Diagnostic value of ST-segment deviations during cardiac exercise stress testing: Systematic comparison of different ECG leads and time-points.
BACKGROUND
Exercise ECG stress testing is the most widely available method for evaluation of patients with suspected myocardial ischemia. Its major limitation is the relatively poor accuracy of ST-segment changes regarding ischemia detection. Little is known about the optimal method to assess ST-deviations.


METHODS
A total of 1558 consecutive patients undergoing bicycle exercise stress myocardial perfusion imaging (MPI) were enrolled. Presence of inducible myocardial ischemia was adjudicated using MPI results. The diagnostic value of ST-deviations for detection of exercise-induced myocardial ischemia was systematically analyzed 1) for each individual lead, 2) at three different intervals after the J-point (J+40ms, J+60ms, J+80ms), and 3) at different time points during the test (baseline, maximal workload, 2min into recovery).


RESULTS
Exercise-induced ischemia was detected in 481 (31%) patients. The diagnostic accuracy of ST-deviations was highest at +80ms after the J-point, and at 2min into recovery. At this point, ST-amplitude showed an AUC of 0.63 (95% CI 0.59-0.66) for the best-performing lead I. The combination of ST-amplitude and ST-slope in lead I did not increase the AUC. Lead I reached a sensitivity of 37% and a specificity of 83%, with similar sensitivity to manual ECG analysis (34%, p=0.31) but lower specificity (90%, p<0.001).


CONCLUSIONS
When using ECG stress testing for evaluation of patients with suspected myocardial ischemia, the diagnostic accuracy of ST-deviations is highest when evaluated at +80ms after the J-point, and at 2min into recovery.
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Christian
C
Puelacher
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Max
M
Wagener
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland; Research, Schiller AG, Baar, Switzerland; Lucerne University of Applied Sciences and Arts (HSLU), Horw, Switzerland.
Roger
R
Abächerli
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Ursina
U
Honegger
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Nundsin
N
Lhasam
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Nicolas
N
Schaerli
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Gil
G
Prêtre
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Ivo
I
Strebel
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Raphael
R
Twerenbold
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Jasper
J
Boeddinghaus
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Thomas
T
Nestelberger
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Maria
M
Rubini Giménez
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Petra
P
Hillinger
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Karin
K
Wildi
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Zaid
Z
Sabti
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Patrick
P
Badertscher
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Janosch
J
Cupa
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Nikola
N
Kozhuharov
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Jeanne
J
du Fay de Lavallaz
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Michael
M
Freese
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Isabelle
I
Roux
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Jens
J
Lohrmann
Research, Schiller AG, Baar, Switzerland.
Remo
R
Leber
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Stefan
S
Osswald
Division of Nuclear Medicine, University Hospital Basel, University Basel, Switzerland.
Damian
D
Wild
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Michael J
MJ
Zellweger
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland.
Christian
C
Mueller
Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University Basel, Switzerland. Electronic address: tobias.reichlin@usb.ch.
Tobias
T
Reichlin
D000368:Aged; D004562:Electrocardiography / Q000295:instrumentation / Q000379:methods*; D005080:Exercise Test / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D000072657:ST Elevation Myocardial Infarction / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D013997:Time Factors
Bicycle ergometry test; Electrocardiography; MeSH heading: sensitivity and specificity; Myocardial perfusion imaging; ST-segment