Exercise ECG testing: Performing the test and interpreting the ECG results
- Panithaya Chareonthaitawee, MD
Panithaya Chareonthaitawee, MD
- Associate Professor of Medicine
- Mayo Clinic College of Medicine
- J. Wells Askew, MD
J. Wells Askew, MD
- Assistant Professor of Medicine
- Mayo Clinic College of Medicine
- Section Editors
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Patricia A Pellikka, MD, FACC, FAHA, FASE
Patricia A Pellikka, MD, FACC, FAHA, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine
- Mayo Clinic College of Medicine
The exercise electrocardiogram (ECG) is a well-validated procedure for establishing the diagnosis and prognosis of coronary heart disease, as well as assessing exercise capacity (ie, functional capacity). The exercise ECG indirectly detects myocardial ischemia, which is the physiologic consequence of a mismatch between myocardial oxygen delivery (coronary blood flow) and myocardial oxygen demand (myocardial work). (See "Angina pectoris: Chest pain caused by myocardial ischemia".)
A well-recognized sequence of events is precipitated by an imbalance between myocardial oxygen supply and demand (figure 1). This sequence helps explain why measures of ischemia obtained with echocardiographic or radionuclide imaging are more sensitive indicators than ECG measures; they occur at a lower intensity of ischemia, and thereby precede ECG changes. Similarly, silent ischemia that is identified electrocardiographically often occurs at a lower ischemic threshold than that needed for the symptomatic expression of ischemia.
This topic provides a brief overview of exercise ECG testing including methodology, indications, and contraindications, and discusses the ECG manifestations of exercise-induced ischemia. A discussion on how to select the optimal cardiac stress test in a given patient is presented elsewhere. (See "Selecting the optimal cardiac stress test".)
There are many patients in whom exercise ECG testing can be used for diagnostic or prognostic purposes, including those with:
●Symptoms suggesting myocardial ischemia
- Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific statement from the american heart association. Circulation 2009; 119:3144.
- Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation 2002; 106:1883.
- Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA Guidelines for Exercise Testing. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). J Am Coll Cardiol 1997; 30:260.
- Modesto KM, Møller JE, Freeman WK, et al. Safety of exercise stress testing in patients with abnormal concentrations of serum potassium. Am J Cardiol 2006; 97:1247.
- Pierce GL, Seferlis C, Kirshenbaum J, Hartley LH. Lack of association of exercise testing with coronary stent closure. Am J Cardiol 2000; 86:1259.
- Hlatky MA, Pryor DB, Harrell FE Jr, et al. Factors affecting sensitivity and specificity of exercise electrocardiography. Multivariable analysis. Am J Med 1984; 77:64.
- Kwok JM, Miller TD, Christian TF, et al. Prognostic value of a treadmill exercise score in symptomatic patients with nonspecific ST-T abnormalities on resting ECG. JAMA 1999; 282:1047.
- Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. Am Heart J 1973; 85:546.
- Naughton, J, Sevellus, G, Balke, B. Physiologic responses of normal and pathologic subjects to a modified work capacity test. J Sports Med 1963; 31:201.
- Skalski J, Allison TG, Miller TD. The safety of cardiopulmonary exercise testing in a population with high-risk cardiovascular diseases. Circulation 2012; 126:2465.
- Herbert WG, Dubach P, Lehmann KG, Froelicher VF. Effect of beta-blockade on the interpretation of the exercise ECG: ST level versus delta ST/HR index. Am Heart J 1991; 122:993.
- Gauri AJ, Raxwal VK, Roux L, et al. Effects of chronotropic incompetence and beta-blocker use on the exercise treadmill test in men. Am Heart J 2001; 142:136.
- Gerstenblith G, Lakatta EG, Weisfeldt ML. Age changes in myocardial function and exercise response. Prog Cardiovasc Dis 1976; 19:1.
- Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001; 37:153.
- Gulati M, Shaw LJ, Thisted RA, et al. Heart rate response to exercise stress testing in asymptomatic women: the st. James women take heart project. Circulation 2010; 122:130.
- Gamble P, McManus H, Jensen D, Froelicher V. A comparison of the standard 12-lead electrocardiogram to exercise electrode placements. Chest 1984; 85:616.
- Frolkis JP, Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med 2003; 348:781.
- Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694.
- Lachterman B, Lehmann KG, Abrahamson D, Froelicher VF. "Recovery only" ST-segment depression and the predictive accuracy of the exercise test. Ann Intern Med 1990; 112:11.
- Rywik TM, Zink RC, Gittings NS, et al. Independent prognostic significance of ischemic ST-segment response limited to recovery from treadmill exercise in asymptomatic subjects. Circulation 1998; 97:2117.
- Vincent GM, Abildskov JA, Burgess MJ. Mechanisms of ischemic ST-segment displacement. Evaluation by direct current recordings. Circulation 1977; 56:559.
- Holland RP, Brooks H. Precordial and epicardial surface potentials during Myocardial ischemia in the pig. A theoretical and experimental analysis of the TQ and ST segments. Circ Res 1975; 37:471.
- Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation 1989; 80:87.
- Miranda CP, Liu J, Kadar A, et al. Usefulness of exercise-induced ST-segment depression in the inferior leads during exercise testing as a marker for coronary artery disease. Am J Cardiol 1992; 69:303.
- Mark DB, Hlatky MA, Lee KL, et al. Localizing coronary artery obstructions with the exercise treadmill test. Ann Intern Med 1987; 106:53.
- Tavel ME, Shaar C. Relation between the electrocardiographic stress test and degree and location of myocardial ischemia. Am J Cardiol 1999; 84:119.
- Rijneke RD, Ascoop CA, Talmon JL. Clinical significance of upsloping ST segments in exercise electrocardiography. Circulation 1980; 61:671.
- Stuart RJ, Ellestad MH. Upsloping S-T segments in exercise stress testing. Six year follow-up study of 438 patients and correlation with 248 angiograms. Am J Cardiol 1976; 37:19.
- Rywik TM, O'Connor FC, Gittings NS, et al. Role of nondiagnostic exercise-induced ST-segment abnormalities in predicting future coronary events in asymptomatic volunteers. Circulation 2002; 106:2787.
- Stiles GL, Rosati RA, Wallace AG. Clinical relevance of exercise-induced S-T segment elevation. Am J Cardiol 1980; 46:931.
- Nakano A, Lee JD, Shimizu H, et al. Reciprocal ST-segment depression associated with exercise-induced ST-segment elevation indicates residual viability after myocardial infarction. J Am Coll Cardiol 1999; 33:620.
- Lahiri A, Subramanian B, Millar-Craig M, et al. Exercise-induced S-T segment elevation in variant angina. Am J Cardiol 1980; 45:887.
- Matsuda Y, Ozaki M, Ogawa H, et al. Coronary arteriography and left ventriculography during spontaneous and exercise-induced ST segment elevation in patients with variant angina. Am Heart J 1983; 106:509.
- Uthamalingam S, Zheng H, Leavitt M, et al. Exercise-induced ST-segment elevation in ECG lead aVR is a useful indicator of significant left main or ostial LAD coronary artery stenosis. JACC Cardiovasc Imaging 2011; 4:176.
- Bunch TJ, Chandrasekaran K, Gersh BJ, et al. The prognostic significance of exercise-induced atrial arrhythmias. J Am Coll Cardiol 2004; 43:1236.
- Grady TA, Chiu AC, Snader CE, et al. Prognostic significance of exercise-induced left bundle-branch block. JAMA 1998; 279:153.
- LIMITATIONS TO EXERCISE ECG TESTING
- TYPES OF EXERCISE
- Comparison of types of exercise
- Common exercise protocols
- - Bruce protocol
- - Modified Bruce protocol
- - Naughton protocol
- - Other treadmill protocols
- - Bicycle testing
- EXERCISE TEST PROCEDURE
- Pre-test instructions
- Patient interview and examination
- Establishing the target heart rate
- Blood pressure measurements
- Symptoms and perceived exertion
- Test endpoints
- - Patient-determined endpoints
- - Provider-determined endpoints
- - Protocol-determined endpoints
- Submaximal testing
- Recovery period
- Life-threatening complications
- Exercise test summary report
- ECG ABNORMALITIES DURING EXERCISE
- Electrophysiology of myocardial ischemia
- ST segment depression
- - Upsloping ST segment depression
- - Horizontal or downsloping ST segment depression
- - Resting ST segment depression
- ST segment elevation
- - ST segment elevation in aVR
- Bundle branch block
- ECG ABNORMALITIES DURING RECOVERY
- ST segment depression
- Frequent ventricular ectopy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS