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Sensitivity of Exercise Electrocardiography for Acute Cardiac Events During Moderate and Strenuous Physical Activity: The Lipid Research Clinics Coronary Primary Prevention Trial

Sensitivity of Exercise Electrocardiography for Acute Cardiac Events During Moderate and... Abstract We determined whether the exercise electrocardiogram predicted acute cardiac events during moderate or strenuous physical activity among 3617 asymptomatic, hypercholesterolemic men (age range, 35 to 59 years) who were followed up in the Coronary Primary Prevention Trial. Submaximal exercise test results were obtained at entry and at annual follow-up visits in years 2 through 7. ST-segment depression or elevation (≥ 1 mm or 10 μV-sec) was considered to be a positive test result. The circumstances that surrounded each nonfatal myocardial infarction and coronary heart disease death were determined through a record review. The cumulative incidence of activity-related acute cardiac events was 2% during a mean follow-up period of 7.4 years. The risk was increased 2.6-fold in the presence of clinically silent, exercise-induced, ST-segment changes at entry (95% confidence interval [CI], 1.3 to 5.2) after adjustment for 11 other potential risk factors. Of 62 men who experienced an activity-related event, 11 had a positive test result at entry (sensitivity, 18%; 95% CI, 8 to 27). The specificity of the entry exercise test was 92% (95% CI, 91 to 93). The sensitivity and specificity were similar when the length of follow-up was restricted to 1 year after testing. For a newly positive test result on a follow-up visit, the sensitivity was 24% (95% CI, 12 to 36), and the specificity was 85% (95% CI, 84 to 86); for any positive test result during the study (mean number of tests per subject, 6.2), the sensitivity was 37% (95% CI, 25 to 49), and the specificity was 79% (95% CI, 77 to 80). Our findings suggested that the presence of clinically silent, exercise-induced, ischemic ST-segment changes on a submaximal test was associated with an increased risk of activity-related acute cardiac events. However, this test was not sensitive when used to predict the occurrence of activity-related events among asymptomatic, hypercholesterolemic men. For this reason, the utility of the submaximal exercise test to assess the safety of physical activity among asymptomatic men at risk of coronary heart disease is likely to be limited. (Arch Intern Med. 1991;151:325-330) References 1. Schlant RC, Blomquist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the Joint American College of Cardiology American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Exercise Testing) . Circulation. 1986;74:653. Abstract.Crossref 2. Levy RI. Exercise and Your Heart . Washington, DC: US Dept of Health and Human Services publication NIH 81-1677; 1981. 3. Vuori I. The cardiovascular risks of physical activity . Acta Med Scand Suppl. 1986;711:205-214. 4. Froelicher VF, Maron D. Exercise testing and ancillary techniques to screen for coronary heart disease . Prog Cardiovasc Dis. 1981;24:261-274.Crossref 5. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigorous exercise . N Engl J Med. 1984;311:874-877.Crossref 6. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980 . JAMA. 1982;247:2535-2538.Crossref 7. Gibbons LW, Cooper KH, Meyer BM, Ellison RC. The acute cardiac risk of strenuous exercise . JAMA. 1980;244:1799-1801.Crossref 8. The Lipid Research Clinics Program. The Coronary Primary Prevention Trial: design and implementation . J Chronic Dis. 1979;32:609-631.Crossref 9. The Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;251:351-364.Crossref 10. Sheffield LT, Roitman D. Stress testing methodology . Prog Cardiovasc Dis. 1976;19:33-49.Crossref 11. Sheffield LT, Haskell W, Heiss G, et al. Safety of exercise testing volunteer subjects: the Lipid Research Clinics Prevalence Study experiment . J Cardiac Rehabil. 1982;2:395-400. 12. Sheffield LT, Holt JH, Lester FM, Conroy DV, Reeves TJ. On-line analysis of the exercise electrocardiogram . Circulation. 1969;40:935.Crossref 13. Gordon DJ, Probstfield JL, Rubinstein C, et al. Coronary risk factors and exercise test performance in asymptomatic hypercholesterolemic men: application of proportional hazards analysis . Am J Epidemiol. 1984;120:210-224. 14. Ekelund LG, Suchindran CM, McMahon RP, et al. Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: the LRC Coronary Primary Prevention Trial. J Am Coll Cardiol. 1989;14;556-563. 15. McManus BM, Waller BF, Graboys TB, et al. Current problems in cardiology . In: Exercise and Sudden Death . Chicago, Ill: Year Book Medical Publishers Inc; 1981;16(pt 1, No. (9) ):10-89. 16. Virmani R, Robinowitz M, McAllister H Jr. Exercise and the heart: a review of cardiac pathology associated with physical activity . Pathol Annu. 1985;20:431-462. 17. Froehlicher VF Jr, Thompson AJ, Wolthius R, et al. Angiographic findings in asymptomatic air crewmen with electrocardiographic abnormalities . Am J Cardiol. 1977;39:32-38.Crossref 18. Gordon DJ, Ekelund LG, Karon JM, et al. Predictive value of the exercise tolerance test for mortality in North American men: the Lipid Research Clinics Mortality Follow-up Study . Circulation. 1986;74:252-261.Crossref 19. Multiple Risk Factor Intervention Trial Research Group. Exercise electrocardiogram and coronary heart disease mortality in the Multiple Risk Factor Intervention Trial . Am J Cardiol. 1985;55:16-24.Crossref 20. McHenry PL, O'Donnell J, Morris SN, Jordan JJ. The abnormal exercise electrocardiogram in apparently healthy men: a predictor of angina pectoris as an initial coronary event during long-term follow-up . Circulation. 1984;70:547-551.Crossref 21. Detrano R, Froelicher V. A logical approach to screening for coronary artery disease . Ann Intern Med. 1987;106:846-852.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Sensitivity of Exercise Electrocardiography for Acute Cardiac Events During Moderate and Strenuous Physical Activity: The Lipid Research Clinics Coronary Primary Prevention Trial

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Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1991.00400020079017
Publisher site
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Abstract

Abstract We determined whether the exercise electrocardiogram predicted acute cardiac events during moderate or strenuous physical activity among 3617 asymptomatic, hypercholesterolemic men (age range, 35 to 59 years) who were followed up in the Coronary Primary Prevention Trial. Submaximal exercise test results were obtained at entry and at annual follow-up visits in years 2 through 7. ST-segment depression or elevation (≥ 1 mm or 10 μV-sec) was considered to be a positive test result. The circumstances that surrounded each nonfatal myocardial infarction and coronary heart disease death were determined through a record review. The cumulative incidence of activity-related acute cardiac events was 2% during a mean follow-up period of 7.4 years. The risk was increased 2.6-fold in the presence of clinically silent, exercise-induced, ST-segment changes at entry (95% confidence interval [CI], 1.3 to 5.2) after adjustment for 11 other potential risk factors. Of 62 men who experienced an activity-related event, 11 had a positive test result at entry (sensitivity, 18%; 95% CI, 8 to 27). The specificity of the entry exercise test was 92% (95% CI, 91 to 93). The sensitivity and specificity were similar when the length of follow-up was restricted to 1 year after testing. For a newly positive test result on a follow-up visit, the sensitivity was 24% (95% CI, 12 to 36), and the specificity was 85% (95% CI, 84 to 86); for any positive test result during the study (mean number of tests per subject, 6.2), the sensitivity was 37% (95% CI, 25 to 49), and the specificity was 79% (95% CI, 77 to 80). Our findings suggested that the presence of clinically silent, exercise-induced, ischemic ST-segment changes on a submaximal test was associated with an increased risk of activity-related acute cardiac events. However, this test was not sensitive when used to predict the occurrence of activity-related events among asymptomatic, hypercholesterolemic men. For this reason, the utility of the submaximal exercise test to assess the safety of physical activity among asymptomatic men at risk of coronary heart disease is likely to be limited. (Arch Intern Med. 1991;151:325-330) References 1. Schlant RC, Blomquist CG, Brandenburg RO, et al. Guidelines for exercise testing: a report of the Joint American College of Cardiology American Heart Association Task Force on Assessment of Cardiovascular Procedures (Subcommittee on Exercise Testing) . Circulation. 1986;74:653. Abstract.Crossref 2. Levy RI. Exercise and Your Heart . Washington, DC: US Dept of Health and Human Services publication NIH 81-1677; 1981. 3. Vuori I. The cardiovascular risks of physical activity . Acta Med Scand Suppl. 1986;711:205-214. 4. Froelicher VF, Maron D. Exercise testing and ancillary techniques to screen for coronary heart disease . Prog Cardiovasc Dis. 1981;24:261-274.Crossref 5. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigorous exercise . N Engl J Med. 1984;311:874-877.Crossref 6. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980 . JAMA. 1982;247:2535-2538.Crossref 7. Gibbons LW, Cooper KH, Meyer BM, Ellison RC. The acute cardiac risk of strenuous exercise . JAMA. 1980;244:1799-1801.Crossref 8. The Lipid Research Clinics Program. The Coronary Primary Prevention Trial: design and implementation . J Chronic Dis. 1979;32:609-631.Crossref 9. The Lipid Research Clinics Program. The Lipid Research Clinics Coronary Primary Prevention Trial results, I: reduction in incidence of coronary heart disease . JAMA. 1984;251:351-364.Crossref 10. Sheffield LT, Roitman D. Stress testing methodology . Prog Cardiovasc Dis. 1976;19:33-49.Crossref 11. Sheffield LT, Haskell W, Heiss G, et al. Safety of exercise testing volunteer subjects: the Lipid Research Clinics Prevalence Study experiment . J Cardiac Rehabil. 1982;2:395-400. 12. Sheffield LT, Holt JH, Lester FM, Conroy DV, Reeves TJ. On-line analysis of the exercise electrocardiogram . Circulation. 1969;40:935.Crossref 13. Gordon DJ, Probstfield JL, Rubinstein C, et al. Coronary risk factors and exercise test performance in asymptomatic hypercholesterolemic men: application of proportional hazards analysis . Am J Epidemiol. 1984;120:210-224. 14. Ekelund LG, Suchindran CM, McMahon RP, et al. Coronary heart disease morbidity and mortality in hypercholesterolemic men predicted from an exercise test: the LRC Coronary Primary Prevention Trial. J Am Coll Cardiol. 1989;14;556-563. 15. McManus BM, Waller BF, Graboys TB, et al. Current problems in cardiology . In: Exercise and Sudden Death . Chicago, Ill: Year Book Medical Publishers Inc; 1981;16(pt 1, No. (9) ):10-89. 16. Virmani R, Robinowitz M, McAllister H Jr. Exercise and the heart: a review of cardiac pathology associated with physical activity . Pathol Annu. 1985;20:431-462. 17. Froehlicher VF Jr, Thompson AJ, Wolthius R, et al. Angiographic findings in asymptomatic air crewmen with electrocardiographic abnormalities . Am J Cardiol. 1977;39:32-38.Crossref 18. Gordon DJ, Ekelund LG, Karon JM, et al. Predictive value of the exercise tolerance test for mortality in North American men: the Lipid Research Clinics Mortality Follow-up Study . Circulation. 1986;74:252-261.Crossref 19. Multiple Risk Factor Intervention Trial Research Group. Exercise electrocardiogram and coronary heart disease mortality in the Multiple Risk Factor Intervention Trial . Am J Cardiol. 1985;55:16-24.Crossref 20. McHenry PL, O'Donnell J, Morris SN, Jordan JJ. The abnormal exercise electrocardiogram in apparently healthy men: a predictor of angina pectoris as an initial coronary event during long-term follow-up . Circulation. 1984;70:547-551.Crossref 21. Detrano R, Froelicher V. A logical approach to screening for coronary artery disease . Ann Intern Med. 1987;106:846-852.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Feb 1, 1991

References