| Author, Year (Reference) | Sample | Exclusion Criteria | Mean Years of Followup | Test | Abnormal Test Result | Cumulative Event Rate | Adjusted Relative Risk (95% CI) for CHD Events with Abnormal ST-Segment Response | Sensitivity for CHD Events | Positive Predictive Value of Abnormal ST Response | Variables for Which Relative Risk Was Adjusted | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Definition | Prevalence | ||||||||||
| Giagnoni et al., 198336 | 514 factory workers in Italy Age range: 18-65 y 73% men |
Positive history and physical exam for CVD, resting blood pressure >160/95 mm Hg, abnormal resting electocard-iogram | 6 y | Submaximal supine cycle ergometry | >1 mm of horizontal/downsloping ST-segment depression during or after exercise | NR | Normal exercise test 3.4% Abnormal exercise test result 15.6%b |
5.5 (2.8-11.2) |
62 | 15 | Age, systolic blood pressure, smoking, coronary risk index |
MRFIT Trial Research Group, 19858 Rautaharju et al., 198650 |
6,205 men in the upper 10% to 15% Framingham risk score distribution Age range: 35-57 100% men |
Clinical heart disease, life-limiting conditions, diastolic blood pressure >115 mm Hg, cholesterol >350 mg/dL | 7 y | Submaximal | Computer code ST- segment depression 16 muV-s or more in leads CS5, aVL, aVF, V5 during or after exercise (in electrocard-iogram with less than 6 muV-s depression at rest) | 12.2% | Normal exercise test result 2/1,000 person yearsb Abnormal exercise test result 7.6/1,000 person yearsb |
3.5 1.61 |
NR | 36 | Age, diastolic blood pressure, cholesterol, number of cigarettes smoked daily |
Gordon et al., 198641 Ekelund et al., 198926 |
3,640 white men in Lipid Research Clinics Prevalence Survey in United States and Canada Mean age: 47 Age range: 35-59 y 100% men |
Evidence of CHD by history, resting electrocardiogram, and physician exam. Secondary hyperlipidem-ia, BMI >32.1 kg/m2, blood pressure >165/105 mm Hg with antihypertensive or cardiovascular medication; diabetes mellitus. | 8.1 y | Submaximal modified Bruce | >1 mm of ST-segment depression or elevation or computer- ST integral decreased or increased >10 muV-s from resting value | 8.3% | Placebo group Abnormal exercise test result 1.9/1,000 person yearsb |
Placebo group 3.3 |
30 | 7.1 | Age, LDL cholesterol level, HDL cholesterol level, systolic blood pressure, smoking, family history |
Cholestyramine group Normal exercise test result 7.2/1,000 person yearsb Abnormal exercise test result 1.5/1,000 person yearsb |
Cholestyramine group 4.9
2.9 |
||||||||||
| Fleg et al., 199019 | 407 residents of Baltimore, Maryland (mainly white) Mean age ±SD 60 ±11 y Range: 40-90 y 71% men |
NR | 4.6 y | Maximal treadmill with thallium modified Balke | >1 mm of horizontal/ downsloping ST-segment during or after exercise | Abnormal electro-cardiogram only 16.0% Abnormal thallium scan only 14% Both tests abnormal 6.0% |
Both test results normal, 7% Abnormal electrocardiogram only, 12% Abnormal thallium scan, only 3% Both tests abnormal, 48% |
1.0 2.4 3.6 |
40
N/A 28 |
24
N/A 48 |
Age, sex, hypertension, fasting blood glucose, total cholesterol, BMI, smoking, exercise duration |
| Okin et al., 199140 | 3,168 participants in the Framingham Offspring Study Mean age ±SD, 44 ±10 y Age range: 17-70 y 48% male |
Medical contraindica-tions to exercise, history of myocardial infarction, CHF, valvular disease, syncope, conduction abnormalities, digoxin use, atrial fibrillation | 4.3 y | Standard Bruce | ST segment corrected for heart rate index >1.6 muV per beat per min or abnormal rate recovery loop | 416/3168 (either test abnormal) |
Both tests normal 1.6% Either test abnormal 4.1% Both tests abnormal 9.8% |
1.0 1.6 2.7 |
23% 8% |
4% 10% |
Age, sex, smoking, diastolic blood pressure, total cholesterol level, fasting blood glucose, left ventricular hypertrophy on electrocardiography |
| Siscovick et al., 199112 | 3,617 white men in the Lipid Research Clinics Prevalence Survey Mean age: NR 100% male |
Clinical evidence of CHD or CHF on history, various resting electrocard-iogram abnormalities | 7.4 y | Submaximal modified Bruce | Visual code >1 mm ST-segment depression or elevation or computer code >10 muV 1/N s | 6.6% | Overall 2%d | 2.6 (1.3 - 5.2)d | 18% | 5% | Age, LDL cholesterol level, HDL cholesterol level, smoking, physical activity, workload achieved, family history of CHD, BMI, alcohol consumption |
| Blumenthal et al., 199632 | 264 healthy siblings of individuals with CAD before age 60 in Baltimore, Maryland Mean age ±SD, 46 ± 8 69% men |
Known CAD, corti-costeriods, collagen vascular disease, decreased life expectancy, functional status limitations | 6.2 y | Modified Bruce and thallium scintigraphy | >1 mm (>2 mm for women) of horizontal or downsloping depression in 3 consecutive beats during exercise or first 3 min of recovery | Abnormal exercise electrocard-iogram 5.4% Abnormal plus thallium scan 18.1% Abnormal exercise electrocard-iogram and scan 4.6% |
Normal 3% | 1.0 | Age, sex | ||
| Abnormal exercise electrocardiogram 7% | 1.5 (0.2-12.5) |
N/A | N/A | ||||||||
| Abnormal thallium scan 13% | 3.6 (1.1-11.4) |
63% | 20% | ||||||||
| Abnormal exercise electrocard-iogram and scan 50% | 14.5 (4.2-50.2) |
32% | 50% | ||||||||
| Okin et al., 199639 | 5,940 men in the usual care group of MRFIT Mean age: NR 100% men |
No evidence of CHD by history, physical examination, or resting electrocard-iography | 7 y | Submaximal treadmill | ST segment corrected for heart rate index >1.6 muV per beats per min | 729/5,940 (12.3%) |
Normal exercise test result 1.3%b Abnormal exercise test result 5.4%b |
3.6 |
36% | 5% | Age. Diastolic blood pressure, cholesterol level, smoking |
| Katzel et al., 199929 | 170 healthy sedentary obese men living in the Baltimore-Washington, DC area (96% white) Mean age: NR 100% men |
History or laboratory evidence of CAD, diabetes mellitus, hypertension, hyperlipidemia | 7.3 y | Maximal Bruce | >1 mm of horizontal or downsloping ST-segment depression in 2 or more leads | 37/170 (22%) |
Overall 18% | 4.23 (2.03-8.83) |
55% | 46% | Age, BMI, maximal VO2, fasting glucose level |
| Gibbons et al., 200033 | 25,927 patients of a preventive medicine clinic in Texas (mainly white) Mean age: 42.9 100% men |
Evident CHD, severe aortic stenosis, acute systemic illness, uncontrolled atrial or ventricular arrhythmias, pericarditis, myocarditis, thrombophlebitis or exercise- limiting orthopedic problems | 8.4 y | Maximal treadmill modified Blake | Chest pain and >1mm ST-segment depression or elevation, exercise induced-decrease >10 mm in systolic blood pressure, systolic blood pressure >250 mm Hg, diastolic blood pressure >120 mm Hg, ventricular tachycar-dia, left bundle-branch block, right bundle branch block, super-ventricular tachycardia | No risk factors, 3.0% | No risk factors Abnormal ETT 2.8/1000 person yearsb |
21 |
60 | 2.2 | Age |
| >1 risk factor, 7.1% |
>1 risk factor Abnormal exercise test result 7.6/1000 person yearsb |
9b | 61 | 7.7 | |||||||
Josephson et al., 199011 Rywik et al., 200221 |
1,083 participants in the Baltimore Longitudinal Study of Aging Mean age ±SD, 52 ±18 y 57% men |
History of angina or heart failure, Q wave on resting electrocardio-graphy, valvular disease, use of anti-arrhythmic drugs, inability to achieve 85% of maximal heart rate | 7.9 | Modified Balke | Normal | Men 4% Women 3% |
1.0e | Men 74 Women 68 |
Men 16 Women 7 |
Age, cholesterol, sex, exercise duration | |
| Minnesota Code 11.1e | 20% | Men 17% Women 8% |
2.7 (1.6-4.7)f |
||||||||
| Minnesota Code 11.5e | 5.5% | Men 17% Women 11% |
2.7 (1.05-7.10)f |
||||||||
| Minnesota Code 11.2e | 7% | Men 10% Women 5% |
OR 1.8f (0.6-5.4) |
||||||||
| Minnesota Code 11.4e | 11.5% | Men 17% Women 3% |
OR 1.3f (0.6-2.9) |
||||||||
| Jouven and Ducimetiere, 200045 | 6,101 Frenchmen in Paris Civil Service Age range: 42-53 y 100% men |
Known or suspected CVD, resting systolic blood pressure ±180 mm Hg, resting Electrocard-iographic abnormality | 23 | Bicycle ergometry | J-point depression of at least 1 mm with a flat or downsloping ST segment during exercise or recovery | 4.4% | Normal exercise test result, 6.4% Abnormal exercise test result 16.7%b |
2.6 (1.93-3.59)b |
10 | 17-25 | Age, BMI, heart rate at rest, smoking, physical activity, diabetes mellitus, total cholesterol level, premature ventricular complex |
| Laukkanen et al., 200120 | 1,769 participants, population in Kupio Ischemic Heart Disease
Study base sample of Finnish men
Mean age ±SD, |
Known CHD or symptoms suggestive of CHD | 10 | Maximal Bicycle ergometry | >1 mm ST-segment depression during exercise | 10.7% | Normal exercise test result 9.2% Abnormal 15.3% |
1.7 3.5 |
16 | 15 | Age, examination year, smoking, systolic blood pressure, alcohol consumption, BMI, max oxygen uptake, diabetes mellitus, LDL cholesterol level, HDL cholesterol level |
| Rutter et al., 200213 | 86 diabetic patients in the United Kingdom Mean age ±SD, 72% men |
History of CAD | 2.8 | Treadmill | >1 mm of horizontal or downsloping ST-segment depression for 3 consecutive beats | 52% | Both normal and abnormal exercise test results 17% |
21 (2-204) |
100% | 20% | Ankle brachial index, microalbuminuria, Framingham 10-y CHD risk >30%, fibrinogen level |
| Mora et al., 200342 | 2994 women enrolled in the Lipid Research Clinics Prevalence Study Age range 30-80 0% men |
Pregnancy or significant cardiovascu-lar disease | 20.3 | Maximal Bruce | >1mm horizontal or downsloping ST-segment depression at 0.08 seconds after the J point during recovery or exercise | 4.7% | Both normal and abnormal exercise tolerance test results 5%b 14%c |
0.88 0.69 |
|
|
Age, smoking, diabetes, family history of premature heart disease, obesity, HDL cholesterol level, LDL cholesterol level, triglyceride level, hypertension |
aEvents are CHD events unless otherwise indicated. BMI = body mass index; CAD = coronary heart disease; CVD = cardiovascular disease; HDL = high-density lipoprotein; LDL = low-density lipoprotein; MRFIT = Multiple Risk Factor Intervention Trial Research Group; NA = not applicable; NR = not reported.
bCHD death.
cAll-cause death.
dFor CHD events occurring during exercise.
eMinnesota code 11.1 = >1 mm J-point depression with flat or downsloping ST segment in most complexes in any lead except aVR; Minnesota code 11.2 = horizontal or downsloping ST-segment depression of 0.5-1.0 mm; Minnesota code 11.4 = J-point depression of >1 mm with upsloping ST; Minnesota code 11.5 = ST-segment depression at rest that worsens to 11.1 during exercise.
fValues are odds ratios (95% CI).