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The diagnosis of angina pectoris
Fundamentals of clinical cardiology
Peter C. Gazes, M.D.* M. Rodney Culler, M.D.** James K. Stokes, M.D.*** Charleston, S. C.
I‘
T
here is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it.“l The concept that the history is the essential feature in the clinical diagnosis of angina pectoris was established by William Heberden in 1768.’ In 1964, this is essentially unchanged, but the development of the two-step exercise test” and advances in electrocardiography have given us objective studies. Recent advances in therapy make early and correct diagnosis essential so that appropriate treatment can be instituted. The diagnosis remains dependent upon the history and electrocardiographic changes, and these parameters must be critically evaluated in any patient in whom angina is considered. History
The classic description of Heberden is partially applicable today: “Those who are afflicted with it are seized while they are walking (more especially if it be up hill and soon after eating), with a painful and most disagreeable sensation in the breast, which seemsas if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasinessvanishes.“* The difficulty experienced by the patient
with angina is appropriately described as a distress or discomfort, and not a pain. Frequently, they object to the word pain. The distress may be classified according to location, precipitating factors, quality, intensity, and duration. It may vary considerably from person to person, but tends to remain constant in the individual patient. It is “his discomfort.” 1. Location. “The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the OS sterni; and more often inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm the pain sometimes reaches to the right arm as well as the left, and even down to the hands. . . . “I The location of the distress of angina is related to the sensory innervation of the heart. Fibers originate in the sensory ganglia of the first to fourth thoracic spinal roots and accompany the sympathetic cardiac nerves. With overlapping of sensory nerves and internuncial communications, the cardiac pain dermatomes extend from CT to Tg. Roberg states that the extension of the trigeminal nucleus into the cervical chord may explain the location of distress in the lower jaw. The classic location of angina1 distress
From the Departments of Medicine and Pharmacology, Medical Received for publication Sept. 20. 1963. *.4ssistant Professor of Medicine (Cardiology) and Plmrmac~~lopy. **Chief Resident in Medicine. -*Intern in Medicine.
830
College Address;:
of South
Carolina,
.55. D
Charlestor~. rhidcst~m.
3. (‘. s. I’.
I’oltwcc ,\‘umber
67 6
Fig. 1. Ischemic right-angle S-T segment depression. i%ote that the degree of S-T depression is measured from the top of the continuation of the P-R interval.
the retrosternal (T1 to TF) area, with radiation to the inner -aspect of the left arm (Ti), the hypothenar eminence (CS), and the fourth and fifth fingers (CT). The discomfort may radiate to the neck and corresponding areas of the right arm, to both arms, and to the lower jaw. It is important to remember that the distress of angina may occur in onlv a segment of this distribution, that is, -it may be only in the chest, only in the jaw, only in the left arm, or even only in the right arm. In differentiating angina1 distress from psychoneurosis, the psychoneurotic will usually pinpoint his discomfort with one finger, whereas the patient with angina will use his entire hand to designate the area. 2. Precipitating factors. The distress occurs with exertion, digestion, excitement, and emotion, and is relieved promptly by rest. The discomfort is usually brought on by increased cardiac work. The attacks do not occur regularly each day tmless related to exercise or emotion.4 Angina pectoris may be precipitated by “walking up hill after a meal, or in the cold or by ‘disturbance of the mind.’ “l The distress will frequently respond promptly to nitroglycerin. It has been demonstrated that prophylactic nitroglycerin prevents the angina1 distress and eliminates certain abnormal cardiac pulsations which occur during the angina1 attacks.5 In the psychoneurotic, the distressful sensation occurs after the exertion and not during the exertion, as is seen in the patient with true angina. Prinzmetal* described a variant form of angina in which the attack is not precipitated by increased cardiac work or emois in
Diagnosis
of angina pectoris
831
tional upsets. It occurs at about the same time each day and is not relieved by rest. The distress is more intense and of longer duration than the classic form of angina, and usually disappears dramatically after infarction. Nocturnal angina pectoris, “angina decubitus,” is apparently related to the decreased supply of oxygen to the myocardium during recumbency, often associated with pulmonary venous congestion (left heart failure), and occurs primarily when coronary atherosclerosis is complicated by valvular disease, hypertensive heart disease, or car pulmonale. 3. Quality and intensity. Characteristically, angina1 distress is described as a burning sensation, tight sensation, or heavy feeling. It may be variously described as strong, constricting, expanding, burning, aching, or pressing. It may be a mild oppression, slight smothering, gassy fullness, sense of weakness, or faintness with mild nausea. The arms, hands, and fingers may experience a severe aching, burning, numbness, or tingling. There may be an aching, tingling, or bursting sensa-
COMTROL’
Fig. 2. After exercise, the S-T segment elevation in Leads Vz and V, is followed by T-wave inversion in 4 minutes and a return to the control in 10 minutes. Several months later the patient had an anteroseptal infarction.
832
Gazes, Culler, and Stokes
Am. Heart Jwre,
tion in the lower jaw. Very seldom is it sharp SO that the patient refers to it as “pain.” 1. Durafiion. The angina1 sensation usually develops gradually and progressively over a period of 10 seconds to 2 minutes and is constant. It subsides rapidly on rest, and particularly after nitroglycerin, within a minute or two. Variant forms of angina tend to be more severe and of longer duration.4 It has been demonstrated by Levine6 and Freedberg’ that angina1 pain could be relieved by carotid sinus massage. Levine6 considers this to be diagnostic in many instances. With the patient sitting up and the angina1 discomfort present, the right carotid sinus is massaged. If this is not successful, the left carotid sinus is tried, but not both at the same time. Auscultation of the heart is carried out during manipulation, and if significant slowing of the heart occurs, massage is stopped. Massage should not be carried out for more than 3 to 5 seconds at a time. The test is positive for angina pectoris if relief of distress occurs within seconds, with usually concomitant slowing of the heart. Since relief occurs at times without slowing of the heart, the carotid massage may be producing an interruption of sympathetic reflex arcs or sensory pathways7 A negative response does not rule out angina. Electrocardiogram We usually plan on performing a double two-step Master’s test, preferably with the patient in the fasting state, rather than beginning with the single-step test. If the
Fig.
3.
Intermittent
left bundle
branch
.I. 1964
patient develops any of his symptoms prior to completion of the required number of trips, the test is stopped and postexercise tracings are taken. in many instances, patients will give a classic description while exercising, yet in relating their histories just before exercise they were very vague. For this reason, it is important to be present when the test is performed, as well as to prevent any undue attack of prolonged coronary insufficiency or even occlusion. It is preferable to take Leads Vc or Vc (depending on which has the greater R-wave amplitude), V?, Ll, and L2 in this order: immediately, at 1 minute, 3 minutes, and 5 minutes after exercise. If abnormal change develops, then tracings are taken until there is a return to normal. Radioelectrocardiography during exercise may give additional information, as shown by Bellet and associates.8 Often, attempting to reproduce the patient’s symptoms b,, exposing him to his particular type of precipitating factor may be beneficial, taken at this ;111 d an electrocardiogram time may be significant. Abnormal changes have been seen in such instances, even though a double Master’s test was negative. Positive electrocardiographic changes after exercise. 1.
S-T
SEGMENT
DEPRESSION.
E‘Or
lllatly
).ears, the degree of S-T segment depression was considered to be most important. how, the type of S-T segment depression”-‘4 is given most attention. When the S-T segment is depressed at a right angle to the vertical, as seen in Fig. 1, a half millimeter or more of depression is con-
block
after
exercise.
V&me 67 Number6
Diagnosis
AFTER
ZmjA.
Cl
EXERCISE
AFTER
EXERCISE
Aw.
%
Fig. 4. Patient with history of angina and previous old myocardial infarction with residual inverted T waves. After exercise the T waves became upright.
-Fig. 5. Note inverted premature ventricular
T waves which follow and atria1 complexes.
of angina $ectoris
833
Levy i5 advocated the anoxemia test, which is performed by having the patient breathe a combination of 10 per cent oxygen and 90 per cent nitrogen for 20 minutes. During this interval, electrocardiograms are taken every 5 minutes, and significant S-T segment depression is noted. This test requires special apparatus and is fraught with some danger. 2. S-T SEGMENT ELEVATION. @XaSiOnally after exercise, S-T segment elevation develops instead of S-T segment depression.4 This usually denotes severe ischemia and, in our experience, indicates that a coronary vessel is on the verge of occlusion. Frequently, these patients will develop an occlusion in the area in which the S-T segment elevation is noted. The patient represented by Fig. 2 developed S-T segment elevation in the Vz and Vg positions with exercise. After 4 minutes the S-T segment became isoelectric with the T waves inverted, and after 10 minutes the tracing resembled the control. Several months later this patient developed an anteroseptal occlusion, and has now been asymptomatic for 4 years. 3. BUNDLE BRANCH BLOCK. Fig. 3 demonstrates the occurrence of intermittent left bundle branch block in the V., position after exercise. This is significant9 and usually denotes ischemia of the septal coronary branch. 4. INVERTED T WAVES BECOMING UPRIGHT. In evaluating a patient with known coronary artery disease, especially after infarction, it may be necessary to have him perform the exercise test. If the inverted T waves become upright, this is a significant finding (Fig. 4).
the
sidered to be significant, with or without T-wave inversion. Note that the base line is measured at the upper portion of the continuation of the P-R interval, as shown by the dotted line. The S-T change may be present in one or several leads. If early repolarization is present in the control, the S-T segment has to return below the base line to be abnormal. Frequently in such cases it becomes isoelectric with exercise.
Fig. 6. Junctional or “J” producing an acute angle. ments are shown.
S-T segment depression Q-X and Q-T measure-
Fig. 7. Negative double iWaster’s test. ‘Tracing curred each morning reveals inverted ‘i’ waves Q-T interval.
5.
T
WAVES
INCREASING
IN
AMPLITUDE.
If after exercise the T waves, especially in Lead V4, exceed 5 mm. or 300 per cent or more of the resting value,14J6 ischemia is present. Also, the development of an inverted U wave14 is significant. Suggestive electrocardiographic changes after exercise. 1. ARRHYTHMIAS. Ventricular or atria1 premature beats which occur after exercise and persist over 3 minutes are suggestive of coronary insufficiency, particularly when runs of premature beats or ventricular premature beats from several foci occur. A
Fig. 8. After exercise, the amplitude of the P wave increases and a large T, wave results in S-T segment displacement which is suggestive of the rightangle type. The apparent S-T depression is due to the carry-over of the T,, wave which rauses the P-R segment to slope downward.
taken greater
during paiu which w:than 2 mm. with long
few premature beats, especially those that occur immediately after exercise and then disappear, are of no significance. 2. T WAVES INVERTED MORE THAN 2 MM. WITH
OR WITHOVT
EXERCISE.
It
iS important
to consider the many nonsignificant causes of T-wave inversion. It is not unusual to see inverted T waves after exposure to after cold,l’ smoking, l8 hyperventilation,‘g a large meal, and in L2, L3, and aVF in socalled “suspended” heartqzO and in patients with early repolarization.*l Inverted T waves can occur on an autonomic basis, after fear, ansiety, or neurocirculatory asthenia. Many other nonspecific etiologies exist. The duration of the Q-T interval should be considered in an evaluation of inverted T waves. If the Q-T interval is prolonged, with an inverted T wave, and there is no known electrolyte imbalance, this is more suggestive of myocardial ischemia than is T-wave inversion with a short Q-T interval,” especially if the inversion is more than 2 111111.~~ 3. POSTEr;TRAS\-STOLIC T-\V.%VE CHANGE, WITH OK WITHOI.T EXERCISE. This has been referred to as a “built-in-Master’s test.“z3 The T wave of the complex which follows a premature ventricular beat, and, occasionallJ~, of that which follows a preInature atria1 beat, is inverted. Jn the tracing shown in Fig. 5, such changes can be seen in the complexes which follow both the ventricular and atria1 premature conFagin’” did not correlate the tractions. phenomena with coronar!. artery disease,
Diagnosis
of angina pectoris
835
but we are of the opinion that when this is present it is very suggestive of myocardial ischemia. 4. JUNCTIONAL OR DEPKESS~ON GREATERTHAN
“J"
2
S-T MM.
SEGMENT
This type of S-T segment depression does not form a right angle with the vertical, but makes an acute angle, and there is a constant ascent to the base line. The return is rapid or slow, but the segment is never entirely horizontal or sagging. Only the junction of the QRS with the RS-T segment is depressed (Fig. 6). MasterlO believes that this type of change is significant, and that if the junctional depression is 2 mm. or more, it is practically always an indication of coronary artery disease. In addition, he considered to be positive a Q-x/Q-T fraction of 50 per cent or more, or a Q-T ratio (actual to normal Q-T for rate) of 1.08 or more, or both. The Q-X interval is measured from the beginning of the QRS until it returns to the base line (Fig. 6). Levine23 and Russekl’ have stated that some junctional S-T segment depression occurs in
L2
v4
Fig. 10. A 3.5year-old heart disease in whom when she was standing, given a sympatholytic intramuscularly).
normal individuals after exercise. We believe at present that if the junctional S-T depression is 2 mm. or greater, and especially if it persists for longer than 2 minutes and the ascent reaches the base line at 0.08 second or greater, it is suggestive of myocardial ischemia. Positive OY suggestive eleclroca:ardiographic changes during distress. This phenomenon of positive or suggestive electrocardiographic changes which occur spontaneously during distress is of the same significance as positive or suggestive changes which occur with exercise. The patient represented by Fig. 7 had a normal control and double two-step Master’s test. He experienced an ache in his jaw on the right side in the early mornings just after drinking coffee. He did not have any chest sensation. Note the T-wave changes recorded during one of these morning periods. Negative or false-positive electrocardiographic changes after exercise. 1. Jc:NCTIONAL PRESSION LESS
Pig. Y. A 20-year-old patient with no evidence of heart disease has inverted T waves less than 2 mm. with a short Q-T interval after exercise.
woman with no evidence of the labile T waves inverted but not after she had been drug, ergotamine (0.5 mg.
OR THAN
“J"
S-T
SEGMENT
DE-
2 MM. As stated previously, it has become apparent that the type of S-T segment depression is of more srgnificance than the degree of depression. We consider junctional S-T depression to be suggestive onlv if it satisfies the criteria above; otherwise \t is negative. 2. T UF P DEPRESSION. The most clearly recognizable evidence of atria1 repolarization is the T, wave which follows the P wave and is normally of opposite polarity.
Fig. 11. False-positive 0.5 mg. of ergotamine
Master’s test with right-angle S-T segment there are no changes on standing or after
This deflection usually results in a P-R segment located at a different level than the isoelectric T-P segment, and it usually extends into and beyond the QRS complex and influences the level of the S-T segment. There is evidence of a direct relationship between the area of the normal P wave and that of the T, wave which follows. Thus, in the presence of a large P wave, a large T, wave may be expected, and S-T segment displacement as a result of this latter wave is likely. After exercise, the amplitude of the P wave increasesz5 and large T, waves result in S-T segment displacement, as seen in Fig. 8. This S-T segment superficially resembles the rightangle type; however, on close inspection, it is noted that the apparent S-T depression is due to the carry-over of the T,, wave which causes the P-R interval to slope downward instead of straight. 3. T WAVES INVERTED LESS THAN 2 MM., WITH OH WITHOUT EXERCISE. It has been stated previously that T-wave inversion may be produced by a variety of activities. This should be re-emphasized. The patient represented by Fig. 9 has no heart disease, but after exercise there is a slight inversion of the T wave, less than 2 mm. There is no significant S-T segment depression, and the Q-T interval is short. The patient has
also produced depression, a double Master’s test.
by &lnding.
After
been completely asymptomatic and without evidence of heart disease for 7 years since this tracing was recorded. However, dismissal of early electrocardiographic changes as insignificant must be given careful scrutiny, especially in the light of other findings. I8 The pendulum must not be allowed to swing so far that all minor or fluctuating T-wave changes are considered to be nonsignificant. 4. AUTONOMICCHANGESWITHORWITHOUT EXERCISE. Increased sympathetic stimulation may produce inverted T waves and S-T segment changes which appear to be significant and give a false-positive test.26-28 These sympathetic changes can be shown in electrocardiograms taken with the patient in different positions, and can be blocked by sympatholytic drugs, such as ergotamine (Fig. 10). The patient represented by Fig. 11 was a 39-year-old white woman who was considered to have angina because of a “positive Master’s test.” Her symptoms were those of the hyperventilation syndrome. The control tracing, recorded when she was in the supine position, was within normal limits, but when she stood, right-angle S-T segment depression and T-wave inversion developed in Leads II, III, aVr, and V,. The same changes also occurred after a double two-
Vokme Number
67 6
Lliagnosis
site in direction and proportionate in magnitude to the main deflection of the QRS complex in area) may occur in the presence of hypertrophy or bundle branch block patterns, and in the Wolff-Parkinson-white syndrome. In our series, 7 exercised patients with the Wolff-Parkinson-white syndrome had right-angle S-T depression. False-positives can also occur in digitalized patients or in those with healed pericarditis, at times even when the resting tracings are normal. The effect of digitalis on the S-T segment and the T wave may be altered by many hemodynamic factors; therefore, one cannot in-
step Master’s test. Thirty minutes after she had been given 0.5 mg. of ergotamine intramuscularly, the tracing was normal while she was in the supine and standing positions and after a double two-step Master’s test. However, all ST-T changes in tense individuals should not be minimized, for an occasional case of asymptomatic coronary sclerosis with associated myocardial damage may be missed. In a double-blind evaluation, Friedbergzg found a high percentage of false-positive results in nonanginal cases. 5. MISCELLANEOUS FALSE-POSITIVES. After exercise, secondary ST-T changes (oppoTable I. Results of Master’s
two-step
test
I Patients with angina Total number Positive Suggestive Negative
190 110 (57.9%) 27 (14.2%) 53 (27.9%)
Normal subjects Total number Positive
160 7
Table II. Incidence
Electrocardiographic
150 7
Junctional
> 2 mm.
S-T depression
> 2 mm.
Negative Junctional S-T depression < 2 mm. T of P depression Inverted T waves < 2 mm. No change
(4.6%)
1412 (94.0%) (1.4%)
Incompleted
test
92 56 (60.8oj,)
6 (6.6%) 30 (32.6%)
10 0 1: (100%)
response to exercise
change
Positive Right-angle S-T depression of .5 mm or greater S-T elevation Bundle branch block or 5 mm. T waves increased 300 per cent in amplitude Suggestive Arrhythmias Inverted T waves
test
(!s.l’r,) 21 (21.4%) 23 (23.5%)
(4.4%)
of electrocardiographic
Completed
2
1512 (94.4%) (1.2%)
Suggestive Negative
837
of angina pectoris
Of 190 patients with angina (Number and per cent of patients) 110 (57.9%) 104 (54.7%)
2 (1.1%) 2 (1.1%) 2 (1.1%) 27 (14.2%) 7 (3.6%) 10 (5.3%) 10 (5.3%) 53 (27.9%) 4 (2.1%) 1 (0.5%) 4: (25.3yc)
Of 160 patients with no angina (Number and per cent of patients) 7 (4.4%) 7 (4.4%)
0 0 0
2 (1.2%) 1 (0.6%) 0 1 151 9 4 4 134
(0.6%) (94.4%), (5.6%) (2.5%) (2.5%) (83.8%)
tcij)rYt ;I11 cxwcise lest in ;I lxtticlrt \vl10 is rcceivillg digitalis. 111 fact, ii1 the digitalized patient, tilting to the upright position or the taking of 3 deep breath ciui produce distinct S-T changes. ITsing the above-outlined criteria, we have analyzed the double Master’s esercise test in 350 patients with normal resting electrocardiograms from the private practice of one of us (P. C. G.). One huridred ninety of these patients had a definite history of angina, and 160 had a negative history. Table I summarizes the findings in those who completed and those who did not complete the test. Eighty-two of the patients with known angina could not complete the test because angina developed during exercise, and 10 could not complete the test because of dyspnea, dizziness, or tiredness. Table II lists the incidence of the various electrocardiographic responses in both categories. Rightangle S-T depression comprised 95 per cent of the 110 positives: 54.7 per cent of the 190 patients with angina. A separate group of 7 patients with angina who had inverted T waves in the control tracing was exercised and the T waves became upright. Of 7 patients with old infarction and angina, right-angle S-T depression developed in 2, and the T waves became upright in 2. Seven patients with a negative history and the Wolff-Parkinson-White syndrome developed right-angle S-T depression after exercise. Summary The diagnosis of angina pectoris is dependent upon the history and electrocardiographic changes. It should be emphasized that electrocardiographic changes must be interpreted with a knowledge of the clinical history, so that the significance of suggestive changes is more apparent. The difficulty experienced by the patient with angina is characterized as a distress or discomfort, and not a pain. The discomfort is provoked by exertion, digesand emotion, and is tion, excitement, classically located in the retrosternal area, with radiation to the inner aspect of the left arm, the hypothenar eminence, and the fourth and fifth fingers. The distress may radiate to the neck, the right arm,
:111(1the j;lur . ;1i1(111la) octwr iI1 (III/J- ;I sexIlwnt d the tlisi rihl ioil. I t develops wdually over ;I pxiod of 10 seconds to 2 minutes and is relieved promptly by rest or nitroglycerin. It may also be relieved by carotid sinus massage. It is usually wise to perform a double two-step Master’s test, with the test discontinued if the patient develops discomfort. Positive electrocardiographic changes after exercise include: (1) right-angle S-T segment depression of 0.5 mm. or more, (2) S-T segment elevation, (3) bundle branch block, (4) inverted T waves becoming upright, and (5) T waves increasing .5 mm. or 300 per cent in amplitude, or inverted U waves. These changes are also significant if they occur spontaneously during the period of angina1 distress. Suggestive electrocardiographic changes after exercise are: (1) arrhythmias, (2) inverted T waves with or without exercise, especially if the inversion is more than 2 mm., (3) postestrasystolic T-wave change with or without exercise, and (4) junctional S-T segment depression greater than 2 mm. Negative and false-positive changes after exercise include: (1) junctional S-T segment depression of less than 2 mm., (2) T of P depression, (3) inverted T waves less than 2 mm. with or without exercise, (4) autonomic changes, and (5) falsepositive results in patients with hypertrophy, bundle branch block, Wolff-Parkinson-white syndrome, after digitalization, or pericarditis. A double Master’s esercise test was analyzed in 350 patients with normal resting electrocardiograms. One hundred and ninety had a definite history of angina, with positive changes in 57.9 per cent, suggestive changes in 14.2 per cent, and negative changes in 27.9 per cent. One hundred and sixty had a negative history, with positive changes in only 4.4 per cent, suggestive in 1.2 per cent, and negative in 94.4 per cent. Of 14 patients with coronary disease and inverted T waves in the control tracing, 2 had right-angle S-T depression, in 9 the T waves became upright, and in 3 there was no change. With improving methods of therapy, correct and early diagnosis is essential in the proper management of the patient with angina pectoris.
Volume Mrambcr
1.
2. 3. 4.
5.
6.
67 6
Diagnosis
REFERENCES Heberden, W.: Commentaries on the history and cure of diseases, 1786, 1n Major, R. H.: Classic descriptions of disease, ed. 3, Oxford, 1948, Blackwell Scientific Publications. Master, A. M.: The two-step test of myocardial function,A~. HEART J. 10:495, 1934-35. Roberg, N. B.: The diagnosis of angina pectoris, Nebraska M. J. 46:407,1961. Prinzmetal, M., et al.: Angina pectoris. II. Observations on the classic form of angina oectoris. AM. HEART T. 57~530. 1957. Skinner; N. S., Jr., j!eibeskind, R. S., Phillips, H. L., and Harrison, T. R.: Angina pectoris: effect of exertion and nitrites on precordial movements,AM. HEART J. 61:250,1961. Levine, S. A.: Carotid sinus massage-A new diagnostic test for angina pectoris, J.A.M.A. 182:1333,1962.
7.
8.
9.
10.
11. 12.
Freedberg, A. S., and Riseman, J. E. F.: Observations on the carotid sinus reflex and angina pectoris, Circulation 7:58, 19.53. Bellet, F., Eliakim, M., Deliyiannis, S., and LaVan, D.: Radioelectrocardiography during exercise in patients with angina pectoris, Circulation 25:5, 1962. Myers, G. B., and Talmers, F. N.: Electrocardiographic diagnosis of acute myocardiai ischemia, Ann. Int. Med. 43:301, 1955. Master, A. M., and Rosenfeld, I.: Criteria for the clinical application of the “two-step” exercise test, J.A.M.A. 178:283, 1961. Russek, H. I.: Master’s two-step test in coronary artery disease, J.A.M.A. 165:1772, 1957. Brody, A. J.: Master’s two-step exercise test in clinically unselected patients, J.A.M.A. 171:1195,
13.
19.59.
Robb, G. P., Marks, H. H., and Mattingly, T. W.: The value of the double standard twostep exercise test in the detection of coronary artery disease, Transactions of the Association of Life Insurance Medical Directors of America 40~52,
1957.
Lepeschkin, E., and Surawicz, B.: Characteristics of true-positive and false-positive results of electrocardiographic Master two-step exercise test, New England J. Med. 258:511, 1958. 1.5. Levy, R. L., Williams, N. E., Bruenn, H. G., and Carr, H. A.: The “anoxemia test” in the diagnosis of coronary insufficiency, AM. HEART 14.
J. 21:634,
1941.
of angina pectoris
839
Yu, P. N., and Soffer, A.: Studies of the electrocardiographic changes during exercise (modified double two-step test), Circulation 6:183, 1952. 17. Hellerstein, H. K.: Factors influencing T waves of the electrocardiogram, AM. HEART J. 39:35, 16.
1950.
18. Burch, G. E.: Significance of certain early changes in the T wave in coronary disease, T.A.M.A. 165:1781. 1957. 19. “Wasserburger, R. H., et al.: The effect of hyperventilation on the normal adult electrocardiogram, Circulation 13:850, 1956. 20. Evans, W., and Lloyd-Thomas, H. G.: The syndrome of the suspended heart, Brit. Heart J. 19:153, 1957. 21. Thomas, J., Harris, E., and Lassiter, G.: Observations on the T wave and S-T segment changes in the precordial electrocardiograms of 320 young Negro adults, Am. J, Cardiol. 5:468,
1960.
Friedberg, C. K., and Zager, A.: “Nonspecific” S-T and T-wave changes, Circulation 23:655, 1961. 23. Levine, H. A.: Static and dynamic electrocardiographic phenomena in coronary artery disease, J.A.M.A. 167:964, 1958. 24. Fagin, D.: Post-extrasystolic T-wave changes, Am. J. Cardiol. 1:597, 1958. 2.5. Gross, D.: The auricular T wave and its correlation to the cardial rate and to the P wave, 22.
AM. HEART 26.
J. 50:24,1955.
Wendkos, M. H., and Logue, R. B.: Unstable T waves in Leads II and III in oerson with neurocirculatory asthenia, AM. ‘HEART J. 31:711,
1946.
Pordy, L., and Master, A.: Dihydroergocornine in the differential diagnosis of functional heart disturbance and organic heart disease, Circulation 17:26, 1950. 28. Master, A.: The “two-step” exercise EKG in functional heart disturbance and in organic heart disease, Circulation 1:692, 1950. 29. Friedberg, C. K., Jaffe, H. I~., Pordy, L., and Chesky, K.: The two-step exercise electrocardiogram. A double-blind evaluation of its use in the diagnosis of angina pectoris, Circulation 27.
24:1254,
1962.
Peter C. Gazes, M.D.* M. Rodney Culler, M.D.** James K. Stokes, M.D.*** Charleston, S. C.
I‘
T
here is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it.“l The concept that the history is the essential feature in the clinical diagnosis of angina pectoris was established by William Heberden in 1768.’ In 1964, this is essentially unchanged, but the development of the two-step exercise test” and advances in electrocardiography have given us objective studies. Recent advances in therapy make early and correct diagnosis essential so that appropriate treatment can be instituted. The diagnosis remains dependent upon the history and electrocardiographic changes, and these parameters must be critically evaluated in any patient in whom angina is considered. History
The classic description of Heberden is partially applicable today: “Those who are afflicted with it are seized while they are walking (more especially if it be up hill and soon after eating), with a painful and most disagreeable sensation in the breast, which seemsas if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasinessvanishes.“* The difficulty experienced by the patient
with angina is appropriately described as a distress or discomfort, and not a pain. Frequently, they object to the word pain. The distress may be classified according to location, precipitating factors, quality, intensity, and duration. It may vary considerably from person to person, but tends to remain constant in the individual patient. It is “his discomfort.” 1. Location. “The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the OS sterni; and more often inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm the pain sometimes reaches to the right arm as well as the left, and even down to the hands. . . . “I The location of the distress of angina is related to the sensory innervation of the heart. Fibers originate in the sensory ganglia of the first to fourth thoracic spinal roots and accompany the sympathetic cardiac nerves. With overlapping of sensory nerves and internuncial communications, the cardiac pain dermatomes extend from CT to Tg. Roberg states that the extension of the trigeminal nucleus into the cervical chord may explain the location of distress in the lower jaw. The classic location of angina1 distress
From the Departments of Medicine and Pharmacology, Medical Received for publication Sept. 20. 1963. *.4ssistant Professor of Medicine (Cardiology) and Plmrmac~~lopy. **Chief Resident in Medicine. -*Intern in Medicine.
830
College Address;:
of South
Carolina,
.55. D
Charlestor~. rhidcst~m.
3. (‘. s. I’.
I’oltwcc ,\‘umber
67 6
Fig. 1. Ischemic right-angle S-T segment depression. i%ote that the degree of S-T depression is measured from the top of the continuation of the P-R interval.
the retrosternal (T1 to TF) area, with radiation to the inner -aspect of the left arm (Ti), the hypothenar eminence (CS), and the fourth and fifth fingers (CT). The discomfort may radiate to the neck and corresponding areas of the right arm, to both arms, and to the lower jaw. It is important to remember that the distress of angina may occur in onlv a segment of this distribution, that is, -it may be only in the chest, only in the jaw, only in the left arm, or even only in the right arm. In differentiating angina1 distress from psychoneurosis, the psychoneurotic will usually pinpoint his discomfort with one finger, whereas the patient with angina will use his entire hand to designate the area. 2. Precipitating factors. The distress occurs with exertion, digestion, excitement, and emotion, and is relieved promptly by rest. The discomfort is usually brought on by increased cardiac work. The attacks do not occur regularly each day tmless related to exercise or emotion.4 Angina pectoris may be precipitated by “walking up hill after a meal, or in the cold or by ‘disturbance of the mind.’ “l The distress will frequently respond promptly to nitroglycerin. It has been demonstrated that prophylactic nitroglycerin prevents the angina1 distress and eliminates certain abnormal cardiac pulsations which occur during the angina1 attacks.5 In the psychoneurotic, the distressful sensation occurs after the exertion and not during the exertion, as is seen in the patient with true angina. Prinzmetal* described a variant form of angina in which the attack is not precipitated by increased cardiac work or emois in
Diagnosis
of angina pectoris
831
tional upsets. It occurs at about the same time each day and is not relieved by rest. The distress is more intense and of longer duration than the classic form of angina, and usually disappears dramatically after infarction. Nocturnal angina pectoris, “angina decubitus,” is apparently related to the decreased supply of oxygen to the myocardium during recumbency, often associated with pulmonary venous congestion (left heart failure), and occurs primarily when coronary atherosclerosis is complicated by valvular disease, hypertensive heart disease, or car pulmonale. 3. Quality and intensity. Characteristically, angina1 distress is described as a burning sensation, tight sensation, or heavy feeling. It may be variously described as strong, constricting, expanding, burning, aching, or pressing. It may be a mild oppression, slight smothering, gassy fullness, sense of weakness, or faintness with mild nausea. The arms, hands, and fingers may experience a severe aching, burning, numbness, or tingling. There may be an aching, tingling, or bursting sensa-
COMTROL’
Fig. 2. After exercise, the S-T segment elevation in Leads Vz and V, is followed by T-wave inversion in 4 minutes and a return to the control in 10 minutes. Several months later the patient had an anteroseptal infarction.
832
Gazes, Culler, and Stokes
Am. Heart Jwre,
tion in the lower jaw. Very seldom is it sharp SO that the patient refers to it as “pain.” 1. Durafiion. The angina1 sensation usually develops gradually and progressively over a period of 10 seconds to 2 minutes and is constant. It subsides rapidly on rest, and particularly after nitroglycerin, within a minute or two. Variant forms of angina tend to be more severe and of longer duration.4 It has been demonstrated by Levine6 and Freedberg’ that angina1 pain could be relieved by carotid sinus massage. Levine6 considers this to be diagnostic in many instances. With the patient sitting up and the angina1 discomfort present, the right carotid sinus is massaged. If this is not successful, the left carotid sinus is tried, but not both at the same time. Auscultation of the heart is carried out during manipulation, and if significant slowing of the heart occurs, massage is stopped. Massage should not be carried out for more than 3 to 5 seconds at a time. The test is positive for angina pectoris if relief of distress occurs within seconds, with usually concomitant slowing of the heart. Since relief occurs at times without slowing of the heart, the carotid massage may be producing an interruption of sympathetic reflex arcs or sensory pathways7 A negative response does not rule out angina. Electrocardiogram We usually plan on performing a double two-step Master’s test, preferably with the patient in the fasting state, rather than beginning with the single-step test. If the
Fig.
3.
Intermittent
left bundle
branch
.I. 1964
patient develops any of his symptoms prior to completion of the required number of trips, the test is stopped and postexercise tracings are taken. in many instances, patients will give a classic description while exercising, yet in relating their histories just before exercise they were very vague. For this reason, it is important to be present when the test is performed, as well as to prevent any undue attack of prolonged coronary insufficiency or even occlusion. It is preferable to take Leads Vc or Vc (depending on which has the greater R-wave amplitude), V?, Ll, and L2 in this order: immediately, at 1 minute, 3 minutes, and 5 minutes after exercise. If abnormal change develops, then tracings are taken until there is a return to normal. Radioelectrocardiography during exercise may give additional information, as shown by Bellet and associates.8 Often, attempting to reproduce the patient’s symptoms b,, exposing him to his particular type of precipitating factor may be beneficial, taken at this ;111 d an electrocardiogram time may be significant. Abnormal changes have been seen in such instances, even though a double Master’s test was negative. Positive electrocardiographic changes after exercise. 1.
S-T
SEGMENT
DEPRESSION.
E‘Or
lllatly
).ears, the degree of S-T segment depression was considered to be most important. how, the type of S-T segment depression”-‘4 is given most attention. When the S-T segment is depressed at a right angle to the vertical, as seen in Fig. 1, a half millimeter or more of depression is con-
block
after
exercise.
V&me 67 Number6
Diagnosis
AFTER
ZmjA.
Cl
EXERCISE
AFTER
EXERCISE
Aw.
%
Fig. 4. Patient with history of angina and previous old myocardial infarction with residual inverted T waves. After exercise the T waves became upright.
-Fig. 5. Note inverted premature ventricular
T waves which follow and atria1 complexes.
of angina $ectoris
833
Levy i5 advocated the anoxemia test, which is performed by having the patient breathe a combination of 10 per cent oxygen and 90 per cent nitrogen for 20 minutes. During this interval, electrocardiograms are taken every 5 minutes, and significant S-T segment depression is noted. This test requires special apparatus and is fraught with some danger. 2. S-T SEGMENT ELEVATION. @XaSiOnally after exercise, S-T segment elevation develops instead of S-T segment depression.4 This usually denotes severe ischemia and, in our experience, indicates that a coronary vessel is on the verge of occlusion. Frequently, these patients will develop an occlusion in the area in which the S-T segment elevation is noted. The patient represented by Fig. 2 developed S-T segment elevation in the Vz and Vg positions with exercise. After 4 minutes the S-T segment became isoelectric with the T waves inverted, and after 10 minutes the tracing resembled the control. Several months later this patient developed an anteroseptal occlusion, and has now been asymptomatic for 4 years. 3. BUNDLE BRANCH BLOCK. Fig. 3 demonstrates the occurrence of intermittent left bundle branch block in the V., position after exercise. This is significant9 and usually denotes ischemia of the septal coronary branch. 4. INVERTED T WAVES BECOMING UPRIGHT. In evaluating a patient with known coronary artery disease, especially after infarction, it may be necessary to have him perform the exercise test. If the inverted T waves become upright, this is a significant finding (Fig. 4).
the
sidered to be significant, with or without T-wave inversion. Note that the base line is measured at the upper portion of the continuation of the P-R interval, as shown by the dotted line. The S-T change may be present in one or several leads. If early repolarization is present in the control, the S-T segment has to return below the base line to be abnormal. Frequently in such cases it becomes isoelectric with exercise.
Fig. 6. Junctional or “J” producing an acute angle. ments are shown.
S-T segment depression Q-X and Q-T measure-
Fig. 7. Negative double iWaster’s test. ‘Tracing curred each morning reveals inverted ‘i’ waves Q-T interval.
5.
T
WAVES
INCREASING
IN
AMPLITUDE.
If after exercise the T waves, especially in Lead V4, exceed 5 mm. or 300 per cent or more of the resting value,14J6 ischemia is present. Also, the development of an inverted U wave14 is significant. Suggestive electrocardiographic changes after exercise. 1. ARRHYTHMIAS. Ventricular or atria1 premature beats which occur after exercise and persist over 3 minutes are suggestive of coronary insufficiency, particularly when runs of premature beats or ventricular premature beats from several foci occur. A
Fig. 8. After exercise, the amplitude of the P wave increases and a large T, wave results in S-T segment displacement which is suggestive of the rightangle type. The apparent S-T depression is due to the carry-over of the T,, wave which rauses the P-R segment to slope downward.
taken greater
during paiu which w:than 2 mm. with long
few premature beats, especially those that occur immediately after exercise and then disappear, are of no significance. 2. T WAVES INVERTED MORE THAN 2 MM. WITH
OR WITHOVT
EXERCISE.
It
iS important
to consider the many nonsignificant causes of T-wave inversion. It is not unusual to see inverted T waves after exposure to after cold,l’ smoking, l8 hyperventilation,‘g a large meal, and in L2, L3, and aVF in socalled “suspended” heartqzO and in patients with early repolarization.*l Inverted T waves can occur on an autonomic basis, after fear, ansiety, or neurocirculatory asthenia. Many other nonspecific etiologies exist. The duration of the Q-T interval should be considered in an evaluation of inverted T waves. If the Q-T interval is prolonged, with an inverted T wave, and there is no known electrolyte imbalance, this is more suggestive of myocardial ischemia than is T-wave inversion with a short Q-T interval,” especially if the inversion is more than 2 111111.~~ 3. POSTEr;TRAS\-STOLIC T-\V.%VE CHANGE, WITH OK WITHOI.T EXERCISE. This has been referred to as a “built-in-Master’s test.“z3 The T wave of the complex which follows a premature ventricular beat, and, occasionallJ~, of that which follows a preInature atria1 beat, is inverted. Jn the tracing shown in Fig. 5, such changes can be seen in the complexes which follow both the ventricular and atria1 premature conFagin’” did not correlate the tractions. phenomena with coronar!. artery disease,
Diagnosis
of angina pectoris
835
but we are of the opinion that when this is present it is very suggestive of myocardial ischemia. 4. JUNCTIONAL OR DEPKESS~ON GREATERTHAN
“J"
2
S-T MM.
SEGMENT
This type of S-T segment depression does not form a right angle with the vertical, but makes an acute angle, and there is a constant ascent to the base line. The return is rapid or slow, but the segment is never entirely horizontal or sagging. Only the junction of the QRS with the RS-T segment is depressed (Fig. 6). MasterlO believes that this type of change is significant, and that if the junctional depression is 2 mm. or more, it is practically always an indication of coronary artery disease. In addition, he considered to be positive a Q-x/Q-T fraction of 50 per cent or more, or a Q-T ratio (actual to normal Q-T for rate) of 1.08 or more, or both. The Q-X interval is measured from the beginning of the QRS until it returns to the base line (Fig. 6). Levine23 and Russekl’ have stated that some junctional S-T segment depression occurs in
L2
v4
Fig. 10. A 3.5year-old heart disease in whom when she was standing, given a sympatholytic intramuscularly).
normal individuals after exercise. We believe at present that if the junctional S-T depression is 2 mm. or greater, and especially if it persists for longer than 2 minutes and the ascent reaches the base line at 0.08 second or greater, it is suggestive of myocardial ischemia. Positive OY suggestive eleclroca:ardiographic changes during distress. This phenomenon of positive or suggestive electrocardiographic changes which occur spontaneously during distress is of the same significance as positive or suggestive changes which occur with exercise. The patient represented by Fig. 7 had a normal control and double two-step Master’s test. He experienced an ache in his jaw on the right side in the early mornings just after drinking coffee. He did not have any chest sensation. Note the T-wave changes recorded during one of these morning periods. Negative or false-positive electrocardiographic changes after exercise. 1. Jc:NCTIONAL PRESSION LESS
Pig. Y. A 20-year-old patient with no evidence of heart disease has inverted T waves less than 2 mm. with a short Q-T interval after exercise.
woman with no evidence of the labile T waves inverted but not after she had been drug, ergotamine (0.5 mg.
OR THAN
“J"
S-T
SEGMENT
DE-
2 MM. As stated previously, it has become apparent that the type of S-T segment depression is of more srgnificance than the degree of depression. We consider junctional S-T depression to be suggestive onlv if it satisfies the criteria above; otherwise \t is negative. 2. T UF P DEPRESSION. The most clearly recognizable evidence of atria1 repolarization is the T, wave which follows the P wave and is normally of opposite polarity.
Fig. 11. False-positive 0.5 mg. of ergotamine
Master’s test with right-angle S-T segment there are no changes on standing or after
This deflection usually results in a P-R segment located at a different level than the isoelectric T-P segment, and it usually extends into and beyond the QRS complex and influences the level of the S-T segment. There is evidence of a direct relationship between the area of the normal P wave and that of the T, wave which follows. Thus, in the presence of a large P wave, a large T, wave may be expected, and S-T segment displacement as a result of this latter wave is likely. After exercise, the amplitude of the P wave increasesz5 and large T, waves result in S-T segment displacement, as seen in Fig. 8. This S-T segment superficially resembles the rightangle type; however, on close inspection, it is noted that the apparent S-T depression is due to the carry-over of the T,, wave which causes the P-R interval to slope downward instead of straight. 3. T WAVES INVERTED LESS THAN 2 MM., WITH OH WITHOUT EXERCISE. It has been stated previously that T-wave inversion may be produced by a variety of activities. This should be re-emphasized. The patient represented by Fig. 9 has no heart disease, but after exercise there is a slight inversion of the T wave, less than 2 mm. There is no significant S-T segment depression, and the Q-T interval is short. The patient has
also produced depression, a double Master’s test.
by &lnding.
After
been completely asymptomatic and without evidence of heart disease for 7 years since this tracing was recorded. However, dismissal of early electrocardiographic changes as insignificant must be given careful scrutiny, especially in the light of other findings. I8 The pendulum must not be allowed to swing so far that all minor or fluctuating T-wave changes are considered to be nonsignificant. 4. AUTONOMICCHANGESWITHORWITHOUT EXERCISE. Increased sympathetic stimulation may produce inverted T waves and S-T segment changes which appear to be significant and give a false-positive test.26-28 These sympathetic changes can be shown in electrocardiograms taken with the patient in different positions, and can be blocked by sympatholytic drugs, such as ergotamine (Fig. 10). The patient represented by Fig. 11 was a 39-year-old white woman who was considered to have angina because of a “positive Master’s test.” Her symptoms were those of the hyperventilation syndrome. The control tracing, recorded when she was in the supine position, was within normal limits, but when she stood, right-angle S-T segment depression and T-wave inversion developed in Leads II, III, aVr, and V,. The same changes also occurred after a double two-
Vokme Number
67 6
Lliagnosis
site in direction and proportionate in magnitude to the main deflection of the QRS complex in area) may occur in the presence of hypertrophy or bundle branch block patterns, and in the Wolff-Parkinson-white syndrome. In our series, 7 exercised patients with the Wolff-Parkinson-white syndrome had right-angle S-T depression. False-positives can also occur in digitalized patients or in those with healed pericarditis, at times even when the resting tracings are normal. The effect of digitalis on the S-T segment and the T wave may be altered by many hemodynamic factors; therefore, one cannot in-
step Master’s test. Thirty minutes after she had been given 0.5 mg. of ergotamine intramuscularly, the tracing was normal while she was in the supine and standing positions and after a double two-step Master’s test. However, all ST-T changes in tense individuals should not be minimized, for an occasional case of asymptomatic coronary sclerosis with associated myocardial damage may be missed. In a double-blind evaluation, Friedbergzg found a high percentage of false-positive results in nonanginal cases. 5. MISCELLANEOUS FALSE-POSITIVES. After exercise, secondary ST-T changes (oppoTable I. Results of Master’s
two-step
test
I Patients with angina Total number Positive Suggestive Negative
190 110 (57.9%) 27 (14.2%) 53 (27.9%)
Normal subjects Total number Positive
160 7
Table II. Incidence
Electrocardiographic
150 7
Junctional
> 2 mm.
S-T depression
> 2 mm.
Negative Junctional S-T depression < 2 mm. T of P depression Inverted T waves < 2 mm. No change
(4.6%)
1412 (94.0%) (1.4%)
Incompleted
test
92 56 (60.8oj,)
6 (6.6%) 30 (32.6%)
10 0 1: (100%)
response to exercise
change
Positive Right-angle S-T depression of .5 mm or greater S-T elevation Bundle branch block or 5 mm. T waves increased 300 per cent in amplitude Suggestive Arrhythmias Inverted T waves
test
(!s.l’r,) 21 (21.4%) 23 (23.5%)
(4.4%)
of electrocardiographic
Completed
2
1512 (94.4%) (1.2%)
Suggestive Negative
837
of angina pectoris
Of 190 patients with angina (Number and per cent of patients) 110 (57.9%) 104 (54.7%)
2 (1.1%) 2 (1.1%) 2 (1.1%) 27 (14.2%) 7 (3.6%) 10 (5.3%) 10 (5.3%) 53 (27.9%) 4 (2.1%) 1 (0.5%) 4: (25.3yc)
Of 160 patients with no angina (Number and per cent of patients) 7 (4.4%) 7 (4.4%)
0 0 0
2 (1.2%) 1 (0.6%) 0 1 151 9 4 4 134
(0.6%) (94.4%), (5.6%) (2.5%) (2.5%) (83.8%)
tcij)rYt ;I11 cxwcise lest in ;I lxtticlrt \vl10 is rcceivillg digitalis. 111 fact, ii1 the digitalized patient, tilting to the upright position or the taking of 3 deep breath ciui produce distinct S-T changes. ITsing the above-outlined criteria, we have analyzed the double Master’s esercise test in 350 patients with normal resting electrocardiograms from the private practice of one of us (P. C. G.). One huridred ninety of these patients had a definite history of angina, and 160 had a negative history. Table I summarizes the findings in those who completed and those who did not complete the test. Eighty-two of the patients with known angina could not complete the test because angina developed during exercise, and 10 could not complete the test because of dyspnea, dizziness, or tiredness. Table II lists the incidence of the various electrocardiographic responses in both categories. Rightangle S-T depression comprised 95 per cent of the 110 positives: 54.7 per cent of the 190 patients with angina. A separate group of 7 patients with angina who had inverted T waves in the control tracing was exercised and the T waves became upright. Of 7 patients with old infarction and angina, right-angle S-T depression developed in 2, and the T waves became upright in 2. Seven patients with a negative history and the Wolff-Parkinson-White syndrome developed right-angle S-T depression after exercise. Summary The diagnosis of angina pectoris is dependent upon the history and electrocardiographic changes. It should be emphasized that electrocardiographic changes must be interpreted with a knowledge of the clinical history, so that the significance of suggestive changes is more apparent. The difficulty experienced by the patient with angina is characterized as a distress or discomfort, and not a pain. The discomfort is provoked by exertion, digesand emotion, and is tion, excitement, classically located in the retrosternal area, with radiation to the inner aspect of the left arm, the hypothenar eminence, and the fourth and fifth fingers. The distress may radiate to the neck, the right arm,
:111(1the j;lur . ;1i1(111la) octwr iI1 (III/J- ;I sexIlwnt d the tlisi rihl ioil. I t develops wdually over ;I pxiod of 10 seconds to 2 minutes and is relieved promptly by rest or nitroglycerin. It may also be relieved by carotid sinus massage. It is usually wise to perform a double two-step Master’s test, with the test discontinued if the patient develops discomfort. Positive electrocardiographic changes after exercise include: (1) right-angle S-T segment depression of 0.5 mm. or more, (2) S-T segment elevation, (3) bundle branch block, (4) inverted T waves becoming upright, and (5) T waves increasing .5 mm. or 300 per cent in amplitude, or inverted U waves. These changes are also significant if they occur spontaneously during the period of angina1 distress. Suggestive electrocardiographic changes after exercise are: (1) arrhythmias, (2) inverted T waves with or without exercise, especially if the inversion is more than 2 mm., (3) postestrasystolic T-wave change with or without exercise, and (4) junctional S-T segment depression greater than 2 mm. Negative and false-positive changes after exercise include: (1) junctional S-T segment depression of less than 2 mm., (2) T of P depression, (3) inverted T waves less than 2 mm. with or without exercise, (4) autonomic changes, and (5) falsepositive results in patients with hypertrophy, bundle branch block, Wolff-Parkinson-white syndrome, after digitalization, or pericarditis. A double Master’s esercise test was analyzed in 350 patients with normal resting electrocardiograms. One hundred and ninety had a definite history of angina, with positive changes in 57.9 per cent, suggestive changes in 14.2 per cent, and negative changes in 27.9 per cent. One hundred and sixty had a negative history, with positive changes in only 4.4 per cent, suggestive in 1.2 per cent, and negative in 94.4 per cent. Of 14 patients with coronary disease and inverted T waves in the control tracing, 2 had right-angle S-T depression, in 9 the T waves became upright, and in 3 there was no change. With improving methods of therapy, correct and early diagnosis is essential in the proper management of the patient with angina pectoris.
Volume Mrambcr
1.
2. 3. 4.
5.
6.
67 6
Diagnosis
REFERENCES Heberden, W.: Commentaries on the history and cure of diseases, 1786, 1n Major, R. H.: Classic descriptions of disease, ed. 3, Oxford, 1948, Blackwell Scientific Publications. Master, A. M.: The two-step test of myocardial function,A~. HEART J. 10:495, 1934-35. Roberg, N. B.: The diagnosis of angina pectoris, Nebraska M. J. 46:407,1961. Prinzmetal, M., et al.: Angina pectoris. II. Observations on the classic form of angina oectoris. AM. HEART T. 57~530. 1957. Skinner; N. S., Jr., j!eibeskind, R. S., Phillips, H. L., and Harrison, T. R.: Angina pectoris: effect of exertion and nitrites on precordial movements,AM. HEART J. 61:250,1961. Levine, S. A.: Carotid sinus massage-A new diagnostic test for angina pectoris, J.A.M.A. 182:1333,1962.
7.
8.
9.
10.
11. 12.
Freedberg, A. S., and Riseman, J. E. F.: Observations on the carotid sinus reflex and angina pectoris, Circulation 7:58, 19.53. Bellet, F., Eliakim, M., Deliyiannis, S., and LaVan, D.: Radioelectrocardiography during exercise in patients with angina pectoris, Circulation 25:5, 1962. Myers, G. B., and Talmers, F. N.: Electrocardiographic diagnosis of acute myocardiai ischemia, Ann. Int. Med. 43:301, 1955. Master, A. M., and Rosenfeld, I.: Criteria for the clinical application of the “two-step” exercise test, J.A.M.A. 178:283, 1961. Russek, H. I.: Master’s two-step test in coronary artery disease, J.A.M.A. 165:1772, 1957. Brody, A. J.: Master’s two-step exercise test in clinically unselected patients, J.A.M.A. 171:1195,
13.
19.59.
Robb, G. P., Marks, H. H., and Mattingly, T. W.: The value of the double standard twostep exercise test in the detection of coronary artery disease, Transactions of the Association of Life Insurance Medical Directors of America 40~52,
1957.
Lepeschkin, E., and Surawicz, B.: Characteristics of true-positive and false-positive results of electrocardiographic Master two-step exercise test, New England J. Med. 258:511, 1958. 1.5. Levy, R. L., Williams, N. E., Bruenn, H. G., and Carr, H. A.: The “anoxemia test” in the diagnosis of coronary insufficiency, AM. HEART 14.
J. 21:634,
1941.
of angina pectoris
839
Yu, P. N., and Soffer, A.: Studies of the electrocardiographic changes during exercise (modified double two-step test), Circulation 6:183, 1952. 17. Hellerstein, H. K.: Factors influencing T waves of the electrocardiogram, AM. HEART J. 39:35, 16.
1950.
18. Burch, G. E.: Significance of certain early changes in the T wave in coronary disease, T.A.M.A. 165:1781. 1957. 19. “Wasserburger, R. H., et al.: The effect of hyperventilation on the normal adult electrocardiogram, Circulation 13:850, 1956. 20. Evans, W., and Lloyd-Thomas, H. G.: The syndrome of the suspended heart, Brit. Heart J. 19:153, 1957. 21. Thomas, J., Harris, E., and Lassiter, G.: Observations on the T wave and S-T segment changes in the precordial electrocardiograms of 320 young Negro adults, Am. J, Cardiol. 5:468,
1960.
Friedberg, C. K., and Zager, A.: “Nonspecific” S-T and T-wave changes, Circulation 23:655, 1961. 23. Levine, H. A.: Static and dynamic electrocardiographic phenomena in coronary artery disease, J.A.M.A. 167:964, 1958. 24. Fagin, D.: Post-extrasystolic T-wave changes, Am. J. Cardiol. 1:597, 1958. 2.5. Gross, D.: The auricular T wave and its correlation to the cardial rate and to the P wave, 22.
AM. HEART 26.
J. 50:24,1955.
Wendkos, M. H., and Logue, R. B.: Unstable T waves in Leads II and III in oerson with neurocirculatory asthenia, AM. ‘HEART J. 31:711,
1946.
Pordy, L., and Master, A.: Dihydroergocornine in the differential diagnosis of functional heart disturbance and organic heart disease, Circulation 17:26, 1950. 28. Master, A.: The “two-step” exercise EKG in functional heart disturbance and in organic heart disease, Circulation 1:692, 1950. 29. Friedberg, C. K., Jaffe, H. I~., Pordy, L., and Chesky, K.: The two-step exercise electrocardiogram. A double-blind evaluation of its use in the diagnosis of angina pectoris, Circulation 27.
24:1254,
1962.