Correlation of “critical” left coronary artery lesions with positive submaximal exercise tests in patients with chest pain

Cheitlin, M.D.; Davia, James E.; Castro, Carlos M. de; Barrow, Emile A.; Anderson, Warren T.

doi:10.1016/0002-8703(75)90080-0

Cited by 68 publications

(10 citation statements)

References 9 publications

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“…12 Patients with chest pain and > 2.0 mm of exerciseinduced ST-segment depression in a left precordial (V,) lead have been reported to have a 75% incidence of left main, left main equivalent or proximal left anterior descending coronary artery disease. 13 Another study reported similar results, but the authors found that 50% of the patients who demonstrated > 2.0 mm ST depression did not have critical lesions.14 While providing important predictive information, extrapolation of this criterion to specific coronary anatomic lesions may result in a significant chance of error.…”

Section: Resultsmentioning

confidence: 91%

Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery.

Gerson¹,

Phillips²,

Morris³

et al. 1979

Circulation

132

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SUMMARY The prevalence and cineangiographic correlates of exercise-induced inversion of U waves were studied in 248 patients. Exercise-induced U-wave inversion was observed in 36 patients (15%), of whom 35 had > 75% stenosis in one or more of the major coronary arteries. The proximal left anterior descending or left main coronary artery was involved in 33 of these patients, including 24 patients with no electrocardiographic evidence of anterior myocardial infarction. Exercise-induced U-wave inversion was observed in the absence of an abnormal ST-segment response in eight of the 166 patients (4.8%) with coronary artery disease, and five of these patients had a normal resting 12-lead ECG. Only one of the 82 patients (1.2%) without significant coronary artery disease demonstrated exercise-induced U-wave inversion, and this patient had a primary cardiomyopathy. We conclude that exercise-induced inversion of the U-wave is highly predictive of significant coronary artery disease and, more specifically, of disease of the proximal left anterior descending coronary artery.INVERTED U WAVES in the left precordial leads of a 12-lead ECG have been described in patients with left ventricular hypertrophy and coronary artery disease.' Similarly, the development of U-wave inversion during exercise has been described as an indicator of coronary artery disease and exercise-induced myocardial ischemia.2 3 The coronary cineangiographic correlates of exercise-induced U-wave inversion have not been reported. We previously reported an apparent high prevalence of disease of the proximal left anterior descending coronary artery in patients with exercise-induced inversion of U waves.4 This study of 257 consecutive patients who underwent treadmill exercise testing and coronary arteriographic studies was undertaken to determine the prevalence and coronary cineangiographic correlates of exercise-induced Uwave inversion. were six patients with electrocardiographic evidence of left ventricular hypertrophy by the Estes criteria5 and three patients with resting U-wave inversion. These nine patients were excluded from further study, leaving 248 patients. There were 190 males (77%) and 58 females (23%), mean age 51 years (range 19-73 years). Twenty patients were taking a digitalis preparation, 91 taking propranolol, 92 taking long-acting nitrates, four taking quinidine and one taking disopyramide. Two hundred seventeen patients had a history of chest pain and 126 were considered to have typical exterional angina pectoris. Nine patients underwent cardiac catheterization as a part of an evaluation for refractory ventricular arrhythmias and 10 asymptomatic subjects were evaluated because of an abnormal treadmill exercise test. The remaining 12 patients underwent cardiac catheterization for other reasons. Thirty-eight patients had electrocardiographic patterns of anterior myocardial infarction. They were considered as a separate subgroup because patients with these electrocardiographic patterns would be expected to have a high incidence of significant...

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Section: Resultsmentioning

confidence: 91%

Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery.

Gerson¹,

Phillips²,

Morris³

et al. 1979

Circulation

132

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“…Thus, graphic representations of the marginal costs of each strategy show a clear increase in the slope of the curve between Strategy 3 and Strategy 4 (figs. [5][6][7][8].…”

Section: Discussionmentioning

confidence: 99%

Cost-Effectiveness of Screening Strategies for Left Main Coronary Artery Disease in Patients with Stable Angina

Lee¹,

Fukui²,

Weinstein³

et al. 1988

Med Decis Making

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To define optimal strategies for screening for left main coronary artery disease (LMCAD), the authors evaluated the cost-effectiveness of exercise tolerance testing and cardiac catheterization in patients with mild stable chest pain, such as patients with definite or probable angina in the Coronary Artery Surgery Study registry (prevalence of LMCAD = 9%). Performance characteristics of the exercise test, operative mortality, long-term survival rates, and rates of crossing over to surgical therapy for patients initially managed with medical therapy were derived from pooled literature data; cost estimates were based on local charge data. Strategies using the exercise test to identify candidates for catheterization were associated with longer life expectancies than either the conservative strategy in which patients would be observed or the more aggressive strategy in which all patients would undergo coronary angiography. The most cost-effective option was to screen patients with an exercise test and to perform catheterization in patients with greater than or equal to 2 mm of ST-segment change. Compared with a strategy of catheterization for greater than or equal to 3 mm of ST-segment change only, this strategy increased life expectancy at marginal costs per year of life saved ranging from $11,263 to $18,100 for 40- to 70-year-old patients, respectively, while, compared with a strategy of observation unless symptoms worsened, its incremental cost-effectiveness was $6,510 to $12,428 per year of life saved. Thus, screening patients with stable chest pain syndromes with exercise tests and performing catheterization for patients with greater than or equal to 2 mm of ST-segment change has cost-effectiveness comparable to that of the treatment of moderate diastolic hypertension.

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“…In a highly selected group of patients with known coronary artery disease, subjects demon strating greater than or equal to 3 mm o f S-T segment depression had a higher prevalence of multivessel disease and left anterior descending stenosis compared with those with lesser degrees of S-T segment depression (9). Others have noted patients with 2 mm or more of S-T segment depression were more likely to have 'critical lesions' (left main, left main equivalent or proximal left anterior descending) compared with those having less pronounced changes (7). Although these earlier investigations show a correlation between extensive coronary artery disease and marked degrees of S-T segment depression, only patients with documented coronary artery obstruction were included for evaluation.…”

Section: Discussionmentioning

confidence: 99%

Clinical, Angiographic and Hemodynamic Characteristics of Patients with a Strongly Positive Exercise Test

Williams

Most

1980

Cardiology

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To determine the clinical, angiographic and hemodynamic characteristics of patients with a strongly positive exercise test, 37 subjects demonstrating ≧ 3 mm S-T segment depression were identified among 892 consecutive diagnostic treadmill evaluations. Typical angina by history was present in 78%. 30 patients (81%) had a normal resting electrocardiogram. The strongly positive exercise response was elicited at < 90% of the predicted maximal heart rate in 31 patients (84%). 20% of patients did not experience angina during testing. 20 patients underwent cardiac catheterization. All 20 demonstrated multivessel disease and each had significant stenosis of either the left main (25%) or left anterior descending (95%) coronary artery. Left ventricular function was well preserved.

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Correlation of “critical” left coronary artery lesions with positive submaximal exercise tests in patients with chest pain

Cited by 68 publications

References 9 publications

Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery.

Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery.

Cost-Effectiveness of Screening Strategies for Left Main Coronary Artery Disease in Patients with Stable Angina

Clinical, Angiographic and Hemodynamic Characteristics of Patients with a Strongly Positive Exercise Test

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