title: Chronotropic response to exercise. Improved performance of ST-segment depression criteria after adjustment for heart rate reserve.
abstract: BACKGROUND
  Heart rate (HR) response to exercise plays an important role in the diagnosis of coronary artery disease (CAD). Adjustment of ST-segment depression for the change in HR with exercise increases the accuracy of the exercise ECG in the detection of CAD. In addition, an attenuated HR response to exercise, a manifestation of chronotropic incompetence, may have independent diagnostic value for CAD.
  
  
  RESULTS
  The diagnostic value of adjusting the magnitude of ST-segment depression, the ST-segment (ST)/HR index, and the ST/HR slope for chronotropic response to exercise was assessed in 283 control subjects and 337 patients with CAD by dividing each ST measurement by the fraction of HR reserve achieved. At a matched specificity of 96%, ST-segment depression of > 160 microV identified CAD with a sensitivity of 52%, an ST/HR index of > 1.69 microV/bpm identified CAD with a sensitivity of 90%, and an ST/HR slope of > 2.96 microV/bpm identified CAD with a sensitivity of 88%. Adjustment for HR reserve improved the sensitivity of each method: adjusted ST-segment depression of > 176 had a sensitivity of 87% (P < .0001), an adjusted ST/HR index of > 2.14 had a sensitivity of 94% (P = .005), and an adjusted ST/HR slope of > 3.47 had a sensitivity of 93% (P = .0001). In addition, the 94% and 93% sensitivities of the adjusted ST/HR index and ST/HR slope were significantly greater than the 87% sensitivity of adjusted ST-segment depression (P < .0001).
  
  
  CONCLUSIONS
  Correction for an attenuated HR response to exercise improves performance of the simple and HR-adjusted ST-segment depression criteria for the identification of CAD. These findings support assessment of the degree of chronotropic reserve in routine evaluation of the exercise ECG.
authors.affiliation: Division of Cardiology, New York Hospital-Cornell Medical Center, New York 10021, USA. pokin@mail.med.cornell.edu
authors.forename: P M
authors.initials: PM
authors.lastname: Okin
authors.forename: M S
authors.initials: MS
authors.lastname: Lauer
authors.forename: P
authors.initials: P
authors.lastname: Kligfield
mesh_terms: D003327:Coronary Disease / Q000503:physiopathology*; D004562:Electrocardiography; D005080:Exercise Test; D005260:Female; D006339:Heart Rate; D006801:Humans; D008297:Male; D008875:Middle Aged; D005082:Physical Exertion; D012016:Reference Values; D012680:Sensitivity and Specificity; D012727:Sex Characteristics; D013997:Time Factors