Accuracy of the ST/HR hysteresis and of cardiopulmonary stress testing parameters in the diagnosis of exercise induced myocardial ischemia

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1 G. D ANNUNZIO UNIVERSITY - CHIETI FACULTY OF MEDECINE DEPARTMENT OF CARDIOLOGY Director: Prof. R. De Caterina Accuracy of the ST/HR hysteresis and of cardiopulmonary stress testing parameters in the diagnosis of exercise induced myocardial ischemia L. Barnabei 1, R. Madonna 1, G. Palmieri 1, M. Perrucci 2, M. Zimarino 1, A. Corazzini 1, A. Tatasciore 1, F. Iachini Bellisarii 1, R. De Caterina 1 - (1) G. D Annunzio University, Department of Cardiology, Chieti, Italy (2) G. D'Annunzio University, Institute of Advanced Biomedical Technologies, Chieti, Italy Dr. Luca Barnabei ESC Congress - Paris, August 29th, 2011

2 DECLARATION OF CONFLICT OF INTEREST I have no conflict of interest

3 ECG Markers of Myocardial ischemia ST-T SEGMENT DEPRESSION: THE STANDARD CRITERION HORIZONTAL DOWNLOPING UPLOPING SENSITIVITY SPECIFICITY ST-T 0.10 mv Gianrossi et al, Circulation 1989;80(1):87-98

4 ECG Markers of Myocardial ischemia ST/HR SLOPE Cut Off Sensitivity (%) Specificity (%) > 2.08 μv/b/min > 6.0 μv/b/min 93 (3CAD) 57 (3CAD) Cut Off Sensitivity (%) Specificity (%) 1.41 μv/b/min μv/b/min Okin PM et al, J Am Coll Cardiol. 1995;25(7):

5 ECG Markers of Myocardial ischemia THE ST/HR RECOVERY LOOP AND HYSTERESIS Coronary Artery Disease Normal Different directions of the HR recovery loop may be better markers of myocardial ischemia: clockwise in non-ischemic conditions; counterclockwise in myocardial ischemia

6 Cardiopulmonary Exercise Test Flow / Volume Analysis O 2 and CO 2 Analysis ECG Pulse Oximetry Blood Pressure VO 2 peak EXERCISE TOLERANCE % VO 2 max UNDIAGNOSED EXERCISE INTOLERANCE O 2 pulse HEART FAILURE % O 2 pulse CARDIAC TRANSPLANTATION VO 2 /Work slope CARDIAC REHABILITATION VO 2 /Work aa 1 slope C O P D VO 2 /Work bb 1 slope VO 2 /Work (aa 1 - bb 1 ) UNEXPLAINED DYSPNEA AT PULMONARY VASCULAR DISEASE % AT PREOPERATIVE EVALUATION LUNG SURGERY VE/VO 2 PULMONARY REHABILITATION VE/VCO 2

7 Cardiopulmonary Exercise Test Markers of myocardial ischemia Myocardial Ischemia VO 2 /W (bb 1 ) slope < 3.9 ml/min/w O 2 Pulse < 95 s Belardinelli et al, Eur Heart J. 2003;24(14):

8 The Study Accuracy of the ST/HR hysteresis and of cardiopulmonary stress testing parameters in the diagnosis of exercise induced myocardial ischemia

9 Study Population INCLUSION CRITERIA ECG exercise stress test with EQUIVOCAL ECG findings: horizontal ST-T segment depression mv or upsloping ST-T segment depression mv OR left ventricular hypertrophy 2747 ECG Exercise Test n 1086 Non-interpretable 56 exercise test Male (n) (LBBB, PMK, AF, non-interpretable ECG) 45 (80.3%) Age (years ± SD) 1561 Clearly positive 59.7±13.6 or negative Hypertension (n) ECG Exercise Test 36 (64.3%) Diabetes 100 CPET a (n) 11 (19.6%) Smoking (n) 10 (17.8%) Dyslipidemia (n) 6 Refusing to undergo CPET or with uninterpretable 22 (39.3%) CPET findings Family History of premature CAD (n) 7 (12.5%) Performance of MIBI-SPECT (n) 38 Not undergoing MIBI-SPECT 55 (98.2%) 56 MIBI-SPECT

10 Methods ECG EXERCISE STRESS TEST ST/HR Hysteresis (mv) ST-max (mv) 56 pts CARDIOPULMONARY TEST VO 2 peak (ml/kg/min) % VO 2 max (%) O 2 Pulse (ml/beats per minute) % O 2 pulse (%) VO 2 /Work aa 1 slope (ml/kg/w) VO 2 /Work bb 1 slope (ml/kg/w) VO2/Work (aa 1 - bb 1 ) (ml/kg/w) AT (L/min) % AT (%) Tc-99m-MIBI SPECT REVERSIBLE MYOCARDIAL PERFUSION DEFECT TO DETECT ISCHEMIC SUBJECTS VE/VO 2 VE/VCO 2

11 Methods: VO2/W slope Myocardial Ischemia VO 2 /Work aa 1 slope VO 2 /Work bb 1 slope VO2/Work (aa 1 - bb 1 )

12 Results ECG Exercise StressTest ST-max (mv), mean (95% confidence interval [CI]) All Non-Ischemic Ischemic P (n = 56) (n = 33) (n =23) ( to ) ( to 0.066) ( to ) ST/HR hysteresis (mv), mean (95% confidence interval [CI]) ( to 0.006) ( to ) (0.003 to 0.049) CPET VO 2 peak (ml/kg/min) 20.1± ± ±7.4 NS % VO 2 max (%) 80.6± ± ±27.9 NS O 2 Pulse (ml/beats per minute) 11.4± ± ±4.3 NS % VOO 2 /Work 2 pulse bb(%) 1 slope (ml/kg/w) 87.5± ± ±2.3 94± ± ± NS VO 1 2 /Work (aa 1 slope - bb 1 ) c (ml/kg/w) 12.3± ± ± ± ± ± NS VO 2 /Work bb 1 slope (ml/kg/w) 10.9± ± ± VO 2 /Work (aa 1 - bb 1 ) c (ml/kg/w) 1.5± ± ± AT (L/min) 0.9± ± ±0.3 NS % AT (%) 43.9± ± ±15.1 NS VE/VO ± ± ±6.6 NS VE/VCO ± ± ±6.5 NS

13 Results: ROC curve AUC analysis ST/HR hysteresis: 0.82 ST-max: 0.68 P= P= 0.06 VO 2 /Work bb 1 slope: 0.63 VO 2 /Work (aa 1 - bb 1 ): 0.61 P= 0.09 P= 0.1

14 Results: ROC curve AUC analysis AUC 95 % CI P ST/HR hysteresis to ST-max to VO 2 /Work bb 1 slope to VO2/Work (aa 1 - bb 1 ) to ST-HR hysteresis ST-max ΔVO2/ΔWR bb1 ΔVO2/ΔWR (aa1-bb1) SENSITIVITY SPECIFICITY ST/HR hysteresis 70.8% 84.4% ST-max 50% 87.5% ST/HR Hysteresis compared with ECG and CPET variables Difference Between Areas P ST/HR hysteresis vs ST-max (0.82 vs 0.68) 0.14 ( to 0.133) 0.09 ST/HR hysteresis vs VO2/Work bb 1 slope (0.82 vs 0.63) 0.19 (0.030 to 0.377) 0.02 ST/HR hysteresis vs VO2/Work (aa 1 - bb 1 ) (0.82 vs 0.61) 0.21 (0.033 to 0.389) 0.05

15 Conclusion ST/HR hysteresis is more accurate than CPET variables in detecting stress-induced myocardial ischemia at exercise testing in patients with equivocal exercise ECG findings We therefore advocate a wider use of the ST/HR hysteresis during any standard ECG stress test for the diagnosis of stress-induced myocardial ischemia

16 Thank you for your attention!