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Prognostic importance of exercise electrocardiography in patients with suspected microvascular disease
Morten Kraen1, Shahnaz Akil2, Bo Hedén2
1Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden morten.kraen@med.lu.se.
Insights
ST-segment depression on exercise ECG has limited prognostic value for coronary microvascular dysfunction (CMD) in chest pain patients. Reduced exercise capacity, however, remains a key independent risk factor for major adverse cardiac events (MACE).
Area of Science:
- Cardiology
- Diagnostic Imaging
- Clinical Research
Background:
- Coronary microvascular dysfunction (CMD) is linked to poor prognosis and challenging non-invasive diagnosis.
- Previous studies suggested high positive predictive value (PPV) for ST-segment depression on exercise ECG (ex-ECG) in specific patient groups.
Purpose of the Study:
- To evaluate the prognostic value of ex-ECG findings in chest pain patients with suspected CMD, after excluding epicardial stenosis using myocardial perfusion SPECT (MPS).
Main Methods:
- A single-center observational study included 1021 patients undergoing MPS and ex-ECG.
- Patients with ischaemia on MPS or inconclusive ex-ECG were excluded, leaving 760 for analysis.
- Major adverse cardiac events (MACE) were tracked via national registries over a mean of 8.5 years.
Main Results:
- Abnormal ex-ECG was observed in 17% of the final cohort (n=760).
- While Kaplan-Meier curves showed separation (p=0.01), abnormal ex-ECG was not an independent predictor of MACE after multivariable adjustment (HR 1.1, p=0.6).
- The prognostic PPV of abnormal ex-ECG for MACE was low (25%), decreasing further in patients without known coronary artery disease (17%).
Conclusions:
- Ischaemic ST-segment changes on ex-ECG have limited prognostic value for MACE in patients with suspected CMD.
- Reduced exercise capacity emerged as an independent risk factor for MACE.
- Ex-ECG may still be valuable for functional assessment when warranted in clinical practice.
Background:
Coronary microvascular dysfunction (CMD) is associated with a poor prognosis but is difficult to diagnose non-invasively. In a recent paper, ST-segment depression on exercise-ECG was found to have a very high positive predictive value (PPV) for CMD in a highly selected group of patients.
Objectives:
In the present study of chest pain patients, we used myocardial perfusion single photon emission CT (MPS) to rule out ischaemia due to epicardial coronary stenosis. In the remaining patients with suspected CMD, we studied the prognostic value of ex-ECG findings.
Methods:
A single-centre observational study of 1021 consecutive patients examined with MPS and ex-ECG. Follow-up data were acquired from national registries. Major adverse cardiac events (MACE) were defined as cardiovascular death, myocardial infarction, unstable angina and unplanned revascularisation. A total of 113 patients were excluded due to inconclusive ex-ECG findings or missing data, and 148 due to ischaemia on MPS.
Results:
In the final study cohort (n=760) with a mean age of 63 years and 55% female, ex-ECG was abnormal in 126 patients (17%). During a mean follow-up of 8.5 years, MACE occurred in 31 (25%) patients with abnormal ex-ECG and 103 (16%) patients with normal ex-ECG. The Kaplan-Meier curves for cumulative events separated significantly (log-rank p=0.01), but when adjusting for age, sex, comorbidities and exercise capacity, abnormal ex-ECG was no longer significantly associated with MACE (HR 1.1, CI 0.7 to 1.7, p=0.6). The prognostic PPV of an abnormal ex-ECG was only 25% (31/126) and this decreased to 17% (11/66) when excluding patients with known coronary artery disease (n=323).
Conclusions:
In patients with suspected CMD, ischaemic ST-segment changes are of limited prognostic value, showing poor sensitivity and low PPV for the occurrence of MACE. However, reduced exercise capacity was an independent risk factor and, therefore, ex-ECG testing could be considered if a functional assessment of patients is warranted.
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