How to Use Heart Rate

Changes to Improve
Exercise Test Results

V. Froelicher, MD
Professor of Medicine
Stanford University
VA Palo Alto HCS
What are the Questions being
asked regarding Coronary
Disease and Exercise Testing

Does this patient have or not have

Coronary Disease?
Is this patient going to experience
a Cardiac Event?
Is an invasive intervention
appropriate?
Why do we need more than ST
depression?
Classic criteria of one mm ST
depression has low sensitivity and hi
specificity
Other more expensive modalities
appear to have better discriminatory
characteristics
Exercise ST depression has not been
prognostic in all studies
Goal is convince you:
Functional capacity is the strongest
predictor of prognosis and Heart rate
recovery adds to it.
Maximal Heart rate is an important part
of diagnostic scores
We should stop worshipping ST
segments and cardiac cath for
prognostic and diagnostic assessments.
Statistical Prediction
Rules
Based on mathematical models
or equations that can be
simplified as scores
They increase accuracy by
enhancing the odds that any
decision will be correct (a
reliable second opinion)
Clinical Scores
1. Predicting Outcomes
Follow up required (time, complete)
Endpoint Limitations (Death, CABG)
No Natural History
2. Predicting Angiographic Findings
Instant Epidemiology
Limitations of Angiography
Sub-ischemic Lesions cause events
Making any of these Five Mistakes
Evaluating Diagnostic Tests can
invalidate Scores & Stats
Limiting the population Challenge
by choosing extremes
Failure to reduce Work up bias
Use of Heart rate targets
Inclusion of MI patients
Use of Surrogates
Making any of these Four Mistakes
Evaluating Prognostic Tests can
invalidate Scores & Stats
Limited Challenge and work
up bias
Incomplete Follow up
Failure to Censor
Using Misleading Endpoints
Population Selection Critical!!
 Consecutive patients
presenting with the
problem for evaluation
 Limit work up bias
 Avoid limited challenge
Duke Treadmill Score (uneven lines, the elderly?)
The HR Recovery Studies Hi-light
problems with Prediction of
Prognosis
Failure to remove patients with interventions
results in prediction of outcome after
application of standard therapies
Failure to use infarct-free survival or
cardiovascular death as outcome negates
development of strategies or scores for
treatment of CAD
Does not allow for prediction of who should
receive therapies or interventions
Cause of death Age Variable HR
Resting ST depression 1.7
Delta PRP 1
≥65 CABS History 1.7
years MI /Q waves 1.5
Cardiac Abnormal exercise ST 1.2
METs .9
65 CABS History 1.9
years MI /Q waves 1.7
Abnormal exercise ST 1.2
METs .9
≥65 Resting ST depression 1.5
All causes years Delta PRP 1
METs .9
65 years Abnormal resting ECG 1.4
CABS History 1.4
 The ST/HR index studies
highlight the problem of limited
challenge

Comparison of the sickest to the most

well exaggerates the discriminatory value

The well have high heart rates , the sick

have low maximal HRs
 Variable Circle response Sum
Maximal Heart Rate Less than 100 bpm = 30 Males
100 to 129 bpm = 24
130 to 159 bpm =18
160 to 189 bpm =12 Choose
190 to 220 bpm =6 only one
Exercise ST Depression 1-2mm =15
per
group
> 2mm =25

Age >55 yrs =20

40 to 55 yrs = 12

Angina History Definite/Typical = 5

Probable/atypical =3 <40=low prob

Non-cardiac pain =1 40-60=
Hypercholesterolemia? Yes=5 intermediate
Diabetes? Yes=5 probability
Exercise test Occurred =3 >60=high
induced Angina Reason for stopping =5 probability
Total Score:
 Comparison of Tests
Grouping # of Total # Sens Spec Predictive
Studies Patients Accuracy
Standard ET 147 24,047 68% 77% 73%
 ET Scores 24 11,788 80%
 Score Strategy 2 >1000 85% 92% 88%
Thallium Scint 59 6,038 85% 85% 85%
SPECT 16+14 5,272 88% 72% 80%
Adenosine SPECT 10+4 2,137 89% 80% 85%
Exercise ECHO 58 5,000 84% 75% 80%
Dobutamine ECHO 5 <1000 88% 84% 86%
Dobutamine Scint 20 1014 88% 74% 81%
Electron Beam 16 3,683 60% 70% 65%
Tomography (EBCT)
 Therefore scores,
ST/HR index and
Heart rate recovery
should be part of
every standard
ECG Exercise test