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Continuous monitoring for ventricular arrhythmias during exercise tests.

Exercise stress testing is being increasingly used to verify exercise-induced arrhythmia and to aid in assessing antiarrhythmic drug efficacy. The true prevalence of ventricular arrhythmia during exercise testing is underestimated by means other than continuous monitoring. We compared the yield of ventricular premature beats (VPBs) between a continuous recording system ("trendscription") and intermittent monitoring among 39 patients undergoing a total of 50 consecutive exercise studies. By intermittent monitoring, 22 (44%) of 50 of the exercise tests demonstrated VPBs; with trendscription, 31 (62%) exhibited such arrhythmia. Most striking, however, was a sixfold increase in the disclosure of complex and repetitive forms of VPBs (56 vs nine episodes). Thus, this form of monitoring presents a cost-efficient, on-line method that allows concentration on the patient during exercise as well as clear recording of all arrhythmic events.

Anti-Arrhythmia Agents

[Comparative diagnostic value of the isoproterenol test and the exercise test in detection of coronary insufficiency].

It appears that a constant-speed infusion of isoproterinol is as reliable and sensitive a method of detecting coronary insufficiency as the exercise test. It is indicated when: - the exercise test is impossible or not submaximal; - there is disagreement between the clinical findings, which are suggestive, and ergometry, which is negative; - there is pure angina of effort arising spontaneously.

Adult

Reduced heart rate response to exercise in ischemic heart disease: the fallacy of the target heart rate in exercise testing.

When exercise testing 159 patients with prior myocardial infarction, we identified 39 who were limited by fatigue. This group was all in sinus rhythm; none were taking drugs likely to impair the chronotropic response of the heart; none experienced chest pain or developed ischemic ECG changes. In 18 of this group, maximal heart rate achieved with exercise was 2SD or more below the age predicted value, and their heart rate response to exercise was reduced compared to that of the other 21 whose maximal exercise heart rates were within 2SD of age predicted values. A subgroup of 8 subjects with reduced exercise heart rates was studied before and after vagal blockade. In the 4 subjects whose infarction was inferior, the reduction in heart rate response was more profound and persisted after vagal blockade, suggesting either reduced pacemaker responsivness, due to ischemia or infarction, or autonomic imbalance as possible mechanisms. All 8 showed alinear increases in ventilation at higher power outputs and mean blood lactate postexercise was 7.5 mM/I without vagal blockade. Our findings suggest that a reduced heart rate response to exercise, already shown to imply added coronary risk, may be subdivided aetiologically and possibly prognostically. The use of a "Target Heart Rate" in such patients offers no safety margin, and maximal exercise capacity will be grossly over-estimated if extrapolated from the submaximal heart rate response. A cardiovascular limitation to exercise may be detected by an alinear increase in ventilation.

Adult

Exercise testing in children.

Exercise testing has a definite role in pediatrics today. Different methods are presented, and the value of maximal exercise with determination of oxygen uptake and blood lactate is stressed. In children with heart disease, exercise testing with precordial electrocardiogram can be of both diagnostic and prognostic value. The cardiovascular function at different intensities of exercise is evaluated, serious dysrhythmias may be revealed, hypertension judged and the effect of drug therapy can be checked by exercise testing. It is an important way in assessing the child's functional capacity after heart surgery in the decision whether she or he should take part in physical education and sports activities and in the choice of profession. It is also of great psychological value to the parents and the patient himself. In children with other chronic diseases, e.g., diabetes, obesity, asthma, neurocirculatory dysfunctions--physical training together with exercise testing is of importance for therapy and rehabilitation.

Adolescent

Maximal exercise testing--Bruce protocol.

Maximal treadmill exercise testing is feasible for the family physician's office especially in a group setting. The Bruce Exercise Test is described in detail and is helpful in the diagnosis of asymptomatic coronary heart disease, following the course of coronary heart disease, diagnosis of other cardiac disease, and in preventive testing and exercise prescription. Sensitivity and specificity of ST changes may be improved by recognizing factors which cause false positive and negative ST responses. The Bruce Test is safe when the procedure is followed meticulously. There have been 2,490 tests performed in the laboratory of three family physicians without serious morbidity. The screening exercise test with preventive exercise prescription is particularly pertinent to the present day concepts of family practice.

Adult

Exercise testing in congenital aortic stenosis.

Treadmill exercise testing was performed on 23 patients with isolated congenital aortic stenosis. It was found that eight patients, with a negative exercise test and a normal rise in systolic blood pressure on exercise, had gradients less than 45 mmHg. Fifteen patients with gradients greater than 50 mmHg had positive exercise tests and their systolic blood pressure did not rise normally. It is suggested that the left heart studies to measure aortic valve gradients can safely be postponed if an exercise test is negative. Serial exercise testing of such patients will give an indication when left heart catheterization should be considered.

Adolescent

Detection of ventricular ectopy in patients with coronary heart disease and normal subjects by exercise testing and ambulatory electrocardiography.

Maximal exercise testing and 24-hour ambulatory electrocardiographic recording (Holter monitor) were utilized in the detection of ventricular ectopy in 90 patients with stable chronic coronary heart disease and in 30 normal subjects. Although the occurrence of any ventricular ectopic activity, as detected by either or both methods, was common, the incidence was significantly higher (P less than 0.001) in patients with coronary heart disease (86 percent; 77/90), as compared to that in normal subjects (40 percent; 12/30). Ventricular arrhythmia was more frequently detected by the 24-hour continuous electrocardiographic recording, being found in 70 of the 90 patients with coronary heart disease and in ten of the 30 normal subjects. In comparison, exercise testing disclosed ventricular ectopy in 56 of the 90 patients with coronary heart disease and in two of the 30 normal subjects. Multiform and repetitive patterns of ventricular ectopy were detected twice as commonly by continuous electrocardiographic recording than with exercise testing, and these patterns were present in one-half of the patients with coronary heart disease. Both methods of examination adjunctively disclosed more ventricular ectopy than either method alone.

Angina Pectoris

[Hyperventilation test in coronary disease: a comparison with a bicycle ergometer exercise test. Report of 100 cases].

A hundred cases have been studied and divided into three categories:--60 normal subjects;--30 coronary subjects with a positive exercise test;--10 subjects with defective nervous control of the circulation; using the exercise test, we studied the effects of hyperventilation on repolarisation of the ventricle. In the normal subjects there was no ischaemic depression of the ST segment, but there were minor changes in repolarisation which affected the T wave in 73% of subjects and were essentially posterior in distribution. In the coronary subjects, we found three with ischaemic depression of the ST segment and one with ST elevation of 2.5 mm (6.7% of the coronary subjects). This last finding is evidence against the commonly held hypothesis that reproduction of ST depression by hyperventilation during the exercise test indicates a false positive test. In the patients with defective nervous control of the circulation, 9 had an ischaemic type of ST depression, either as a new feature or as a more severe one compared with that found at rest. The mechanism by which these depressions are produced has not been totally explained:--in the cases with defective nervous control of the circulation, it appears that latent increased sympathetic activity is increased by the hyperventilation;--in the coronary subjects, it may be caused by true ischaemia or by an associated defect in nervous control of the circulation.

Adult

The predictive value of anginal chest pain as an indicator of coronary disease during exercise testing.

To determine the significance of anginal chest pain during exercise testing, a series of 302 patients undergoing coronary arteriography with exercise testing was reviewed. Of the 302 patients, 85 had ischemic ECG changes and chest pain (Group I); 87 patients had ischemic ECG changes but no chest pain (Group II); 25 patients had chest pain but no ischemic ECG changes (Group III); 105 patients had neither chest pain nor ischemic ECG changes (Group IV). Coronary artery disease was present in 95% of Group I, 75% of Group II, 72% of Group III, and 28% of Group IV. Of those patients with coronary disease, multiple vessels were involved in 94% of Group I, 51% of Group II, 67% of Group III, and 21% of Group IV. The predictive value for presence and extent of coronary disease showed Group I greater than Groups II and III greater than Group IV (p less than 0.025). We conclude that (1) anginal chest pain during exercise testing predicts the presence and extent of coronary disease more accurately than its absence; (2) the presence of chest pain even without an ischemic ECG response during exercise testing appears to be as predictive of coronary disease as an ischemic ECG response alone; and (3) the combination of anginal chest pain during exercise testing and an ischemic ECG response is highly predictive of multivessel coronary artery disease.

Angina Pectoris