comparison of exercise tests and 24-hour ambulatory ... · type stdepression ofat least i...

British Heart3Journal, I974, 36, 90-95.

Comparison of exercise tests and 24-hourambulatory electrocardiographic monitoring indetection of ST-T changes'

Eliana Wolf, Dan Tzivoni, and Shlomo SternFrom the Department of Physical Medicine and Rehabilitation, Medicine A, the Cardiology Service and theCardiac Stationfor Diagnosis and Follow-up, Hadassah University Hospital and Hebrew University-HadassahMedical School, erusalem, Israel

Forty-seven subjects over the age of 40 years, with atypical praecordial symptoms and a normal restingelectrocardiogram, were evaluated for early detection of ischaemic heart disease using the single two-stepexercise test, the multistage bicycle ergometric test, and continuous 24-hour ambulatory electrocardiographicmonitoring. In 40 of the 47 subjects the results of both the ergometric test and the 24-hour monitoring were

similar; in i9 of them both tests were negative and in 2I subjects ST-T changes were detected by both ergo-metry and 24-hour monitoring. A discrepancy between the two tests wasfound in only 7 subjects, 4 of whomshowed ST-T changes on ergometry only and 3 on monitoring only. The single two-step test was positive in onlyiI of the 47 patients and is regarded as much less sensitive than the other two methods.A good correlation wasfound between the multistage bicycle exercise test and 24-hour monitoring, and the

combined application of both tests will increase the yield of detection of ST-T changes in patients with sus-

pected ischaemic heart disease.

Patients suffering from atypical praecordial symp-toms and who have normal resting electrocardio-grams frequently present a diagnostic problem.Master's two-step exercise test was originally de-signed for detecting 'silent' coronary heart disease(Master, 1953). Subsequently, more sensitive ergo-metric bicycle or treadmill tests, which include re-cording of the electrocardiogram during exerciseand in the postexercise period, have been widelyused (K6nig and Messin, 1970). Continuous 24-hour electrocardiographic monitoring during un-restricted daily activities has recently been used asa new method for detecting transient arrhythmias(Gilson, Holter, and Glasscock, I964; Cordayet al., I965; Stern et al., I970), but insufficient in-formation is at present available on the possibilityof detecting ischaemic ST-T changes by thismethod.

In the present study the efficacy of 24-hourelectrocardiographic monitoring in detecting ST-Tchanges was tested, by comparing the findings inReceived 25 April 1973.

' Supported (in part) by a grant from the Joint Research Fundof the Hebrew University-Hadassah Medical School.

patients with atypical praecordial symptoms withthe results of the Master's two-step test and multi-stage bicycle ergometric examinations.

Subjects and methodsStudies were made on 30 men and 17 women over theage of 40 years. They all suffered from praecordial dis-comfort, and were referred for evaluation by generalpractitioners. In all cases the I2-lead electrocardiogramwas normal at rest, and remained so in the erect positionduring hyperventilation and during the Valsalva manoeu-vre. Master's single two-step test was performed in theusual way (Master and Rosenfeld, I967), and thecriteria for a positive test were restricted to ischaemic-type ST depression of at least i mm and/or T wave in-version.The multistage exercise test was performed on the

Elema bicycle ergometer, starting with a load of I50kilopond metre per minute (p kpm/mnin) at a speed of50 revolutions per minute, and increasing it graduallyby I50 p kpm/min increments. Each exercise phaselasted 5 minutes after which a 5-minute rest periodfollowed. Lead Vs only was recorded during the exercise,while leads I, II, aVL, aVF, and Vs were recorded everyhalf a minute during the rest period. Blood pressure wasmeasured before exercise and during the first, third, and

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E',xercise tests and 24-hour monitoring 91i

fifth minutes of the rest period. The test was discontinuedif the heart rate exceeded 150 beats a minute in patientsaged 40 to 6o years., and 130 beats a minute in patientsover the age of 6o, if the patients complained of chestpain or extreme fatigue, or if severe ST-T changes orarrhythmias occurred. ST depression of i mm or more,occurring in any lead during or after exercise, or majorT wave inversion, served as criteria for a positive ergo-

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metric test. Patients who developed multiple ventricularpremature beats or paroxysmal tachycardia in theabsence of ST-T changes during the exercise or therecovery period were not included in this study.

All patients underwent continuoUS 24-hour electro-cardiographic monitoring within a week of the ergo-metric test. The Holterl recording system was used, with' Avionics, Los Angeles, California.

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Rest H.R 70 4' Ex. H.R. 120 5' Stlop H.R. 120

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2'Rec. HR.9O 3' Rec H.R 68 5 Rec H.R.74

FIG. I Positive multistage exercise test. Ex.=exercise; Rec.=recovery; H.R.=heart rate.

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F I G. 2 Upper row: normal ST-T segment recorded during 24-hour electrocardiographicmonitoring. Lower row: pronounced ST depression during the monitoring period, without sign'cant change in heart rate.

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92 Wolf, Tzivoni, and Stern

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FIG. 3 Upper row: normal ST-T segment recordedduring 24-hour electrocardiographic monitoring.Lower row: ST depression during effort, withtachycardia.

3 non-polarizable silver-silver chloride electrodesattached to the patient's chest. The exploring electrodewas placed in the 5th intercostal space at the Vs positionof the conventional cardiograph; the 'negative' electrodewas at the right sternal border in the 4th interspace andthe 'ground' electrode was attached to the manubriumsterni. The electrocardiographic configuration obtainedby this method resembled that seen in V5. Each patientwas examined in the supine and the erect positions inorder to avoid false interpretation due to posturalchanges. The patient was equipped with the Model EElectrocardiocorder which has an improved low fre-quency response. The reliability of this recorder wastested and the reproduction of the ST-T segment wasfound to be accurate (Stern and Tzivoni, I972). Duringthe 24 hours of monitoring, the patient continued hisusual daily activities and was instructed to record accu-rately his praecordial symptoms, and details of physicaleffort undertaken, emotional excitement, and time andduration of sleep. The magnetic tapes were examined forpossible electrocardiographic changes, and the findingswere related to the patient's symptoms and activities.

TABLE 2 Results of multistage bicycle test and 24-hour electrocardiographic monitoring in 47 patients

24-hour electrocardiographic monitoring Multistage bicycle test

Positive Negative

Positive in 24 2I 3Negative in 23 4 I9

Total 47 25 22

An improved method of operating the Holter system wasused (Tzivoni and Stern, I972). Electrocardiographicmonitoring was interpreted as positive if ST depressionor elevation of at least i mm and/or major T wave inver-sion were detected for several consecutive beats.

ResultsIn I9 patients no ST-T changes were detectedeither by the 24-hour monitoring or by the multi-stage bicycle ergometric or two-step exercise tests.In the remaining 28 patients at least one of thesetests gave positive results, and the details are shownin Tables I to 5. Illustrative tracings are given inFig. 1-3. The Master two-step test was positive inii patients, the bicycle ergometric test in 25, and24-hour electrocardiograph mornitoring in 24 patients(Tables i and 2). Twenty-one patients had positivefindings on both ergometry and prolonged monitor-ing, though only IO of them had a positive two-steptest (Table 3). The ST-T changes detected by themonitoring coincided with praecordial symptoms in7 patients, whereas in the rest of them no sympto-matology accompanied these findings. Though theST-T changes were more prevalent during periodsof activity, in ii patients they were noted alsoduring periods of rest and even during sleep.Among the 7 patients in whom the results by the

ergometry and 24-hour monitoring tests differed, 4had ST-T changes on bicycle exercise but were

negative on electrocardiograph monitoring (Table 4)

TABLE I Summary of ST-T changes observed during 24-hour monitoring, multistage bicycle test, and singletwo-step test

Positive

ST depression ST elevation T wave Both Total Negative TotalI mm or more I mm or more inversion ST and T

change

24-hour monitoring 7 2 5 IO 24 23 47Multistage bicycle test I2 6 7 25 22 47Single two-step test 4 - 3 4 II 36 47



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Exercise tests and 24-hour monitoring 93

TABLE 3 Details on ST-T changes in 21 patients with positive findings on both multistage bicycle test and24-hour electrocardiographic monitoring

Case Age Sex Single 24-hour electrocardio- Multistage bicycle testNo. two-step graphic monitoring

testST T wave ST T wave Maximal Change in leadsdepression inversion depression inversion heart rate(mm) (mm)

I 46 F Positive I2 62 F Positive I3 56 F Negative I4 55 M Positive I-55 44 M Negative I6 43 M Negative 27 43 M Negative No8 57 M Negative 29 45 M Negative NoI0 56 F Positive 2II 45 F Positive II2 54 M Positive II3 43 F Positive 2I4 53 M Positive 3

I5 5i M Negative No

i6 50 M Positive NoI7 48 M Positive -2*I8 6i F Negative 2I9 48 M Negative o-520 40 F Negative No21 60 M Negative I

No I-5Yes 2No I-5No I-5No IYes 2Yes IBiphasic 2Yes IYes I-5No I-5Yes 2No 2

No IYes NoYes NoBiphasic NoYes IYes IYes NoNo No

No I20 V5No I25 vsNo I35 V5, IINo 100 V5, IINo I35 V5, I, II, aVLNo I40 V5, I, IIYes I55 V, I, IINo 140 II, III, aVFYes I35 V5, aVFNo I40 V5No 120 V5Yes I20 V5, III, aVFNo I05 VsYes II0 V5Yes I50 III, aVFYes II0 V5Yes I00 V5No Ioo V5Yes I35 V5Yes I45 V5, IIIYes I25 III, aVF

* ST elevation.

TABLE 4 Details on ST-T changes in 4 patients with positive multistage test and negative 24-hour monitoring

Case Age Sex Single 24-hour electro- Multistage bicycle testNo. two-step cardiographic

test monitoring ST T Maximal Change indepression wave heart rate leads(mm) inversion

22 44 F Negative Negative I Yes I45 II, III, aVF23 47 M Negative Negative I.5 No I35 III, aVF24 57 F Negative Negative No Yes II5 II, III, aVF25 54 F Positive Negative I.5 Yes I30 V5

TABLE 5 Details on ST-T change in 3 patients with positive 24-hour monitoring and negative multistagebicycle test

Case Age Sex Single 24-hour electrocardiographic Multistage bicycle testNo. two-step monitoring

testST depression T wave(mm) inversion

26 40 M Negative - 2* No Negative27 54 F Negative I Yes Negative28 40 M Negative I No Negative

* ST elevation.



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94 Wolf, Tzivoni, and Stern

and 3 had ST-T changes on prolonged monitoringbut were negative on the bicycle exercise tests(Table 5).

Changes in the ST segment without T wavechanges were slightly more prevalent on ergometry(I2 patients) than on electrocardiographic monitor-ing (9 patients); isolated T wave changes werefound with a similar frequency by the two methods,while changes in both the ST segments and Twaves were more frequent on monitoring (Table i).In only one patient were the findings negative onmonitoring but positive on both the Master's testand bicycle ergometry. In another patient, withnegative exercise tests, there was a transient eleva-tion of the ST segment during 24-hour monitoring.

DiscussionThe importance of the exercise tests in the diagnosisof asymptomatic and/or atypical ischaemic heartdisease has been well established in the past decade(Mattingly, I962; Robb and Marks, I967). In recentyears, multistage exercise bicycle or treadmill testshave taken the place of the Master's two-step test.These tests are more strenuous and the amount ofexercise performed is better controlled. The sensi-tivity of the maximal exercise capacity test was foundto be nine times greater than that of the doubleMaster two-step test in a recent report by Doanet al. (I965). Sheffield, Holt, and Reeves (I965), in astudy on patients with ischaemic heart disease, re-ported 20 to 25 per cent more positive results fromthe maximal exercise test than from the double two-step test. Similarly, Bellet and Roman (I967) foundthat the maximal treadmill exercise test increased theyield of positive results by I2 per cent, as comparedto the double two-step test.

Continuous 24-hour electrocardiographic mon-itoring by the Holter system has been used mainlyfor detection of cardiac arrhythmias and there areonly a few descriptions of ST-T segment changesduring monitoring (Norland and Semler, I964;Aronow et al., I972; Golding et al., I973). This ispossibly due to the report by Hinkle et al. (i967)who raised doubts concerning the reliability of theHolter system in recording ST-T changes. How-ever, the new model of the Electrocardiocorder hasbeen recently found to be reliable in this respect andno artefacts due to the recording system were de-tected when recording either normal or pathologicalpatterns (Stem and Tzivoni, I972). Moreover, in acontrol group of 42 normal subjects with no clinicalor electrocardiographic evidence of cardiovaspulardisease, no ST-T changes were found during the24-hour monitoring period (Stern and Tzivoni,I973), making highly improbable the possibility offalse positive results.

The present study on 47 patients with suspectedischaemic heart disease confirns that the multi-stage ergometry test is much more sensitive in de-tecting ischaemic ST-T changes than the 'singleMaster's test'. Moreover, both ergometry and the24-hour electrocardiographic monitoring discloseST-T changes in a relatively high percentage of thecases, and a good correlation was found between theresults obtained by these two methods. A dis-crepancy was found in only 7 patients: in 4 of themthere were ST-T changes in ergometry but notduring monitoring and this may have been due tothe fact that only one chest lead is recorded duringmonitoring so that changes occurring only in thelimb leads may escape detection; in fact, in 3 ofthese 4 patients the changes on ergometry were con-fined to the limb leads. However, 2 other patientswith ST-T changes confined to the limb leadsduring ergometry revealed similar changes onmonitoring. In i of the 3 patients with positivefindings on monitoring only, but negative exercisetests, the discrepancy was explained by the factthat the ST elevation seen on monitoring was mostprobably the phenomena of 'Prinzmetal's angina',appearing at rest and therefore not detectable byexercise tests (Hilal and Massumi, I967).There are no generally accepted criteria for the

interpretation of ST-T changes during or afterquantitated exercise tests and even less so for thechanges occurring during effort or under the in-fluence of stress and emotion. The appearanceof ST depression of the 'segmental' type afterexercise tests is, however, regarded as pathogno-monic of ischaemic heart disease. The degree ofischaemic ST depression indicates the degree ofcoronary insufficiency and prognosis (Master andGeller, I969). We believe that the appearance ofthis change during ambulatory monitoring underunrestricted daily activities is similarly indicativeof coronary disease, especially if seen in patientsover the age of 40 with praecordial symptoms.This assumption is supported by the good correla-tion found between this and the ergometric test,with respect to the detection of ST depression. Thediagnostic value of T wave inversion in the courseof exercise tests is even less clearly defined(Mattingly, 1962), and we only regarded deep in-version as positive, both for the exercise test and forthe monitoring. In this respect also there was goodcorrelation between the two tests, as in 3 of 5patients with isolated T wave inversion on mon-itoring similar changes were also detected by theexercise test.The fairly good correlation between the findings

on 24-hour ambulatory monitoring under dynamicconditions and in the multistage ergometric test



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Exercise tests and 24-hour monitoring 95

indicates the reliability of the former method indetecting early ST-T changes in patients withatypical praecordial symptoms. Moreover, it is ourexperience that the two tests complement oneanother, and that the yield of detection of positivecases can be increased by performing both tests inpatients with suspected ischaemic heart disease.The authors thank Mrs. Batia Glassman for her tech-nical assistance.

ReferencesAronow, W. S., Harris, C. N., Isbel, M. W., Rokaw, S. N., and

Imparato, B. (I972). Effect of freeway travel on anginapectoris. Annals of Internal Medicine, 77, 669.

Bellet, S., and Roman, L. (i967). Comparison of the doubletwo-step test and the maximal exercise treadmill test:studies in coronary-prone subjects. Circulation, 36, 238.

Corday, E., Bazika, V., Lang, T. W., Pappelbaum, S., Gold,H., and Bernstein, H. (i965). Detection of phantomarrhythmias and evanescent electrocardiographic abnormal-ities. Use of prolonged direct electrocardiocording. Journalof the American Medical Association, 193, 417.

Doan, A. E., Peterson, D. R., Blackmon, J. R., and Bruce,R. A. (i965). Myocardial ischemia after maximal exercisein healthy men: a method for detecting potential coronaryheart disease? American Heart Journal, 69, II.

Gilson, J. S., Holter, N. J., and Glasscock, W. R. (i964).Clinical observations using the Electrocardiocorder -AVSEP continuous electrocardiographic system; tenta-tive standards and typical patterns. American Journal ofCardiology, 14, 204.

Golding, B., Wolf, E., Tzivoni, D., and Stern, S. (I973).Transient S-T elevation detected by 24-hour ECG moni-toring during normal daily activity. American HeartJournal, 86, 50I.

Hilal, H., and Massumi, R. (I967). Variant angina pectoris.American Journal of Cardiology, i9, 607.

Hinkle, L. E., Meyer, J., Stevens, M., and Carver, S. T.(I967). Tape recordings of the E.C.G. of active men:limitations and advantages of the Holter-Avionics instru-ments. Circulation, 36, 752.

Konig, K., and Messin, R. (I970). Methods of evaluation ofthe physical capacity. Acta Cardiologica, Suppl., I4, 30.

Master, A. M. (I953). The 'two-step' exercise electrocardio-gram. Its use in heart disease, including valvular heartdisease of adults. Bulletin of the St. Francis Hospital andSanatorium, Io, i.

Master, A. M., and Geller, A. J. (I969). The extent of com-pletely asymptomatic coronary artery disease. AmericanJournal of Cardiology, 23, 173.

Master, A. M., and Rosenfeld, J. (I967). Two-step exercisetest: current status after twenty-five years. Modern Con-cepts of Cardiovascular Diseases, 36, I9.

Mattingly, T. W. (I962). The postexercise electrocardiogram:its value in the diagnosis and prognosis of coronaryarterial disease. American Journal of Cardiology, 9, 395.

Norland, C. C., and Semler, H. J. (I964). Angina pectoris andarrhythmias documented by cardiac telemetry. Journal ofthe American Medical Association, 190, II5.

Robb, G. P., and Marks, H. H. (I967). Postexercise electro-cardiogram in arteriosclerotic heart disease: its value indiagnosis and prognosis. Journal of the American MedicalAssociation, 200, 9I8.

Sheffield, L. T., Holt, J. H., and Reeves, T. J. (I965). Exer-cise graded by heart rate in electrocardiographic testingfor angina pectoris. Circulation, 32, 622.

Stern, S., Ben-Shachar, G., Tzivoni, D., and Braun, K.(1970). Detection of transient arrhythmias by continuouslong-term recording of electrocardiograms of active sub-jects. Israel_Journal of Medical Sciences, 6, 103.

Stern, S., and Tzivoni, D. (I972). The reliability of theHolter-Avionics system in reproducing the ST-T seg-ment. American Heart Journal, 84, 427.

Stern, S., and Tzivoni, D. (I973). Dynamic changes in theST-T segment during sleep in ischemic heart disease.American Journal of Cardiology, 32, I7.

Tzivoni, D., and Stern, S. (I972). Improved method of oper-ating the Holter-Avionics ECG recording system. Ameri-can Heart_Journal, 83, 846.

Requests for reprints to Dr. Shlomo Stern, Departmentof Cardiology, Hadassah University Hospital, P.O.B.499, Jerusalem, Israel.



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