Elsevier

The Lancet

Volume 356, Issue 9241, 4 November 2000, Pages 1592-1597
The Lancet

Seminar
Exercise testing in clinical medicine

https://doi.org/10.1016/S0140-6736(00)03138-XGet rights and content

Summary

Exercise-induced changes in the electrocardiogram have been used to identify coronary artery disease for almost a century. Over the past decade, however, clinicians have increasingly focused on more expensive diagnostic tools believing them to offer improved diagnostic accuracy. In fact, by incorporating historical data, the simple exercise test can in most cases outperform the newer tests. The use of prediction equations and non-staged exercise protocols can improve the test still further, while advances in the use of the test for prognosis, with the discovery of novel risk factors and the addition of gas analysis, may in the future shift the primary emphasis away from diagnosis. Brief, inexpensive, and done in most cases without the presence of a cardiologist, the exercise test offers the highest value for predictive accuracy of any of the non-invasive tests for coronary artery disease.

Section snippets

Diagnosis

Meta-analysis of trials has shown that the exercise test has a specificity of around 80% and a sensitivity of around 70% for obstructive coronary disease confirmed by angiography.4 However, many of these studies had methodological problems of limited challenge and work-up bias. The former takes place when patients already known to have coronary artery disease (eg, those with previous myocardial infarction) are used to challenge a diagnostic test. Work-up bias describes the situation in which

Prognosis and novel indications

The overriding paradigm in the diagnosis of cardiovascular disease over the past decades has been the presumptive identification of obstructive coronary disease in order to direct interventional angiography or bypass surgery. However, shortcomings in non-invasive tests such as the work-up bias mentioned above, combined with limitations fundamental to angiography16 have led some to suggest that the principal place for the exercise test is in the assessment of prognosis (table 2). The appropriate

Protocol

Experience and history show that the pervasiveness of an idea, method, or product relies only in part on its intrinsic quality. Rather more, the acceptance of an idea relies on its extrinsic survival potential, a complex attribute with temporal, logistical, and experiential dimensions.39 In applied exercise testing, these features are apparent in relation to the choice of treadmill protocol. When treadmill and cycle ergometer testing was first introduced into clinical practice, practitioners

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