From the Laboratory of Cardiovascular Science, Gerontology Research
Center, National Institute on Aging, Baltimore, Md.
Correspondence to Jerome L. Fleg, MD, Laboratory of Cardiovascular Science, Gerontology Research Center, National Institute on Aging, NIH, 5600 Nathan Shock Dr, Baltimore, MD 21224.
Methods and Results—We analyzed the treadmill exercise
tests of 825 healthy volunteers who were 22 to 89 years of age from the
Baltimore Longitudinal Study of Aging. All subjects were free from
coronary heart disease by history, physical examination, and
resting ECG. From 825 participants, 611 (group 0) had no
ischemic ST-segment changes during or after treadmill exercise,
while 214 subjects developed
Conclusions—Thus, ischemic ST-segment changes developing
during recovery from treadmill exercise in apparently healthy
individuals have adverse prognostic significance similar to those
appearing during exercise.
The present study was therefore designed to determine whether
recovery-onset ischemic ST-segment responses to treadmill
exercise in apparently healthy male and female volunteers across a
broad age range have prognostic significance for future
coronary events similar to that of an ischemic response
appearing during exercise. All subjects were volunteers from the
Baltimore Longitudinal Study of Aging (BLSA) and were free from
coronary heart disease by history, physical examination, and
resting ECG.
Exercise Testing Protocol
A total of 285 subjects demonstrated an ischemic ST-segment
response to exercise. Of these, 71 subjects were excluded for the
following reasons: exercise-induced angina pectoris before or on the
index visit (n=32), pathological Q waves (Minnesota code 1:1 or 1:2)
present on any ECG before the index visit (n=4), follow-up time <2
years (n=11), known valvular heart disease (n=12), and the
presence of cardiac glycosides or other antiarrhythmic drugs (n=12).
Thus, 214 individuals with a positive exercise ECG met the inclusion
criteria for our study. After these same exclusion criteria were
applied to the 788 subjects with a normal exercise ECG and after
elimination of 77 subjects who did not achieve
Follow-up
Statistical Analysis
It is noteworthy that only 6% of exercise tests in group 1 were
submaximal (defined either by failure to achieve 85% of predicted
maximal heart rate or a Borg perceived exertion rating <15) versus
23% in group 2 (P<0.01). When those subjects with
submaximal effort were removed from the analysis, the results
for groups 1 and 2 remained similar. By study design, group 0 contained
no subjects with submaximal tests. Five individuals (3.3%) in group 1
and 1 (1.6%) in group 2 were receiving ß-blockers for hypertension.
Calcium channel blockers for hypertension were used by 4 subjects, all
from group 1.
During a mean follow-up time of 9 years, 55 subjects experienced a
coronary event: 21 (3.4%) in group 0, 22 (14.6%) in group 1,
and 12 (19.7%) in group 2 (P=0.001; Table 3
Table 3
Table 4
To determine the independent predictors of future coronary
events, we constructed a multiple logistic regression model with age,
sex, serum cholesterol level, smoking status, prevalence of
hypertension, and onset time of ST-segment changes (exercise versus
recovery). Maximal heart rate during exercise, duration of exercise,
and peak VO2 were not included
because of their high correlation with age (r=-0.75,
-0.61, and -0.57, respectively). The full model was strongly
predictive of future events (
The concept of exercise screening for the prediction of future
coronary events in apparently healthy populations has received
considerable attention.1 2 3 4 5 6 7 8 9 10 11 12 20 21 22 Numerous
studies have demonstrated that asymptomatic subjects with
exercise-induced ischemic ST-segment depression have a
severalfold higher risk of future coronary events than those
with negative exercise ECGs.1 2 3 4 5 6 7 8 9 10 11 12 These findings
have led to the practice of performing exercise testing to screen
middle-aged and older adults, especially those with a high
coronary risk profile. In these surveys, the predictive value
of an ischemic ST-segment response for future coronary
events ranged from 5% to almost 40%. Such wide variation is probably
due to the inclusion of different outcome criteria (ie, inclusion of
"soft" events, such as angina pectoris, versus hard events, such
myocardial infarction or cardiac death, only) and population
differences in CAD prevalence. In the present study, angina was the
presenting event in approximately half of the cases,
consistent with findings from McHenry et
al,9 Erikssen and
Thaulow,22 and others. In a pooled
analysis comprising nearly 20 000 individuals from 10 studies,
Detrano and Froelicher23 found that
ischemic ST-segment depression induced by exercise testing had
a 20% predictive value for future events. In that analysis,
however, the prognostic significance of ST-segment changes limited to
recovery versus those appearing during exercise was not assessed. Given
the general absence of hard data, it has been proposed that
ischemic ST changes appearing after cessation of exercise are
more likely to be false-positive compared with those developing during
exercise.24
Over the last 20 years, only a few studies have addressed the
diagnostic or prognostic value of ischemic
ST-segment changes appearing after cessation of
exercise.13 14 15 16 25 However nearly all of them
were limited to symptomatic populations and examined only
the angiographic prevalence of CAD.13 14 15
Karnegis and colleagues14 examined 328 subjects
with a history of a myocardial infarction and a blood
cholesterol level of
To the best of our knowledge, only one prior study has examined the
significance of recovery-onset ST-segment depression versus ST
depression appearing during exercise in apparently healthy subjects.
Among 140 young, asymptomatic, male aircrew with
ischemic ECG changes induced by exercise testing, 36% of
subjects developed ST-segment changes limited to
recovery.16 In the 111 male aircrew with a
positive exercise ECG who underwent cardiac
catheterization, the positive predictive value for
angiographic coronary stenosis >50% was 28% for
subjects with changes limited to recovery versus 33% for subjects with
onset of ST-segment changes during exercise (P=NS). Over a
mean follow-up of 6.3 years, the positive predictive value for future
coronary events for individuals with "recovery-only"
ST-segment depression was 12% versus 24% for those with onset of ST
segment changes starting during exercise (P=NS). However,
these results may not be representative for the general
population, because the study group was limited to young men and ECG
changes were analyzed only in one lead. On the contrary, our
study included both sexes across a wide range of ages and
analyzed multiple ECG leads, allowing extrapolation to the
broad spectrum of apparently healthy individuals likely to undergo
screening exercise tests.
The prevalence of recovery-onset ischemic ST-segment changes
appears to be higher in asymptomatic populations compared
with those with symptomatic CAD. Among individuals with
suspected CAD, the prevalence of postexercise ischemic ECG
changes reported by Savage et al,15 Karnegis et
al,14 and Lachterman et
al13 was 3%, 6%, and 16%, respectively.
However, in asymptomatic subjects, the prevalence was 36%
in the young male aircrew members described by Froelicher et
al.16 In our study, individuals with postexercise
ST-segment depression constituted 29% of the entire sample. Thus,
ischemic ST-segment responses limited to recovery period from
exercise comprise approximately one third of abnormal exercise ECGs in
asymptomatic populations, a much higher proportion than
observed in those with clinically manifest CAD.
The mechanisms for the onset of ischemic ST-segment depression
during recovery from treadmill exercise are unclear. In our sample, all
baseline characteristics and exercise tests variables such as
duration of exercise, maximal heart rate, peak systolic blood
pressure, peak rate-pressure product, and
VO2peak were similar in both groups
with ischemic ST changes. Thus, a lack of
diagnostic ST-segment changes during exercise cannot be
ascribed to inadequate effort, except perhaps in the 23% of group 2
subjects with submaximal tests. Other
authors13 14 also failed to find significant
differences in these variables between symptomatic
patients who developed ischemic ST-segment changes during
exercise versus recovery.
One possible mechanism for the initial appearance of ischemic
ST-segment changes during recovery is augmentation of plasma
catecholamines in the early postexercise
period.26 27 Higher catecholamine
levels could augment myocardial oxygen demand by increasing myocardial
contractility, even as rate-pressure product
decreases. In addition, the postural change from erect during exercise
to supine or sitting during recovery may augment left
ventricular preload, which could facilitate subendocardial
ischemia by increasing wall stress.15
Furthermore, the decline in diastolic blood pressure during
recovery reduces the myocardial perfusion pressure gradient and may
impair subendocardial blood flow.
In summary, the present findings indicate that in an
asymptomatic population, ischemic ST-segment
changes that begin after cessation of exercise have an adverse
prognostic significance for future coronary events similar to
that for ST changes appearing during exercise. Both patterns of ST
changes presaged an
Received October 15, 1997;
revision received January 15, 1998;
accepted January 23, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Independent Prognostic Significance of Ischemic ST-Segment Response Limited to Recovery From Treadmill Exercise in Asymptomatic Subjects
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Although exercise-induced
ST depression is an independent predictor of future coronary
events in asymptomatic populations, the predictive value of
ST depression beginning after exercise cessation is unknown. 
1-mm flat or downsloping ST depression:
151 (group 1) had ST changes starting during exercise, and 63 (group 2)
had changes limited to recovery. Groups 1 and 2 were similar in age,
sex, smoking status, hypertension prevalence, fasting plasma glucose,
and serum cholesterol (CHOL). However, both groups were
older and had higher CHOL and prevalence of hypertension than group 0.
Treadmill exercise duration, peak oxygen consumption, and maximal heart
rate were similar between groups 1 and 2 but were lower than in group 0
(each P<0.05). During a mean follow-up time of 9 years,
55 subjects developed coronary events (angina pectoris,
myocardial infarction, or coronary death): 21 of 611 (3.4%) in
group 0, 22 of 151 (14.6%) in group 1, and 12 of 63 (19%) in group 2
(P=0.001). By survival analysis, the risk of
coronary events was similar in groups 1 and 2 but significantly
higher than in group 0 (P<0.0001). Multiple logistic
regression showed that age (odds ratio [OR]=1.07 per year,
P=0.00001), CHOL (OR=1.02 per 1 mg,
P=0.0001), and presence of ST-segment depression
(OR=2.59, P=0.007 and OR=2.38, P=0.04 for
groups 1 and 2, respectively) were independent predictors of
events.
Key Words: exercise • electrocardiography • ischemia • prognosis
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Despite the
availability of newer methods, exercise ECG testing is still the most
widely used screening test for coronary artery disease (CAD).
Numerous studies, including a prior one from our
laboratory,1 have shown that an ischemic
ST-segment response to exercise is a powerful harbinger for future
coronary events (ie, angina pectoris, myocardial infarction, or
sudden cardiac death) in apparently healthy
populations,1 2 3 4 5 6 7 8 9 10 11 12 independent of conventional
risk factors. An unsettled issue, however, is whether ischemic
ST-segment changes that begin during the recovery period have
diagnostic and prognostic significance similar to that of
ST-segment depression appearing during exercise. Studies in
symptomatic patients comparing exercise-onset versus
recovery-onset ST-segment depression have demonstrated similar
sensitivity and specificity for angiographic
CAD.13 14 15 In contrast, only a single study
limited to young male aircrew personnel has examined the significance
of ischemic ST-segment depression beginning during
recovery.16 Because age is a major risk factor
for CAD, extrapolation of these findings to the general population
requires additional support.
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Population
Since its beginning in 1958, the BLSA has enrolled >2400
community-dwelling volunteers who return biennially to the Gerontology
Research Center of the National Institute on Aging in Baltimore, Md,
for 21/2 days of extensive testing.17 This
population of upper-middle-class subjects is generally well educated
and health conscious and has a low to intermediate risk profile for
coronary heart disease. Approximately two thirds report some
aerobic physical activity each week. BLSA participants undergo a
thorough history and physical examination and resting 12-lead ECG.
Those without clinical evidence of heart disease who are able to
exercise (>80% of subjects) perform a maximal treadmill exercise test
on alternate visits.
Between January 1978 and December 1993, 1500 subjects underwent
exercise treadmill testing. Before exercise, a routine 12-lead ECG was
recorded with the subject in the supine and seated positions after
30 seconds of forced hyperventilation and after 30 seconds of standing.
All subjects then exercised to exhaustion on a motorized treadmill
according to a modified Balke protocol, during which the treadmill
grade was increased 3% every 2 minutes, starting from a horizontal
position; women walked at a constant speed of 3.0 mph; men, at 3.5
mph.1 A 12-lead ECG and brachial artery cuff
blood pressure were recorded every 2 minutes during exercise, at
maximal effort, immediately after exercise cessation, and every 2
minutes for at least 6 minutes into recovery. Testing was terminated
because of fatigue, dyspnea, or leg discomfort. All postexercise ECGs
were taken in the seated position. Individuals who developed anginal
pain during the test were excluded from the analysis. ECG
changes were assessed according to Minnesota Code
criteria18 by a single observer (J.L.F.). A
positive or ischemic response was defined as 1-mm J-point
depression with ST segment flat or downsloping in the majority of
complexes in any ECG lead except AVR (Minnesota code 4:1). The ECG
response was not an indication for test modification or termination.
Individuals with significant ST-segment abnormalities (Minnesota code
4:1, 4:2, 4:3, or 4:4) at rest or induced by postural shift or
hyperventilation who demonstrated worsening ST-segment depression
during or after exercise (n=101) were considered indeterminate
responders and were not included in the data set. In addition, subjects
who demonstrated intermediate exercise-induced ST changes (Minnesota
code 11:2, n=110; code 11:3, n=51; and code 11:4, n=165; total=326)
were excluded from analysis. 85% of predicted
maximal heart rate (defined by 220 minus their age), 611 individuals
constituted the control group.
All participants, with or without asymptomatic
ischemic ST-segment responses to treadmill exercise, were
evaluated for the development of new coronary events during
subsequent biennial visits to the Gerontology Research Center.
Coronary events were defined as follows: angina pectoris,
myocardial infarction, or coronary death (fatal myocardial
infarction or sudden death). The subsequent development of angina
pectoris was determined from the subject's response to a standard
questionnaire and clinical assessment by a specially trained
cardiopulmonary technologist and was made independent of
exercise test results. Myocardial infarction was diagnosed by
conventional clinical criteria during a subsequent hospitalization or
by the development of diagnostic Q waves on the resting ECG
(Minnesota code 1:1 or 1:2). For deceased individuals, the cause of
death was determined by the consensus of three BLSA physicians after
review of the death certificate, hospital records, and autopsy data
and communication with subject's family and personal physician as
available. Follow-up time for individuals who experienced an event was
calculated to the event date. When subjects developed more than one
event, only the first event was used and the follow-up analysis
was censored after this time, unless otherwise described. For subjects
free from coronary events, follow-up time was calculated to
their last biennial visit or their death from a noncoronary
cause.
Subjects were divided into three groups: group 0 consisted of
individuals free of ST-segment changes, group 1 comprised individuals
with ST-segment depression 1 mm starting during exercise, and
group 2 consisted of those with ST-segment shift limited to the
recovery period. The following baseline characteristics were compared
among the three groups: age, sex, current smoking status (smoker
defined by 10 cigarettes a day), prevalence of hypertension (blood
pressure >160/95 mm Hg or currently on antihypertensive
medication), fasting plasma glucose, body mass index, and serum
cholesterol. Duration of exercise, peak oxygen consumption
(available in 75%, 85%, and 51% of groups 0, 1, and 2,
respectively), maximal heart rate, peak systolic pressure, and
rate-pressure product at peak exercise were also compared.
Comparisons were made among the three groups by use of
2, ANOVA, or Kruskal-Wallis tests as
appropriate. Adjustments were made for multiple comparisons by the
method of Tukey for ANOVA and by least-squares means for the
Kruskal-Wallis test. Bonferroni correction was used in comparing
proportions. To adjust for differences in follow-up time,
coronary events rates were calculated per person-year of
observation. The 2, unpaired t
test, or Wilcoxon rank sum test was used when appropriate to
compare event and nonevent groups. Multiple logistic regression was
used to determine the independent predictors of coronary events
in the entire sample. Indicator variables were used to identify
differences between groups 1 and 0 and between groups 2 and 0. The
2 test was used to test the hypothesis that
there is a difference between groups 1 and 2 in predicting events (ie,
a difference in the parameters of the logistic model)
compared with group 0. Event-free survival was compared in the three
groups by Kaplan-Meier survival analysis by use of the log rank
statistic. For all analyses, a two-tailed value
of P<0.05 was required for statistical significance. All
analyses were done with the Statistical Analysis System
(SAS Corp).
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Between January 1978 and December 1993, 214 subjects with
asymptomatic ischemic ST-segment changes during or
after treadmill exercise and 611 subjects (group 0) free of ST changes
fulfilled the inclusion criteria. Of these 214, 151 (70.6%) developed
ischemic ECG responses during exercise (group 1), whereas 63
(29.4%) manifested ST-segment depression only in the postexercise
period (group 2). Baseline characteristics of all groups are
presented in Table 1
. Age, sex
distribution, the prevalence of smoking and hypertension, fasting
plasma glucose levels, body mass index, and serum
cholesterol were similar in groups 1 and 2, whereas
individuals in group 0 were younger and had a lower level of
cholesterol, a lower prevalence of hypertension, but a
higher percentage of current smokers compared with the other two
groups. With regard to exercise test variables (Table 2), the two groups with ischemic
ST changes were similar, but compared with subjects with no ECG
changes, both groups had a shorter duration of exercise, lower maximal
heart rate, and lower peak oxygen consumption but higher peak
systolic blood pressure. Both the lower maximal heart rate and
peak oxygen consumption in groups 1 and 2 versus group 0 are explicable
by the respective 17- and 19-year age
differences.19 The peak rate-pressure product
was similar among groups. Groups 1 and 2 also did not differ with
regard to heart rate (158±17 versus 152±22 bpm, P=NS),
systolic blood pressure (181±29 versus 179±36 mm Hg,
P=NS), or rate-pressure product (28 369±5195 versus
27 396±5734, P=NS) in the immediate postexercise
period.
View this table:
[in a new window]
Table 1. Clinical Characteristics
View this table:
[in a new window]
Table 2. Exercise Test Variables ). A total of 29 cases of angina
pectoris, 15 nonfatal myocardial infarctions, and 11 coronary
deaths were distributed among the groups as follows: 5 cases of angina
pectoris, 10 nonfatal myocardial infarctions, and 6 coronary
deaths in group 0; 16 cases of angina pectoris, 4 nonfatal myocardial
infarctions, and 2 coronary deaths in group 1; and 8 cases of
angina pectoris, 1 nonfatal myocardial infarction, and 3
coronary deaths in group 2. In group 0, 1, and 2, there were 0,
3, and 5 individuals, respectively, who experienced more than one end
point; ie, after developing angina pectoris as the initial
manifestation of coronary artery disease, they later developed
myocardial infarction or coronary death. Coronary
revascularization was performed after the initial
event in 5 subjects in group 0 (3 with angina pectoris and 2 with
infarction), 7 subjects in group 1 (all with initial angina) and 4
subjects in group 2 (1 with angina and 3 with infarction).
View this table:
[in a new window]
Table 3. Incidence of Coronary Events 
compares the incidence of coronary events between
groups. Because there were group differences in median follow-up
duration (8.9, 4.5, and 12 years for groups 0, 1, and 2, respectively;
P=0.0001 for groups 1 and 2 versus group 0 and
P<0.05 for group 2 versus group 1), the coronary
event rates were also calculated per person-year. This analysis
verified that event rates were higher in groups 1 and 2 compared with
group 0 but were similar between groups 1 and 2. Although hard events
(myocardial infarction or coronary death) tended to appear more
often in group 2 versus group 1, adjustment for person-years of
follow-up eliminated this difference. However, the incidence of hard
events was significantly higher in both groups compared with group 0.
When group 1 was stratified by median onset time of ischemic
ST-segment changes during exercise (median, 7 minutes), the incidence
of future coronary events was higher in the early-onset
subgroup (21% versus 7%, P=0.02). These subgroups did not
differ with regard to age, cholesterol level, body mass
index, maximal heart rate, or ST depression, but subjects with late
onset of ST-segment depression had greater exercise duration, peak
oxygen consumption, peak systolic blood pressure, and
rate-pressure product than those with earlier onset of ST-segment
changes. compares clinical and exercise
test variables between the subset of subjects who developed a
coronary event versus those who remained event free, regardless
of exercise test results. As shown in the table, age, prevalence of
hypertension, serum cholesterol, and peak systolic
blood pressure were higher, whereas duration of exercise, maximal heart
rate, and VO2peak were lower in the
subset who experienced a coronary event compared with those who
did not. In contrast, sex distribution, smoking prevalence, fasting
blood glucose, and body mass index were similar in the two subsets, as
was rate-pressure product at exhaustion.
View this table:
[in a new window]
Table 4. Univariate Predictors of Future
Coronary Events 2=99.9,
P=0.0001). As shown in Table 5, age, cholesterol, and
ST-segment depression 1 mm were positive independent predictors
of future coronary events, whereas male sex, smoking status,
and hypertension did not reach statistical significance. The
probability of experiencing a coronary event was 2.5 times as
high in subjects with ischemic ECG changes as in those with a
normal exercise ECG. Most importantly, the onset time of ST-segment
changes (ie, exercise versus recovery) did not influence future
prognosis in this model (2=0.05,
P=NS). A survival analysis (see Figure) confirmed
the adverse effect of ST-segment depression, regardless of time of
onset, on future coronary event risk. When onset time of
ST-segment depression during exercise was further stratified into early
and late subgroups, no independent effect of onset time was found by
multiple logistic regression analysis.
View this table:
[in a new window]
Table 5. Multivariate Predictors of Future
Coronary Events
View larger version (15K):
[in a new window]
Figure 1. Event-free survival for groups 0 (normal exercise tests), 1
(ischemic ST response during exercise), and 2 (ischemic
ST response limited to recovery). Survival curves for groups 1 and 2
are similar but lie significantly below that of group 0.
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
In a prior study conducted in our laboratory on apparently healthy
BLSA volunteers, we showed that an ischemic ST-segment response
to treadmill exercise is associated with a nearly threefold relative
risk of future coronary events, independent of conventional
risk factors.1 The present study,
encompassing a larger sample of the same asymptomatic BLSA
population, confirms previous findings and extends them to indicate
that ischemic ST changes developing during recovery from
exercise have adverse prognostic significance similar to those
appearing during exercise. By multiple logistic regression
analysis, older age, higher serum cholesterol, and
ST-depression induced by exercise testing but not the onset time of
ischemic ST-segment changes (exercise versus recovery) are
independent predictors of coronary events during a mean
follow-up of 9 years. 220 mg/dL who had exercise-induced
ischemic ST-segment changes during treadmill exercise or
recovery. There were no significant differences in baseline
characteristics and hemodynamic variables between
subjects with onset of ST changes during recovery versus during
exercise. Both groups had similar severity of CAD, with positive
predictive values for coronary artery disease near 90%. Savage
et al15 evaluated 62 subject with suspected CAD
who experienced ischemic ST-segment depression limited to the
postexercise period. In the subset of subjects with positive thallium
scans, the positive predictive value for angiographic CAD was 96%.
Ellestad25 reported that in 308
symptomatic subjects with ischemic ST changes
starting 3 to 8 minutes after exercise cessation, these
ischemic ECG changes were a definite but a weak predictor of
subsequent coronary events. In subjects with suspected CAD,
Lachterman et al13 found that ischemic
ECG changes limited to active exercise time or prolonged into recovery
period had almost the same predictive value (87% versus 84%,
respectively) for angiographic coronary artery stenoses
>75% as ST-segment depression that developed after exercise. Neither
clinical characteristics nor exercise test variables were
significantly different between those with ST changes limited to
recovery and those with changes starting earlier. 
2.5-fold independent risk for future
coronary events compared with individuals with a normal
exercise ECG. Thus, how one recovers from exercise appears to be as
important as how one performs it.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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