Vol 24, No 2 (2017)
Original articles — Clinical cardiology
Published online: 2016-10-17

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Increased sensitivity of prolonged P-wave during exercise stress test in detection of angiographically documented coronary artery disease

Agnieszka Wsol, Wioletta Wydra, Marek Chmielewski, Andrzej Swiatowiec, Marek Kuch
Pubmed: 27748499
Cardiol J 2017;24(2):159-166.


Background: A retrospective study was designed to investigate P-wave duration changes in exercise stress test (EST) for the prediction of angiographically documented substantial coronary artery disease (CAD).

Methods: We analyzed 265 cases of patients, who underwent EST and subsequently coronary angiography. Analysis of P-wave duration was performed in leads II, V5 at rest, and in the recovery period.

Results: The sensitivity and specificity for the isolated ST-segment depression were only 31% and 76%, respectively. The combination of ST-depression with other exercise-induced clinical and electrocardio­graphic abnormalities (chest pain, ventricular arrhythmia, hypotension, left bundle branch block) was characterized by 41% sensitivity and 69% specificity. The combination of abnormal recovery P-wave duration (≥ 120 ms) with ST-depression and other exercise-induced abnormalities had 83% sensitivity but only 20% specificity. Combined analysis of increased delta P-wave duration, ST-depression and other exercise-induced abnormalities had 69% sensitivity and 42% specificity. Sensitivity and specificity of the increase in delta P-wave duration for left CAD was 69% and 47%, respectively, and for 3-vessel CAD 70% and 50%, respectively. The presence of arterial hypertension negatively influenced the prog­nostic value of P-wave changes in the stress test.

Conclusions: The results of the study show that an addition of P-wave duration changes assessment to ST-depression analysis and other exercise-induced abnormalities increase sensitivity of EST, especially for left CAD and 3-vessel coronary disease. We have also provided evidence for the negative influence of the presence of arterial hypertension on the predictive value of P-wave changes in the stress test. (Cardiol J 2017; 24, 2: 159–166)

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  1. Montalescot G, Sechtem U, Achenbach S, et al. Task Force Members, ESC Committee for Practice Guidelines, Document Reviewers. 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; 34(38): 2949–3003.
  2. 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; 128(8): 873–934.
  3. Mark DB, Hlatky MA, Harrell FE Jr, et al. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med. 1987; 106(6): 793–800.
  4. Amsterdam EA, Kirk JD, Bluemke DA, et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and Interdisciplinary Council on Quality of Care and Outcomes Research. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010; 122(17): 1756–1776.
  5. Dilaveris PE, Gialafos EJ, Andrikopoulos GK, et al. Clinical and electrocardiographic predictors of recurrent atrial fibrillation. Pacing Clin Electrophysiol. 2000; 23(3): 352–358.
  6. Akutsu Y, Kaneko K, Kodama Y, et al. A combination of P wave electrocardiography and plasma brain natriuretic peptide level for predicting the progression to persistent atrial fibrillation: comparisons of sympathetic activity and left atrial size. J Interv Card Electrophysiol. 2013; 38(2): 79–84.
  7. Alpert MA, Munuswamy K. Electrocardiographic diagnosis of left atrial enlargement. Arch Intern Med. 1989; 149(5): 1161–1165.
  8. Russo V, Ammendola E, De Crescenzo I, et al. Severe obesity and P-wave dispersion: the effect of surgically induced weight loss. Obes Surg. 2008; 18(1): 90–96.
  9. Can I, Aytemir K, Demir AU, et al. P-wave duration and dispersion in patients with obstructive sleep apnea. Int J Cardiol. 2009; 133(3): e85–e89.
  10. Nawathe A, Ariyarajah V, Apiyasawat S, et al. Correlation of echocardiographic left atrial abnormality with myocardial ischemia during myocardial perfusion assessment in the presence of known left ventricular hypertrophy. Am J Cardiol. 2013; 112(3): 416–419.
  11. Benjamin EJ, D'Agostino RB, Belanger AJ, et al. Left atrial size and the risk of stroke and death. The Framingham Heart Study. Circulation. 1995; 92(4): 835–841.
  12. Myrianthefs MM, Shandling AH, Startt-Selvester RH, et al. Analysis of the signal-averaged P-wave duration in patients with percutaneous coronary angioplasty-induced myocardial ischemia. Am J Cardiol. 1992; 70(7): 728–732.
  13. Yilmaz R, Demirbag R. P-wave dispersion in patients with stable coronary artery disease and its relationship with severity of the disease. J Electrocardiol. 2005; 38(3): 279–284.
  14. Ozmen F, Atalar E, Aytemir K, et al. Effect of balloon-induced acute ischaemia on P wave dispersion during percutaneous transluminal coronary angioplasty. Europace. 2001; 3(4): 299–303.
  15. Myrianthefs MM, Ellestad MH, Startt-Selvester RH, et al. Significance of signal-averaged P-wave changes during exercise in patients with coronary artery disease and correlation with angiographic findings. Am J Cardiol. 1991; 68(17): 1619–1624.
  16. Bruce RA. Exercise testing of patients with coronary heart disease. Principles and normal standards for evaluation. Ann Clin Res. 1971; 3(6): 323–332.
  17. Maganis JC, Gupta B, Gamie SH, et al. Usefulness of p-wave duration to identify myocardial ischemia during exercise testing. Am J Cardiol. 2010; 105(10): 1365–1370.
  18. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001; 104(14): 1694–1740.
  19. Maganis JC, Drimmer DA, Rojo FB, et al. Enhanced recognition of ischemia by three variable analysis of the exercise stress test. J Electrocardiol. 2013; 46(6): 644–648.
  20. Dunbar CC, Saul BI, Kassotis J, et al. Usefulness of P-wave morphology during submaximal treadmill exercise to predict coronary artery disease. Am J Cardiol. 2005; 96(6): 781–783.
  21. Kohli P, Gulati M. Exercise stress testing in women: going back to the basics. Circulation. 2010; 122(24): 2570–2580.
  22. Barolsky SM, Gilbert CA, Faruqui A, et al. Differences in electrocardiographic response to exercise of women and men: a non-Bayesian factor. Circulation. 1979; 60(5): 1021–1027.
  23. Heikkilä J, Hugenholtz PG, Tabakin BS. Prediction of left heart filling pressure and its sequential change in acute myocardial infarction from the terminal force of the P wave. Br Heart J. 1973; 35(2): 142–151.
  24. Nesto RW, Kowalchuk GJ. The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol. 1987; 59(7): 23C–30C.
  25. Dagli N, Karaca I, Yavuzkir M, et al. Are maximum P wave duration and P wave dispersion a marker of target organ damage in the hypertensive population? Clin Res Cardiol. 2008; 97(2): 98–104.
  26. Tsai WC, Lee KT, Wu MT, et al. Significant correlation of P-wave parameters with left atrial volume index and left ventricular diastolic function. Am J Med Sci. 2013; 346(1): 45–51.