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Diagnostic performance and partition values of exercise electrocardiographic variables in the detection of coronary artery disease - improved accuracy by using ST/HR hysteresis
KTH, School of Technology and Health (STH), Medical Engineering.
KTH, School of Technology and Health (STH), Medical Engineering.
KTH, School of Technology and Health (STH), Medical Engineering.
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2010 (English)In: Clinical Physiology and Functional Imaging, ISSN 1475-0961, E-ISSN 1475-097X, Vol. 30, no 2, 98-106 p.Article in journal (Refereed) Published
Abstract [en]

P>Exercise electrocardiography is widely used for initial identification of patients with coronary artery disease (CAD). This study compares the measurements of ST-segment changes during exercise and during early postexercise recovery in terms of diagnostic discrimination capacity and optimal partition values. Data from 1876 patients undergoing a routine bicycle exercise test were analysed. CAD was angiographically verified in 668 patients, and excluded by angiography (n = 119), myocardial scintigraphy (n = 250), and on clinical grounds (n = 839) in 1208 patients. Postexercise ST/HR hysteresis was calculated as normalized for heart rate (HR) ST/HR loop area during the first 3 min of recovery. ST/HR index was obtained by dividing the overall ST amplitude change during exercise by exercise-induced HR change, and ST/HR slope was calculated using linear regression analysis of ST/HR data pairs during exercise. ST-segment depression was measured during, and for 3 min after the exercise. Discriminating capacity of the methods was evaluated in terms of receiver operating characteristic areas and optimal partition values providing the combination of the best sensitivity and specificity were established. The best diagnostic discrimination was provided by ST/HR hysteresis at optimal partition value of -15 mu V, followed by postexercise ST amplitude measurements at gender-specific partition values of -10 to -90 mu V, ST/HR slope [partition value 2 center dot 4 mu V (beats/min)-1], ST/HR index [partition value 1 center dot 6 mu V (beats/min)-1], and ST-segment depression during exercise (partition value 70 mu V in men and 90 mu V in women). The results demonstrate that analysis of postexercise ST/HR hysteresis offers the most accurate and gender indifferent identification of patients with CAD.

Place, publisher, year, edition, pages
2010. Vol. 30, no 2, 98-106 p.
Keyword [en]
exercise test, ischemic heart disease, ST, HR hysteresis, HR index, HR slope, ST-segment depression
National Category
Medical Laboratory and Measurements Technologies
Identifiers
URN: urn:nbn:se:kth:diva-14210DOI: 10.1111/j.1475-097X.2009.00909.xISI: 000274438800003Scopus ID: 2-s2.0-76949103976OAI: oai:DiVA.org:kth-14210DiVA: diva2:331774
Note
QC 20110126Available from: 2010-07-26 Created: 2010-07-26 Last updated: 2017-12-12Bibliographically approved
In thesis
1. Diagnostic and Prognostic Value of Exercise Electrocardiographic Test Variables in Coronary Artery Disease
Open this publication in new window or tab >>Diagnostic and Prognostic Value of Exercise Electrocardiographic Test Variables in Coronary Artery Disease
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The diagnostic performance of conventional analysis of the exercise electrocardiographic (ECG) test for the detection of coronary artery disease (CAD) is limited to 70-75%. The exercise ECG test is the most widely used non-invasive method for assessing CAD and even a small improvement in the diagnostic performance is important. The objective of this thesis was to investigate the diagnostic performance of the exercise ECG test for diagnosis of CAD and the prognostic performance of the test for predicting acute myocardial infarction (AMI), in both men and women.

In the diagnostic part of the present study, aimed at finding the optimal diagnostic information during the exercise and recovery phase, 1,877 electrocardiograms selected from 8,322 consecutive patients undergoing a routine exercise test on bicycle ergometer were evaluated. CAD was verified angiographically in 669 patients and excluded in 1,208 patients, by angiography (119 patients), by myocardial scintigraphy (250 patients), or on clinical grounds (839 patients).

The diagnostic performance of ST-segment amplitude, and the difference between heart rate (HR) matched recovery and exercise ST-segment amplitudes (ST/HR difference), were evaluated by constructing receiver operating characteristic (ROC) curves for each sample point every 12th second during 10 minutes of recovery as well as the last 4 minutes of exercise for the ST-segment amplitude. ST-segment amplitude performed better after exercise than during exercise and best within the first 2 minutes of recovery. Its diagnostic ability did not differ from the ST/HR difference. Both methods performed better in men than in women and the diagnostic information appeared mainly in leads I, -aVR, II, V4, V5 and V6.

The effect of different sampling rates (1, 2 and 5 samples/min) on the CAD discrimination ability of ST/HR loop area was evaluated by using ROC curves. A use of sampling frequency below 2 samples/min resulted in a significantly diminished diagnostic performance.

ST-segment and ST/HR variables were compared during exercise and during early post-exercise recovery in terms of diagnostic discrimination capacity and optimal partition values. Discriminating capacity of the methods was evaluated by the use of ROC areas. Partition values, providing the combination of the best sensitivity and specificity, were established. The results demonstrate that analysis of post-exercise ST/HR hysteresis offers the most accurate and gender indifferent identification of patients with CAD.

The prognostic part of the study included 8,317 of the 8,322 patients and covered a mean follow-up period of 9.5 years. This part of the study was used to evaluate the long-term prognostic value of ST/HR hysteresis in predicting AMI and all-cause mortality in men and women. ST/HR hysteresis appears to improve the prognostic ability of an exercise ECG test for AMI and all-cause mortality in a long term perspective compared to conventional ST-segment and ST/HR indicators in both genders and clearly more markedly in women.

Place, publisher, year, edition, pages
Stockholm: KTH, 2009. 65 p.
Series
Trita-STH : report, ISSN 1653-3836 ; 2009:3
Keyword
exercise ECG test, coronary artery disease, acute myocardial infarction
National Category
Medical Laboratory and Measurements Technologies
Identifiers
urn:nbn:se:kth:diva-11289 (URN)978-91-7415-457-3 (ISBN)
Public defence
2009-11-06, Sal 4-221, Alfred Nobels Allé 12, Huddinge, 09:00 (English)
Opponent
Supervisors
Note
QC 20100726Available from: 2009-10-14 Created: 2009-10-14 Last updated: 2010-07-26Bibliographically approved

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