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(Circulation. 2002;106:2787.)
© 2002 American Heart Association, Inc.

Clinical Investigation and Reports

Role of Nondiagnostic Exercise-Induced ST-Segment Abnormalities in Predicting Future Coronary Events in Asymptomatic Volunteers

Tomasz M. Rywik, MD; Frances C. O’Connor, MPH; Neil S. Gittings; Jeanette G. Wright; Akbar A. Khan, MD; Jerome L. Fleg, MD

From the Gerontology Research Center, National Institute on Aging, National Institutes of Health, Baltimore, Md. Dr Rywik is now at the Heart Failure Department, National Institute of Cardiology, Warsaw, Poland.

Correspondence to Jerome L. Fleg, MD, NHLBI, DECA, 6701 Rockledge Dr, Room 8112, MSC 7936, Bethesda, MD 20892. E-mail flegj{at}nhlbi.nih.gov

Background— Whether exercise-induced ST-segment depression <1 mm is an independent predictor of future coronary events (CEs) in asymptomatic subjects is unknown.

Methods and Results— We performed maximal treadmill exercise tests on 1083 volunteers from the Baltimore Longitudinal Study of Aging who were free from clinical coronary heart disease. Exercise ST-segment changes were stratified by Minnesota code criteria: 11:1 (n=213), flat or downsloping ST depression 1 mm; 11:2 (n=66), flat or downsloping ST depression 0.5 mm and <1 mm; 11:4 (n=124), ST-J depression 1 mm with slowly rising ST segments; and 11:5 (n=69), minor ST depression (<0.5 mm) before exercise that worsened to flat or downsloping ST depression 1 mm during or after exercise. Risk of CE was compared with subjects with normal exercise ECG (n=611). Over a mean follow-up of 7.9 years, 76 subjects developed CEs (angina pectoris, myocardial infarction, or coronary death). On univariate analysis, age (relative risk [RR]=1.07/year, P<0.0001), male sex (RR=1.98, P=0.009), plasma cholesterol (RR=1.02/mg per dL, P<0.0001), hypertension (RR=2.23, P=0.002), duration of exercise (RR=0.71/min, P=0.0001), and systolic blood pressure at peak effort (RR=1.02/mm Hg, P=0.002) were associated with CE. By Cox proportional hazards analysis, age (RR=1.06/year, P<0.0001), male sex (RR=2.76, P=0.0002), plasma cholesterol (RR=1.02 per 1 mg/dL, P<0.0001), duration of exercise (RR=0.87/min, P=0.004), and ST-segment changes coded as either 11:1 (RR=2.70, P=0.0005) or 11:5 (RR=2.73, P=0.04) were independent predictors of CE.

Conclusions— Both a classic ischemic ST-segment exercise response and intensification of minor preexercise ST-segment depression to levels 1 mm independently predicted future CE in this asymptomatic population. Neither slowly rising ST depression nor horizontal ST depression <1 mm was prognostic.

Key Words: exercise • coronary disease • prognosis

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