Diagnosis of Obstructive Coronary Disease by Maximal Exercise and Atrial Pacing

Abstract

The reliability of graded maximal exercise treadmill testing and right atrial pacing in diagnosing significant obstructive coronary artery disease was evaluated in 74 consecutive patients referred to a cardiac unit with chest pain consistent with angina pectoris. The results of maximal exercise testing and right atrial pacing, with regard to the presence or absence of the patient's characteristic chest pain or discomfort and ischemic ST segment depression, were compared with the findings determined by selective coronary arteriography. Ischemic ST segment depression was defined as a downward displacement of one full mm or more of a horizontal or downward sagging ST segment.Forty-nine of the 74 patients studied were found to have significant coronary arteriographic obstruction, i.e., greater than 75% obstruction of one major coronary artery. The occurrence of the patient's characteristic chest pain or discomfort during maximal exercise testing or right atrial pacing is an excellent indicator of the presence of obstructive coronary artery disease, since all of the 41 patients developing their characteristic pain on maximal exercise testing had coronary arteriograms positive for obstructive coronary disease (no false positives), and 46 of 47 patients with characteristic chest pain on right atrial pacing had selective coronary arteriograms positive for obstructive coronary disease. When present, one mm ST depression during maximal exercise treadmill testing also reliably indicates arteriographic obstructive coronary disease (26 of 27 patients). However, the presence or absence of ischemic ST depression during right atrial pacing is a particularly unreliable indication of the presence or absence of arteriographic obstructive coronary disease: 15 of 25 false positive tests, and 13 of 49 false negative tests.Additional Indexing Words: Coronary arteriographyChest pain T HE ABILITY to distinguish chest pain due to obstructive coronary artery disease from chest pain from other causes is of obvious clinical importance. Two methods of stressing the heart that have been used extensively, and that appear to be most useful in making this differentiation, are maximal exercise testingl-5 and right atrial pacing. 61

Cardiac Function in Chronic Bronchitis: Effects of Pacing and Plasma Expansion

“…Fast atrial pacing is a safe procedure to detect coronary insufficiency (Kelemen et al, 1973;Piessens, Van Mieghem, Kesteloot & De Geest, 1974). We cannot state with certainty that our patients do not have coronary heart disease but their normal pacing tests make it unlikely.…”

“…We used acute plasma volume expansion to reveal incipient left ventricular dysfunction (Sanghvi, Khaja, Mark & Parker, 1972;Roche, Masquet, Gourgon, Macrez & Bouvrain, 1974) and atrial pacing to detect coronary artery disease (Linhart, 1972a;Kelemen, Gillilan, Bouchard, Heppner & Warbasse, 1973). (Documenta Geigy, 1963).…”

Analysis of multiple noninvasive test procedures for the diagnosis of coronary artery disease

“…Although a mainstay in diagnosing coronary artery disease (CAD), the exercise ECG has a reported false-negative rate of approximately 35% and a false-positive rate of 15% in large populations of symp tomatic patients (Ascoop et al, 1971;Bartel et al. 1974a;Degenais et al, 1977;Goldschlager et al, 1976;Kaplan et al, 1973;Kassebaum et al, 1978;Kelemen et al, 1973;Linhart and Turnoff, 1974;McHenry et al 1972;Martin and McConahay, 1972;Mason et al, 1967;Roitman et al, 1970;Sketch et al. 1975;Vieweg et al, 1977).…”

A high-pass phaseless filter for eliminating low-frequency ECG noise during exercise and its clinical application to automatic analysis of the heart rate and ST segment level.

“…phaseless filter ; heart rate ; ST segment level ; exercise stress test A maximal or submaximal exercise ECG test has been advocated as a reliable method for the early detection of coronary artery disease, but there are still some limitations in the clinical application of these tests. Many reports have shown that about 10 to 19% of patients with ischemic heart disease revealed significant ST segment level changes only during exercise (Bellet et al 1961;McConahay et al 1971;McHenry et al 1972; Kehleman et al 1973;Froelicher et al 1974). These reports have suggested that ECG recording during exercise is required for accurate diagnosis.…”