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Exercise Testing

  • Abhay Atul Laddu
  • Lisa Alderson
  • Bernard R. Chaitman
Chapter
Part of the Cardiovascular Medicine book series (CVM)

Abstract

Patients with known or suspected coronary artery disease often undergo exercise stress testing to either diagnose coronary artery disease or to determine functional status or prognosis. Frequently, though, more advanced imaging techniques are combined with the exercise ECG portion and the information obtained from the exercise ECG test is underappreciated. In this chapter, we review the current indications and contraindications of exercise ECG testing, as well as interpretations of exercise ECG testing. We also review how the exercise ECG can aid in the diagnosis of coronary artery disease, and the prognostic implications of a normal or abnormal test result. Finally, as the economic landscape of medicine rapidly changes and more emphasis is being placed on cost-saving, we discuss the cost-effectiveness of exercise ECG testing compared to more advanced stress imaging protocols.

Keywords

Coronary disease Cost-benefit analysis, diagnosis Electrocardiography Exercise Ischemia 

Abbreviations

ACIP

Asymptomatic Cardiac Ischemia Pilot

ACLS

Advanced cardiac life support

BARI

Bypass Angioplasty Revascularization Investigation

CABG

Coronary artery bypass grafting

CAD

Coronary artery disease

CCU

Cardiac care unit

CPET

Cardiopulmonary exercise testing

DTS

Duke treadmill score

ECG

Electrocardiogram

ETT

Exercise treadmill testing

HRR

Heart-rate recovery

LAD

Left anterior descending

MET

Metabolic equivalents

MI

Myocardial infarction

MPI

Myocardial perfusion imaging

NIH

National Institutes of Health

PCI

Percutaneous coronary intervention

PTCA

Percutaneous transluminal coronary angioplasty

STS

Society of Thoracic Surgeons

WOMEN

What Is the Optimal Method for Ischemia Evaluation in Women Trial

References

  1. 1.
    Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Washington, DC: American College of Cardiology; 2002.Google Scholar
  2. 2.
    Chaitman BR. Exercise stress testing. In: Bonow R, Mann DL, Zipes D, Libby P, editors. Braunwald’s 9th edition of heart disease (a textbook of cardiovascular medicine). Philadelphia: Elsevier; 2011. p. 168–99.Google Scholar
  3. 3.
    Noël M, Jobin J, Marcoux A, Poirier P, Dagenais G, Bogaty P. Comparison of myocardial ischemia on the ergocycle versus the treadmill in patients with coronary heart disease. Am J Cardiol. 2010;105:633–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Chan AK, Ilias-Khan NA, Xian H, Inman C, Martin WH. Arm exercise stress perfusion imaging predicts clinical outcome. J Appl Physiol. 2011;111:1546–53.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Porszasz J, Casaburi R, Somfay A, Woodhouse LJ, Whipp B. A treadmill protocol using simultaneous changes in speed and grade. Med Sci Sports Exerc. 2003;35:1596–603.CrossRefPubMedGoogle Scholar
  6. 6.
    Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, et al. Testing of low-risk patients presenting to the emergency department with chest pain. A scientific statement from the American Heart Association. Circulation. 2010;122:1756–76.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Azarbal B, Hayes SW, Lewin HC, Hachamovitch R, Cohen I, Berman DS. The incremental prognostic value of percentage of heart rate reserve achieved over myocardial perfusion single-photon emission computed tomography in the prediction of cardiac death and all-cause mortality: superiority over 85 % of maximal age-predicted heart rate. J Am Coll Cardiol. 2004;44:423–30.CrossRefPubMedGoogle Scholar
  8. 8.
    Brubaker PH, Kitzman DW. Chronotropic incompetence. Causes, consequences, and management. Circulation. 2011;123:1010–20.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Gulati M, Shaw LJ, Thisted RA, Black HR, Bairey Merz CN, Arnsdorf MF. Heart rate response to exercise stress testing in asymptomatic women. The St James Women Take Heart Project. Circulation. 2010;122:130–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Vivekananthan DP, Blackstone EH, Potheir CE, Lauer MS. Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease. J Am Coll Cardiol. 2003;42:831–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Gayda M, Bourassa MG, Tardif JC, Fortier A, Juneau M, Nigam A. Heart rate recovery after exercise and long-term prognosis in patients with coronary artery disease. Can J Cardiol. 2012;28:201–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Jolly MA, Brennan DM, Cho L. Impact of exercise on heart rate recovery. Circulation. 2011;124:1520–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Rich D, Chen S, Ward RP. Comparison of high risk stress myocardial perfusion imaging findings in men with rapid versus prolonged recovery of ST-segment depression after exercise stress testing. Am J Cardiol. 2010;105:1361–4.CrossRefPubMedGoogle Scholar
  14. 14.
    Uthamalingam S, Zheng H, Leavitt M, Pomerantsev E, Ahmado I, Gurm GS, et al. Exercise-induced ST-segment elevation in ECG lead aVR is a useful indicator of significant left main or ostial LAD coronary artery stenosis. J Am Coll Cardiol Img. 2011;4:176–86.CrossRefGoogle Scholar
  15. 15.
    Gianrossi R, Detrano R, Mulvihill D, Lehmann K, Dubach P, Colombo A, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation. 1989;80:87–98.CrossRefPubMedGoogle Scholar
  16. 16.
    Froelicher VF, Fearon WF, Ferguson C, Morise AP, Heidenreich P, West J, et al. Lessons learned from studies of the standard exercise ECG test. Chest. 1999;116:1442–51.CrossRefPubMedGoogle Scholar
  17. 17.
    Morise AP, Diamond GA. Comparison of the sensitivity and specificity of exercise electrocardiography in biased and unbiased populations of men and women. Am Heart J. 1995;130:741–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346:793–801.CrossRefPubMedGoogle Scholar
  19. 19.
    Marshall AJ, Hutchings F, James AJ, Kelion AD. Prognostic value of a nine-minute treadmill test in patients undergoing myocardial perfusion scintigraphy. Am J Cardiol. 2010;106:1423–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. 1987;106:793–800.CrossRefPubMedGoogle Scholar
  21. 21.
    Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med. 1991;325:849–53.CrossRefPubMedGoogle Scholar
  22. 22.
    Kwok JMF, Miller TD, Hodge DO, Gibbons RJ. Prognostic value of the Duke treadmill score in the elderly. J Am Coll Cardiol. 2002;39:1475–81.CrossRefPubMedGoogle Scholar
  23. 23.
    Alexander KP, Shaw LJ, DeLong ER, Mark DB, Peterson ED. Value of exercise treadmill testing in women. J Am Coll Cardiol. 1998;32:1657–64.CrossRefPubMedGoogle Scholar
  24. 24.
    Morise AP, Jalisi F. Evaluation of pretest and exercise test scores to assess all-cause mortality in unselected patients presenting for exercise testing with symptoms of suspected coronary artery disease. J Am Coll Cardiol. 2003;42:842–50.CrossRefPubMedGoogle Scholar
  25. 25.
    Morise AP, Olson MB, Merz CNB, Mankad S, Rogers WJ, Pepine WJ, et al. Validation of the accuracy of pretest and exercise test scores in women with a low prevalence of coronary disease: the NHLBI-sponsored Women’s Ischemia Syndrome Evaluation (WISE) study. Am Heart J. 2004;147:1085–92.CrossRefPubMedGoogle Scholar
  26. 26.
    Aktas MK, Ozduran V, Pothier CE, Lang R, Lauer MS. Global risk scores and exercise testing for predicting all-cause mortality in a preventive medicine program. JAMA. 2004;292:1462–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Erikssen G, Bodegard J, Bjornholt JV, Liestol K, Thelle DS, Erikssen J. Exercise testing of healthy men in a new perspective: from diagnosis to prognosis. Eur Heart J. 2004;25:978–86.CrossRefPubMedGoogle Scholar
  28. 28.
    Gibbons LW, Mitchell TL, Wei M, Blair SN, Cooper KH. Maximal exercise test as a predictor of risk for mortality from coronary heart disease in asymptomatic men. Am J Cardiol. 2000;86:53–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Balady GJ, Larson MG, Vasan RS, Leip EP, O’Donnell CJ, Levy D. Usefulness of exercise testing in the prediction of coronary disease risk among asymptomatic persons as a function of the Framingham Risk Score. Circulation. 2004;110:1920–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham Score for risk prediction in asymptomatic individuals. JAMA. 2004;291:210–5.CrossRefPubMedGoogle Scholar
  31. 31.
    Gulati M, Pandey DK, Arnsdorf MF, Lauderdale DS, Thisted RA, Wicklund RH, et al. Exercise capacity and the risk of death in women. The St James Women Take Heart Project. Circulation. 2003;108:1554–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Mora S, Redberg RF, Cui Y, Whiteman MK, Flaws JA, Sharrett AR, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women. A 20-year follow-up of the Lipid Research Clinics Prevalence Study. JAMA. 2003;290:1600–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Kotowycz MA, Cosman TL, Tartaglia C, Afzal R, Syal RP, Natarajan MK. Safety and feasibility of early hospital discharge in ST-segment elevation myocardial infarction – a prospective and randomized trial in low-risk primary percutaneous coronary intervention patients (the Safe-Depart Trial). Am Heart J. 2010;159:117.e1–6.CrossRefGoogle Scholar
  34. 34.
    Kandzari DE, Tcheng JE, Cohen DJ, Bakhai A, Grines CL, Cox DA, et al. Feasibility and implications of an early discharge strategy after percutaneous intervention with Abciximab in acute myocardial infarction (the CADILLAC Trial). Am J Cardiol. 2003;92:779–84.CrossRefPubMedGoogle Scholar
  35. 35.
    Jeremy RW. Early discharge after percutaneous intervention – we can but should we? Heart Lung Circ. 2011;20:351–2.CrossRefPubMedGoogle Scholar
  36. 36.
    Newby LK, Eisenstein EL, Califf RM, Thompson TD, Nelson CL, Peterson ED, et al. Cost effectiveness of early discharge after uncomplicated acute myocardial infarction. N Engl J Med. 2000;342:749–55.CrossRefPubMedGoogle Scholar
  37. 37.
    Blankstein R, Ahmed W, Bamberg F, Rogers IS, Schlett CL, Nasir K, et al. Comparison of exercise treadmill testing with cardiac computed tomography angiography among patients presenting o the emergency room with chest pain. The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) Study. Circ Cardiovasc Imaging. 2012;5:233–42.CrossRefPubMedGoogle Scholar
  38. 38.
    Gibbons RJ, Hodge DO, Berman DS, Akinboboye OO, Heo J, Hachamovitch R, et al. Long-term outcome of patients with intermediate-risk exercise electrocardiograms who do not have myocardial perfusion defects on radionuclide imaging. Circulation. 1999;100:2140–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Dewey FE, Kapoor JR, Williams RS, Lipinski MJ, Ashley EA, Hadley D, et al. Ventricular arrhythmias during clinical treadmill testing and prognosis. Arch Intern Med. 2008;168:225–34.CrossRefPubMedGoogle Scholar
  40. 40.
    Engel G, Beckerman JG, Froelicher VF, Yamazaki T, Chen HA, Richardson K, et al. Electrocardiographic arrhythmia risk testing. Curr Probl Cardiol. 2004;29:365–432.CrossRefPubMedGoogle Scholar
  41. 41.
    Tan JH, Scheinman MM. Exercise-induced polymorphic ventricular tachycardia in adults without structural heart disease. Am J Cardiol. 2008;101:1142–6.CrossRefPubMedGoogle Scholar
  42. 42.
    Morshedi-Meibodi A, Evans JC, Levy D, Larson MG, Vasan RS. Clinical correlates and prognostic significance of exercise-induced ventricular premature beats in the community: the Framingham Heart Study. Circulation. 2004;109:2417–22.CrossRefPubMedGoogle Scholar
  43. 43.
    Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med. 2003;348:781–90.CrossRefPubMedGoogle Scholar
  44. 44.
    O’Neill JO, Young JB, Pothier CE, Lauer MS. Severe frequent ventricular ectopy after exercise as a predictor of death in patients with heart failure. J Am Coll Cardiol. 2004;44:820–6.CrossRefPubMedGoogle Scholar
  45. 45.
    Bunch TJ, Chadrasekaran K, Gersh BJ, Hammill SC, Hodge DO, Khan AH, et al. The prognostic significance of exercise-induced atrial arrhythmias. J Am Coll Cardiol. 2004;43:1236–40.CrossRefPubMedGoogle Scholar
  46. 46.
    Jeger RV, Zellweger MJ, Kaiser C. Prognostic value of stress testing in patients over 75 years of age with chronic angina. Chest. 2004;125:1124–31.CrossRefPubMedGoogle Scholar
  47. 47.
    Lai S, Kaykha A, Yamazaki T, Goldstein M, Spin JM, Myers J, et al. Treadmill scores in elderly men. J Am Coll Cardiol. 2004;43:606–15.CrossRefPubMedGoogle Scholar
  48. 48.
    Messinger-Rapport B, Pothier Snader CE, Slbackstone EH, Yu D, Lauer MS. Value of exercise capacity and heart rate recovery in older people. J Am Geriatr Soc. 2003;51:63–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Afilalo J, Eisenberg MJ, Morin JF, Bergman H, Monette J, Noiseux N, et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol. 2010;56:1668–76.CrossRefPubMedGoogle Scholar
  50. 50.
    Krone RJ, Hardison RM, Chaitman BR, Gibbons RJ, Sopko G, Bach R, et al. Risk stratification after successful coronary revascularization: the lack of a role for routine exercise testing. J Am Coll Cardiol. 2001;38:136–42.CrossRefPubMedGoogle Scholar
  51. 51.
    Sellier P, Chatellier G, D’Agrosa-Boiteux MC, Douard H, Dubois C, Goepfert PC, et al. Use of non-invasive cardiac investigations to predict clinical endpoints after coronary bypass graft surgery in coronary artery disease patients: results from the prognosis and evaluation of risk in the coronary operated patient (PERISCOP) study. Eur Heart J. 2003;24:916–26.CrossRefPubMedGoogle Scholar
  52. 52.
    Roffi M, Wenaweser P, Windecker S, Mehta H, Eberli FR, Seiler C, et al. Early exercise after coronary stenting is safe. J Am Coll Cardiol. 2003;42:1569–73.CrossRefPubMedGoogle Scholar
  53. 53.
    Weisman IM, Beck KC, Casaburi R, Cotes JE, Crapo RO, Dempsey JA, et al. ATS/ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med. 2003;167:211–77.CrossRefGoogle Scholar
  54. 54.
    Corra U, Mezzani A, Bosimini E, Giannuzzi P. Cardiopulmonary exercise testing and prognosis in chronic heart failure: a prognosticating algorithm for the individual patient. Chest. 2004;126:942–50.CrossRefPubMedGoogle Scholar
  55. 55.
    Arena R, Sietsema KE. Cardiopulmonary exercise testing in the clinical evaluation of patients with heart and lung disease. Circulation. 2011;123:668–80.CrossRefPubMedGoogle Scholar
  56. 56.
    Holland DJ, Kumbhani DJ, Ahmed SH, Marwick TH. Effects of treatment on exercise tolerance, cardiac function, and mortality in heart failure with preserved ejection fraction: a meta-analysis. J Am Coll Cardiol. 2011;57:1676–86.CrossRefPubMedGoogle Scholar
  57. 57.
    Lee MS, Finch W, Weisz G, Kirtane AJ. Cardiac allograft vasculopathy. Rev Cardiovasc Med. 2011;12:143–52.PubMedGoogle Scholar
  58. 58.
    Shaw LJ, Mieres JH, Hendel RH, Boden WE, Gulati M, Veledar E, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease. Results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) Trial. Circulation. 2011;124:1239–49.CrossRefPubMedGoogle Scholar
  59. 59.
    Shah BR, Cowper PA, O’Brien SM, Jensen N, Drawz M, Patel MR, et al. Patterns of cardiac stress testing after revascularization in community practice. J Am Coll Cardiol. 2010;56:1328–34.CrossRefPubMedGoogle Scholar
  60. 60.
    Galper BZ, Moran A, Coxson PG, Pletcher MJ, Heidenreich P, Lazar LD, et al. Using stress testing to guide primary prevention of coronary heart disease among intermediate-risk patients. A cost-effectiveness analysis. Circulation. 2012;125:260–70.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer-Verlag London 2015

Authors and Affiliations

  • Abhay Atul Laddu
    • 1
  • Lisa Alderson
    • 1
  • Bernard R. Chaitman
    • 1
  1. 1.Center for Comprehensive Cardiovascular Care, Department of Internal MedicineSaint Louis University School of MedicineSt. LouisUSA

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