Chronic stable angina exercise electrocardiography
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Differentiating Chronic Stable Angina from Acute Coronary Syndromes | ||
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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
- The exercise ECG is more useful than the 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.
- Upsloping ST segments are much less specific indicators of CAD.
- 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
- 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.
- 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.
- Variables of the Treadmill Exercise Test which indicate the high risk are:
- Short exercise duration <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]
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Class I1. 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 IIa1. Patients with suspected vasospastic angina. (Level of Evidence: C) Class IIb1. 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 III1. Patients with the following baseline ECG abnormalities:
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) |
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See Also
Sources
- TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina [2]
- The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina [1]
- The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina [3]
References
- ↑ 1.0 1.1 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
- ↑ 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
- ↑ 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