Exercise Graded by Heart Rate in Electrocardiographic Testing for Angina Pectoris

Standardization of an exercise electrocardiographic test for myocardial ischemia is desirable. Standardization of exercise should be based upon a standardized challenge to the coronary circulation, not upon a standardized challenge to the skeletal muscles, for the stresses upon the heart are not identical. With the use of heart rate during exercise as an index of cardiac stress, the levels of exercise prescribed on the basis of age, sex, and weight in standard "two-step" test tables produce widely varying levels of cardiac stress-sometimes too low to induce significant ST-segment depression in patients with angina pectoris and, occasionally, much greater than necessary to produce such diagnostic electrocardiographic changes. The graded exercise test, using 85 per cent of the maximal age-predicted heart rate that may be induced by exercise, produces a closer approximation of a standardized cardiac stress, regardless of age, sex, or body build. Its use with angina pectoris patients and normal subjects results in increased sensitivity (fewer false negatives) and increased specificity (fewer false positives). Use of the graded exercise test as described is considered not to increase the hazard of testing, and perhaps even to decrease it.