Long‐term follow‐up of patients undergoing standardized bicycle exercise stress testing: new recommendations for grading of exercise capacity are clinically relevant

Abstract

Summary Introduction A new grading of exercise capacity during bicycle stress testing has been proposed in Sweden based on the new reference material (‘the Kalmar material’), which has not been validated. We aimed to examine the prognostic information of the new grading of exercise capacity during exercise stress testing. Methods Data on all bicycle exercise tests performed at the Department of Clinical Physiology in Kalmar between May 2005 and October 2016 were cross‐linked with the Causes of Death Register (until 30 April 2019) and the National Patient Register (until 12 December 2017). Exercise capacity was graded based on predicted exercise capacity: ≥120% (good), 75 to <120% (normal), 70 to <75% (mildly reduced), 50 to <70% (moderately reduced) and <50% (severely reduced). Associations with all‐cause mortality, cardiovascular mortality and hospitalization for ischaemic heart disease (IHD) and heart failure were analysed using Cox regression. Results A total of 13 887 patients were followed a median of 7·7 years (interquartile range 5·0–10·8); 1809 patients died (546 from cardiovascular disease). Compared to normal exercise capacity, reduction of exercise capacity was strongly associated with increased all‐cause mortality [(hazard ratio; 95% confidence interval): mild (3·0; 2·6–3·5); moderate (4·4; 3·9–4·9); and severe reduction (8·5; 7·2–10·0)]. Reduced exercise capacity was also associated with increased risks of cardiovascular hospitalization and mortality. Conclusion Reduced exercise capacity is associated with increased all‐cause and cardiovascular mortality, as well as increased risk of future IHD and heart failure diagnosis and hospitalization. In patients with reduced exercise capacity, mortality is progressively increased with worsening grade of exercise capacity.

Age- and gender-specific upper limits and reference equations for workload-indexed systolic blood pressure response during bicycle ergometry

“…This can possibly be explained by the confounding effect of maximum workload (exercise capacity), associated both with higher SBP (via greater cardiac output) 12,14,15 and with better survival. 27,28 Using the workload-indexed SBP response to exercise may circumvent this bias, accounting for both exercise capacity and SBP. 11 Whether the SBP/W-slope or peak SBP/W-ratio provide prognostic value remains to be elucidated, although recent data on the SBP/METslope in males were promising.…”

Typical angina during exercise stress testing improves the prediction of future acute coronary syndrome

“…In addition, the SBP response (Hedman, et al 2019; Sipila, et al 2019; Tsuda, et al 1993), exercise capacity (Forslund, et al 2000; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019) and heart rate recovery (Cole, et al 1999; Sipila, et al 2019) have been shown prognostic of future ACS and mortality. In the same cohort, we have previously shown that exercise capacity is strongly associated with both all‐cause and cardiovascular mortality, as well as hospitalization for ischaemic heart disease and heart failure (Lindow, et al 2019). Thus, despite that exercise stress testing has been shown to have poor diagnostic accuracy regarding obstructive coronary heart disease, using anatomical coronary angiography as reference standard (Knuuti, et al 2018), this study highlights the clinical usefulness of exercise stress testing, especially from a prognostic perspective, but also the importance of not interpreting the test based on the ST response alone.…”

“…This study adds to the mountain of evidence of the prognostic information available in exercise stress testing (Cole, et al 1999; Cole & Ellestad, 1978; Daugherty, et al 2011; Forslund, et al 2000; Hedman, et al 2019; Ho, et al 2008; Lindow, et al 2019; Mark, et al 1987; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019; Tsuda, et al 1993; Weiner, et al 1984; Weiner, et al 1986). In the most recent guidelines for management of patients with chronic coronary syndrome, exercise stress testing is no longer recommended as the initial diagnostic test in patients with stable chest pain patients (Knuuti, et al 2019).…”

“…In most studies, the diagnostic accuracy of exercise testing is based on ECG criteria alone during exercise and anatomical coronary angiography as the reference standard (Beygui, et al 2000; Chae, et al 1993; Daou, et al 2002; Hecht, et al 1993; Kajinami, et al 1995; Koskinen, et al 1987; Nallamothu, et al 1995). However, exercise stress testing also provides important prognostic information regarding all‐cause mortality, cardiovascular mortality and incident non‐fatal myocardial infarction (AMI) or unstable angina (UA) (Cole, et al 1999; Cole & Ellestad, 1978; Daugherty, et al 2011; Forslund, et al 2000; Hedman, et al 2019; Ho, et al 2008; Lindow, et al 2019; Mark, et al 1987; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019; Weiner, et al 1984; Weiner, et al 1986). Besides ST depression (Mark, et al 1987; Weiner, et al 1984), the systolic blood pressure response during exercise (Hedman, et al 2019; Sipila, et al 2019), chronotropic incompetence (Daugherty, et al 2011; Ho, et al 2008), exercise capacity (Daugherty, et al 2011; Forslund, et al 2000; Lindow, et al 2019; Myers, et al 2002; Salokari, et al 2019; Sipila, et al 2019) and heart rate recovery (Cole, et al 1999; Sipila, et al 2019) have been found to be associated with future mortality and morbidity.…”

Prognostic implications of structural heart disease and premature ventricular contractions in recovery of exercise

“…We performed a consecutive cohort study including patients aged 18 years or older who had performed a clinical bicycle exercise stress test and a resting transthoracic echocardiography within 90 days of the exercise stress test at the Department of Clinical Physiology at Kalmar County Hospital, Sweden, between 31 May 2005 and 31 Oct 2016. The exercise stress test database has been described in detail elsewhere [16][17][18][19]. We excluded those who had an exercise time less than 3 minutes or had atrial fibrillation, considering the challenge of distinguishing aberrantly conducted supraventricular complexes from PVCs.…”