Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography

Daubert, Melissa A.; Sivak, Joseph; Dunning, Allison; Douglas, Pamela S.; Coyne, Brian J.; Wang, Tracy Y; Mark, Daniel B.; Velázquez, Eric J.

doi:10.1001/jamainternmed.2019.6958

“…[1][2][3][4] In the ischaemic cascade, regional wall abnormalities occur before ECG changes. [17] Non-ischaemic stress echocardiograms have been shown to have very low event rates in follow up [1][2][3][4][5][6] including the patients in this cohort (1.2% for all patients at 3 years post testing). As a consequence, patients with ST changes with normal stress imaging have been felt to have a low risk result.…”

Section: Discussionmentioning

confidence: 99%

“…Subsequently, one well conducted study has been published suggesting that abnormal exercise ECG findings in the setting of normal stress imaging may result in increased adverse events. [6]…”

Section: Introductionmentioning

confidence: 99%

What are the prognostic implications and factors relating to exercise induced electrocardiographic ST segment changes in the setting of a non-ischaemic stress echocardiogram?

Fitzgerald¹,

Smith²,

Scalia³

2022

Preprint

0

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Background. Electrocardiographic (ECG) changes during stress testing are a common and perplexing finding during non-ischaemic stress echocardiography (SE). Research has provided conflicting results regarding the implications. Methods. SE was performed after maximal Bruce protocol treadmill exercise. Results. 3020 consecutive patients, mean age 58±12 years, 36% female, were followed-up for up to 9 years (mean 36±21 months) post SE. Time to first cardiac event (composite of heart failure admission, worsening New York Heart Association class, worsening ejection fraction, acute coronary syndrome, revascularization, angina or cardiovascular death) was analyzed and adjusted using Cox proportional hazards regression. Prognostic significance was found with 1.5mm of downsloping or horizontal ST depression. Adjusting for baseline differences, increased risk of composite major adverse cardiac events was shown with at least 1.5mm of exercise induced ST depression (Hazard ratio [HR] of 2.47, 95% Confidence ratio [CI] 1.67-3.72, p<0.0001). Patients achieving high level exercise capacity (≥13 metabolic equivalents or METs) with ST depression lower risk of cardiac events during follow-up Conclusion. Patients with ST segment depression but non-ischaemic stress imaging have poorer prognosis compared to patients with non-ischaemic stress echocardiograms with normal stress ECGs. ST depression of 1.5mm or more was established as a prognostically significance value. High exercise capacity improves prognosis, and ECG changes in that setting can be regarded as false positives. Overall, however, ST depression during non-ischaemic stress imaging is not a benign finding.

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“…Noninvasive testing made a similar prediction of obstructive CAD compared to clinical factors. In addition, a Duke University study of over 15,000 patients found that among patients referred for ICA, those with a positive stress test were less likely to have obstructive CAD compared to those with either a negative stress test or no testing at all [ 19 ]. Recently, the NIH-funded international ISCHEMIA trial demonstrated that in patients with moderate-severe ischemia on functional stress testing, over 14% demonstrated no obstructive CAD on coronary CTA [ 20 ].…”

Section: Discussionmentioning

confidence: 99%

“…Patients with discordant or equivocal stress results have an excess risk for adverse cardiac events. In a recent large single-center study, researchers analyzed >15,000 patients undergoing stress testing and found that patients with equivocal stress tests had higher rates of major adverse cardiac events compared to patients with negative stress findings [ 19 ]. Coronary CTA and FFR CT may play an important role in the diagnosis and management of patients with equivocal stress tests.…”

Section: Discussionmentioning

confidence: 99%

Relationship of Stress Test Findings to Anatomic or Functional Extent of Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve

Doukas

¹

,

Allen

²

,

Wozniak

³

et al. 2021

BioMed Research International

1

0

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Background. In the United States, functional stress testing is the primary imaging modality for patients with stable symptoms suspected to represent coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is excellent at identifying anatomic coronary artery disease (CAD). The application of computational fluid dynamics to coronary CTA allows fractional flow reserve (FFR) to be calculated noninvasively (FFRCT). The relationship of noninvasive stress testing to coronary CTA and FFRCT in real-world clinical practice has not been studied. Methods. We evaluated 206 consecutive patients at Loyola University Chicago with suspected CAD who underwent noninvasive stress testing followed by coronary CTA and FFRCT when indicated. Patients were categorized by stress test results (positive, negative, indeterminate, and equivocal). Duke treadmill score (DTS), METS, exercise duration, and chest pain with exercise were analyzed. Lesions ≥ 50 % stenosis were considered positive by coronary CTA. FF R CT < 0.80 was considered diagnostic of ischemia. Results. Two hundred and six patients had paired noninvasive stress test and coronary CTA/FFRCT results. The median time from stress test to coronary CTA was 49 days. Average patient age was 60.3 years, and 42% were male. Of the 206 stress tests, 75% were exercise (70% echocardiographic, 26% nuclear, and 4% EKG). There were no associations of stress test results with CAD > 50 % or FF R CT < 0.80 ( p = 0.927 and p = 0.910 , respectively). Of those with a positive stress test, only 30% (3/10) had CAD > 50 % and only 50% (5/10) had FF R CT < 0.80 . Chest pain with exercise did not correlate with CAD > 50 % or FF R CT < 0.80 ( p = 0.66 and p = 0.12 , respectively). There were no significant correlations between METS, DTS, or exercise duration and FFRCT ( r = 0.093 , p = 0.274 ; r = 0.012 , p = 0.883 ; and r = 0.034 , p = 0.680 ; respectively). Conclusion. Noninvasive stress testing, functional capacity, chest pain with exercise, and DTS are not associated with anatomic or functional CAD using a diagnostic strategy of coronary CTA and FFRCT.

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“…Women with evidence of ischemia, identified by objective evidence such as abnormal stress or biomarker testing, are more likely to present with no obstructive coronary arteries (INOCA) compared to men, although women report more chest pain. Traditionally, the presence of ischemic ECG changes in the absence of wall motion abnormalities on stress echocardiography is labeled as a “false-positive” stress test, but emerging data indicate that abnormal stress ECG regardless of echocardiographic response should be considered prognostic ( 92 – 94 ). Additional investigations should be considered to evaluate CMD and vasospasm, as ischemic ECG changes have high specificity for CMD in patients with non-obstructive CAD ( 95 ) and a high prevalence of coronary vasospasm is found in patients with typical exertional angina ( 96 ).…”

Section: Sex/gender In Chest Pain and Ischemic Heart Diseasementioning

confidence: 99%

Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine

Mehta

¹

,

Wei

²

,

Shufelt

³

et al. 2021

Front. Cardiovasc. Med.

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Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.

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Implications of Abnormal Exercise Electrocardiography With Normal Stress Echocardiography

Cited by 23 publications

References 28 publications

What are the prognostic implications and factors relating to exercise induced electrocardiographic ST segment changes in the setting of a non-ischaemic stress echocardiogram?

What are the prognostic implications and factors relating to exercise induced electrocardiographic ST segment changes in the setting of a non-ischaemic stress echocardiogram?

Relationship of Stress Test Findings to Anatomic or Functional Extent of Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve

Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine

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