Exercise ECG Testing and Stress Cardiac Magnetic Resonance for Risk Prediction in Patients With Chronic Coronary Syndrome

Abstract

Risk Prediction With ExECG Testing and Stress CMR E7E xercise ECG testing (ExECG) is a widespread and inexpensive technique routinely used in cardiology practice. Because of its limited diagnostic power to rule in or rule out significant coronary artery disease (CAD), 1 it has been downgraded from a first-line diagnostic test to detect ischemia in recent guidelines. 2 Noninvasive imaging tests are the current first-line recommendation in the diagnostic workup of patients with suspected chronic coronary syndrome (CCS). Specifically, vasodilator stress cardiac magnetic resonance (VS-CMR) has become a valuable technique for comprehensive, noninvasive evaluation of patients with CCS in terms of diagnosis, risk stratification, and decision making. This technique can accurately confirm or exclude CAD in a wide range of populations 3 and predict the risk of adverse outcomes with relatively high precision. [4][5][6] This robust demonstration of ischemia and outcomes can subsequently guide patient management, for instance, in the decision to revascularize or not. 7,8 The prognostic value of ExECG in patients has also been well established. 9 Several parameters such as the Duke Treadmill Score can predict the probability of CAD and mortality risk. 10 Contemporary registries show that excellent functional capacity during ExECG can predict a low risk of all-cause mortality 11 and high-risk CAD. 12 Its role in guiding exercise training in cardiac rehabilitation programs has also been important, 13,14 and its diagnostic and prognostic values can be enhanced if cardiopulmonary assessments are incorporated. 15,16 Exercise and cardiopulmonary stress testing are still and will probably continue to be recommended for prognostic evaluation of patients with CCS and other cardiac-related conditions. 2,17,18 However, in the era of increasingly available, more powerful diagnostic techniques such as VS-CMR that can also provide prognostic information in patients with known or suspected CCS, the role of ExECG, even for risk stratification purposes, is unclear. The aim of the present study was to explore whether ExECG can contribute to risk stratification beyond VS-CMR in patients with known or suspected CCS.

Heart Rate Response to Exercise and Recovery

“…[1][2][3] It has additional clinical applications, including the assessment of cardiorespiratory fitness (CRF) and the presence of arrhythmia, in diverse patient populations. [3][4][5][6][7] In recent years, the role of exercise electrocardiogram in the diagnostic evaluation of chronic coronary syndromes is diminishing, whereas noninvasive imaging modalities such as coronary computed tomography angiography are often recommended to diagnose obstructive coronary artery disease. 8,9 Nevertheless, much information is obtained during ET beyond electrocardiographic-related changes and regardless of the test indication, which may have important diagnostic and prognostic implications.…”

“…Maximal exercise testing (ET) is often used for the assessment of exercise-induced myocardial ischemia 1–3. It has additional clinical applications, including the assessment of cardiorespiratory fitness (CRF) and the presence of arrhythmia, in diverse patient populations 3–7. In recent years, the role of exercise electrocardiogram in the diagnostic evaluation of chronic coronary syndromes is diminishing, whereas noninvasive imaging modalities such as coronary computed tomography angiography are often recommended to diagnose obstructive coronary artery disease 8,9.…”