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The relation between QRS amplitude changes and left ventricular ejection fraction during exercise
ABSTRACTS
HEMODYNAMIC CORRELATES OF INCREASED R WAVE SUM IN MULTIPLE LEAD TREADMILL EXERCISE TESTS Julian L. Berman, MD; Joshua Wynne, MD, FACC; Peter F. Cohn, MD, FACC, Peter Bent Brigham Hospital, Boston, MA. We have previously shown an association between increased R wave sum (+ER) in multiple E(~G leads (that i.s, R in AVL, AVF and V3-V6 plus S in Vl and V2) during maximal treadmill exercise (TET), and diminished exercise tolerance and decreased peak double product. In the present study, hemodynamics and ventricular wall motion of patients (pts) who underwent cardiac catheterization after TET were evaluated. Resting ventricular asynergy index (AI) was defined by assigning a value of 0 to normokinesis, l to hypokinesis, 2 to akinesis and 3 to dyskinesis, and summing the values for 5 ventricular segments (posterior, inferior, septal, apical and lateral). Of 230 pts, 167 had significant coronary artery disease (CAD); 63 did not. +TR predicted CAD in 93% (93/I01) of pts. Resting left ventricular end-diastolic pressure (LVEDP) was significantly higher (p<.001), AI significantly greater (p<.001), and resting ejection fraction significantly lower (p<.O01) in all 101 pts with +TR as opposed to those with ¢~R. ST depression (ST+) subgroups were defined: >2 mm ST+, I-2 mm ST+, no ST+ at >85% predicted maximum heart rate, no ST+ at <85% predicted maximum heart rate. There were significant differences between pts with +ZR and those with +Y.R for each ST+ subgroup. Also, in a subgroup not Statistically different in resting LVEDP from the group as a whole, LVEDP after left ventriculography was significantly higher (p<.O05) in pts with +TR. This difference also remained significant for pts with +TR and +ER within each ST¢ subgroup. Of 93 pts with +TR and CAD, 76 had ventricular asynergy; of 70 with ~rTR and CAD, only 26 had ventricular asynergy (p<.005). We conclude that +TR in TET is a marker for resting and stress left ventricular dysfunction with CAD.
THE RELATION BETWEEN QRS AMPLITUDE CHANGES AND LEFT VENTRICULAR EJECTION FRACTION DURING EXERClSE Alexander Battler MD; Robert Slutsky MD; Matthlas Pfisterer MD; Kiyoshi Watanabe MD; George Chrlstlson, William Ashburn MD; and Victor Froelicher MD, FACC, University of California, San Diego. Studies have suggested that an exercise-lnduced increase in R wave indicates LV dysfunction and that sums of QRS amplitudes at rest correlate with resting ejection fraction (EF). To investigate the relationship of exercise-induced QRS amplitude changes to LV function, we studied 13 normals (NL) and 30 coronary artery disease (CAD) patients (pts) and analyzed simultaneously ECGVCG and equillbrium radlonucllde anglography (RNA) EF at rest and at peak supine bike exercise. The sum of R waves in X and Y, and Q wave in 7 (RX + RY + QZ = ~ R) correlates better with EF than any other combination of QRS components (NL and CAD at rest r = .66; peak exercise r = . 68). The results of EF ( -+ SD) and mV ~R ( + SD) for the NL and CAD at rest and peak Ex were: Rest EF Peak Ex. EF Rest ~R Peak Ex. ~R NLS 0.62 (_+ 0.07) 0,74 (+ 0.06) 2.69 ( ~ ; 7 5 ~ 2 . 3 2 [+ 0.64) CAD 0.52 ( + 0 . 1 1 ) 0.52 ( + 0 . 1 3 ) 1 . 8 8 ( + 0 . 7 1 ) 1.52 ( + 0 . 6 0 ) At rest and peak Ex the EF and ~ R of NL were significantly higher than the EF and ~R of the CAD pts (p< .005). The peak Ex EF in NL increased significantly from rest (p< .005) and did not change in the CAD pts. All subjects decreased and there was no significant change of ~ R in both groups from rest to peal< Ex. After also considering other single and combinations of other QRS amplitudes we conclude that change in QRS amplitudes during exercise do not separate patients with normal and abnormal LVEF responses to exercise.
354
February 1979
The American Journal of CARDIOLOGY
CAN THE AXIS OR MORPHOLOGY OF VENTRICULAR PREMATURE COMPLEXES OCCURRING DURING EXERCISE STRESS TESTING ENHANCE THE TEST'S SENSITIVITY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE? T. Joseph Mardelli, MD; Leonard S. Dreifus, MD, FACC;Joel Morganroth, MD, FACC, Lankenau Hospital,Jefferson Medical College, Philadelphia, PA.
The p r e v a l e n c e o f v e n t r i c u l a r p r e m a t u r e complexes(VPCs) d u r i n g e x e r c i s e t e s t i n g h a s n o t been h e l p f u l in p r e d i c t i n g the presence of coronary artery disease(CAD). To d e t e r mine w h e t h e r t h e m o r p h o l o g y o r a x i s o f VPCs may improve the test's s e n s i t i v i t y , 63 p a t i e n t s (PTS) w i t h CAD wore comp a r e d t o 43 normal c o n t r o l s ( G ) . 24 PTS w i t h CAD had c o r onary arteriography,and t h e r e m a i n d e r h a s had documented myocardial infarction. Eight C had normal coronary arteriography and the remainder were asymptomatic with normal ECGs and exercise tests. Both groups had undergone continuous 12-lead ECG monitoring using a Bruce protocol. VPCs with a superior axis(-30o tO -120O)were present in 49/63(78%)of PTS with CAD vs 9/43(21%)of C. An axis of -30o to +150o was observed in 12/63(19%)CAD and 33/43(77%) of C. An undetermined axis(-120o to +150o) was present in 2 PTS with CAD and 1 C. In 63 PTS with CAD, 46 instances of right bundle branch block (RBBB) and 26 instances of left (LBBB)morphology of VPCs were observed. In the 43 C, 23 had LBBB and 20 RBBB. 25 of 65 PTS with CAD had normal or borderline (
EXERCISE-INDUCED U WAVE INVERSION AS A ~ OF STENOSIS OF THE LEFT ANTERIOR DESDENDING CORONARY ARTERY Myron C. Gerson, MD; John F. Phillips, MD, FACC; Stephen N. Morris, MD, FACC; Paul L. McHenry, MD, FACC: Krannert Institute of Cardiology, Indiana Univ. School of Medicine, and the VA Hospital, Indianapolis, Indiana To assess the value of exercise-induced U wave inversion (UWI) as a predictor of significant left anterior descending (LAD) coronary artery stenosis, we reviewed 257 consecutive treadmill exercise tests performed prior to coronary cineangiographic studies. Patients (pts) with ECG evidence of left ventricular hypertrophy, anterior myocardial infarction or resting UWI were excluded from the final group designated as demonstrating exerciseinduced UWI. The mounted resting and exercise ECG records of simultaneously recorded bipolar V5 and lead II systems were initially reviewed. UWI was considered present when there was a consistent and discrete negative deflection in the T-P segment below the PR segment on the V5 lead. UWI was then independently verified by two of the authors by reviewing segments of the exercise ECG retrieved from magnetic tape recordings. 28 examples of exercise-induced UWI were detected. 9 pts had no other exercise ECG abnormalities. Coronary cineangiographic studies revealed ~75% stenosis of the proximal 1/3 of the LAD in 24 of 28 pts. Of the ~ remaining pts, 1 had a 50% left main lesion, 1 had a 75% stenosis of the first diagonal branch of the LAD and a 90% lesion of the right coronary artery, 1 had a 100% left circumflex lesion, and 1 had no significant coronary disease. The latter pt was receiving disopyramide phosphate for recurrent ventricular tachycardia. Of the 257 pts studied, 122 had ~75% LAD lesions including 38 with anterior infarction patterns. We conclude that UWI during treadmill exercise testing is highly correlated (P>0.01) with significant stenosis of the proximal LAD coronary artery.
Volume 43
HEMODYNAMIC CORRELATES OF INCREASED R WAVE SUM IN MULTIPLE LEAD TREADMILL EXERCISE TESTS Julian L. Berman, MD; Joshua Wynne, MD, FACC; Peter F. Cohn, MD, FACC, Peter Bent Brigham Hospital, Boston, MA. We have previously shown an association between increased R wave sum (+ER) in multiple E(~G leads (that i.s, R in AVL, AVF and V3-V6 plus S in Vl and V2) during maximal treadmill exercise (TET), and diminished exercise tolerance and decreased peak double product. In the present study, hemodynamics and ventricular wall motion of patients (pts) who underwent cardiac catheterization after TET were evaluated. Resting ventricular asynergy index (AI) was defined by assigning a value of 0 to normokinesis, l to hypokinesis, 2 to akinesis and 3 to dyskinesis, and summing the values for 5 ventricular segments (posterior, inferior, septal, apical and lateral). Of 230 pts, 167 had significant coronary artery disease (CAD); 63 did not. +TR predicted CAD in 93% (93/I01) of pts. Resting left ventricular end-diastolic pressure (LVEDP) was significantly higher (p<.001), AI significantly greater (p<.001), and resting ejection fraction significantly lower (p<.O01) in all 101 pts with +TR as opposed to those with ¢~R. ST depression (ST+) subgroups were defined: >2 mm ST+, I-2 mm ST+, no ST+ at >85% predicted maximum heart rate, no ST+ at <85% predicted maximum heart rate. There were significant differences between pts with +ZR and those with +Y.R for each ST+ subgroup. Also, in a subgroup not Statistically different in resting LVEDP from the group as a whole, LVEDP after left ventriculography was significantly higher (p<.O05) in pts with +TR. This difference also remained significant for pts with +TR and +ER within each ST¢ subgroup. Of 93 pts with +TR and CAD, 76 had ventricular asynergy; of 70 with ~rTR and CAD, only 26 had ventricular asynergy (p<.005). We conclude that +TR in TET is a marker for resting and stress left ventricular dysfunction with CAD.
THE RELATION BETWEEN QRS AMPLITUDE CHANGES AND LEFT VENTRICULAR EJECTION FRACTION DURING EXERClSE Alexander Battler MD; Robert Slutsky MD; Matthlas Pfisterer MD; Kiyoshi Watanabe MD; George Chrlstlson, William Ashburn MD; and Victor Froelicher MD, FACC, University of California, San Diego. Studies have suggested that an exercise-lnduced increase in R wave indicates LV dysfunction and that sums of QRS amplitudes at rest correlate with resting ejection fraction (EF). To investigate the relationship of exercise-induced QRS amplitude changes to LV function, we studied 13 normals (NL) and 30 coronary artery disease (CAD) patients (pts) and analyzed simultaneously ECGVCG and equillbrium radlonucllde anglography (RNA) EF at rest and at peak supine bike exercise. The sum of R waves in X and Y, and Q wave in 7 (RX + RY + QZ = ~ R) correlates better with EF than any other combination of QRS components (NL and CAD at rest r = .66; peak exercise r = . 68). The results of EF ( -+ SD) and mV ~R ( + SD) for the NL and CAD at rest and peak Ex were: Rest EF Peak Ex. EF Rest ~R Peak Ex. ~R NLS 0.62 (_+ 0.07) 0,74 (+ 0.06) 2.69 ( ~ ; 7 5 ~ 2 . 3 2 [+ 0.64) CAD 0.52 ( + 0 . 1 1 ) 0.52 ( + 0 . 1 3 ) 1 . 8 8 ( + 0 . 7 1 ) 1.52 ( + 0 . 6 0 ) At rest and peak Ex the EF and ~ R of NL were significantly higher than the EF and ~R of the CAD pts (p< .005). The peak Ex EF in NL increased significantly from rest (p< .005) and did not change in the CAD pts. All subjects decreased and there was no significant change of ~ R in both groups from rest to peal< Ex. After also considering other single and combinations of other QRS amplitudes we conclude that change in QRS amplitudes during exercise do not separate patients with normal and abnormal LVEF responses to exercise.
354
February 1979
The American Journal of CARDIOLOGY
CAN THE AXIS OR MORPHOLOGY OF VENTRICULAR PREMATURE COMPLEXES OCCURRING DURING EXERCISE STRESS TESTING ENHANCE THE TEST'S SENSITIVITY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE? T. Joseph Mardelli, MD; Leonard S. Dreifus, MD, FACC;Joel Morganroth, MD, FACC, Lankenau Hospital,Jefferson Medical College, Philadelphia, PA.
The p r e v a l e n c e o f v e n t r i c u l a r p r e m a t u r e complexes(VPCs) d u r i n g e x e r c i s e t e s t i n g h a s n o t been h e l p f u l in p r e d i c t i n g the presence of coronary artery disease(CAD). To d e t e r mine w h e t h e r t h e m o r p h o l o g y o r a x i s o f VPCs may improve the test's s e n s i t i v i t y , 63 p a t i e n t s (PTS) w i t h CAD wore comp a r e d t o 43 normal c o n t r o l s ( G ) . 24 PTS w i t h CAD had c o r onary arteriography,and t h e r e m a i n d e r h a s had documented myocardial infarction. Eight C had normal coronary arteriography and the remainder were asymptomatic with normal ECGs and exercise tests. Both groups had undergone continuous 12-lead ECG monitoring using a Bruce protocol. VPCs with a superior axis(-30o tO -120O)were present in 49/63(78%)of PTS with CAD vs 9/43(21%)of C. An axis of -30o to +150o was observed in 12/63(19%)CAD and 33/43(77%) of C. An undetermined axis(-120o to +150o) was present in 2 PTS with CAD and 1 C. In 63 PTS with CAD, 46 instances of right bundle branch block (RBBB) and 26 instances of left (LBBB)morphology of VPCs were observed. In the 43 C, 23 had LBBB and 20 RBBB. 25 of 65 PTS with CAD had normal or borderline (
EXERCISE-INDUCED U WAVE INVERSION AS A ~ OF STENOSIS OF THE LEFT ANTERIOR DESDENDING CORONARY ARTERY Myron C. Gerson, MD; John F. Phillips, MD, FACC; Stephen N. Morris, MD, FACC; Paul L. McHenry, MD, FACC: Krannert Institute of Cardiology, Indiana Univ. School of Medicine, and the VA Hospital, Indianapolis, Indiana To assess the value of exercise-induced U wave inversion (UWI) as a predictor of significant left anterior descending (LAD) coronary artery stenosis, we reviewed 257 consecutive treadmill exercise tests performed prior to coronary cineangiographic studies. Patients (pts) with ECG evidence of left ventricular hypertrophy, anterior myocardial infarction or resting UWI were excluded from the final group designated as demonstrating exerciseinduced UWI. The mounted resting and exercise ECG records of simultaneously recorded bipolar V5 and lead II systems were initially reviewed. UWI was considered present when there was a consistent and discrete negative deflection in the T-P segment below the PR segment on the V5 lead. UWI was then independently verified by two of the authors by reviewing segments of the exercise ECG retrieved from magnetic tape recordings. 28 examples of exercise-induced UWI were detected. 9 pts had no other exercise ECG abnormalities. Coronary cineangiographic studies revealed ~75% stenosis of the proximal 1/3 of the LAD in 24 of 28 pts. Of the ~ remaining pts, 1 had a 50% left main lesion, 1 had a 75% stenosis of the first diagonal branch of the LAD and a 90% lesion of the right coronary artery, 1 had a 100% left circumflex lesion, and 1 had no significant coronary disease. The latter pt was receiving disopyramide phosphate for recurrent ventricular tachycardia. Of the 257 pts studied, 122 had ~75% LAD lesions including 38 with anterior infarction patterns. We conclude that UWI during treadmill exercise testing is highly correlated (P>0.01) with significant stenosis of the proximal LAD coronary artery.
Volume 43