S-T segment elevation during exercise: Electrocardiographic and arteriographic correlation in 38 patients

doi:10.1016/0002-9149(80)90119-8

The American Journal of Cardiology

Volume 45, Issue 4, April 1980, Pages 762-768

https://doi.org/10.1016/0002-9149(80)90119-8 Get rights and content

Abstract

The clinical significance and underlying mechanisms of S-T segment elevation during exercise were evaluated by correlating the exercise-induced S-T elevation with the coronary arteriograms and left ventriculogram in 38 patients. Of these, 37 (97 percent) showed significant coronary artery disease; 71 percent of these had proximal lesions. Of 27 patients with old myocardial infarction manifested in the electrocardiogram at rest, 25 had significant coronary artery disease and a ventricular aneurysm. All 11 patients with no previous myocardial infarction in the electrocardiogram at rest had significant coronary artery disease but only 2 (18 percent) had a ventricular aneurysm. One patient had a ventricular aneurysm without coronary artery disease. The sites of S-T elevation correctly localized the area of ventricular aneurysm of 30 (91 percent) of 33 instances and the area of the compatible diseased vessels in 38 (95 percent) of 40 instances.

Our data suggest that (1) S-T elevation during exercise in the absence of a pattern of previous myocardial infarction in the electrocardiogram at rest indicates significant proximal coronary artery disease without ventricular aneurysm, whereas in the presence of such a pattern it is indicative of both ventricular aneurysm and significant proximal coronary artery disease; (2) the sites of S-T elevation accurately identify the location of ventricular aneurysm and the compatible diseased vessels; and (3) ischemia and abnormal wall motion may independently or additively underlie the mechanism for S-T elevation during exercise.

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Cited by (30)

Stress-induced ST elevation with or without concomitant ST depression is predictive of presence, location and amount of myocardial ischemia assessed by myocardial perfusion SPECT, whereas isolated stress-induced ST depression is not
2016, Journal of Electrocardiology
Citation Excerpt :
The findings in the present study show that BSTs with stress-induced ST elevation reflect more severe myocardial ischemia as compared to stress-induced ST depression. This result is supported by the high prevalence of critical coronary stenosis (> 90% stenosis) in patients with stress-induced ST elevation [6,9,14]. The ST elevation population in the present study can be divided into two distinct groups: those with (n = 17) and those without signs of prior infarction (n = 11) on the resting ECG.
Evaluation of stress-induced ST deviations constitutes a central part when interpreting the findings from an exercise test. The aim of this analysis was to assess the pathophysiologic correlate of stress-induced ST elevation and ST depression with regard to presence, amount and location of myocardial ischemia as assessed by myocardial perfusion SPECT (MPS) in patients with suspected coronary artery disease.
226 patients who had undergone bicycle stress test in conjunction with MPS were included. Of these, 198 were consecutive patients while 28 patients were included on the basis of having stress-induced ST elevation mentioned in their clinical report. The amount and location of ST changes were related to MPS findings. Summed stress scores (SSS) from MPS images were used to measure the amount of stress-induced ischemia.
The positive predictive values for detecting stress-induced ischemia were 28% for the consecutive patients with ST depression and 75% for patients with ST elevation. The maximum and sum of stress-induced ST elevations correlated with SSS (r² =0.58, p< 0.001 and r² =0.73, p < 0.001), whereas the maximum and sum of significant ST depressions did not (r² =0.022, p = 0.08 and r² =0.024, p = 0.10). The location of ST elevation corresponded to the location of ischemia by MPS (kappa = 1.0), whereas the location of ST depression did not (kappa = 0.20).
Stress-induced ST elevation, with or without concomitant ST depression, is predictive of the presence, amount and location of myocardial ischemia assessed by MPS, whereas stress-induced ST depression without concomitant ST elevation is not.
ST segment elevation during dobutamine stress echocardiography after acute myocardial infarction: Clinical significance and correlation with contractile recovery
2012, Egyptian Heart Journal
Citation Excerpt :
At that time, other studies already suggested that myocardial ischemia secondary to severe coronary disease may play an important role7 because coronary artery bypass surgery could result in abolition of exercise-induced ST-segment elevation. Some investigators concluded that these electrocardiographic changes may be caused by abnormal wall motion, peri-infarctional ischemia, or both.8–10 Recent studies have provided a new look to the significance of exercise-induced ST-segment elevation.
The aim of this study was the evaluation of the value of dobutamine stress induced ST-segment elevation after acute myocardial infarction in predicting spontaneous contractile recovery.
Fifty eight consecutive patients were studied within 7 days after first acute myocardial infarction (AMI) with dobutamine stress echocardiography (DSE). A score model based on 16 segments and four grades was used to assess the left ventricular function and a twelve-lead electrocardiography was continuously monitored throughout the test. Follow up was performed by trans-thoracic echocardiography at 90 days. At follow up, contractile recovery was defined as improvement of wall motion score by more than one grade in at least two myocardial segments.
ST-segment elevation was observed in 24 (41%) out of the 58 patients studied. During DSE; persistent segmental wall motion abnormalities were more frequently observed in patients without ST-segment elevation while improvement without subsequent worsening was more frequently observed in patients with ST-segment elevation (P = 0.001). On follow up, contractile recovery was reported in 37 (64%) patients, it was more frequently observed in patients who already developed ST-segment elevation during DSE (P = 0.007). Dobutamine induced ST-Segment elevation has the sensitivity, specificity, positive and negative predictive values of 66%, 86%, 88% and 53%, respectively to predict spontaneous contractile recovery after AMI, while the combined sensitivity, specificity, positive and negative predictive values of dobutamine echocardiography and electrocardiography were 73%, 89%, 94% and 64%, respectively.
Dobutamine stress induced ST segment elevation occurring in electrocardiographic leads exploring an infarct area is a predictor of spontaneous contractile recovery after AMI particularly when combined with echocardiogarphic evidence of myocardial viability.
Stress-induced ST-segment elevation in patients without prior Q-wave myocardial infarction
2008, Journal of Electrocardiology
Citation Excerpt :
Eighty-seven percent of the patients had critical CAD, and 59% had multivessel disease. Our results are in accord with prior studies,4,5,24-27 which found that ST-segment elevation during stress test is a marker of significant CAD. In light of the conflicting data available regarding whether ST-segment elevation during exercise stress test can localize the culprit artery,15,28-30 the present study shows a significant correlation between stress-induced ST-segment elevation localization and culprit artery by angiography.
Stress-induced ST-segment elevation is an uncommon finding that usually occurs in patients with prior myocardial infarction (MI). Our purpose was to assess the angiographic and clinical significance of this finding in patients without prior MI.
Of the 29 002 consecutive ambulatory patients who underwent stress myocardial perfusion imaging over a 5-year period, 205 (0.7%) developed stress-induced ST-segment elevation, of whom 39 (19%) had no Q-wave MI in leads showing ST-segment elevation during either exercise (n = 31) or dipyridamole (n = 8) stress myocardial perfusion imaging. All 39 patients were hospitalized and underwent coronary angiography.
Significant coronary artery disease was found in all 39 patients: 87% had critical (≥90%) stenosis, and 59% had multiple vessel disease. During hospitalization, 37 patients (95%) underwent revascularization.
In patients without prior Q-wave MI, stress-induced ST-segment elevation is associated with critical coronary artery disease. Therefore, these patients should be considered for early coronary investigation.
Stress Test
2008, Chou's Electrocardiography in Clinical Practice: Adult and Pediatric
Relevance of simultaneous ST segment elevation and depression in an exercise treadmill test
2001, International Journal of Cardiology
Simultaneous ST segment elevation and depression recorded during an exercise treadmill test and its correlation with coronary angiogram is a new finding that does not find a place in medical literature. We conclude that in the presence of simultaneous ST segment elevation and ST segment depression during exercise treadmill test (1) the localizing value of isolated ST elevation is lost and (2) there is severe triple vessel disease warranting early intervention.
ST-segment elevation during dobutamine stress testing predicts functional recovery after acute myocardial infarction
1999, American Heart Journal
Objectives The aims of this study were (1) to assess the relation between ST-segment elevation and wall motion response occurring during dobutamine testing and (2) to evaluate the usefulness of stress-induced ST-segment elevation for predicting functional recovery after acute myocardial infarction. Background Clinical significance of stress-induced ST-segment elevation after acute myocardial infarction remains controversial. According to previous studies, it may reflect a larger infarcted area, depressed left ventricular function, left ventricular aneurysm, stress-induced dyskinesia, residual myocardial ischemia, or viability in the affected region. Whether transient ST-segment elevation occurring during dobutamine testing may predict functional recovery is unknown. Methods and Results We studied 38 patients who underwent dobutamine stress testing early (5 ± 2 days) after a first acute myocardial infarction. Dobutamine was infused at increasing doses from 5 to a maximum of 40 μg/kg per minute, with the addition of up to 1 mg of atropine if the target rate could not be reached by dobutamine alone. Twelve-lead electrocardiography and cross-sectional echocardiography were continuously monitored throughout the test. Dobutamine-induced ST-segment elevation was defined as a new or worsening ≥1 mm elevation, 80 ms after J point, in ≥2 infarct-related leads. Quantitative angiography was available in all patients before hospital discharge. Follow-up resting echocardiography was recorded in all patients 12 to 18 months after the acute event. ST-segment elevation was observed in 20 of the 38 patients. There were no significant differences between patients with and those without dobutamine-induced ST-segment elevation in age, site of infarction, peak level of total creatine kinase enzyme, and use of thrombolytic therapy, angioplasty, or both. Persistent akinesis without change during dobutamine stress testing was more frequently observed in patients without ST elevation (P < .05). A biphasic response during dobutamine testing was more frequently observed in patients with ST-segment elevation (P = .01). Multivariate analysis selected 2 independent variables associated with ST-segment elevation: a biphasic response during dobutamine stress (chi-square = 7.3; P = .007) and the minimal lumen diameter of the infarct-related vessel at quantitative angiography (chi-square = 5.5; P < .02). Functional recovery was demonstrated in 26 patients. Sensitivity of ST-segment elevation for the prediction of functional recovery was 69%, specificity 83%, positive predictive value 90%, and accuracy 74%. Two independent variables predicting functional recovery were selected: dobutamine-induced ST-segment elevation (chi-square = 9.1; P = .003) and a biphasic response during stress (chi-square = 6.15; P = .013). Conclusions Dobutamine-induced ST-segment elevation in the infarct-related leads is an ancillary sign of viable myocardium in jeopardy. It has a high specificity and an acceptable sensitivity for the prediction of functional recovery after acute myocardial infarction. (Am Heart J 1999;137:500-11.)

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^☆: This study was supported in part by a grant from the Fraternal Order of Eagles, Pittsburgh, Pennsylvania and Grant 493735 from the Pennsylvania Department of Health, Harrisburg, Pennsylvania.

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Clinical studyS-T segment elevation during exercise: Electrocardiographic and arteriographic correlation in 38 patients☆

Abstract

Am J Cardiol

Am Heart J

Am J Med

J Electrocardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Clinical study
S-T segment elevation during exercise: Electrocardiographic and arteriographic correlation in 38 patients☆