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==Exercise ECG==
==Exercise ECG==
*The exercise ECG is more useful than the resting ECG in detecting [[myocardial ischemia]] and evaluating the cause of [[chest pain]].  
*The exercise [[ECG]] is more useful than the [[Chronic stable angina electrocardiography|resting ECG]] in detecting [[myocardial ischemia]] and evaluating the cause of [[chest pain]].  
:*Down sloping or horizontal ST segment depressions are very suggestive of myocardial ischemia, particularly when these changes occur at a low workload, during early stages of exercise, persist for more than 3 minutes after exercise, or are accompanied by chest discomfort that is compatible with [[angina]].  
:*Down sloping or horizontal [[ST segment depression]]s are very suggestive of myocardial ischemia, particularly when these changes occur:
:*Upsloping ST segments are much less specific indicators of [[CAD]].  
::*at a low workload,  
::*during early stages of exercise,  
::*persist for more than 3 minutes after exercise, or  
::*are accompanied by chest discomfort that is compatible with [[angina]].  
:*Upsloping [[ST segment]]s are much less specific indicators of [[CAD]].  




*Conditions that increase the probability of exercise ECG yielding '''false positive''' results are:
*Conditions that increase the probability of exercise [[ECG]] yielding '''false positive''' results are:
:*An abnormal resting ECG associated with [[left ventricular hypertrophy]], intra ventricular conduction abnormalities, pre-excitation syndromes (Long Ganong Lewine Syndrome=LGL, Wolf Parkinson White syndrome=WPW and Mahaim type), electrolyte imbalance or therapy with [[digitalis]]
:*An abnormal [[Chronic stable angina electrocardiography|resting ECG]] associated with [[left ventricular hypertrophy]], intra ventricular conduction abnormalities, pre-excitation syndromes (Long Ganong Lewine Syndrome=LGL, [[Wolf-Parkinson-White syndrome]]=WPW and Mahaim type), electrolyte imbalance or therapy with [[digitalis]]
:*In women, the lower prior probability of [[CAD]] is associated with more false positive results on [[ECG]].
:*In women, the lower prior probability of [[CAD]] is associated with more false positive results on [[ECG]].


*On the other hand, a fall in systolic pressure of 10 mmHg or more during exercise or the appearance of a murmur of [[mitral regurgitation]] during exercise increases the probability that, an abnormal stress ECG is a '''true positive''' test result.
*On the other hand, a fall in systolic pressure of 10 mmHg or more during exercise or the appearance of a murmur of [[mitral regurgitation]] during exercise increases the probability that, an abnormal stress ECG is a '''true positive''' test result.


*Exercise electrocardiography has a '''sensitivity of about 70%''' for detecting [[CAD]] and a '''specificity of about 75%''' for excluding it. To assess the probability of coronary artery disease in an individual patient, the exercise ECG result must be integrated with the clinical presentation.
*Exercise electrocardiography has a '''sensitivity of about 70%''' for detecting [[CAD]] and a '''specificity of about 75%''' for excluding it. To assess the probability of [[coronary artery disease]] in an individual patient, the exercise ECG result must be integrated with the clinical presentation.




*[[Treadmill exercise]] test is more preferable to [[bicycle exercise test]] (or ergometer) for detecting [[myocardial ischemia]]. In patients who cannot perform treadmill exercise, pharmacologic stress scintigraphy or echocardiography is preferable to upper body arm exercise.  
*[[Treadmill exercise]] test is more preferable to [[bicycle exercise test]] (or ergometer) for detecting [[myocardial ischemia]]. In patients who cannot perform treadmill exercise, [[Chronic stable angina perfusion scintigraphy with pharmacologic stress|pharmacologic stress scintigraphy]] or [[Chronic stable angina echocardiography|echocardiography]] is preferable to upper body arm exercise.  


*Variables of the Treadmill Exercise Test which indicate the high risk are:
*Variables of the Treadmill Exercise Test which indicate the '''high risk''' are:
:*Short exercise duration <5 METs,  
:*Short exercise duration less than 5 METs,  
:*Significant [[ST segment depression]] (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,  
:*Significant [[ST segment depression]] (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,  
:*Significant changes in [[blood pressure]]: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),  
:*Significant changes in [[blood pressure]]: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),  
Line 30: Line 34:




==ACC / AHA Guidelines- Exercise ECG for Diagnosis (DO NOT EDIT)<ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref>==
==ACC / AHA Guidelines- Exercise ECG for Diagnosis (DO NOT EDIT)<ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>==
{{cquote|
{{cquote|
===Class I===
===Class I===
Line 49: Line 53:
===Class III===
===Class III===
'''1.''' Patients with the following baseline ECG abnormalities:
'''1.''' Patients with the following baseline ECG abnormalities:
:a. Preexcitation ([[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White]]) syndrome. ''(Level of Evidence: B)''
:a. Preexcitation ([[Wolff-Parkinson-White syndrome]]). ''(Level of Evidence: B)''
:b. Electronically paced ventricular rhythm. ''(Level of Evidence: B)''
:b. Electronically paced ventricular rhythm. ''(Level of Evidence: B)''
:c. More than 1 mm of rest ST depression. ''(Level of Evidence: B)''
:c. More than 1 mm of rest ST depression. ''(Level of Evidence: B)''
Line 55: Line 59:


'''2.''' Patients with an established diagnosis of [[CAD]] due to prior [[MI]] or [[coronary angiography]]; however, testing can assess functional capacity and prognosis. ''(Level of Evidence: B)''}}
'''2.''' Patients with an established diagnosis of [[CAD]] due to prior [[MI]] or [[coronary angiography]]; however, testing can assess functional capacity and prognosis. ''(Level of Evidence: B)''}}
==ESC Guidelines- Exercise ECG for Initial diagnostic assessment of angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
{{cquote|
===Class I===
'''1.''' Patients with symptoms of [[angina]] and intermediate pre-test probability of [[coronary artery disease]] based on age, gender, and symptoms, unless unable to exercise or displays [[ECG]] changes which make ECG non-evaluable. ''(Level of Evidence: B)''
===Class IIb===
'''1.''' Patients with more than 1 mm [[ST-depression]] on [[Chronic stable angina electrocardiography|resting ECG]] or taking [[digoxin]]. ''(Level of Evidence: B)''
'''2.''' In patients with low pre-test probability (less than 10% probability) of coronary disease based on age, gender, and symptoms. ''(Level of Evidence: B)''}}
==ESC Guidelines- Exercise ECG for Routine re-assessment in patients with chronic stable angina (DO NOT EDIT)<ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>==
{{cquote|
===Class IIb===
'''1.''' Routine periodic exercise ECG in the absence of clinical change. ''(Level of Evidence: C)''}}


==See Also==
==See Also==
Line 60: Line 79:


==Sources==
==Sources==
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="Gibbons2">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV, Gibbons RJ, Alpert JS, Antman EM, Hiratzka LF, Fuster V, Faxon DP, Gregoratos G, Jacobs AK, Smith SC Jr; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003 Jan 7; 107 (1): 149-58. PMID 12515758 </ref>
*Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology <ref name="pmid16735367">{{cite journal| author=Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F et al.| title=Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. | journal=Eur Heart J | year= 2006 | volume= 27 | issue= 11 | pages= 1341-81 | pmid=16735367 | doi=10.1093/eurheartj/ehl001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16735367  }} </ref>
 
*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid10351980">Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10351980 ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina).] ''Circulation'' 99 (21):2829-48. PMID: [http://pubmed.gov/10351980 10351980]</ref>


*The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Gibbons1"> Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP–ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999; 99: 2829–2848. PMID 10351980</ref>
*TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina <ref name="pmid12515758">Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12515758 ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina).] ''Circulation'' 107 (1):149-58. PMID: [http://pubmed.gov/12515758 12515758]</ref>


*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="Fraker"> Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Gardin JM, O'Rourke RA, Williams SV, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW; American College of Cardiology; American Heart Association; American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4; 116 (23): 2762-72. Epub 2007 Nov 12. PMID 17998462 </ref>
*The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina <ref name="pmid17998462">Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17998462 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina.] ''Circulation'' 116 (23):2762-72. [http://dx.doi.org/10.1161/CIRCULATIONAHA.107.187930 DOI:10.1161/CIRCULATIONAHA.107.187930] PMID: [http://pubmed.gov/17998462 17998462]</ref>


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Disease state]]
[[Category: Disease state]]  
[[Category:Ischemic heart diseases]]
[[Category: Ischemic heart diseases]]
[[Category:Cardiology]]
[[Category: Cardiology]]
[[Category:Emergency medicine]]
[[Category: Emergency medicine]]


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Revision as of 04:51, 19 July 2011

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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Cafer Zorkun, M.D., Ph.D. [2]; Associate Editor-in-Chief: Smita Kohli, M.D.

Exercise ECG

  • Down sloping or horizontal ST segment depressions are very suggestive of myocardial ischemia, particularly when these changes occur:
  • at a low workload,
  • during early stages of exercise,
  • persist for more than 3 minutes after exercise, or
  • are accompanied by chest discomfort that is compatible with angina.


  • Conditions that increase the probability of exercise ECG yielding false positive results are:
  • On the other hand, a fall in systolic pressure of 10 mmHg or more during exercise or the appearance of a murmur of mitral regurgitation during exercise increases the probability that, an abnormal stress ECG is a true positive test result.
  • Exercise electrocardiography has a sensitivity of about 70% for detecting CAD and a specificity of about 75% for excluding it. To assess the probability of coronary artery disease in an individual patient, the exercise ECG result must be integrated with the clinical presentation.


  • Variables of the Treadmill Exercise Test which indicate the high risk are:
  • Short exercise duration less than 5 METs,
  • Significant ST segment depression (magnitude ≥2 mm, starts at exercise stage I or II, duration of exercise test is <5 minutes and ≥5 leads with ST changes,
  • Significant changes in blood pressure: low peak systolic blood pressure (<130 mm Hg), significant decrease in systolic blood pressure during the test (below the resting standing blood pressure),
  • Inability to attain to the target heart rate,
  • Presence of exercise induced angina,
  • Presence of frequent ventricular ectopy (e.g. couplets or tachycardia) at low workload.


ACC / AHA Guidelines- Exercise ECG for Diagnosis (DO NOT EDIT)[1]

“

Class I

1. Patients with an intermediate pretest probability of CAD based on age, gender, and symptoms, including those with complete right bundle-branch block or <1 mm of rest ST depression (exceptions are listed below in classes II and III). (Level of Evidence: B)

Class IIa

1. Patients with suspected vasospastic angina. (Level of Evidence: C)

Class IIb

1. Patients with a high pretest probability of CAD by age, gender, and symptoms. (Level of Evidence: B)

2. Patients with a low pretest probability of CAD by age, gender, and symptoms. (Level of Evidence: B)

3. Patients taking digoxin with ECG baseline ST segment depression <1 mm. (Level of Evidence: B)

4. Patients with ECG criteria for LV hypertrophy and <1 mm of baseline ST-segment depression. (Level of Evidence: B)

Class III

1. Patients with the following baseline ECG abnormalities:

a. Preexcitation (Wolff-Parkinson-White syndrome). (Level of Evidence: B)
b. Electronically paced ventricular rhythm. (Level of Evidence: B)
c. More than 1 mm of rest ST depression. (Level of Evidence: B)
d. Complete left bundle-branch block. (Level of Evidence: B)

2. Patients with an established diagnosis of CAD due to prior MI or coronary angiography; however, testing can assess functional capacity and prognosis. (Level of Evidence: B)

”

ESC Guidelines- Exercise ECG for Initial diagnostic assessment of angina (DO NOT EDIT)[2]

“

Class I

1. Patients with symptoms of angina and intermediate pre-test probability of coronary artery disease based on age, gender, and symptoms, unless unable to exercise or displays ECG changes which make ECG non-evaluable. (Level of Evidence: B)

Class IIb

1. Patients with more than 1 mm ST-depression on resting ECG or taking digoxin. (Level of Evidence: B)

2. In patients with low pre-test probability (less than 10% probability) of coronary disease based on age, gender, and symptoms. (Level of Evidence: B)

”

ESC Guidelines- Exercise ECG for Routine re-assessment in patients with chronic stable angina (DO NOT EDIT)[2]

“

Class IIb

1. Routine periodic exercise ECG in the absence of clinical change. (Level of Evidence: C)

”

See Also

Sources

  • Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology [2]
  • The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
  • TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [3]
  • The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [4]

References

  1. ↑ 1.0 1.1 Gibbons RJ, Chatterjee K, Daley J, Douglas JS, Fihn SD, Gardin JM et al. (1999) ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Chronic Stable Angina). Circulation 99 (21):2829-48. PMID: 10351980
  2. ↑ 2.0 2.1 2.2 Fox K, Garcia MA, Ardissino D, Buszman P, Camici PG, Crea F; et al. (2006). "Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology". Eur Heart J. 27 (11): 1341–81. doi:10.1093/eurheartj/ehl001. PMID 16735367.
  3. ↑ Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS et al. (2003) ACC/AHA 2002 guideline update for the management of patients with chronic stable angina--summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation 107 (1):149-58. PMID: 12515758
  4. ↑ Fraker TD, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J et al. (2007) 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation 116 (23):2762-72. DOI:10.1161/CIRCULATIONAHA.107.187930 PMID: 17998462


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