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Downstream Testing After Exercise Treadmill Testing

February 5, 2014

Downstream Testing After Exercise Treadmill Testing

  1. Kirsten E. Fleischmann, MD, MPH

Rapid resolution of electrocardiogram changes during exercise was associated with excellent prognoses.

  1. Kirsten E. Fleischmann, MD, MPH

Current guidelines (NEJM JW Cardiol Nov 1 2002) still support exercise treadmill testing (ETT) as an initial test for evaluation of ischemia in patients who have normal baseline electrocardiograms (ECGs) and are able to exercise. To assess the efficacy of additional testing, investigators recorded downstream testing within 6 months of ETT in 3656 patients without known coronary artery disease who underwent ETT at a large U.S. medical center. Tests were performed mostly for chest pain (61%) and various other symptoms (33%) but occasionally for asymptomatic patients (6%). ETT was positive in 4%, inconclusive in 29%, and negative in 68% of patients.

Within 6 months of ETT, 9.1% of patients were referred to noninvasive imaging, and 2.3% were referred to invasive angiography. During mean follow-up of 2.5 years, annual incidence of a combined endpoint (cardiovascular-related death, myocardial infarction, and coronary revascularization) was 12.4%, 1.3%, and 0.2% in those with positive, inconclusive, and negative ETT results, respectively. Rapid resolution of ECG changes during exercise was associated significantly with negative downstream tests and excellent prognoses, whereas typical angina despite negative ECG findings was associated significantly with positive downstream tests and poorer prognoses. Younger age, female sex, and achieving a higher level of exercise were associated significantly with negative downstream tests.

Comment

These data confirm that exercise treadmill testing can help stratify risk for adverse cardiac events in patients without known coronary artery disease, although the combined endpoint included coronary revascularization, which might be a result of abnormal test results. Only limited conclusions can be drawn because of the study's single-center design and our inability to determine whether downstream testing was appropriate. Nonetheless, we should remember that rapidly resolving ECG changes are associated with a higher proportion of negative downstream tests and that typical angina on the treadmill is a cause for concern, even if ECG does not confirm inducible ischemia.

  • Disclosures for Kirsten E. Fleischmann, MD, MPH at time of publication Grant / research support NIH Leadership positions in professional societies American College of Cardiology and American Heart Association (Vice Chair, Writing Committee for Guidance on Cardiovascular Evaluation and Care for Noncardiac Surgery)

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Reader Comments (2)

chakrapani seshachar Physician, Cardiology, hospital

i fully agree with authors.This concept is well known in era of less invasive cardiology.But this study proved that it holds good even in agreessive invasive cardiology era.

Rob

EST

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