Key result
Abnormal exercise ECG shows no link to future cardiac events in patients with normal SPECT.
Why the study?
Coronary microvascular dysfunction (CMD) is difficult to diagnose noninvasively, and the prognostic value of exercise ECG findings was evaluated in chest pain patients with potential CMD after ruling out ischemia on MPS.
Does an abnormal exercise ECG predict adverse cardiovascular events in patients with chest pain and normal myocardial perfusion SPECT?
Cohort (n=760)
No
Does an abnormal exercise ECG predict adverse cardiovascular events in patients with chest pain and normal myocardial perfusion SPECT?
In patients with chest pain and normal myocardial perfusion imaging, an abnormal exercise ECG suggestive of microvascular dysfunction does not independently predict future ischemic events.
Answers are grounded in this paper and cite their sources.
Abnormal exercise ECG should not yet inform prognosis after normal SPECT; leaves open the independent role of microvascular dysfunction.
Background Coronary microvascular dysfunction (CMD) is common and associated with a poor prognosis, but is difficult to diagnose noninvasively. ST-segment depression on exercise ECG (ex-ECG), in the absence of coronary stenosis, was recently found to have a very high positive predictive value (PPV) for CMD in a selected group of patients with a high prevalence of disease [1]. In the present study of consecutive chest pain patients, we used myocardial perfusion SPECT (MPS) to rule out stress-induced ischemia due to epicardial coronary stenosis. In the remaining group of patients with potential CMD, we studied the prognostic value of ex-ECG findings. Methods/material This was a single-center study of 941 patients referred for evaluation of chest pain and examined with MPS and ex-ECG. Ischemia on MPS was defined as a stress-induced perfusion deficit. Ex-ECG was considered abnormal when ST-segment depression ≥1mV occurred in relation to exercise. Follow-up data were acquired from national registries. The composite endpoint consisted of cardiovascular death, myocardial infarction, unstable angina and coronary angiography/ PCI. A total of 33 patients were excluded due to inconclusive ex-ECG findings and 148 was found to have stress-induced ischemia by MPS. Results The final study cohort (n=760) consisted of 55 % women with a mean age of 63±9 years and 43% prevalence of ischemic heart disease (IHD). Ex-ECG was abnormal in 126 patients (16%). During a mean follow-up of 8.5 years, the composite endpoint occurred in 25% (n=31) of subjects with abnormal ex-ECG and in 16% (n=103) with normal ex-ECG. Kaplan-Meier curves for cumulative events separated significantly (log-rank p=0.01) based on ex-ECG results (Figure1). However, in a multivariable analysis adjusting for age, sex, IHD, comorbidities and exercise capacity, abnormal ex-ECG was no longer significantly associated with adverse outcome (HR 1.1, CI 0.7-1.7, p=0.6). The PPV of an abnormal ex-ECG, for future cardiac events, was only 25% (31/126) and decreased to 17% (11/66) when excluding patients with prior IHD (Table 1). Conclusions In patients with angina and no signs of ischemia on MPS, ex-ECG findings suggestive of coronary microvascular dysfunction have limited prognostic relevance for future ischemic events.
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Kraen et al. (2025) conducted a cohort in Chest pain without stress-induced ischemia (n=760). Abnormal exercise ECG (ST-segment depression ≥1mV) vs. Normal exercise ECG was evaluated on Composite of cardiovascular death, myocardial infarction, unstable angina and coronary angiography/PCI (HR 1.1, 95% CI 0.7-1.7, p=0.6). An abnormal exercise ECG in patients with chest pain and no ischemia on MPS was not associated with adverse cardiovascular events after adjustment.
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