title: ST segment/heart rate hysteresis improves the diagnostic accuracy of ECG stress test for coronary artery disease in patients with left ventricular hypertrophy.
abstract: The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients.
  
  
  
  In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis.
  
  
  
  We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the 'neutral' receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score.
  
  
  
  Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy.
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Zimarino
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Montebello
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Radico
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Sabina
authors.initials: S
authors.lastname: Gallina
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Perfetti
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Iachini Bellisarii
authors.affiliation: Misericordia Hospital, Grosseto, Italy.
authors.forename: Silva
authors.initials: S
authors.lastname: Severi
authors.affiliation: Misericordia Hospital, Grosseto, Italy.
authors.forename: Ugo
authors.initials: U
authors.lastname: Limbruno
authors.affiliation: G. Monasterio Foundation, Pisa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Emdin
authors.affiliation: University Cardiology Division and Institute of Cardiology, "G. d'Annunzio" University, Italy rdecater@unich.it.
authors.forename: Raffaele
authors.initials: R
authors.lastname: De Caterina
mesh_terms: D000368:Aged; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000209:etiology; D018450:Disease Progression; D004452:Echocardiography; D004562:Electrocardiography / Q000379:methods*; D015444:Exercise / Q000502:physiology*; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000150:complications* / Q000175:diagnosis; D008297:Male; D012372:ROC Curve; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016277:Ventricular Function, Left
keywords: ECG stress test; ST-segment depression/heart rate hysteresis; coronary artery disease; left ventricular hypertrophy