Exercise Testing for Chronotropic Assessment

Wilkoff, Bruce L.; Miller, Raymond E.

doi:10.1016/s0733-8651(18)30211-x

Cited by 176 publications

(148 citation statements)

References 34 publications

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“…Heart rate recovery (HRR), the ability to slow the heart rate after an exercise stress test, has been suggested as a measure of chronotrophic competence 4-9 and as a useful addition to current criteria for predicting cardiac and all-cause mortality from an exercise stress test. [4][5][6][7][8][10][11][12][13][14][15] Recent work has focused on the decrease in heart rate within a fixed period after termination of the stress test. [4][5][6][7][10][11][12][13][14][15] The definition of abnormal has varied both in the time frame and in the magnitude of the decrease, but the most commonly used value defines abnormal HRR as a decrease of fewer than 12 beats per minute within the first minute.…”

Section: Introductionmentioning

confidence: 99%

Test-Retest Reproducibility of Heart Rate Recovery After Treadmill Exercise

Yawn

Ammar²,

Thomas³

et al. 2003

The Annals of Family Medicine

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BACKGROUND Slowed heart rate recovery (HRR) of less than 12 beats per minute in the first minute after an exercise stress test has been suggested as a useful addition to the criteria currently used to assess exercise stress test results. Although HRR has been tested in large populations, the short-term test-retest stability (reproducibility) of abnormal HRR for an individual has not been assessed. METHODSThe study was a retrospective comparison of medical record information using a community-practice-based sample of 90 patients undergoing 2 exercise stress tests separated by 18 weeks or less. Concordance of abnormal HRR results on the first and second stress tests were assessed for individual patients using definitions of abnormal HRR from the medical literature.RESULTS Individual patient's HRR was markedly variable from the first to second stress test. In this sample, no definition of abnormal HRR provided more than 55% concordance between results from the first and second stress tests.CONCLUSION These preliminary data suggest that HRR appears to have limited short-term test-retest stability or reproducibility and therefore might not be a reliable addition to current results of exercise stress tests. INTRODUCTIONH eart disease is the second leading diagnosis in patients visiting the offices of adult generalist physicians (family physicians and general internists).1 More than 75% of general internists and 13% of family physicians perform and interpret exercise stress tests in their offices.1,2 Many other generalist physicians must help patients understand the results of exercise stress tests performed by cardiologists and integrate the test results into their management plans. Currently several indicators, such as symptoms and ST segment elevation and T wave inversion on electrocardiogram (ECG) tracings, are included in stress test interpretation to determine which patients are at increased risk for cardiac mortality. Heart rate recovery (HRR), the ability to slow the heart rate after an exercise stress test, has been suggested as a measure of chronotrophic competence 4-9 and as a useful addition to current criteria for predicting cardiac and all-cause mortality from an exercise stress test. [4][5][6][7][8][10][11][12][13][14][15] Recent work has focused on the decrease in heart rate within a fixed period after termination of the stress test. [4][5][6][7][10][11][12][13][14][15] The definition of abnormal has varied both in the time frame and in the magnitude of the decrease, but the most commonly used value defines abnormal HRR as a decrease of fewer than 12 beats per minute within the first minute.11 In both community-based and cardiology clinic populations, slower HRR (slower decrease in beats per minute in the first 1 or 2 minutes after exercise) has been associated with all-cause mortality, but it has not been linked reproducibly with cardiac-related mortality, [5][6][7][11][12][13]15,16 nor has it been an independent risk factor for abnormal angiography findings. 4,[11][12][13] and no agreement h...

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Section: Introductionmentioning

confidence: 99%

Test-Retest Reproducibility of Heart Rate Recovery After Treadmill Exercise

Yawn

Ammar²,

Thomas³

et al. 2003

The Annals of Family Medicine

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“…Phan et al [8] found that 34% of patients with HFpEF have CI during maximal exercise when defined by %Max PHR and 63% when defined by %HRR. In order to avoid age, functional capacity and resting HR biases of each individual [1,4,5,[20][21][22][23][24], for comparison analysis of patient data we have used %HRR. It is now well known that both parameters of CI were associated with adverse risk profile, whereby %HRR represents an isolated measure of chronotropy that appeared as an independent predictor of mortality.…”

Section: Discussionmentioning

confidence: 99%

“…Chronotropic incompetence (CI) was defined to be a diminished heart rate (HR) response to exercise on the basis of the following two criteria [4,18,[20][21][22][23][24]: failure to achieve 85% of the maximum age-predicted heart rate (%Max PHR) where %Max PHR was calculated as 220 -age (years) [23] and percentage of HR reserve (%HRR) of ≤ 80% which was calculated using following equation: (HR at peak exercise -resting HR)/[(220 -age) -resting HR)] [4,[20][21][22][23][24]. We decided in our study to use the latter criterion because it outweighs the possible confounding effects of age, physical fitness and resting HR.…”

Section: Chronotropic Incompetencementioning

confidence: 99%

Echocardiographic Predictors of Chronotropic Incompetence to Exercise in Patients with Heart Failure with Preserved Ejection Fraction

Projevska-Donegati

Georgievska-Ismail

2014

Prilozi

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Objective: Exercise intolerance in patients with heart failure with preserved ejection fraction (HFpEF) is most often attributed to diastolic dysfunction (DD); however, chronotropic incompetence (CI) could also play an important role. We intended to examine whether there are predictive echocardiographic parameters of DD for impaired chronotropic response to exercise. Methods and Results: Patients (n = 143) with unexplained dyspnea and/or exercise intolerance who fulfilled clinical and echocardiographic criteria of HFpEF presence underwent a symptom-limited exercise test using a treadmill (ETT) according to the Bruce protocol. CI was defined as an achieved heart rate reserve (HRR) of ≤ 80%. Comparison of the groups with (n = 98) and without CI (n = 45) did not show any statistically significant difference regarding demographic and clinical characterristics except for use of beta blockers (BB) that were more frequently present (p = 0.012) in patients with CI in comparison with those without. Patients with CI had a higher mean E-wave velocity, E/A ratio, increased E/E' septal, lateral as well as average ratio and abnormal IVRT/T E-e' index all consistent with elevated LV filling pressures. E/E' average ratio > 15 was statistically insignificantly more frequently present in patients with CI. In addition, by multivariate stepwise regression analysis value of E' septal (β = 3.697, 95%CI 0.921-6.473, p = 0.009) along with use of BB, current smoking and basal heart rate appeared as statistically significant independent predictors of lower HRR %. Conclusion: Patients with HFpEF frequently have chronotropic incompetence to graded exercise which may partly be predicted with echocardiographic parameters that are consistent with elevated LV filling pressures.

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“…According to Wilkoff 18,19 , the index is described as the ratio between reserve HF and the metabolic reserve used during peak exercise. Where METs refer to metabolic equivalents measured by gas analysis, stage refers to any stage of exercise, and peak refers to the peak of exercise.…”

Section: Methodsmentioning

confidence: 99%

“…Under these conditions, the index should be at the rate of reserve HR used, based only on variables of resting HR, peak HR and age. Chronotropic index smaller than 0.8 defines chronotropic incompetence [18][19][20][21] . Based on this index, patients were divided into incompetent group (IG) and competent group (CG).…”

Section: Methodsmentioning

confidence: 99%