Skip to main content
SpringerLink
Log in

Testing Special Populations

  • Chapter
Exercise Stress Testing for Primary Care and Sports Medicine

Much of the evidence for recommendations regarding electrocardiogram (ECG) treadmill stress testing has come from studies involving middle-aged men. Special consideration must be given when deciding who, when and how to screen for cardiovascular disease in patients who fall outside of this category. There is less data on noninvasive testing in women, older adults and people with diabetes, although this issue is being recognized and addressed through recent studies and literature. The previous conception that coronary artery disease is only a disease found in men is quickly being replaced. Clinicians are recognizing that different standards must be used for identification of patients at risk, testing protocols and test interpretation. This chapter addresses the use of ECG treadmill stress testing in women, the elderly and persons with diabetes.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Heart Disease and Stroke Statistics: 2007 Update. American Heart Association. http://www.americanheart.org

  2. ACC/AHA 2002 Guideline Update for Exercise Testing: Summary Article. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) http://www.americanheart.org

  3. Gulati M, Pandey DK, Arnsdorf MF, et al. Exercise capacity and the risk of death in women: the St James Women Take Heart Project. Circulation. 2003;108:1554–9.

    Article  PubMed  Google Scholar 

  4. Shaw LJ, Mieres JH. The role of noninvasive testing in the diagnosis and prognosis of women with suspected CAD. J Fam Pract. 2005;Suppl:4–5.

    Google Scholar 

  5. Lee WL, Cheung AM, Cape D, et al. Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. Diabetes Care. 2000;23:962–8.

    Article  PubMed  CAS  Google Scholar 

  6. Rosenfeld JA. Heart disease in women. Postgraduate Medicine 2000;107:111–6

    PubMed  CAS  Google Scholar 

  7. Vittinghoff E, Shlipak MG, Varosy PD, et al. Risk factors and secondary prevention in women with heart disease: the Heart and Estrogen/progestin Replacement Study. Ann Intern Med. 2003;138:81–9.

    PubMed  CAS  Google Scholar 

  8. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results From the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288:321–33.

    Article  PubMed  CAS  Google Scholar 

  9. Kwok Y, Kim C, Grady D, et al. Meta-analysis of exercise testing to detect coronary artery disease in women. Am J Cardiol. 1999;83:660–6.

    Article  PubMed  CAS  Google Scholar 

  10. Michaelides AP, Psomadaki ZD, Dilaveris PE, et al. Improved detection of coronary artery disease by exercise electrocardiography with the use of right precordial leads. N Engl J Med. 1999;340:340–5.

    Article  PubMed  CAS  Google Scholar 

  11. Alexander KP, Shaw LJ, Shaw LK, et al. Value of exercise treadmill testing in women. J Am Coll Cardiol. 1998;32:1657–64.

    Article  PubMed  CAS  Google Scholar 

  12. DeCara, JM. Noninvasive cardiac testing in women. J Am Med Womens Assoc. 2003;58:254–63.

    PubMed  Google Scholar 

  13. Pratt CM, Francis MJ, Divine GW, et al. Exercise testing in women with chest pain. Chest. 1989;95:139–144.

    Article  PubMed  CAS  Google Scholar 

  14. American Heart Association. Role of noninvasive testing in the clinical evaluation of women with suspected coronary artery disease: Consensus statement from the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention. Circulation. 2005;111:682–96.

    Google Scholar 

  15. Fleg, J. Stress Testing in the Elderly. Am J Geriatr Cardiol. 2001;10:308–13.

    Article  PubMed  CAS  Google Scholar 

  16. Goraya TY, Jacobsen SJ, Pellikka PK,et al. Prognostic value of treadmill exercise testing in elderly persons. Ann Intern Med. 2000;132:862–70.

    PubMed  CAS  Google Scholar 

  17. Messinger-Rapport B, Pothier Snader CE, Blackstone EH, et al. Value of exercise capacity and heart rate recovery in older people. J Am Geriatr Soc. 2003;51:63–8.

    Article  PubMed  Google Scholar 

  18. Cole CR, Blackstone EH, Pashkow FJ, et al. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med 1999;341:1351–7.

    Article  PubMed  CAS  Google Scholar 

  19. Lai S, Kaykha A, Yamazaki T, et al. Treadmill scores in elderly men. J Am Coll Cardiol. 2004;43:606–15.

    Article  PubMed  Google Scholar 

  20. https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf

  21. Laing SP, Swerdlow AJ, Slater SD, et al. Mortality from heart disease in a cohort of 23,000 patients with insulin-treated diabetes. Diabetologia. 2003;46:760–765.

    Article  PubMed  CAS  Google Scholar 

  22. https://www.diabetes.org/about-diabetes.jsp

  23. https://www.diabetes.org/diabetes-prevention.jsp

  24. Fox CS, Pencina MJ, Meigs JB, et al. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation. 2006;113:2914–8

    Article  PubMed  Google Scholar 

  25. Conway DG, O’Keefe JH, Reid KJ, et al. Frequency of undiagnosed diabetes mellitus in patients with acute coronary syndrome. Am J Cardiol 2005;96:363–5.

    Article  Google Scholar 

  26. Lee WL, Cheung AM, Cape D, et al. Impact of diabetes on coronary artery disease in women and men: a meta-analysis of prospective studies. Diabetes Care. 2000;23:962–8.

    Article  PubMed  CAS  Google Scholar 

  27. Hu FB, Stampfer MJ, Solomon CG, et al. The impact of diabetes mellitus on mortality from all causes and coronary heart disease in women: 20 years of follow-up. Arch Intern Med. 2001;161:1717–23.

    Article  PubMed  CAS  Google Scholar 

  28. Fox CS, Coady S, Sorlie PD, et al. Trends in cardiovascular complications of diabetes. JAMA 2004;292: 2495–9.

    Article  PubMed  CAS  Google Scholar 

  29. Juutilainen A, Lehto S, Ronnemaa T, et al. Similarity of the impact of type 1 and type 2 diabetes on cardiovascular mortality in middle-aged subjects. Diabetes Care 2008;31:714–9.

    Article  PubMed  Google Scholar 

  30. Jemal A, Ward E, Hoa Y, et al. Trends in the leading causes of death in the United States, 1970–2002. JAMA 2005;294;1255–9.

    Article  PubMed  Google Scholar 

  31. Berry C, Tardif JC, Bourassa MG. Coronary heart disease in patients with diabetes: part I: recent advances in prevention and noninvasive management. J Am Coll Cardiol. 2007;49:631–42.

    Article  PubMed  CAS  Google Scholar 

  32. Hammond T, Tanguay JF, Bourassa MG. Management of coronary artery disease: therapeutic options in patients with diabetes. J Am Coll Cardiol. 2000;36:355–65.

    Article  Google Scholar 

  33. Shorr RI, Franse LV, Resnick HE, et al. Glycemic control of older adults with type 2 diabetes: findings from the Third National Health and Nutrition Examination Survey, 1988–1994. J Am Geriatri Soc. 2000;48:264–7.

    CAS  Google Scholar 

  34. https://www.nhlbi.nih.gov/about/ncep.index.htm

  35. Buse JB, Ginsberg HN, Bakris GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007;115:114–26.

    Article  PubMed  Google Scholar 

  36. Hogan P, Dall T, Nikolov P. American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003;26:917–32.

    Article  PubMed  Google Scholar 

  37. Janand-DelenneB, Savin B, Habib G, et al. Silent myocardial ischemia in patients with diabetes. Diabetes Care. 1999;22:1396–400.

    Article  Google Scholar 

  38. Miettinen H, Lehto S, Veikko S, et al. Impact of diabetes on mortality after the first myocardial infarction. Diabetes Care. 1998;21:69–75.

    Article  PubMed  CAS  Google Scholar 

  39. The BARI Investigators. Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: The Bypass Angioplasty Revascularization Investigation (BARI). Circulation. 1997;96:1761–9.

    Google Scholar 

  40. Gu K, Cowie CC, Harris MI. Diabetes and decline in heart disease mortality in US adults. JAMA. 1999;281:1291–7.

    Article  PubMed  CAS  Google Scholar 

  41. Milicevic Z, Raz I, Beattie SC, et al. Natural history of cardiovascular disease in patients with diabetes. Diabetes Care. 2008;31 (Suppl 2):S155–S160.

    Article  PubMed  CAS  Google Scholar 

  42. Alexander CM, Landsman PB, Teutsch SM. Diabetes mellitus, impaired fasting glucose, atherosclerotic risk factors, and prevalence of coronary artery disease. Am J Cardiol. 2000:86:897–902.

    Article  CAS  Google Scholar 

  43. American Diabetes Association. Consensus development conference on the diagnosis of coronary heart disease in people with diabetes: Miami, Florida. Diabetes Care. 1998;21:1551–9.

    Google Scholar 

  44. Sigal, RJ, Kenny GP, Wasserman DH, et al. Physical activity/ exercise and type 2 diabetes. A Consensus Statement from the American Diabetes Association. Diabetes Care. 2006;29:1433–8.

    Article  PubMed  Google Scholar 

  45. Grundy SM, Garber A, Goldberg R, et al. Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group IV: Lifestyle and medical management of risk factors. Circulation. 2002;105;e153–8.

    Article  PubMed  Google Scholar 

  46. Redberg RF, Greenland P, Fuster V, et al. Prevention Conference VI: Diabetes and Cardiovascular Disease: Writing Group III: Risk assessment in persons with diabetes. Circulation 2002;105:144–52.

    Article  Google Scholar 

  47. Rubler S, Arvan SB. Exercise testing in young asymptomatic diabetic patients. Angiology 1976;27:539–48.

    Article  PubMed  CAS  Google Scholar 

  48. Gibbons RJ, Balady GJ, Beasley JW, et al. ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation 1997;96:345–54.

    PubMed  CAS  Google Scholar 

  49. https://www.dtu.ox.ac.uk/riskengine/download.htm

  50. Stevens RJ, Kothari V, Adler AI, et al. The UKDPS risk engine: A model for the risk of coronary artery disease in Type II diabetes (UKDPS 56). Clinical Sci 2001;101:671–9.

    Article  CAS  Google Scholar 

  51. Eddy DM, Schlessinger L. Archimedes: A trial-validated model of diabetes. Diabetes Care. 2003;26:3093–101.

    Article  PubMed  Google Scholar 

  52. Eddy DM, Schlessinger L. Validation of the Archimedes Diabetes Model. Diabetes Care. 2003;26:3102–10.

    Article  PubMed  Google Scholar 

  53. Wilson PW, D’Agostino RB, Levy D, et al. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97:1837–47.

    PubMed  CAS  Google Scholar 

  54. Fox CS, Coady S, Sorlie PD, et al. Increasing cardiovascular disease burden due to diabetes mellitus: the Framingham Heart Study. Circulation. 2007;115:1544–50.

    Article  PubMed  Google Scholar 

  55. May O, Arildsen H, Damsgaard EM, et al. Prevalence and prediction of silent ischaemia in diabetes mellitus: a population-based study. Cardiovasc Res. 1997;34:241–7.

    Article  PubMed  CAS  Google Scholar 

  56. Nesto RW, Phillips RT, Kett KG, et al. Angina and exertional myocardial ischemia in diabetic and nondiabetic patients: assessment by exercise thallium scintigraphy. Ann Intern Med. 1988;108:170–5.

    PubMed  CAS  Google Scholar 

  57. Lee DP, Fearon WF, Froelicher VF. Clinical utility of the exercise ECG in patients with diabetes and chest pain. Chest. 2001;119:1576–81.

    Article  PubMed  CAS  Google Scholar 

  58. Wacker FJ, Young LH, Inzucchi SE, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: The DIAD study. Diabetes Care. 2004;1954–61.

    Google Scholar 

  59. Riley GP, Oberman A, Scheffield LT. Electrocardiographic effects of glucose ingestion. Arch Intern Med. 1972;130:703–7.

    Article  PubMed  CAS  Google Scholar 

  60. Ellestad MH. Stress Testing: Principles and Practice, 5th ed. New York, Oxford University Press, 2003, 485.

    Google Scholar 

  61. Cosson E, Paycha F, Paries J, et al. Detecting silent coronary stenosis and stratifying cardiac risk in patients with diabetes: ECG stress test or exercise myocardial scintigraphy? Diabet Med. 2004;21:342–8.

    Article  PubMed  CAS  Google Scholar 

  62. Lakkireddy DR, Bhakkad J, Korlakunta HL, et al. Prognostic value of the Duke Treadmill Score in diabetic patients. Am Heart J. 2005;150:516–21.

    Article  PubMed  Google Scholar 

  63. Wei M, Gibbons L, Kampert JB, et al. Low cardiorespiratory fitness and physical inactivity as predictors of mortality in men with type 2 diabetes. Ann Intern Med. 2000;132:605–11.

    PubMed  CAS  Google Scholar 

  64. Seyoum B, Estacio RO, Berhanu B, et al. Exercise capacity is a predictor of cardiovascular events in patients with type 2 diabetes mellitus. Diab Vasc Dis Res. 2006;3:197–201.

    Article  PubMed  Google Scholar 

  65. Myers J, Prakash M, Froelicher V, et al. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346:793–801.

    Article  PubMed  Google Scholar 

  66. Singh JP, Larson MG, O’Donnell CJ, et al. Association of hyperglycemia with reduced heart rate variability (The Framingham Study). Am J Cardiol. 2000;86:309–12.

    Article  PubMed  CAS  Google Scholar 

  67. Seshadri N, Acharya N, Lauer MS. Association of diabetes mellitus with abnormal heart rate recovery in patients without known coronary artery disease. Am J Cardiol. 2003;91:108–11.

    Article  PubMed  Google Scholar 

  68. Valensi P, Sachs RN, Harfouche B, et al. Predictive value of cardiac autonomic neuropathy in diabetic patients with or without silent myocardial ischemia. Diabetes Care. 2001;24:339–43.

    Article  PubMed  CAS  Google Scholar 

  69. Cheng YJ, Lauer MS, Earnest CP, et al. Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all-cause mortality in men with diabetes. Diabetes Care. 2003;26:2052–7.

    Article  PubMed  Google Scholar 

  70. Lauer MS, Francis GS, Okin PM, et al. Impaired chronotropic response to exercise stress testing as a predictor of mortality. JAMA 1999;281:524–9.

    Article  PubMed  CAS  Google Scholar 

  71. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Heart Rate Variability. Circulation. 1996;93:1043–65

    Google Scholar 

  72. Dekker JM, Crow RS, Folsom AR, et al. Low heart rate variability in a 2-minute rhythm strip predicts risk of coronary artery disease and mortality from several causes. The ARIC Study. Circulation. 2000;102:1239–44.

    CAS  Google Scholar 

  73. Risk Mj, Bril V, Broadbridge C. et al. Heart rate variability measurement in diabetic neuropathy: Review of methods. Diabetes Technol Ther. 2001;3(1):63–74.

    Article  PubMed  CAS  Google Scholar 

  74. Malpas SC, Maling TJ. Heart-rate variability and cardiac autonomic function in diabetes. Diabetes 1990;39:1177–81.

    Article  PubMed  CAS  Google Scholar 

  75. Spallone V, Menzinger G. Diagnosis of cardiovascular autonomic neuropathy in diabetes. Diabetes 1997;46(Suppl 2): S67–76.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Family Physician, Oak Grove Medical Clinic, 1900 S. Broadway, Oak Grove, MO 64075, USA

    Bryan C. Hughes

  2. Department of Community and Family Medicine, University of Missouri – Kansas City, Truman Medical Center Lakewood, Kansas City, MO, USA

    Russell D. White

Authors
  1. Bryan C. Hughes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Russell D. White
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Private Practice Family Physician Florida Institute of Family Medicine, Director of Medical Education St. Anthony’s Hospital, St. Petersburg, FL, USA

    Corey H. Evans MD, MPH

  2. Director, Sports Medicine Fellowship Department of Community and Family Medicine, University of Missouri—Kansas City Truman Medical Center Lakewood, Kansas City, MO, USA

    Russell D. White MD (Professor of Medicine) (Professor of Medicine)

Rights and permissions

Reprints and permissions

Copyright information

© 2009 Springer Science+Business Media, LLC

About this chapter

Cite this chapter

Hughes, B.C., White, R.D. (2009). Testing Special Populations. In: Evans, C.H., White, R.D. (eds) Exercise Stress Testing for Primary Care and Sports Medicine. Springer, New York, NY. https://doi.org/10.1007/978-0-387-76597-6_4

Download citation

  • DOI: https://doi.org/10.1007/978-0-387-76597-6_4

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-0-387-76596-9

  • Online ISBN: 978-0-387-76597-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation