Significance of Slow Upsloping ST-Segment Depression on Exercise Stress Testing

• Published in: The American journal of cardiology 1997-03, Vol.79 (6), p.709-712
• Main Authors: Sansoy, Vedat, Watson, Denny D, Beller, George A
• Format: Article
• Language: English
• Subjects: Accuracy; Age; Aged; Biological and medical sciences; Cardiology. Vascular system; Cardiovascular disease; Coronary Disease - diagnosis; Coronary heart disease; Coronary vessels; Criteria; Defects; EKG; Electrocardiography; Electrocardiography - statistics & numerical data; Exercise; Exercise Test - statistics & numerical data; Female; Heart; Heart rate; Humans; Ischemia; Male; Medical imaging; Medical sciences; Medical screening; Mental depression; Middle Aged; Myocardial Ischemia - diagnosis; Patients; Perfusion; Physical training; Predictive Value of Tests; Scintigraphy; Sensitivity; Thallium; Thallium Radioisotopes; Thallium-201
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/S0002-9149(96)00854-5

The supplementary value of varying degrees of upsloping ST-segment depression observed during treadmill exercise testing to the accuracy of the exercise ST-segment response for detection of ischemia was determined by employing a reversible thallium-201 (201Tl) defect as the criteria for ischemia. A group of 199 consecutive patients (168 men) with ≥1 reversible 201Tl defects on quantitative planar perfusion imaging, and a normal group of 366 patients with normal 201Tl scans who achieved ≥85% of age-predicted maximum heart rate were studied. Upsloping ST-segment depression was subcategorized for ≥1.0, ≥1.5, and ≥2.0 mm of sustained ST-segment depression below baseline at 0.08 seconds after the J-point. If only ≥1.0 mm of horizontal or downsloping ST-segment depression was designated as abnormal and all upsloping responses as normal, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the exercise electrocardiogram were 49% (98 of 199), 84% (281 of 336), 64% (98 of 153), 74% (281 of 382), and 71% (379 of 535), respectively. If in addition to >1.0 mm of horizontal or downsloping ST-segment depression, ≥2.0 mm of upsloping ST-segment depression is considered abnormal, these values were 52% (104 of 199), 81% (272 of 336), 62% (104 of 168), 74% (272 of 367), and 70% (376 of 535), respectively. If ≥1.5 mm of upsloping ST-segment depression is considered an abnormal response, these values were 59% (117 of 199), 74% (248 of 336), 57% (117 of 205), 75% (248 of 330), and 68% (365 of 535), respectively. Finally, if ≥1.0 mm of upsloping ST-segment depression is considered abnormal, these values were 71% (142 of 199), 56% (187 of 336), 49% (142 of 291), 77% (187 of 244), and 61% (329 of 535), respectively. Thus, if upsloping ST-segment depression is added to the criteria for a positive exercise test result, sensitivity for detection of ischemia is increased but at the expense of a fall in specificity and a significant decrease in the positive predictive value of the test. The significance of ≥1.0 mm of upsloping ST-segment depression on exercise testing for detection of inducible ischemia was evaluated in 199 patients with thallium-201 (201Tl) redistribution and 366 patients with normal scans on exercise 201Tl scintigraphy. When upsloping ST-segment depression is added to the criteria for a positive exercise test for ischemia, sensitivity is increased (from 49% to 71%) but at the expense of a fall in specificity (84% to 56%