Vnitr Lek 2023, 69(7):E15-E20 | DOI: 10.36290/vnl.2023.094

Do we still need an exercise ECG?

Juraj Dúbrava
Oddelenie neinvazívnej kardiológie, Univerzitná nemocnica Bratislava

The importance of exercise ECG for the diagnosis of myocardial ischaemia has fundamentally decreased in the era of advanced cardiac imaging techniques. The biggest problem is suboptimal diagnostic accuracy, especially unsatisfactory sensitivity. A significant limitation is the high proportion of inconclusive tests and the lower diagnostic accuracy in women. The European Society of Cardiology prefers non-invasive functional imaging or coronary computed tomography angiography for diagnosing obstructive coronary artery disease (CAD). Exercise ECG may be considered as an alternative test to rule-in or rule-out CAD when other non-invasive or invasive imaging methods are not available. American College of Cardiology and American Heart Association on the other hand continue to recommend exercise ECG as an initial examination for intermediate-risk patients with acute chest pain and no known CAD for the diagnosis of myocardial ischemia. Exercise ECG still has an important position in the management of patients with asymptomatic valvular diseases. In an overview, we present the indications and limitations of exercise ECG, its real-world position, and the possible future of exercise ECG.

Keywords: coronary artery disease, coronary computed tomography angiography, exercise ECG, imaging tests, myocardial ischaemia.

Accepted: October 26, 2023; Published: October 26, 2023  Show citation

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Dúbrava J. Do we still need an exercise ECG? Vnitr Lek. 2023;69(7):E15-20. doi: 10.36290/vnl.2023.094.
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    References

    1. Leeds MF, Kroopf SS. The exercise test in electrocardiography; detection of coronary artery diseases. Calif Med. 1953;79(1):36-39.
    2. Bruce RA. Evaluation of functional capacity and exercise tolerance of cardiac patients. Mod Concepts Cardiovasc Dis. 1956;25(4):321-326.
    3. Ananthasubramaniam G, Ananthasubramaniam K. Stress electrocardiography testing in coronary artery disease: Is it time for its swan song or to redefine its role in the modern era? Indian Heart J. 2022;74(2):81-85. Go to original source... Go to PubMed...
    4. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407-477. Go to original source... Go to PubMed...
    5. Juarez­‑Orozco LE, Saraste A, Capodanno D, et al. Impact of a decreasing pre­‑test probability on the performance of diagnostic tests for coronary artery disease. Eur Heart J Cardiovasc Imaging. 2019;20(11):1198-1207. Go to original source... Go to PubMed...
    6. Singh T, Bing R, Dweck MR, et al. Exercise Electrocardiography and Computed Tomography Coronary Angiography for Patients With Suspected Stable Angina Pectoris: A Post Hoc Analysis of the Randomized SCOT­‑HEART Trial. JAMA Cardiol. 2020;5(8):920-928. Go to original source... Go to PubMed...
    7. Maffei E, Seitun S, Martini Ch, et al. CT coronary angiography and exercise ECG in a population with chest pain and low­‑to­‑intermediate pre­‑test likelihood of coronary artery disease. Heart. 2010;96(24):1973-1979. Go to original source... Go to PubMed...
    8. Yin X, Wang J, Zheng W, et al. Diagnostic performance of coronary computed tomography angiography versus exercise electrocardiography for coronary artery disease: a systematic review and meta­‑analysis. J Thorac, Dis. 2016;8(7):1688-1696. Go to original source... Go to PubMed...
    9. van der Wall EE. The exercise ECG: still a useful exercise? Neth Heart J. 2009;17(2):47. Go to original source... Go to PubMed...
    10. Lee SE, Cho I, Hong GR, et al. Differential Prognostic Value of Coronary Computed Tomography Angiography in Relation to Exercise Electrocardiography in Asymptomatic Subjects. J Cardiovasc Ultrasound. 2015;23(4):244-252. Go to original source... Go to PubMed...
    11. Kim KH, Jeon KN, Kang MG, et al. Prognostic value of computed tomographic coronary angiography and exercise electrocardiography for cardiovascular events. Korean J Intern Med. 2016;31(5):880-90. Go to original source... Go to PubMed...
    12. Lau GTE, Wei H, Wickham J, et al. The Significance of Equivocal Exercise Treadmill ECG for Intermediate Risk Chest Pain Assessment - Insight From Coronary CT Angiography Data. Heart Lung Circ. 2018;27(1):50-57. Go to original source... Go to PubMed...
    13. Poldervaart JM, Six AJ, Backus BE, et al. The predictive value of the exercise ECG for major adverse cardiac events in patients who presented with chest pain in the emergency department. Clin Res Cardiol. 2013;102(4):305-312. Go to original source... Go to PubMed...
    14. Kwok Y, Kim C, Grady D, et al. Meta­‑analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol. 1999;83(5):660-666. Go to original source... Go to PubMed...
    15. Akil S, Hedén B, Pahlm O, et al. Gender aspects on exercise­‑induced ECG changes in relation to scintigraphic evidence of myocardial ischaemia. Clin Physiol Funct Imaging. 2018;38(5):798-807. Go to original source... Go to PubMed...
    16. Fitzgerald BT, Scalia WM, Scalia GM. Female False Positive Exercise Stress ECG Testing - Fact Versus Fiction. Heart Lung Circ. 2019;28(5):735-741. Go to original source... Go to PubMed...
    17. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949-3003. Go to original source... Go to PubMed...
    18. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;78(22):2218-2261. Go to original source... Go to PubMed...
    19. Shaw LJ, Mieres JH, Hendel RH, et al. Comparative effectiveness of exercise electrocardiography with or without myocardial perfusion single photon emission computed tomography in women with suspected coronary artery disease: results from the What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. Circulation. 2011;124:1239-1249. Go to original source... Go to PubMed...
    20. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632. Go to original source... Go to PubMed...
    21. Iung B, Delgado V, Rosenhek R, et al. Contemporary presentation and management of valvular heart disease: The EURObservational Research Programme Valvular Heart Disease II Survey. Circulation. 2019;140(14):1156-1169. Go to original source... Go to PubMed...
    22. Dúbrava J. Časové trendy záťažovej a zobrazovacej kardiologickej diagnostiky na Slovensku v rokoch 2011-2021. Časť I. Cardiology Lett 2022;32(5-6):276-283.
    23. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med. 2005;353(18):1889-898. Go to original source... Go to PubMed...
    24. Uthamalingam S, Zheng H, Leavitt M, et al. Exercise­‑induced ST­‑segment elevation in ECG lead aVR is a useful indicator of significant left main or ostial LAD coronary artery stenosis. JACC Cardiovasc Imaging. 2011;4(2):176-186. Go to original source... Go to PubMed...
    25. Murphy JC, Scott PJ, Shannon HJ, et al. ST elevation on the exercise ECG in patients presenting with chest pain and no prior history of myocardial infarction. Heart. 2009;95(21):1792-7. Go to original source... Go to PubMed...
    26. Hendel RC, Berman DS, Di Carli MF, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119(22):e561-87. Go to original source... Go to PubMed...

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