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ARTICLE

The effect of resting ST segment depression on the diagnostic characteristics of the exercise treadmill test

^a Division of Cardiovascular Medicine, Stanford University Medical Center, Palo Alto, California, USA
^b Division of Cardiovascular Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA

Manuscript received December 29, 1998; revised manuscript received October 27, 1999, accepted December 15, 1999.

Reprint requests and correspondence: Dr. William F. Fearon, Division of Cardiovascular Medicine, Falk Cardiovascular Research Building, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305-5406
wfearon{at}stanford.edu

OBJECTIVES

The aim of this study is to demonstrate the effect of resting ST segment depression on the diagnostic characteristics of the exercise treadmill test.

BACKGROUND

Previous studies evaluating the effect of resting ST segment depression on the diagnostic characteristics of exercise treadmill test have been conducted on relatively small patient groups and based only on visual electrocardiogram (ECG) analysis.

METHODS

A retrospective analysis of data collected prospectively was performed on consecutive patients referred for evaluation of chest pain. One thousand two hundred eighty-two patients without a prior myocardial infarction underwent standard exercise treadmill tests followed by coronary angiography, with coronary artery disease defined as a 50% narrowing in at least one major epicardial coronary artery. Sensitivity, specificity, predictive accuracy and area under the curve of the receiver operating characteristic (ROC) plots were calculated for patients with and without resting ST segment depression as determined by visual or computerized analysis of the baseline ECG.

RESULTS

Sensitivity of the exercise treadmill test increased in 206 patients with resting ST segment depression determined by visual ECG analysis compared with patients without resting ST segment depression (77 ± 7% vs. 45 ± 4%) and specificity decreased (48 ± 12% vs. 84 ± 3%). With computerized analysis, sensitivity of the treadmill test increased in 349 patients with resting ST segment depression compared with patients without resting ST segment depression (71 ± 6% vs. 42 ± 4%) and specificity decreased (52 ± 9% vs. 87 ± 3%) (p < 0.0001 for all comparisons). There was no significant difference in the area under the curve of the ROC plots (0.66–0.69) or the predictive accuracy (62–68%) between the four subgroups.

CONCLUSIONS

The diagnostic accuracy and high sensitivity of the exercise treadmill test in a large cohort of patients with resting ST segment depression and no prior myocardial infarction support the initial use of the test for diagnosis of coronary artery disease. The classification of resting ST segment depression by method of analysis (visual vs. computerized) did not affect the results.

Abbreviations and Acronyms   ACC/AHA = American College of Cardiology/American Heart Association   CAD = coronary artery disease   ECG = electrocardiogram   LVH = left ventricular hypertrophy   ROC = receiver operating characteristic

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