Circulation, Vol 83, 866-874, Copyright © 1991 by American Heart Association
PM Okin, KM Anderson, D Levy and P Kligfield
BACKGROUND. Simple heart rate adjustment of ST segment depression during
exercise (delta ST/HR index) and the pattern of ST depression as a function
of heart rate during exercise and recovery (the rate- recovery loop) have
been shown to improve the ability of the exercise electrocardiogram to
detect the presence of coronary heart disease (CHD), but the performance of
these methods for the prediction of future coronary events remains to be
examined. METHODS AND RESULTS. We compared the delta ST/HR index and the
rate-recovery loop with standard electrocardiographic criteria for
prediction of CHD events in 3,168 asymptomatic men and women in the
Framingham Offspring Study who underwent treadmill exercise
electrocardiography and who, at entry, were free of clinical and
electrocardiographic evidence of CHD. After a mean follow-up of 4.3 years,
there were 65 new CHD events: four sudden deaths, 24 new myocardial
infarctions, and 37 incident cases of angina pectoris. When a Cox
proportional hazards model with adjustment for age and sex was used, a
positive exercise electrocardiogram by standard criteria (greater than or
equal to 0.1 mV horizontal or downsloping ST segment depression) was not
predictive of new CHD events (chi 2 = 0.40, p = 0.52). In contrast,
stratification according to the presence or absence of a positive delta
ST/HR index (greater than or equal to 1.6 microV/beat/min) and a positive
(counterclockwise) rate-recovery loop was associated with CHD event risk
(chi 2 = 9.45, p less than 0.01) and separated subjects into three groups
with varying risks of coronary events: high risk, when both tests were
positive (relative risk 3.6; 95% confidence interval, 2.4-5.4);
intermediate risk, when either the delta ST/HR index or the rate-recovery
loop was positive (relative risk, 1.9; 95% confidence interval, 1.3-2.8);
and low risk, when both tests were negative. After multivariate adjustment
for age, sex, smoking, total cholesterol level, fasting glucose level,
diastolic blood pressure, and electrocardiographic evidence of left
ventricular hypertrophy, the combined delta ST/HR index and rate-recovery
loop criteria remained predictive of coronary events (chi 2 = 5.45, p =
0.02). CONCLUSIONS. Heart rate adjustment of ST segment depression by the
delta ST/HR index and the rate-recovery loop during exercise
electrocardiography can improve prediction of future coronary events in
asymptomatic men and women.
ARTICLES
Heart rate adjustment of exercise-induced ST segment depression. Improved risk stratification in the Framingham Offspring Study
Department of Medicine, New York Hospital-Cornell Medical Center, NY 10021.
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