Prognostic capacity of a clinically indicated exercise test for cardiovascular mortality is enhanced by combined analysis of exercise capacity, heart rate recovery and T-wave alternans

Minkkinen, Mikko; Nieminen, Tuomo; Verrier, Richard L.; Leino, Johanna; Lehtimäki, Terho; Viik, Jari; Lehtinen, Rami; Nikus, Kjell; Kööbi, Tiit; Turjanmaa, Väinö; Kähönen, Mika

doi:10.1177/2047487314557190

Cited by 17 publications

(19 citation statements)

References 24 publications

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“…Since the FINCAVAS study contains records of thousands of patients and its results have already been published [14][15][16][17] we plan a future study to analyze the entire cohort with two major goals: (a) verifying the results of this study and past studies that were using the same software and (b) determining an optimal configuration for band limited ECG records which may enhance the performance of HFQRS for this specific configuration.…”

Section: Discussionmentioning

confidence: 99%

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Blinded Analysis of an Exercise ECG Database Using High Frequency QRS Analysis

Omer¹,

Granot²,

Kähönen³

et al. 2017

Computing in Cardiology Conference (CinC)

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Section: Discussionmentioning

confidence: 99%

“…For this study 132 ECG records of bicycle exercise tests were obtained from the FINCAVAS database [14][15][16][17].…”

Section: Analysis Groupmentioning

confidence: 99%

Blinded Analysis of an Exercise ECG Database Using High Frequency QRS Analysis

Omer¹,

Granot²,

Kähönen³

et al. 2017

Computing in Cardiology Conference (CinC)

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“…12,13 Overall, studies have shown that there is a graded continuum of risk and additive prognostic effect with the increase in the number and different combinations of abnormal exercise testing parameters and heart-rate-related measures. [14][15][16] In this issue of the European Journal of Preventive Cardiology, Chrysohoou et al aim to investigate the differential association of exercise testing related parameters with cardio-metabolic risk factors including diabetes, obesity, hypertension, as well as smoking. 17 The authors display numerous correlations between cardiovascular risk factors and exercise testing parameters that reflect inotropic and chronotropic response and exercise capacity; these factors include blood pressure and heart-rate reaction during exercise and recovery, exercise duration, and peak METs achieved.…”

Section: Barak Zafrirmentioning

confidence: 99%

The prognostic value of exercise testing: Exercise capacity, hemodynamic response, and cardio-metabolic risk factors

Zafrir

2017

Eur J Prev Cardiolog

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Treadmill exercise testing is widely available and has been used for more than half a century for the evaluation of exercise related symptoms and assessment of myocardial ischemia. Over the years, additional use and goals for exercise testing have been evolved, including exercise prescription, evaluation of physical capacity and effort tolerance, as well as assessment of arrhythmias, chronotropic competence, and therapeutic response to medications and implanted device interventions.1 With time, it became apparent, that apart from the diagnostic value of the exercise electrocardiogram (ECG) for identification of coronary artery disease and assessment of its severity, aerobic exercise capacity has significant prognostic importance and may aid in the assessment of future cardiovascular risk. The association between low exercise capacity and reduced long-term survival was shown to be independent of traditional risk factors.2 A single measurement of fitness significantly improves classification of both short-term and long-term (25-year) risk for cardiovascular disease mortality when added to traditional risk factors.3 In a meta-analysis of 33 eligible studies of healthy populations a higher level of maximal aerobic capacity amounting to one metabolic equivalent (MET) increase was associated with a 13% risk reduction in all-cause mortality.

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“…3 However, the diagnostic and prognostic value of exercise ECG testing can be enhanced by incorporating in the assessment additional clinical data that exercise testing provides beyond the detection of ST-segment depression: exercise capacity, chronotropic and blood pressure response, heart rate recovery, calculation of the Duke treadmill score, T-wave alternans. [4][5][6][7] The diagnostic accuracy of exercise ECG can further be improved by analysis of the relation between ST-segment depression and heart rate changes during exercise and recovery. 8 Heart rate adjustment of ST-segment depression during exercise performed by calculating the ST-segment/heart rate (ST/HR) slope or the ST/HR index can improve the sensitivity with preservation of specificity, mainly from improved classification of patients with equivocal test responses related to up-sloping ST-segments.…”

Section: Jm Vrintsmentioning

confidence: 99%

“…[4][5][6][7] The diagnostic accuracy of exercise ECG can further be improved by analysis of the relation between ST-segment depression and heart rate changes during exercise and recovery.…”

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Refined interpretation of exercise ECG testing: Opportunities for a comeback in the era of expanding advanced cardiac imaging technologies?

Vrints

2016

Eur J Prev Cardiolog

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Ever since the initial description of the Master step test in 1942 1 exercise electrocardiography (ECG) is the most widely used non-invasive method for the diagnosis of angina pectoris and the risk stratification of patients with known coronary artery disease (CAD). Its diagnostic accuracy in detecting significantly obstructive CAD based on the development of 'ischaemic' horizontal or down-sloping ST-segment depressions during exercise is, however, rather mediocre, with a sensitivity of 68% and a specificity of 77%.2 When tested in populations without referral bias from coronary angiography the sensitivity dropped to 50% whereas the specificity increased to 90%.3 However, the diagnostic and prognostic value of exercise ECG testing can be enhanced by incorporating in the assessment additional clinical data that exercise testing provides beyond the detection of ST-segment depression: exercise capacity, chronotropic and blood pressure response, heart rate recovery, calculation of the Duke treadmill score, T-wave alternans. [4][5][6][7] The diagnostic accuracy of exercise ECG can further be improved by analysis of the relation between ST-segment depression and heart rate changes during exercise and recovery.8 Heart rate adjustment of ST-segment depression during exercise performed by calculating the ST-segment/heart rate (ST/HR) slope or the ST/HR index can improve the sensitivity with preservation of specificity, mainly from improved classification of patients with equivocal test responses related to up-sloping ST-segments.9 Analysis of the ST/HR loop during exercise and early recovery for the presence of hysteresis provides an alternative method for determining exercise ECG test positivity and negativity. ST-segment depression caused by myocardial ischaemia resolves in patients more slowly during the early recovery phase than in normal individuals. This leads to the presence of a positive ST/HR hysteresis in ischaemic patients as the ST-depression during the first few minutes is greater than it was at the same heart rate during exercise, whereas normal individuals show a negative ST/HR hysteresis ( Figure 1). Analysis of post-exercise ST/HR hysteresis has been shown to provide higher diagnostic and prognostic test accuracy than that found for the standard ST-segment depression criteria and other ST/HR indices. 10,11Exercise ECG has a much lower specificity in patients with left ventricular hypertrophy in whom false positive tests are frequently observed.13-15 The present study by Zimarino et al. shows an enhanced diagnostic accuracy of ST/HR hysteresis in patients with hypertension-related left ventricular hypertrophy and confirms the very low specificity of the classic maximal ST-segment depression criterion that is clinically largely unreliable in detecting significant CAD in those patients. 16 The authors call for the adoption of the ST/HR hysteresis analysis in the interpretation of exercise testing in patients with left ventricular hypertrophy in order to limit the need for additional functional imaging tests...

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Prognostic capacity of a clinically indicated exercise test for cardiovascular mortality is enhanced by combined analysis of exercise capacity, heart rate recovery and T-wave alternans

Abstract: The prognostic capacity of the clinical exercise test is enhanced by combined analysis of exercise capacity, heart rate recovery and T-wave alternans.

Cited by 17 publications

References 24 publications

Blinded Analysis of an Exercise ECG Database Using High Frequency QRS Analysis

Blinded Analysis of an Exercise ECG Database Using High Frequency QRS Analysis

The prognostic value of exercise testing: Exercise capacity, hemodynamic response, and cardio-metabolic risk factors

Refined interpretation of exercise ECG testing: Opportunities for a comeback in the era of expanding advanced cardiac imaging technologies?

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