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Relation between the electrocardiographic stress test and degree and location of myocardial ischemia

      Abstract

      Factors that influence frequency and location of stress-induced electrocardiographic (ECG) ST depression and the development of chest pain are incompletely understood. We studied 331 patients with ischemic myocardial nuclear defects in response to routine clinical treadmill testing with simultaneous ECG recording. Nuclear defects were analyzed for location and extent of myocardium involved. Exercise-induced ischemic ST changes were demonstrated in 59% of patients (196 of 331). Subjects with stress-induced ECG changes and/or chest pain had more extensive nuclear perfusion defects. Diabetic patients were significantly less likely to experience chest pain (24%) versus nondiabetics (41%) during testing (p = 0.04). Larger perfusion defects were associated with greater magnitude, lead distribution, and incidence of ECG changes. The number of ECG lead zones (anterior, lateral, and inferior) responding positively were related to both magnitude of ST depression and severity of ischemia, but not to location of ischemic defects. Regardless of location of ischemia, ST depression occurred with similar frequency. Thus, exercise-induced ECG ST depression remains a valuable indicator of the severity of myocardial ischemia. Greater ST depression involving multiple leads usually signified extensive myocardial ischemia, but provided no information regarding its location. Anginal-type chest pain induced by exercise testing also denoted more extensive ischemia.
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      References

        • Nallamothu N
        • Ghoda M
        • Heo J
        • Iskandrian A.S
        Comparison of thallium-201 single photon emission computed tomography and electrocardiographic response during exercise in patients with normal rest electrocardiographic results.
        J Am Coll Cardiol. 1995; 25: 830-836
        • Husted R
        • Crump R
        • Mishkin F
        • Stavitsky Y
        • Ellestad M.H
        The failure of multilead ST depression to predict severity of ischemia.
        Am J Noninvas Cardiol. 1994; 8: 386-390
        • Bogaty P
        • Gavrielides S
        • Mure P
        • Gaspardone A
        • Maseri A
        Duration and magnitude of ST-segment depression during exercise and recovery.
        Am Heart J. 1995; 129: 666-671
        • Wilson R.F
        • Marcus M.L
        • Christensen B.V
        • Talman C
        • White C.W
        Accuracy of exercise electrocardiography in detecting physiologically significant coronary arterial lesions.
        Circulation. 1991; 83: 412-421
        • Philbrick J.T
        • Horwitz R.I
        • Feinstein A.R
        Methodologic problems of exercise testing for coronary artery disease.
        Am J Cardiol. 1980; 46: 807-812
        • Chaitman B.R
        Exercise stress testing.
        in: Braunwald E Heart Disease. 5th Ed. W.B. Saunders Co, Philadelphia, PA1996: 157
        • Gasperetti C.M
        • Burwell L.R
        • Beller G.A
        Prevalence of and variables associated with silent myocardial ischemia on exercise thallium-201 stress testing.
        J Am Coll Cardiol. 1990; 16: 115-123
        • Mahmarian J.J
        • Pratt C.M
        • Cocanougher M.K
        • Verani M.S
        Altered myocardial perfusion in patients with angina pectoris or silent ischemia during exercise as assessed by quantitative thallium-201 single-photon emission computed tomography.
        Circulation. 1990; 82: 1305-1315
        • Hecht H.S
        • DeBord L
        • Sotomayor N
        • Shaw R
        • Ryan C
        Truly silent ischemia and the relationship of chest pain and ST segment changes to the amount of ischemic myocardium.
        J Am Coll Cardiol. 1994; 23: 369-376
        • Miranda C.P
        • Lehmann K.G
        • Lachterman B
        • Coodley E.M
        • Froelicher V.F
        Comparison of silent and symptomatic ischemia during exercise testing in men.
        Ann Int Med. 1991; 114: 649-656
        • Gibson R.S
        • Beller G.A
        • Kaiser D.L
        Prevalence and clinical significance of painless ST segment depression during early postinfarction exercise testing.
        Circulation. 1987; 75: 36-39
        • Kulasegaram R
        • Umachandran V
        • Amepitzia G
        • Kopelman P.G
        • Mills P.G
        • Timmis A.D
        Prolonged anginal perceptual threshold in diabetics.
        J Am Coll Cardiol. 1990; 16: 1120-1124
        • Dunn R.F
        • Bailey I.K
        • Uren R
        • Kelly D.T
        Exercise-induced ST-segment elevation.
        Circulation. 1980; 61: 989-995
        • Bogaty P
        • Guimond J
        • Robitaille N.M
        • Roussear L
        • Simard S
        • Rouleau J.R
        • Dagenais G.R
        A reappraisal of exercise electrocardiographic indexes of the severity of ischemic heart disease.
        J Am Coll Cardiol. 1997; 29: 1497-1504
        • Ribisl P
        • Morris C.K
        • Kawaguchi T
        • Ueshima K
        • Froelicher V.F
        Angiographic patterns and severe coronary artery disease.
        Arch Int Med. 1992; 152: 1618-1624
        • Colby J
        • Hakki A.H
        • Abdulmassih S
        • Iskandrian S
        • Mattleman S
        Hemodynamic, angiographic and scintigraphic correlates of positive exercise electrocardiograms.
        J Am Coll Cardiol. 1983; 2: 21-29
        • Taylor A.J
        • Sackett M.C
        • Beller G
        The degree of ST segment depression on symptom-limited exercise testing.
        Am J Cardiol. 1995; 75: 228-231
        • Mark D.B
        • Hlatky M.A
        • Lee K.L
        • Harrell F.E
        • Califf R.M
        • Pryor D.B
        Localizing coronary artery obstructions with the exercise treadmill test.
        Ann Intern Med. 1987; 106: 53-55
        • Kaplan M.A
        • Harris C.N
        • Parker D.P
        Inability of the submaximal stress test to predict the location of coronary disease.
        Circulation. 1973; 47: 250-258
        • Fuchs R.M
        • Achuff S.C
        • Grunwald L
        • Yin F.C.P
        • Griffith L.S.C
        Electrocardiographic localization of coronary artery narrowings.
        Circulation. 1982; 66: 1168-1176
        • Dunn R.F
        • Freedman B
        • Bailey I.K
        • Uren R.F
        • Kelly D.T
        Localization of coronary artery disease with exercise electrocardiographhy.
        Am J Cardiol. 1981; 48: 836-843
        • Halon D.A
        • Mevorach D
        • Rodeanu M
        • Lewis B.S
        Improved criteria for localization of coronary artery disease from the exercise electrocardiogram.
        Cardiology. 1994; 84: 331-338
        • Gianrossi R
        • Detrano R
        • Mulvihill D
        • Lehmann K
        • Dubach P
        • Colombo A
        • McArthus D
        • Froelicher V
        Exercise induced ST depression in the diagnosis of coronary artery disease. A meta analysis.
        Circulation. 1989; 80: 87-98
        • Ellestad M.H
        Stress Testing. 3rd Edition. F.A. Davis Co, Philadelphia1986: 98
        • Ritchie J.L
        • Bateman T.M
        • Bonow R.O
        • Crawford M.H
        • Gibbons R.J
        • Hall R.J
        • O’Rourke R.A
        • Parisi A.F
        • Verani M.S
        Guidelines for clinical use of cardiac radionuclide imaging.
        J Am Coll Cardiol. 1995; 25: 521-547