Is downstream cardiac testing required in patients with reduced functional capacity and otherwise negative exercise stress test? A single center observational study
Abstract
Background: Exercise stress testing (EST) in patients with poor functional capacity measured by time
on treadmill is typically deemed inconclusive and usually leads to further downstream testing. The aim
of this study was firstly to evaluate the maximum rate pressure product (MRPP) during initial EST to
assessthe need for follow-up testing; and secondly to investigate if MRPP is better than age predicted
maximum heart rate (APMHR) for diagnostic outcome based on follow up cardiovascular (CV) events
in patients with inconclusive EST due to poor functional capacity.
Methods: From a total of 2761 tests performed, 236 tests were considered inconclusive due to poor
functional capacity which were available for analysis. From receiver operating characteristic (ROC)
analysis, a cut-off value for MRPP of 25000 was chosen using CV events as the outcome measure
(sensitivity 97%, specificity 45%). Cases were then categorised into those with an MRPP > 25000 and
< 25000.
Results: Regardless of treadmill time, any patient attaining an MRPP > 25000 had no abnormal
downstream testing or CV events at 2 years follow-up. On ROC analysis MRPP outperformed APMHR
for sensitivity and specificity (area under curve 0.76 vs. 0.59, respectively).
Conclusions: The results suggest that regardless of functional capacity, individuals whose EST is terminated
at maximal fatigue, with no electrocardiogram evidence or symptoms of myocardial ischemia
and yields an MRPP > 25000, do not require further downstream testing. Furthermore, this group
of patients, while not immune to future CV events, have significantly better outcomes than those not
attaining a MRPP > 25000.
Keywords: rate pressure productexercise stress testingmyocardial ischemiadouble productmyocardial index
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