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Treadmill Test - Changing Paradigm


Affiliations
1 Senior consultant cardiologist, Max Diagnostic, India
2 PG resident 1st Year, Dept of Anaesthesiology, D.Y. Patil Hospital, India
     

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Exercise or stress ECG referred to as treadmill test (TMT) has been used for the last several decades for the diagnosis of obstructive coronary artery disease (CAD) but is limited by its low sensitivity and specificity. The advent of other modalities which combines imaging such as echocardiography, nuclear perfusion imaging, computed tomography (CT), and magnetic resonance imaging (MRI) is highly sensitive and specific for the diagnosis of myocardial ischemia. Anatomic imaging of coronary arterial obstruction by CT angiography has also emerged as a highly sensitive and specific test to rule out CAD. TMT now moved from diagnosis of myocardial ischemia to assessment of valvular heart disease, congenital heart disease, pulmonary hypertension, arrhythmia, diastolic dysfunction, genetic CV disease, and peripheral arterial disease. It remains an important test for assessing exercise-induced symptoms, functional capacity, exercise duration, heart rate, and blood pressure during exercise and during recovery after exercise. Of its low sensitivity and specificity TMT should be avoided as a routine test in asymptomatic individuals and in persons with a low probability of CAD. However, due to its wide availability, low-cost and easy interpretation, when used judiciously in cases of moderate to a high probability of CAD, it remains invaluable.

Keywords

Exercise ECG, Stress ECG, TMT, myocardial ischemia, stable coronary artery disease.
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  • Russek HI. Master Two-Step Test in Coronary Artery Disease. JAMA. 1957;165(14):1772–75. DOI:10.1001/jama. 1957.02980320002002.

  • Bruce RA. Evaluation of functional capacity and exercise tolerance of cardiac patients. Mod Concepts Cardiovasc Dis. 1956 Apr;25(4):321-6. PMID: 13309189.

  • Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020 Apr 9;382(15):1395-1407. DOI:10.1056/ NEJMoa1915922. PMID: 32227755; PMCID: PMC7263833.

  • Jeong HC, Kim I, Park KH, Sim DS, Hong YJ, Kim JH, Jeong MH, Cho JG, Park JC, Kim YH, Seon HJ, Moon JD, Ahn Y. New strategy for detection of subclinical coronary atherosclerosis in asymptomatic patients with type 2 diabetes based on cardiac multi-detector computed tomography and treadmill test. Circ J. 2014;78(3):671-8. DOI: 10.1253/circj.cj13-1038. PMID: 24401570.

  • Bourque JM, Beller GA. Value of Exercise ECG for Risk Stratification in Suspected or Known CAD in the Era of Advanced Imaging Technologies. JACC Cardiovasc Imaging. 2015 Nov;8(11):1309-21. DOI: 10.1016/j.jcmg.2015.09.006. PMID: 26563861; PMCID: PMC4646721.

  • Geleijnse ML, Krenning BJ, van Dalen BM, Nemes A, Soliman OI, Bosch JG, Galema TW, ten Cate FJ, Boersma E. Factors affecting sensitivity and specificity of diagnostic testing: dobutamine stress echocardiography. J Am Soc Echocardiogr. 2009 Nov;22(11):1199-208. DOI: 10.1016/j.echo.2009.07.006. Epub 2009 Sep 18. PMID: 19766453.

  • Fox K, Achenbach S, Bax J, Cosyns B, Delgado V, Dweck MR, Edvardsen T, Flachskampf F, Habib G, Lancellotti P, Muraru D, Neglia D, Pontone G, Schwammenthal E, Sechtem U, Westwood M, Popescu BA. Multimodality imaging in cardiology: a statement on behalf of the Task Force on Multimodality Imaging of the European Association of Cardiovascular Imaging. Eur Heart J. 2019 Feb 7;40(6):553- 558. DOI: 10.1093/eurheartj/ehy669. PMID: 30380037

  • Rozanski A, Gransar H, Hayes SW, Min J, Friedman JD, Thomson LE, Berman DS. Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. J Am Coll Cardiol. 2013 Mar 12;61(10):1054- 65. DOI: 10.1016/j.jacc.2012.11.056. PMID: 23473411.

  • Kumar D, Sethi RS, Bansal S, Namgyal PA, Sehgal AK, Malik TS. Diagnostic Accuracy of Stress Myocardial Perfusion Imaging in Indian Diabetic Patients: A Single Centre Experience. Indian J Nucl Med. 2017 Jul-Sep;32(3):177-183. DOI: 10.4103/0972-3919.207873. PMID: 28680199; PMCID: PMC5482011.

  • Truong QA, Schulman-Marcus J, Zakroysky P, et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? Results of the Randomized Comparative Effectiveness ROMICAT II Trial. J Am Heart Assoc. 2016 Mar 22;5(3):e003137. DOI: 10.1161/JAHA.115.003137. PMID: 27006119; PMCID: PMC4943281

  • Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002 Oct 16;40(8):1531-40. DOI: 10.1016/ s0735-1097(02)02164-2. Erratum in: J Am Coll Cardiol. 2006 Oct 17;48(8):1731. PMID: 12392846.

  • Samad Z, Hakeem A, Mahmood SS, Pieper K, Patel MR, Simel DL, Douglas PS. A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department. J Nucl Cardiol. 2012 Apr;19(2):364- 76. DOI: 10.1007/s12350-012-9520-2. PMID: 22322526.

  • Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, Blankstein R, Boyd J, Bullock-Palmer RP. et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. DOI: 10.1161/CIR.0000000000001029. Epub 2021 Oct 28. Erratum in: Circulation. 2021 Nov 30;144(22):e455. PMID: 34709879.

  • Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-e228. DOI: 10.1016/j. jacc.2014.09.017. Epub 2014 Sep 23. Erratum in: J Am Coll Cardiol. 2014 Dec 23;64(24):2713-4. PMID: 25260718.

  • Task Force M, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013 Oct;34(38):2949-3003. DOI: 10.1093/eurheartj/ eht296. Epub 2013 Aug 30. Erratum in: Eur Heart J. 2014 Sep 1;35(33):2260-1. PMID: 23996286.

  • Mieres JH, Gulati M, Bairey Merz N. et al. American Heart Association Cardiac Imaging Committee of the Council on Clinical Cardiology; Cardiovascular Imaging and Intervention Committee of the Council on Cardiovascular Radiology and Intervention. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation. 2014 Jul 22;130(4):350-79. DOI: 10.1161/CIR.0000000000000061. Epub 2014 Jun 16. Erratum in: Circulation. 2014 Jul 22;130(4):e86. PMID: 25047587.

  • Baskaran L, Danad I, Gransar H, Ó Hartaigh B, SchulmanMarcus J, Lin FY, Peña JM, Hunter A, Newby DE, Adamson PD, Min JK. A Comparison of the Updated DiamondForrester, CAD Consortium, and CONFIRM HistoryBased Risk Scores for Predicting Obstructive Coronary Artery Disease in Patients With Stable Chest Pain: The SCOT-HEART Coronary CTA Cohort. JACC Cardiovasc Imaging. 2019 Jul;12(7 Pt 2):1392-1400. DOI: 10.1016/j.jcmg.2018.02.020. Epub 2018 Apr 18. PMID: 29680338.

  • van de Sande DA, Breuer MA, Kemps HM. Utility of Exercise Electrocardiography in Pre-participation Screening in Asymptomatic Athletes: A Systematic Review. Sports Med. 2016 Aug;46(8):1155-64. DOI: 10.1007/s40279-016-0501-5. PMID: 26893099.

  • Moyer VA; U.S. Preventive Services Task Force. Screening for coronary heart disease with electrocardiography: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012 Oct 2;157(7):512-8. DOI: 10.7326/0003- 4819-157-7-201210020-00514. PMID: 22847227.

  • Acampa W, Assante R, Zampella E. The role of treadmill exercise testing in women. J Nucl Cardiol. 2016 Oct;23(5):991- 96. DOI: 10.1007/s12350-016-0596-y. Epub 2016 Jul 25. PMID: 27457528.

  • Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020 Jan 14;41(3):407-77. DOI: 10.1093/eurheartj/ ehz425. Erratum in: Eur Heart J. 2020 Nov 21;41(44):4242. PMID: 31504439

  • Pais P. Treadmill stress tests should not be part of “routine health check package”. Indian Heart J. 2018 NovDec;70(6):934-36. DOI: 10.1016/j.ihj.2018.09.010. Epub 2018 Oct 12. PMID: 30580868; PMCID: PMC6306354.

  • Maculewicz E, Pabin A, Kowalczuk K, Dziuda Ł, Białek A. Endogenous Risk Factors of Cardiovascular Diseases (CVDs) in Military Professionals with a Special Emphasis on Military Pilots. J Clin Med. 2022 Jul 25;11(15):4314. DOI: 10.3390/ jcm11154314. PMID: 35893405; PMCID: PMC9332217.

  • Fletcher GF, Ades PA, Kligfield P, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013 Aug 20;128(8):873-934. DOI: 10.1161/CIR.0b013e31829b5b44. Epub 2013 Jul 22. PMID: 23877260.

  • Miller TD, Askew JW, Anavekar NS. Noninvasive Stress Testing for Coronary Artery Disease. Heart Fail Clin. 2016 Jan;12(1):65-82. DOI: 10.1016/j.hfc.2015.08.006. PMID: 26567975.

  • Fuller CM, Raizner AE, Verani MS, Nahormek PA, Chahine RA, McEntee CW, Miller RR. Early post-myocardial infarction treadmill stress testing. An accurate predictor of multivessel coronary disease and subsequent cardiac events. Ann Intern Med. 1981 Jun;94(6):734-9. DOI: 10.7326/0003-4819-94- 6-734. PMID: 7235413.

  • Henri C, Piérard LA, Lancellotti P, Mongeon FP, Pibarot P, Basmadjian AJ. Exercise testing and stress imaging in valvular heart disease. Can J Cardiol. 2014 Sep;30(9):1012-26. DOI: 10.1016/j.cjca.2014.03.013. Epub 2014 Mar 15. PMID: 25151284.

  • Wasserman K, Hansen JE, Sue DY, Whipp BJ, Froelicher VF. Principles of exercise testing and interpretation. Journal of Cardiopulmonary Rehabilitation and Prevention. 1987 Apr 1;7(4):189.

  • Glaab T, Taube C, Practical guide to cardiopulmonary exercise testing in adults. Respir Res 23, 9 (2022). https://doi. org/10.1186/s12931-021-01895-6


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  • Treadmill Test - Changing Paradigm

Abstract Views: 194  |  PDF Views: 0

Authors

Biswaranjan Mishra
Senior consultant cardiologist, Max Diagnostic, India
Chinmay Divyad
PG resident 1st Year, Dept of Anaesthesiology, D.Y. Patil Hospital, India

Abstract


Exercise or stress ECG referred to as treadmill test (TMT) has been used for the last several decades for the diagnosis of obstructive coronary artery disease (CAD) but is limited by its low sensitivity and specificity. The advent of other modalities which combines imaging such as echocardiography, nuclear perfusion imaging, computed tomography (CT), and magnetic resonance imaging (MRI) is highly sensitive and specific for the diagnosis of myocardial ischemia. Anatomic imaging of coronary arterial obstruction by CT angiography has also emerged as a highly sensitive and specific test to rule out CAD. TMT now moved from diagnosis of myocardial ischemia to assessment of valvular heart disease, congenital heart disease, pulmonary hypertension, arrhythmia, diastolic dysfunction, genetic CV disease, and peripheral arterial disease. It remains an important test for assessing exercise-induced symptoms, functional capacity, exercise duration, heart rate, and blood pressure during exercise and during recovery after exercise. Of its low sensitivity and specificity TMT should be avoided as a routine test in asymptomatic individuals and in persons with a low probability of CAD. However, due to its wide availability, low-cost and easy interpretation, when used judiciously in cases of moderate to a high probability of CAD, it remains invaluable.

Keywords


Exercise ECG, Stress ECG, TMT, myocardial ischemia, stable coronary artery disease.

References