B. disease. Clin Cardiol 2002;25(3):117–22.
Association of fasting plasma glucose with heart rate recovery in [111] Mark DB, Shaw L, Harrell Jr FE, et al. Prognostic value of a treadmill
healthy adults: a population-based study. Diabetes 2002;51(3):803–7. exercise score in outpatients with suspected coronary artery disease.
[92] Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the N Engl J Med 1991;325(12):849–53.
risk of death in women: the St James Women Take Heart Project. [112] Alexander KP, Shaw LJ, Shaw LK, Delong ER, Mark DB, Peterson
Circulation 2003;108(13):1554–9 [Electronic publication 2003 ED. Value of exercise treadmill testing in women. J Am Coll Cardiol
Sep 15]. 1998;32(6):1657–64.
[93] Curtis BM, O'Keefe Jr JH. Autonomic tone as a cardiovascular risk [113] Shaw LJ, Hachamovitch R, Redberg RF. Current evidence on
factor: the dangers of chronic fight or flight. Mayo Clin Proc 2002;77 diagnostic testing in women with suspected coronary artery disease:
(1):45–54. choosing the appropriate test. Cardiol Rev 2000;8(1):65–74.
[94] Laukkanen JA, Kurl S, Salonen R, Lakka TA, Rauramaa R, Salonen [114] Schulman DS, Lasorda D, Farah T, Soukas P, Reichek N, Joye JD.
JT. Systolic blood pressure during recovery from exercise and the risk Correlations between coronary flow reserve measured with a Doppler
of acute myocardial infarction in middle-aged men. Hypertension guide wire and treadmill exercise testing. Am Heart J 1997;134
2004;44(6):820–5 [Electronic publication 2004 Nov 8]. (1):99–104.
[95] Fukui M, Mori Y, Takehana K, et al. Assessment of coronary artery [115] Kraus WE, Douglas PS. Where does fitness fit in? N Engl J Med
disease in hemodialysis patients with delayed systolic blood pressure 2005;353(5):517–9.
response after exercise testing. Blood Purif 2005;23(6):466–72. [116] Shavelle DM, Budoff MJ, LaMont DH, Shavelle RM, Kennedy JM,
[96] McHam SA, Marwick TH, Pashkow FJ, Lauer MS. Delayed systolic Brundage BH. Exercise testing and electron beam computed
blood pressure recovery after graded exercise: an independent tomography in the evaluation of coronary artery disease. J Am Coll
correlate of angiographic coronary disease. J Am Coll Cardiol Cardiol 2000;36(1):32–8.
1999;34(3):754–9. [117] Morris CK, Ueshima K, Kawaguchi T, Hideg A, Froelicher VF. The
[97] Grady TA, Chiu AC, Snader CE, et al. Prognostic significance of prognostic value of exercise capacity: a review of the literature. Am
exercise-induced left bundle-branch block. JAMA 1998;279 Heart J 1991;122(5):1423–31.
(2):153–6. [118] Patel AR, Kuvin JT, Sliney KA, Rand WM, Pandian NG, Karas RH.
[98] Bounhoure JP, Donzeau JP, Doazan JP, et al. Complete bundle branch Peripheral vascular endothelial function correlates with exercise
block during exercise test. Clinical and coronary angiographic data. capacity in women. Clin Cardiol 2005;28(9):433–6.
Arch Mal Coeur Vaiss 1991;84(2):167–71. [119] Shishehbor MH, Litaker D, Pothier CE, Lauer MS. Association of
[99] Vasey C, O'Donnell J, Morris S, McHenry P. Exercise-induced left socioeconomic status with functional capacity, heart rate recovery,
bundle branch block and its relation to coronary artery disease. Am J and all-cause mortality. JAMA 2006;295(7):784–92.
Cardiol 1985;56(13):892–5. [120] Lee TH, Boucher CA. Clinical practice. Noninvasive tests in patients
[100] Maurer MS, Shefrin EA, Fleg JL. Prevalence and prognostic with stable coronary artery disease. N Engl J Med 2001;344
significance of exercise-induced supraventricular tachycardia in (24):1840–5.
apparently healthy volunteers. Am J Cardiol 1995;75(12):788–92. [121] Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis:
[101] Bunch TJ, Chandrasekaran K, Gersh BJ, et al. The prognostic secondary prevention programs for patients with coronary artery
significance of exercise-induced atrial arrhythmias. J Am Coll Cardiol disease. Ann Intern Med 2005;143(9):659–72.
2004;43(7):1236–40. [122] Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for
[102] Liao L, Smith WTt, Tuttle RH, Shaw LK, Coleman RE, Borges-Neto testing and training: a statement for healthcare professionals from the
S. Prediction of death and nonfatal myocardial infarction in high-risk American Heart Association. Circulation 2001;104(14):1694–740.
patients: a comparison between the Duke Treadmill Score, peak [123] Shephard RJ, Balady GJ. Exercise as cardiovascular therapy.
exercise radionuclide angiography, and SPECT perfusion imaging. J Circulation 1999;99(7):963–72.
Nucl Med 2005;46(1):5–11. [124] Motohiro M, Yuasa F, Hattori T, et al. Cardiovascular adaptations to
[103] Lakkireddy DR, Bhakkad J, Korlakunta HL, et al. Prognostic value of exercise training after uncomplicated acute myocardial infarction.
the Duke Treadmill Score in diabetic patients. Am Heart J 2005;150 Am J Phys Med Rehabil 2005;84(9):684–91.
(3):516–21. [125] Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic
[104] Kwok JM, Miller TD, Hodge DO, Gibbons RJ. Prognostic value of significance of dyspnea in patients referred for cardiac stress testing.
the Duke Treadmill Score in the elderly. J Am Coll Cardiol 2002;39 N Engl J Med 2005;353(18):1889–98.
(9):1475–81. [126] Willens HJ, Chirinos JA, Brown WV, et al. Usefulness of arterial
[105] Valeti US, Miller TD, Hodge DO, Gibbons RJ. Exercise single- compliance in the thigh in predicting exercise capacity in
photon emission computed tomography provides effective risk individuals without coronary heart disease. Am J Cardiol 2005;96
stratification of elderly men and elderly women. Circulation (2):306–10.
2005;111(14):1771–6 [Electronic publication 2005 Apr 4]. [127] Pandian S, Amuthan V, Sukumar P, et al. Plasma CRP level predicts
[106] Marwick TH, Case C, Short L, Thomas JD. Prediction of mortality in left ventricular function and exercise capacity in patients with acute
patients without angina: use of an exercise score and exercise myocardial infarction. Indian Heart J 2005;57(1):54–7.
echocardiography. Eur Heart J 2003;24(13):1223–30. [128] Monti LD, Piatti PM. Role of endothelial dysfunction and insulin
[107] Alvarez Tamargo JA, Barriales Alvarez V, Sanmartin Pena JC, et al. resistance in angina pectoris and normal coronary angiogram. Herz
Angiographic correlates of the high-risk criteria for conventional 2005;30(1):48–54.
exercise testing and the Duke Treadmill Score. Rev Esp Cardiol [129] Strike PC, Steptoe A. Systematic review of mental stress-induced
2001;54(7):860–7. myocardial ischaemia. Eur Heart J 2003;24(8):690–703.
[108] Morise AP, Olson MB, Merz CN, et al. Validation of the accuracy of [130] Strike PC, Magid K, Whitehead DL, Brydon L, Bhattacharyya MR,
pretest and exercise test scores in women with a low prevalence of Steptoe A. Pathophysiological processes underlying emotional
coronary disease: the NHLBI-sponsored Women's Ischemia Syn- triggering of acute cardiac events. Proc Natl Acad Sci U S A
drome Evaluation (WISE) study. Am Heart J 2004;147(6):1085–92. 2006;103(11):4322–7 [Electronic publication 2006 Mar 2].
[109] Nishime EO, Cole CR, Blackstone EH, Pashkow FJ, Lauer MS. Heart [131] Rahimi K, Thomas A, Adam M, Hayerizadeh BF, Schuler G, Secknus
rate recovery and treadmill exercise score as predictors of mortality in MA. Implications of exercise test modality on modern prognostic
patients referred for exercise ECG. JAMA 2000;284(11):1392–8. markers in patients with known or suspected coronary artery disease:
treadmill versus bicycle. Eur J Cardiovasc Prev Rehabil 2006;13 [138] Fleischmann KE, Hunink MG, Kuntz KM, Douglas PS. Exercise
(1):45–50. echocardiography or exercise SPECT imaging? A meta-analysis of
[132] Bigi R, Cortigiani L, Gregori D, Bax JJ, Fiorentini C. Prognostic diagnostic test performance. JAMA 1998;280(10):913–20.
value of combined exercise and recovery electrocardiographic [139] Kim C, Kwok YS, Heagerty P, Redberg R. Pharmacologic stress
analysis. Arch Intern Med 2005;165(11):1253–8. testing for coronary disease diagnosis: a meta-analysis. Am Heart J
[133] Bigi R, Gregori D, Cortigiani L, Colombo P, Fiorentini C. Stress 2001;142(6):934–44.
recovery index for risk stratification of asymptomatic patients [140] Armstrong WF, Zoghbi WA. Stress echocardiography: current
following coronary bypass surgery. Chest 2005;128(1):42–7. methodology and clinical applications. J Am Coll Cardiol 2005;45
[134] Turkmen M, Barutcu I, Esen AM, Karakaya O, Esen O, Basaran Y. (11):1739–47.
Exercise-induced QRS amplitude changes in patients with isolated [141] Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE
myocardial bridging: a marker of myocardial ischemia. Angiology 2003 guideline update for the clinical application of echocardio-
2005;56(3):265–71. graphy: summary article: a report of the American College of
[135] Lai S, Kaykha A, Yamazaki T, et al. Treadmill scores in elderly men. J Cardiology/American Heart Association Task Force on Practice
Am Coll Cardiol 2004;43(4):606–15. Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guide-
[136] EXTRA S. http://www.sunnysidebiomedical.com/products_services/, lines for the Clinical Application of Echocardiography). Circulation
Accessed 30 March 2006. 2003;108(9):1146–62.
[137] Johansen A, Hoilund-Carlsen PF, Christensen HW, et al. Diagnostic
accuracy of myocardial perfusion imaging in a study population
without post-test referral bias. J Nucl Cardiol 2005;12(5):530–7.

Electrocardiographic Exercise Stress Testing PDF

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International Journal of Cardiology 116 (2007) 285 – 299

Keywords: Stress testing; Treadmill testing; Gender; Score

1. Introduction 2. Normal versus abnormal tests

3.1. Exercise electrocardiography after an acute coronary

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