Incremental prognostic value of the exercise electrocardiogram in the initial assessment of patients with suspected angina: cohort study (original) (raw)
Related papers
2008
Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
The Prognostic Utility of Exercise Ecg Testing in Patients Over 75 Years of Age with Angina
Journal of the American College of Cardiology, 2010
Background: Exercise testing plays an important role in the diagnostic and prognostic assessment of CAD. The sensitivity and specificity of the tests are largely dependent on the prevalence of CAD and are generally higher for the elderly population. Most clinical studies have been done in the younger and middle age groups. How exercise capacity affects those >75 years of age is unlikely to be the subject of a controlled trial, given the many benefits known to be associated with physical activity. We sought to determine the value of exercise capacity (metabolic equivalents or METS) compared to ECG ischemic changes among patients over 75 years of age referred for CAD workup. Methods: We studied 2383 patients over 75 years who had treadmill exercise stress testing and compared the value of exercise capacity to ECG ischemic changes for prediction of all-cause death. Results: During a mean follow-up of 6.4+/-4.1 years, 1046 patients (44%) died. The median exercise capacity was 6.2 METS. Poor exercise capacity (<6.2 METS) was a strong predictor of death (adjusted hazard ratio of 0.88, 95% CI: 0.85-0.90, p = <0.001) but not ECG ischemic changes (adjusted hazard ratio of 0.97, 95% CI: 0.84-1.13, p = 0.69). Other significant predictors include the male gender and age. Conclusions: Patients 75 and older who can exercise more during ECG stress testing (>6.2 METS) have lower all-cause mortality rates. Exercise capacity is a stronger predictor than ECG ischemic changes in this population of elderly patients referred for chest pain. CORE Metadata, citation and similar papers at core.ac.uk
The American Journal of Emergency Medicine, 2012
Background: Several risk scores are available for prognostic purpose in patients presenting with chest pain. Aim: The aim of this study was to compare Grace, Pursuit, Thrombolysis in Myocardial Infarction (TIMI), Goldman, Sanchis, and Florence Prediction Rule (FPR) to exercise electrocardiogram (ECG), decision making, and outcome in the emergency setting. Methods: Patients with nondiagnostic ECGs and normal troponins and without history of coronary disease underwent exercise ECG. Patients with positive testing underwent coronary angiography; otherwise, they were discharged.
The value of routine non-invasive tests to predict clinical outcome in stable angina
European Heart Journal, 2003
Background Chronic stable angina is a common condition, but considerable differences exist in the likelihood of acute coronary events such as CHD death, non-fatal myocardial infarction (MI) and unstable angina between individual patients. Effective risk prediction is necessary for optimum management. The aim of this study was to identify clinical features and non-invasive test parameters associated with high risk of these coronary events in stable angina and compose a clinically useful model to predict adverse outcomes in this population. Methods Six hundred and eighty-two patients with stable angina and a positive exercise test (1 mm ST depression) from the Total Ischaemic Burden European Trial (TIBET) study, were studied. Resting ECG, exercise tolerance testing and echocardiography were performed at baseline, off anti-anginal therapy. The patients were then randomised to treatment with atenolol, nifedipine or a combination of both. Clinical follow up continued for an average of 2 years (range 1-3 years). Results and conclusions Prior MI or prior CABG were the clinical parameters associated with adverse outcome in patients with stable angina and a positive exercise test. On the ECG, left ventricular hypertrophy was predictive, and on echocardiogram, increased left ventricular dimensions were predictive of adverse events. When combined with time to ischaemia on exercise testing in a simple clinically applicable table these factors could be used to predict of 2 year probability of events for an individual patient.
Coronary Artery Disease, 2017
Background Several variables of electrocardiogram exercise testing (EET) predict cardiovascular events in the general population and in patients with coronary artery disease (CAD). However, most of the studies have not included patients with asymptomatic CAD. The aim of this study was to evaluate the prognostic value of EET in asymptomatic CAD patients. Patients and methods We carried out a retrospective single-center analysis including all patients with asymptomatic CAD documented by angiography who underwent EET from January 2010 to December 2013. A number of EET variables and three exercise scores [Duke Treadmill Score (DTS), Morise score, and FIT score] were analyzed. The primary endpoint was the combined incidence of myocardial infarction (MI), myocardial revascularization, and death from any cause during follow-up. Results A total of 306 patients were included (mean age was 65 ± 10 years, 61% had previous MI, and the median exercise capacity was 9.4 ± 2.7 metabolic equivalent of task). The primary endpoint occurred in 15.7% of patients during 3.3 years of follow-up. The DTS and FIT were independent predictors of the primary endpoint unlike the Morise score (DTS: hazard ratio = 0.91, 95% confidence interval: 0.85-0.99, P = 0.018; FIT score: 0.99, 0.98-0.996, P = 0.001; Morise score: 0.97, 0.93-1.02, P = 0.20). The DTS was independent predictor of MI or revascularization, whereas FIT predicted death from any cause. Excluding patients with early revascularization, DTS had no predictive power at the composite endpoint. Conclusion In our population with asymptomatic CAD, FIT and DTS had significant value for risk prediction and consequently the EET can be a valid tool in the clinical follow-up of this population.
International Journal of Cardiology, 1995
We studied by means of probability analysis the role of exercise ECG in identifying coronary restenosis. A total of 213 patients were independently evaluated by clinical history, conventional assessment of the exercise ECG ('yes or no' statement), D score (a discriminant function derived from exercise ECG), and coronariograpby, 5.4 f 2.8 months after successful coronary angioplasty. The initial probability of restenosis (300/o), that is, the prevalence of the condition, was radically changed by the result of clinical history (77% for patients with angina vs. 17% for those without angina). By contrast, ECG binary assessment, due to its low accuracy (70% vs 82% of clinical history, P < O.OOS), was unable to signiticantly change the established probabilities after symptomatic evaluation. Finally, D score, which greatly enhanced specificity (92% vs. 76% of bivariate assessment, P < O.OOOl), proved to be useful in changing the probability (from 32% to 76% or to 25%) of patients (n = 34) with a discordant result (no angina/positive exercise ECG). When this stepwise approach was tested in 46 new patients, predicted and observed probabilities were actually very similar. We conclude that exercise ECG has a very limited role in identifying coronary restenosis if positive responses are not adjusted with a weighted score which takes into account other exercise derived factors.
Journal of the American College of Cardiology, 1991
From the Halhlrnm tovsca• ulCuNiulngy. Royal Prince Alfred Hospital. Camperdowa. Sydney. su,onlia. Dr. wiko, wa, supported by a Ratgradna Medical Res est, Schulanhip from The Nat,aeaI Hens Fnundmien. The 'in, y eau ,pi anad in pmt by a grant-in11d from The N:aiarsl HeAth and Medical Research C,nn it of na,lrara.
Journal of the American College of Cardiology, 1988
The reldion of siteat ischemia in patients with stable angina to known predictors of severity of coronary dii on exercise stress testing and coronaq angiography is poorly de&d. TLL issue was therefore examined with use ef HOW ekctmmdiipldc (ECG) recordi, treadmill exe&se t&3 Plrd ongiographic i&xes ill 102 patients (not takiq antian&al therapy) and the results were compared with Hdter and tre&niU findings in 42 vohmteers. A total d 159 is&e& episodes (90% silent) were identikd during 2,503 h on Hotter recordiig in 97 patients (mean duration per episode 22.7 + 147 min; range 1 to 234). H&r recordings had a 92% specificity and an 80% positive predictive value, hut a sensitivity of only 37% and a ~@ve predictive value of 27% for coronary dii. sixty-three patients (Group I) had no i&e& on Hdter recordhtg, 22 (Group 11) bad a cumulative duration of 1 to 60 lain&l h and in 12 (Group 111) ischensia exceeded 60 r&O4 h. There WPJ no sigNkant correlation between There is now compelling evidence that spontaneous episodes of transient myocardial ischemia in the absence of symptoms occur in unstable as well as stable coronary syndromes (I-6). Although such asymptomatic episodes. termed "silent cumutative is&e& duratien 011 Helter recur&g exercise duration OT time to ST segmeut depressien 011 treadmill exercise. In genera& th pitter tk msm coronary wssels invelved coronary artery stenosis i!xhemiaaItdtkEolQer on Ho&et recnrdiqg. irmpef3ive of the severity of carenary dii, in about 25% of Hotter w ia each angiographii category there were no ischemic epkodes. The 12 patients in Group III (isehemia duration Ml mid24 h) had a If&d greater probabitity of having three vesselorieft-dfscoseaada4 er probability of h&g a frigllcr proxhd ry slenosis index (p C 8.&33 zr#l p C 0.@4, respectively). Thus, evidcnre of prdoqgd ischenda oa Mter ECG recording increases the liktlikood that a pa&eat has mnttivessei coronary diiase hut its absence is Or We predictive value. (J Am Cd Ctwdkd 1988;I2:M9-76~
The American Journal of Cardiology, 1999
The prognostic significance of ambulatory ischemia, alone and in relation to ischemia during exercise was assessed in 686 patients (475 men) with chronic stable angina pectoris taking part in the Angina Prognosis Study In Stockholm (APSIS), who had 24-hour ambulatory electrocardiographic registrations and exercise tests at baseline (n ؍ 678) and after 1 month (n ؍ 607) of double-blind treatment with metoprolol or verapamil. Ambulatory electrocardiograms were analyzed for ventricular premature complexes and ST-segment depression. During a median follow-up of 40 months, 29 patients died of cardiovascular (CV) causes, 27 had a nonfatal myocardial infarction, and 89 underwent revascularization. Patients with CV death had more episodes (median 5 vs 1; p <0.01) and longer median duration (24 vs 3 minutes; p <0.01) of ST-segment depression than patients without events. For those who had undergone revascularization, the duration was also longer (12 vs 3 minutes; p <0.05). In a multivariate Cox model including sex, history of previous myocardial in-farction, hypertension, and diabetes, the duration of ST-segment depression independently predicted CV death. When exercise testing was included, ambulatory ischemia carried additional prognostic information only among patients with ST-segment depression >2 mm during exercise. When the treatment given and treatment effects on ambulatory ischemia were added to the Cox model, no significant impact on prognosis was found. Ventricular premature complexes carried no prognostic information. Thus, in patients with stable angina pectoris, ischemia during ambulatory monitoring showed independent prognostic importance regarding CV death. Ambulatory electrocardiographic monitoring and exercise testing provide complementary information, but only among patients with marked ischemia during exercise. Treatment reduced ambulatory ischemia, but the short-term treatment effects did not significantly influence prognosis. ᮊ1999 by Excerpta Medica, Inc.