An Update on Exercise Stress Testing

doi:10.1016/j.cpcardiol.2011.11.004

Current Problems in Cardiology

Volume 37, Issue 5, May 2012, Pages 177-202

https://doi.org/10.1016/j.cpcardiol.2011.11.004 Get rights and content

Abstract

Exercise stress testing is the most commonly used noninvasive method to evaluate for coronary artery disease in men and women. Although emphasis has been placed on the diagnostic value of ST-segment depression, the exercise stress test provides other valuable diagnostic and prognostic data, beyond ST-segment depression. The value of these variables, which include exercise capacity, chronotropic response, heart rate recovery, blood pressure response, and the Duke Treadmill Score, are reviewed in this article. In addition, the gender differences seen with these exercise testing variables are reviewed. In this modern era of exercise stress testing, making use of all the information from a stress test and creating a comprehensive stress testing report are recommended in the evaluation of patients with suspected coronary artery disease who undergo exercise stress testing.

Section snippets

ST-Segment Depression

ST-segment depression brought on by exercise stress testing indicates ischemia and may reflect significant coronary obstruction.³ The standard criteria for an abnormal response (positive test) include horizontal or downsloping ST-segment depression of equal to or greater than 1 mm (0.1 mV) at 60-80 ms after the J-point (Fig 1).³ The presence of a right bundle branch block or having less than 1 mm ST-segment depression on a baseline ECG is not a contraindication to being able to interpret

Exercise Capacity

Exercise capacity, also known as cardiorespiratory fitness or functional capacity, is 1 of the most important prognostic and diagnostic measures obtained from an exercise stress test. Exercise capacity is an estimate of the maximal oxygen required for any given workload and is measured in units of metabolic equivalents (METs). One MET is the amount of oxygen consumption required in a resting state and equals 3.5 mL of oxygen per kilogram of body weight per minute for an average adult.³⁸ METs

Chronotropic Response to Exercise

Chronotropic incompetence, or the inability of the heart rate (HR) to increase normally with exercise,17, 55 has important diagnostic and prognostic associations.56, 57, 58, 59, 60, 61, 62 Several measures of chronotropic response exist, including (1) peak HR achieved with maximal exercise stress testing; (2) HR reserve, or the change in HR with exercise (peak HR with exercise minus resting HR); (3) ability to achieve at least 85% of the maximum age-predicted HR (the definition of age-predicted

HR Recovery

Abnormal HR recovery is defined as an attenuated HR response following exercise cessation. The measurement of HR recover is defined as the peak HR achieved minus the HR at 1 minute of recovery. The definition of an abnormal HR recovery varies and is dependent on what type of recovery protocol is used. For those who undergo an upright-cool-down protocol with a slow walk during the first 2 minutes after exercise, a HR recovery of ≤12 bpm in the first minute of recovery is defined as abnormal.⁶⁹

HR-Adjusted Measures of ST-Segment Depression: ST/HR Slope and ΔST/ΔHR Index

Methods have been developed to adjust the amount of ST-segment depression to the HR to improve the diagnostic accuracy of ST-segment depression with exercise stress testing. HR adjustment of ST-segment depression may be more accurate than traditional ST-segment depression. Two such measures that have been well-studied include the ST/HR slope the ΔST/ΔHR index.

Blood Pressure Response to Exercise

In strenuous exercise, there is maximal sympathetic discharge and parasympathetic stimulation is withdrawn.⁸⁷ With increasing exercise, skeletal blood flow increases and peripheral resistance falls. Generally, systolic blood pressure increases and diastolic blood pressure does not change significantly with exercise. There is both diagnostic and prognostic value to abnormalities seen in the blood pressure response to exercise.

Bernard Chaitman: Systolic blood pressure increases with progressive

Duke Treadmill Score

The diagnostic and prognostic values of the exercise stress test have been improved with the creation of scores that combine ECG data with clinical predictors of risk.34, 40, 95, 96 One of the earliest and most commonly used risk scores is the Duke Treadmill Score (DTS), developed by Mark et al.³⁴ This score was developed from 2842 consecutive patients, including 30% women, with known or suspected CAD who underwent an exercise stress test using the Bruce protocol. This was followed by

Summary

The exercise stress test provides a wealth of information, as summarized in Table 1. In patients who undergo exercise stress testing with or without imaging, important diagnostic and prognostic information is readily available and attainable by the exercise stress test, beyond that of classic ST changes. Assessment of exercise capacity is powerful in the prognosis and diagnosis of CAD in both men and women. The use of gender-specific equations relating to predicted exercise capacity and HR

References (103)

R.J. Gibbons et al.
ACC/AHA 2002 guideline update for exercise testing: summary articleA report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 exercise testing guidelines)
J Am Coll Cardiol
(2002)
P.M. Okin et al.
Effect of baseline ST segment elevation on test performance of standard and heart rate-adjusted ST segment depression criteria
Am Heart J
(1990)
R. Detrano et al.
Exercise-induced ST segment depression in the diagnosis of multivessel coronary disease: a meta analysis
J Am Coll Cardiol
(1989)
E.H. Blackstone et al.
Caveat emptor: the treachery of work-up bias
J Thorac Cardiovasc Surg
(2004)
T.D. Miller et al.
Effects of adjustment for referral bias on the sensitivity and specificity of single photon emission computed tomography for the diagnosis of coronary artery disease
Am J Med
(2002)
R.J. Stuart et al.
Upsloping S-T segments in exercise stress testingSix year follow-up study of 438 patients and correlation with 248 angiograms
Am J Cardiol
(1976)
C.P. Miranda et al.
Usefulness of exercise-induced ST-segment depression in the inferior leads during exercise testing as a marker for coronary artery disease
Am J Cardiol
(1992)
M.H. Sketch et al.
Digoxin-induced positive exercise tests: their clinical and prognostic significance
Am J Cardiol
(1981)
M.M. LeWinter et al.
The effects of oral propranolol, digoxin and combination therapy on the resting and exercise electrocardiogram
Am Heart J
(1977)
K. Sundqvist et al.
Effect of digoxin on the electrocardiogram at rest and during exercise in healthy subjects
Am J Cardiol
(1986)

Y. Kwok et al.

Meta-analysis of exercise testing to detect coronary artery disease in women

Am J Cardiol

(1999)

J.F. Lewis et al.

Exercise treadmill testing using a modified exercise protocol in women with suspected myocardial ischemia: findings from the National Heart, Lung and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE)

Am Heart J

(2005)

M.A. Hlatky et al.

Factors affecting sensitivity and specificity of exercise electrocardiographyMultivariable analysis

Am J Med

(1984)

M.H. Sketch et al.

Significant sex differences in the correlation of electrocardiographic exercise testing and coronary arteriograms

Am J Cardiol

(1975)

J.P. Higgins et al.

Electrocardiographic exercise stress testing: an update beyond the ST segment

Int J Cardiol

(2007)

A.P. Morise et al.

The specificity of exercise electrocardiography in women grouped by estrogen status

Int J Cardiol

(1997)

D.A. Weiner et al.

Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease

J Am Coll Cardiol

(1984)

M. Gulati et al.

Prognostic value of the duke treadmill score in asymptomatic women

Am J Cardiol

(2005)

R.A. Bruce et al.

Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease

Am Heart J

(1973)

J.M. Bourque et al.

Achieving an exercise workload of > or = 10 metabolic equivalents predicts a very low risk of inducible ischemia: does myocardial perfusion imaging have a role?

J Am Coll Cardiol

(2009)

D.A. Weiner et al.

Long-term prognostic value of exercise testing in men and women from the coronary artery surgery study (CASS) registry

Am J Cardiol

(1995)

A.M. Arruda-Olson et al.

Prognostic value of exercise echocardiography in 5,798 patients: is there a gender difference?

J Am Coll Cardiol

(2002)

C.E. Snader et al.

Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: report of 3,400 patients from a single center

J Am Coll Cardiol

(1997)

L.W. Gibbons et al.

Maximal exercise test as a predictor of risk for mortality from coronary heart disease in asymptomatic men

Am J Cardiol

(2000)

C.K. Morris et al.

Nomogram based on metabolic equivalents and age for assessing aerobic exercise capacity in men

J Am Coll Cardiol

(1993)

R.D. Wiens et al.

Chronotropic incompetence in clinical exercise testing

Am J Cardiol

(1984)

B. Azarbal et al.

The incremental prognostic value of percentage of heart rate reserve achieved over myocardial perfusion single-photon emission computed tomography in the prediction of cardiac death and all-cause mortality: superiority over 85% of maximal age-predicted heart rate

J Am Coll Cardiol

(2004)

C.M. Pratt et al.

Exercise testing in women with chest painAre there additional exercise characteristics that predict true positive test results?

Chest

(1989)

A.S. Adabag et al.

Relation of heart rate parameters during exercise test to sudden death and all-cause mortality in asymptomatic men

Am J Cardiol

(2008)

A. Elhendy et al.

Prognostic significance of impairment of heart rate response to exercise: impact of left ventricular function and myocardial ischemia

J Am Coll Cardiol

(2003)

B.L. Wilkoff et al.

Exercise testing for chronotropic assessment

Cardiol Clin

(1992)

S.J. Brener et al.

Chronotropic response to exercise predicts angiographic severity in patients with suspected or stable coronary artery disease

Am J Cardiol

(1995)

S. Girotra et al.

Relation of heart rate response to exercise with prognosis and atherosclerotic progression after coronary artery bypass grafting

Am J Cardiol

(2009)

M.N. Khan et al.

Chronotropic incompetence as a predictor of death among patients with normal electrograms taking beta blockers (metoprolol or atenolol)

Am J Cardiol

(2005)

K. Shetler et al.

Heart rate recovery: validation and methodologic issues

J Am Coll Cardiol

(2001)

D.P. Vivekananthan et al.

Heart rate recovery after exercise is a predictor of mortality, independent of the angiographic severity of coronary disease

J Am Coll Cardiol

(2003)

N. Gera et al.

Usefulness of abnormal heart rate recovery on exercise stress testing to predict high-risk findings on single-photon emission computed tomography myocardial perfusion imaging in men

Am J Cardiol

(2009)

P. Kligfield et al.

Value and limitations of heart rate-adjusted ST segment depression criteria for the identification of anatomically severe coronary obstruction: test performance in relation to method of rate correction, definition of extent of disease, and beta-blockade

Am Heart J

(1993)

V.F. Froelicher

Exercise testing in the new millennium

Prim Care

(2001)

P.M. Okin et al.

Prognostic value of heart rate adjustment of exercise-induced ST segment depression in the multiple risk factor intervention trial

J Am Coll Cardiol

(1996)

S.N. Morris et al.

Incidence and significance of decreases in systolic blood pressure during graded treadmill exercise testing

Am J Cardiol

(1978)

S.A. McHam et al.

Delayed systolic blood pressure recovery after graded exercise: an independent correlate of angiographic coronary disease

J Am Coll Cardiol

(1999)

R. Levites et al.

The significance of hypotension developing during treadmill exercise testing

Am Heart J

(1978)

A.P. Morise et al.

Development and validation of a clinical score to estimate the probability of coronary artery disease in men and women presenting with suspected coronary disease

Am J Med

(1997)

K.P. Alexander et al.

Value of exercise treadmill testing in women

J Am Coll Cardiol

(1998)

A.S. Iskandrian et al.

The treadmill exercise score revisited: coronary arteriographic and thallium perfusion correlates

Am Heart J

(1992)

J.H. Mieres et al.

Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association

Circulation

(2005)

R. Gianrossi et al.

Exercise-induced ST depression in the diagnosis of coronary artery diseaseA meta-analysis

Circulation

(1989)

V.F. Froelicher et al.

The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 [QUEXTA] Study Group. Quantitative Exercise Testing and Angiography

Ann Intern Med

(1998)

V.L. Roger et al.

Sex and test verification biasImpact on the diagnostic value of exercise echocardiography

Circulation

(1997)

Cited by (39)

Stable Ischemic Heart Disease
2022, Practical Cardiology: Principles and Approaches
Stable ischemic heart disease (SIHD), commonly caused by atherosclerotic plaque, is the most common clinical manifestation of ischemic heart disease (IHD). IHD remains a major public health problem and is considered as one of the leading causes of mortality worldwide. Unfortunately, the prevalence of coronary artery disease (CAD) is increasing worldwide, especially in the younger population, with increasing cardiovascular risk factors such as increases in the prevalence of obesity, diabetes mellitus, metabolic syndrome, and physical inactivity. Angina pectoris is the initial manifestation of SIHD and is the most common presentation in these patients. Myocardial oxygen supply–demand imbalance is a major mechanism of development of angina in patients with SIHD. Recognition of atypical symptoms, anginal equivalents, especially in women and older adults, and differential diagnosis of angina, especially gastrointestinal disorders, are mandatory. Selection of noninvasive and invasive modalities for diagnosis and determining the prognosis and appropriate treatment with the goals of increasing survival and relieving symptoms in patients with SIHD should be based on current guideline recommendations.
French Society of Cardiology guidelines on exercise tests (part 1): Methods and interpretation
2018, Archives of Cardiovascular Diseases
Citation Excerpt :
For diagnostic purposes, the interpretation of an ET must be multivariable [42,43], and indicate a high, intermediate or weak probability for myocardial ischemia. Several factors must be taken into account, including disease prevalence, presence of risk factors, symptoms, electrocardiogram changes and possible abnormal changes in HR and BP during exercise and immediate recovery [43,44]. A few scoring systems (Duke Treadmill Score [45], Ashley [46]) aid in the establishment of diagnosis and prognosis of CAD patients, stratifying them into one of the three possible risk groups (Table 6).
The exercise test is still a key examination in cardiology, used for the diagnosis of myocardial ischemia, as well as for the clinical evaluation of other heart diseases. The cardiopulmonary exercise test can further define functional capacity and prognosis for any given cardiac pathology. These new guidelines focus on methods, interpretation and indications for an exercise test or cardiopulmonary exercise test, as summarized below. The safety rules associated with the exercise test must be strictly observed. Interpretation of exercise tests and cardiopulmonary exercise tests must be multivariable. Functional capacity is a strong predictor of all-cause mortality and cardiovascular events. Chest pain, ST-segment changes and an abnormal ST/heart rate index constitute the first findings in favor of myocardial ischemia, mostly related to significant coronary artery disease. Chronotropic incompetence, abnormal heart rate recovery, QRS changes (such as enlargement or axial deviations) and the use of scores (based on the presence of various risk factors) must also be considered in exercise test interpretation for a coronary artery disease diagnosis. Arrhythmias or conduction disorders arising during the exercise test must be considered in the assessment of prognosis, in addition to a decrease or low increase in blood pressure during the exercise phase. When performing a cardiopulmonary exercise test, peak oxygen uptake and the volume of expired gas/carbon dioxide output slope are the two main variables used to evaluate prognosis.
L’épreuve d’effort (EE) reste un examen clé en cardiologie pour le diagnostic de l’ischémie myocardique et pour l’évaluation clinique des autres cardiopathies. Le test cardiopulmonaire (CPT) basé sur l’analyse de la mesure des gaz expirés peut préciser la capacité fonctionnelle individuelle et estimer le pronostic des cardiopathies. Ces recommandations, résumées ci-dessous, font le point sur la méthodologie, l’interprétation et les indications de ces deux tests. Les règles de sécurité doivent être strictement respectées. L’interprétation de l’EE et du CPT doit être multivariée. La capacité fonctionnelle est un puissant facteur prédictif de la mortalité toutes causes et des évènements cardiovasculaires. La douleur thoracique, les anomalies du segment ST et de l’index ST/fréquence cardiaque sont les premiers signes en faveur d’une ischémie myocardique le plus souvent en rapport avec des lésions coronaires. L’insuffisance chronotrope, une fréquence de récupération anormale, des modifications des QRS (élargissement, déviation axiale) et l’utilisation de score (basés sur la présence de différents facteurs de risque) doivent aussi être pris en considération pour le diagnostic de la maladie coronaire. Les troubles du rythme et de la conduction survenant pendant l’examen sont considérés comme des facteurs pronostiques comme la diminution ou une augmentation insuffisante de la pression artérielle pendant l’exercice. Lors de l’analyse des gaz expirés, le pic de consommation d’oxygène, la pente du rapport ventilation par la production de gaz carbonique sont les deux principaux paramètres pronostiques utilisés.
Chapter 35 - Stable ischemic heart disease
2017, Practical Cardiology
Stable ischemic heart disease (SIHD), commonly caused by atherosclerotic plaque, is the most common clinical manifestation of ischemic heart disease (IHD). IHD remains a major public health problem and is considered as one of the leading causes of mortality worldwide. Unfortunately, prevalence of coronary artery disease (CAD) is increasing worldwide, especially in the younger population, with increasing cardiovascular risk factors such as increases in the prevalence of obesity, diabetes mellitus, metabolic syndrome, and physical inactivity. Angina pectoris is the initial manifestation of SIHD and is the most common presentation in these patients. Myocardial oxygen supply-demand imbalance is a major mechanism of development of angina in patients with SIHD. Recognition of atypical symptoms, anginal equivalents, especially in women and older adults, and differential diagnosis of angina, especially gastrointestinal disorders, are mandatory. Selection of noninvasive and invasive modalities for diagnosis and determining the prognosis and appropriate treatment with the goals of increasing survival and relieving symptoms in patients with SIHD should be based on current guideline recommendations.
Stable Ischemic Heart Disease
2017, Practical Cardiology
Stable ischemic heart disease (SIHD), commonly caused by atherosclerotic plaque, is the most common clinical manifestation of ischemic heart disease (IHD). IHD remains a major public health problem and is considered as one of the leading causes of mortality worldwide. Unfortunately, prevalence of coronary artery disease (CAD) is increasing worldwide, especially in the younger population, with increasing cardiovascular risk factors such as increases in the prevalence of obesity, diabetes mellitus, metabolic syndrome, and physical inactivity. Angina pectoris is the initial manifestation of SIHD and is the most common presentation in these patients. Myocardial oxygen supply-demand imbalance is a major mechanism of development of angina in patients with SIHD. Recognition of atypical symptoms, anginal equivalents, especially in women and older adults, and differential diagnosis of angina, especially gastrointestinal disorders, are mandatory. Selection of noninvasive and invasive modalities for diagnosis and determining the prognosis and appropriate treatment with the goals of increasing survival and relieving symptoms in patients with SIHD should be based on current guideline recommendations.
Stable angina pectoris
2017, Coronary Artery Disease: From Biology to Clinical Practice
Stable coronary artery disease (SCAD) is generally characterized by episodes of reversible myocardial demand/supply mismatch, related to ischemia or hypoxia, which are usually inducible by exercise, emotion, or other stress and reproducible but also may be occurring spontaneously. Such episodes of ischemia/hypoxia are commonly associated with transient chest discomfort (angina pectoris). SCAD also includes the stabilized, often asymptomatic, phases that follow an acute coronary syndrome. Within the population with stable coronary artery disease, an individual's prognosis can vary considerably, depending on baseline clinical, functional, and anatomical characteristics. Prognostic assessment is an important part of the management of patients with stable angina. On the one hand, it is important to reliably identify those patients with more severe forms of disease, who may have an improvement in outcome with more aggressive investigation and—potentially—intervention, including revascularization. On the other hand, it is also important to identify those patients with a less-severe form of disease and a good prognosis, thereby avoiding unnecessary invasive and noninvasive tests and revascularization procedures.
Revisiting age-predicted maximal heart rate: Can it be used as a valid measure of effort?
2016, American Heart Journal
Citation Excerpt :
Although APMHR is not able to accurately predict an individual's maximal exercise HR, there may still be utility in its clinical use. There is a robust body of literature indicating chronotropic incompetence, commonly defined as an inability to achieve at least 85% of APMHR,3 is a prognostically ominous marker.16–21 As such, the assessment of the chronotropic response to exercise by comparing the HR response to maximal exercise in relation to APMHR may still provide clinically valuable information.
Despite high error ranges, age-predicted maximal heart rate (APMHR) is frequently used to gauge the achievement of adequate effort during an exercise test. The current analysis revisits this issue using the Fitness Registry and the Importance of Exercise: National Database (FRIEND Registry).
A total of 4,796 (63% male) apparently healthy subjects underwent a maximal cardiopulmonary exercise test on a treadmill. The mean age, maximal heart rate (HR), and maximal aerobic capacity of the cohort were 43 ± 12 years, 178 ± 15 beats per minute, and 36.1 ± 10.6 mlO₂ · kg⁻¹ · min⁻¹, respectively. All subjects reached or surpassed a peak respiratory exchange ratio of 1.10. A linear regression equation using age to predict maximal HR was validated in 3,796 subjects and cross-validated in the remaining 1,000 (randomly assigned).
The APMHR equation in the validation cohort was as follows: 209.3 − 0.72(age). The r value and standard error of estimate for this regression was 0.61 (P < .001) and 11.35 beats/min, respectively. A 1-sample t test revealed that the mean difference between actual maximal HR and APMHR was not significantly different from 0 (mean difference = 0.32, P = .43). However, Bland-Altman revealed high limits of agreement (upper 25.31 and lower −24.67) and a significant proportional bias.
The APMHR equation derived from this analysis included a large cohort of apparently healthy individuals with maximal exercise effort validated by the criterion standard (ie, peak respiratory exchange ratio). Using APMHR in this capacity should be discouraged, and new approaches to gauging an individual's exercise effort should be explored.

View all citing articles on Scopus

View full text

An Update on Exercise Stress Testing

Abstract

Section snippets

ST-Segment Depression

Exercise Capacity

Chronotropic Response to Exercise

HR Recovery

HR-Adjusted Measures of ST-Segment Depression: ST/HR Slope and ΔST/ΔHR Index

Blood Pressure Response to Exercise

Duke Treadmill Score

Summary

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am J Med

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am Heart J

Am J Med

Am J Cardiol

Int J Cardiol

Int J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Chest

Am J Cardiol

J Am Coll Cardiol

Cardiol Clin

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

Prim Care

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Am J Med

J Am Coll Cardiol

Am Heart J

Circulation

Exercise-induced ST depression in the diagnosis of coronary artery diseaseA meta-analysis

Circulation

The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 [QUEXTA] Study Group. Quantitative Exercise Testing and Angiography

Ann Intern Med

Sex and test verification biasImpact on the diagnostic value of exercise echocardiography

Circulation