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(Circulation. 1996;93:205-207.)
© 1996 American Heart Association, Inc.

Articles

The Search for a Better Exercise Test

A Self-Fulfilling Prophecy?

Richard O. Cannon, III, MD; Michael Lesch, MD

From the Cardiology Branch, National Heart, Lung, and Blood Institute (R.O.C.), National Institutes of Health, Bethesda, Md, and the Department of Internal Medicine, Henry Ford Hospital (M.L.), Detroit, Mich.

Correspondence to Richard O. Cannon, III, MD, National Institutes of Health, Bldg 10, Room 7B15, 10 Center Dr, MSC 1650, Bethesda, MD 20892-1650, or Michael Lesch, MD, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI 48202-2608.

Key Words: Editorials • coronary disease • exercise • electrocardiography • ischemia

	Introduction

 
Since the demonstration that ST-segment depression is commonly found on the ECGs of coronary artery disease (CAD) patients during stress, graded exercise testing with ECG monitoring has been used to identify patients likely (and unlikely) to have CAD with flow-limiting stenoses that cause myocardial ischemia. Unfortunately, the clinical value of the exercise ECG as a diagnostic test for CAD has been limited by the imperfect association between ST-segment depression (even if >1.0 mm with horizontal or downsloping configuration) and angiographically significant coronary artery lesions, and by use of testing in populations at various degrees of risk for disease.^{1 2 3}

Investigators have derived variations of ECG analysis in an attempt to improve the sensitivity of exercise testing for diagnosing CAD, such as heart rate adjustments of ST-segment depression (ST/heart rate slope, ST/heart rate index) during exercise.^{4 5} However, these analyses are not widely used, in part because of continued dispute regarding the advantages of these data manipulations over conventional ST-segment analysis alone.^{6 7} Frustrated by limitations in the diagnostic utility of the exercise ECG, many cardiologists initially perform nuclear or echocardiographic stress (exercise or pharmacological) testing to diagnose CAD in patients with unknown coronary anatomy or go straight to coronary angiography without prior noninvasive stress testing.⁸

In this issue of Circulation, Barthélémy and coworkers⁹ report a novel approach to analyzing the response to exercise stress, which they believe enhances the clinical usefulness of exercise testing in diagnosing CAD. In addition to recording the ECG and vital signs during exercise, the authors measured plasma . . . [Full Text of this Article]