Exercise Testing and Risk Assessment

  • Christopher R. Cole
  • Michael S. Lauer
Part of the Contemporary Cardiology book series (CONCARD)


With the development of advanced imaging modalities, the regular exercise electro-cardiogram (ECG) test has come to be regarded by some as passé. In large part, this is because of the low sensitivity and specificity for the diagnosis of coronary artery disease (CAD). With newer methods of interpretation, however, exercise testing remains a powerful and inexpensive prognostic tool. The use of the exercise test has important implications for risk stratification as a part of prevention strategies and for after myocardial infarction (MI) management. This chapter focuses primarily on the prognostic implications of exercise testing using cardiovascular events and mortality as endpoints. It examines all aspects of the exercise test, including functional capacity, heart rate (HR) changes during exercise, blood pressure (BP) response, and more-recent methods of computerized interpretation of the exercise ECG.


Heart Rate Recovery Chronotropic Incompetence Coronary Artery Surgery Study Preventive Cardiology Metabolic Reserve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Fletcher GF, Balady G, Froelicher VF, et al. Exercise standards. A statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1995; 91: 580–615.PubMedGoogle Scholar
  2. 2.
    Detrano R, Froelicher VF. Exercise testing: uses and limitations considering recent studies. Prog Cardiovasc Dis 1988; 31: 173–204.PubMedGoogle Scholar
  3. 3.
    Detrano R, Gianrossi R, Mulvihill D, et al. Exercise-induced ST segment depression in the diagnosis of multivessel coronary disease: a meta analysis. J Am Coll Cardiol 1989; 14: 1501–1508.PubMedGoogle Scholar
  4. 4.
    Detrano R, Gianrossi R, Froelicher V. The diagnostic accuracy of the exercise electrocardiogram: a meta-analysis of 22 years of research. Prog Cardiovasc Dis 1989; 32: 173–206.PubMedGoogle Scholar
  5. 5.
    Detrano R. Variability in the accuracy of the exercise ST-segment in predicting the coronary angiogram: how good can we be? J Electrocardiol 1992; 24: 54–61.PubMedGoogle Scholar
  6. 6.
    Gianrossi R, Detrano R, Mulvihill D, et al. Exercise-induced ST depression in the diagnosis of coronary artery disease. A meta-analysis. Circulation 1989; 80: 87–98.PubMedGoogle Scholar
  7. 7.
    Philbrick JT, Horwitz RI, Feinstein AR. Methodologic problems of exercise testing for coronary artery disease: groups, analysis and bias. Am J Cardiol 1980; 46: 807–812.PubMedGoogle Scholar
  8. 8.
    Philbrick JT, Horwitz RI, Feinstein AR, et al. The limited spectrum of patients studied in exercise test research. Analyzing the tip of the iceberg. JAMA 1982; 248: 2467–2470.PubMedGoogle Scholar
  9. 9.
    Choi BC. Sensitivity and specificity of a single diagnostic test in the presence of work-up bias [see comments]. J Clin Epidemiol 1992; 45: 581–586.PubMedGoogle Scholar
  10. 10.
    Diamond GA. Reverend Bayes’ silent majority. An alternative factor affecting sensitivity and specificity of exercise electrocardiography. Am J Cardiol 1986; 57: 1175–1180.PubMedGoogle Scholar
  11. 11.
    Ransohoff DF, Feinstein AR. Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. N Engl J Med 1978; 299: 926–930.PubMedGoogle Scholar
  12. 12.
    Froelicher VF, Lehmann KG, Thomas R, et al. The electrocardiographic exercise test in a population with reduced work-up bias: diagnostic performance, computerized interpretation, and multivariable freedom. Ann Intern Med 1998; 128: 965–974.PubMedGoogle Scholar
  13. 13.
    Christian TF, Miller TD, Bailey KR, Gibbons RJ. Exercise tomographic thallium-201 imaging in patients with severe coronary artery disease and normal electrocardiograms [see comments]. Ann Intern Med 1994; 121: 825–832.PubMedGoogle Scholar
  14. 14.
    Snader CE, Marwick TH, Pashkow FJ, et al. Importance of estimated functional capacity as a predictor of all-cause mortality among patients referred for exercise thallium single-photon emission computed tomography: report of 3,400 patients from a single center. J Am Coll Cardiol 1997; 30: 641–648.PubMedGoogle Scholar
  15. 15.
    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: 1351–1357.PubMedGoogle Scholar
  16. 16.
    Lauer MS, Okin PM, Larson MG, et al. Impaired heart rate response to graded exercise. Prognostic implications of chronotropic incompetence in the Framingham Heart Study. Circulation 1996; 93: 1520–1526.PubMedGoogle Scholar
  17. 17.
    Lauer MS, Francis GS, Okin PM, et al. Impaired chronotropic response to exercise stress testing as a predictor of mortality. JAMA 1999; 281: 524–529.PubMedGoogle Scholar
  18. 18.
    Brener SJ, Pashkow FJ, Harvey SA, et al. Chronotropic response to exercise predicts angiographic severity in patients with suspected or stable coronary artery disease. Am J Cardiol 1995; 76: 1228–1232.PubMedGoogle Scholar
  19. 19.
    Campbell L, Marwick TH, Pashkow FJ, et al. Usefulness of an exaggerated systolic blood pressure response to exercise in predicting myocardial perfusion defects in known or suspected coronary artery disease. Am J Cardiol 1999; 84: 1304–1310.PubMedGoogle Scholar
  20. 20.
    Lauer MS, Pashkow FJ, Harvey SA, et al. Angiographic and prognostic implications of an exaggerated exercise systolic blood pressure response and rest systolic blood pressure in adults undergoing evaluation for suspected coronary artery disease. J Am Coll Cardiol 1995; 26: 1630–1636.PubMedGoogle Scholar
  21. 21.
    Schweikert RA, Pashkow FJ, Snader CE, et al. Association of exercise-induced ventricular ectopic activity with thallium myocardial perfusion and angiographic coronary artery disease in stable, low-risk populations. Am J Cardiol 1999; 83: 530–534.PubMedGoogle Scholar
  22. 22.
    Okin PM, Kligfield P. Heart rate adjustment of ST segment depression and performance of the exercise electrocardiogram: a critical evaluation. J Am Coll Cardiol 1995; 25: 1726–1735.PubMedGoogle Scholar
  23. 23.
    Peters RK, Cady LD Jr, Bischoff DP, et al. Physical fitness and subsequent myocardial infarction in healthy workers. JAMA 1983; 249: 3052–3056.PubMedGoogle Scholar
  24. 24.
    Paffenbarger RS Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med 1986; 314: 605–613.PubMedGoogle Scholar
  25. 25.
    Leon AS, Connett J, Jacobs DRJr, Rauramaa R. Leisure-time physical activity levels and risk of coronary heart disease and death. The Multiple Risk Factor Intervention Trial. JAMA 1987; 258: 2388–2395.PubMedGoogle Scholar
  26. 26.
    Ekelund LG, Haskell WL, Johnson JL, et al. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. The Lipid Research Clinics Mortality Follow-up Study. N Engl J Med. 1988; 319: 1379–1384.PubMedGoogle Scholar
  27. 27.
    Blair SN, Kohl HWD, Paffenbarger RS Jr, et al. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA 1989; 262: 2395–2401.PubMedGoogle Scholar
  28. 28.
    van Saase JL, Noteboom WM, Vandenbroucke JP. Longevity of men capable of prolonged vigorous physical exercise: a 32 year follow up of 2259 participants in the Dutch eleven cities ice skating tour. Br Med J. 1990; 301: 1409–1411.Google Scholar
  29. 29.
    Arraiz GA, Wigle DT, Mao Y. Risk assessment of physical activity and physical fitness in the Canada Health Survey mortality follow-up study. J Clin Epidemiol 1992; 45: 419–428.PubMedGoogle Scholar
  30. 30.
    Paffenbarger RS Jr, Hyde RT, Wing AL, et al. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med 1993; 328: 538–545.PubMedGoogle Scholar
  31. 31.
    Lakka TA, Venalainen JM, Rauramaa R, et al. Relation of leisure-time physical activity and cardiores-piratory fitness to the risk of acute myocardial infarction. N Engl J Med 1994; 330: 1549–1554.PubMedGoogle Scholar
  32. 32.
    Lee IM, Hsieh CC, Paffenbarger RS Jr. Exercise intensity and longevity in men. The Harvard Alumni Health Study. JAMA 1995; 273: 1179–1184.PubMedGoogle Scholar
  33. 33.
    Blair SN, Kohl HW III, Barlow CE, et al. Changes in physical fitness and all-cause mortality. A prospec-tive study of healthy and unhealthy men. JAMA 1995; 273: 1093–1098.PubMedGoogle Scholar
  34. 34.
    Lissner L, Bengtsson C, Bjorkelund C, Wedel H. Physical activity levels and changes in relation to longevity. A prospective study of Swedish women. Am J Epidemiol 1996; 143: 54–62.PubMedGoogle Scholar
  35. 35.
    Ellestad MH, Wan MK. Predictive implications of stress testing. Follow-up of 2700 subjects after maximum treadmill stress testing. Circulation 1975; 51: 363–369.PubMedGoogle Scholar
  36. 36.
    Bruce RA, DeRouen T, Peterson DR, et al. Noninvasive predictors of sudden cardiac death in men with coronary heart disease. Predictive value of maximal stress testing. Am J Cardiol 1977; 39: 833–840.PubMedGoogle Scholar
  37. 37.
    McNeer JF, Margolis JR, Lee KL, et al. The role of the exercise test in the evaluation of patients for ischemic heart disease. Circulation 1978; 57: 64–70.PubMedGoogle Scholar
  38. 38.
    Podrid PJ, Graboys TB, Lown B. Prognosis of medically treated patients with coronary-artery disease with profound ST-segment depression during exercise testing. N Engl J Med 1981; 305: 1111–1116.PubMedGoogle Scholar
  39. 39.
    Bruce RA, Hossack KF, DeRouen TA, Hofer V. Enhanced risk assessment for primary coronary heart disease events by maximal exercise testing: 10 years’ experience of Seattle Heart Watch. J Am Coll Cardiol 1983; 2: 565–753.PubMedGoogle Scholar
  40. 40.
    McKirnan MD, Sullivan M, Jensen D, Froelicher VF. Treadmill performance and cardiac function in selected patients with coronary heart disease. J Am Coll Cardiol 1984; 3: 253–261.PubMedGoogle Scholar
  41. 41.
    Weiner DA, Ryan TJ, McCabe CH, et al. Prognostic importance of a clinical profile and exercise test in medically treated patients with coronary artery disease. J Am Coll Cardiol 1984; 3: 772–779.PubMedGoogle Scholar
  42. 42.
    Weiner DA, Ryan TJ, McCabe CH, et al. The role of exercise testing in identifying patients with improved survival after coronary artery bypass surgery. J Am Coll Cardiol 1986; 8: 741–748.PubMedGoogle Scholar
  43. 43.
    Weiner DA, Ryan TJ, McCabe CH, et al. Value of exercise testing in determining the risk classification and the response to coronary artery bypass grafting in three-vessel coronary artery disease: a report from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 1987; 60: 262–266.PubMedGoogle Scholar
  44. 44.
    Weiner DA, Ryan TJ, Parsons L, et al. Long-term prognostic value of exercise testing in men and women from the Coronary Artery Surgery Study (CASS) registry. Am J Cardiol 1995; 75: 865–870.PubMedGoogle Scholar
  45. 45.
    Bogaty P, Dagenais GR, Cantin B, et al. Prognosis in patients with a strongly positive exercise electro-cardiogram. Am J Cardiol 1989; 64: 1284–1288.PubMedGoogle Scholar
  46. 46.
    Morris CK, Ueshima K, Kawaguchi T, et al. The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991; 122: 1423–1431.PubMedGoogle Scholar
  47. 47.
    Mancini DM, Eisen H, Kussmaul W, et al. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure. Circulation 1991; 83: 778–786.PubMedGoogle Scholar
  48. 48.
    Aaronson KD, Mancini DM. Is percentage of predicted maximal exercise oxygen consumption a better predictor of survival than peak exercise oxygen consumption for patients with severe heart failure? J Heart Lung Transplant 1995; 14: 981–989.PubMedGoogle Scholar
  49. 49.
    Mancini D, Katz S, Donchez L, Aaronson K. Coupling of hemodynamic measurements with oxygen consumption during exercise does not improve risk stratification in patients with heart failure. Circula-tion 1996; 94: 2492–2496.Google Scholar
  50. 50.
    Myers J, Gullestad L, Vagelos R, et al. Clinical, hemodynamic, and cardiopulmonary exercise testdeterminants of survival in patients referred for evaluation of heart failure. Ann Intern Med 1998; 129: 286–293.PubMedGoogle Scholar
  51. 51.
    Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol 1991; 17: 1334–1342.PubMedGoogle Scholar
  52. 52.
    Weber KT, Janicki JS, McElroy PA. Determination of aerobic capacity and the severity of chroniccardiac and circulatory failure. Circulation 1987; 76(Suppl VI): 40–46.Google Scholar
  53. 53.
    Sawada SG, Ryan T, Conley MJ, et al. Prognostic value of a normal exercise echocardiogram. Am Heart J 1990; 120: 49–55.PubMedGoogle Scholar
  54. 54.
    Mark DB, Hlatky MA, Harrell FEJr, et al. Exercise treadmill score for predicting prognosis in coronaryartery disease. Ann Intern Med 1987; 106: 793–800.PubMedGoogle Scholar
  55. 55.
    Mark DB, Shaw L, Harrell FEJr, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991; 325: 849–853.PubMedGoogle Scholar
  56. 56.
    Nallamothu N, Pancholy SB, Lee KR, et al. Impact on exercise single-photon emission computed tomographic thallium imaging on patient management and outcome. J Nucl Cardiol 1995; 2: 334–338.PubMedGoogle Scholar
  57. 57.
    Hayano J, Yamada A, Mukai S, et al. Severity of coronary atherosclerosis correlates with the respiratory component of heart rate variability. Am Heart J 1991; 121: 1070–1079.PubMedGoogle Scholar
  58. 58.
    Okin PM, Anderson KM, Levy D, Kligfield P. Heart rate adjustment of exercise-induced ST segment depression. Improved risk stratification in the Framingham Offspring Study. Circulation 1991; 83: 866–874.PubMedGoogle Scholar
  59. 59.
    Okin PM, Prineas RJ, Grandits G, et al. Heart rate adjustment of exercise-induced ST-segment depres-sion identifies men who benefit from a risk factor reduction program. Circulation 1997; 96: 2899–2904.PubMedGoogle Scholar
  60. 60.
    Okin PM, Grandits G, Rautaharju PM, et al. Prognostic value of heart rate adjustment of exercise-induced ST segment depression in the multiple risk factor intervention trial. J Am Coll Cardiol 1996; 27: 1437–1443.PubMedGoogle Scholar
  61. 61.
    Cole CR, Pashkow FJ, Snader CE, et al. Computerized ST/HR index is a better predictor of mortality than standard ST or thallium [Abstract]. J Am Coll Cardiol 1999; 33: 542A.Google Scholar
  62. 62.
    Okin PM, Kligfield P. Identifying coronary artery disease in women by heart rate adjustment of ST-segment depression and improved performance of linear regression over simple averaging method with comparison to standard criteria. Am J Cardiol 1992; 69: 297–302.PubMedGoogle Scholar
  63. 63.
    Okin PM, Kligfield P. Effect of precision of ST-segment measurement on identification and quantifi-cation of coronary artery disease by the ST/HR index. J Electrocardiol 1992; 24: 62–67.PubMedGoogle Scholar
  64. 64.
    Ribisl PM, Liu J, Mousa I, et al. Comparison of computer ST criteria for diagnosis of severe coronary artery disease. Am J Cardiol 1993; 71: 546–551.PubMedGoogle Scholar
  65. 65.
    Lachterman B, Lehmann KG, Detrano R, et al. Comparison of ST segment/heart rate index to standard ST criteria for analysis of exercise electrocardiogram. Circulation 1990; 82: 44–50.PubMedGoogle Scholar
  66. 66.
    Herbert WG, Dubach P, Lehmann KG, Froelicher VF. Effect of beta-blockade on the interpretation of the exercise ECG: ST level versus delta ST/HR index. Am Heart J 1991; 122: 993–1000.PubMedGoogle Scholar
  67. 67.
    Cullen K, Stenhouse NS, Wearne KL, Cumpston GN. Electrocardiograms and 13 year cardiovascular mortality in Busselton study. Br Heart J 1982; 47: 209–212.PubMedGoogle Scholar
  68. 68.
    Miranda CP, Herbert WG, Dubach P, et al. Post-myocardial infarction exercise testing. Non-Q wave versus Q wave correlation with coronary angiography and long-term prognosis. Circulation 1991; 84: 2357–2365.PubMedGoogle Scholar
  69. 69.
    Stoletniy LN, Pai RG. Value of QT dispersion in the interpretation of exercise stress test in women. Circulation 1997; 96: 904–910.PubMedGoogle Scholar
  70. 70.
    Leroy F, Lablanche JM, Bauters C, et al. Prognostic value of changes in R-wave amplitude during exercise testing after a first acute myocardial infarction. Am J Cardiol 1992; 70: 152–155.PubMedGoogle Scholar
  71. 71.
    Bonoris PE, Greenberg PS, Christison GW, et al. Evaluation of R wave amplitude changes versus ST-segment depression in stress testing. Circulation 1978; 57: 904–910.PubMedGoogle Scholar
  72. 72.
    Bonoris PE, Greenberg PS, Castellanet MJ, Ellestad MH. Significance of changes in R wave amplitude during treadmill stress testing: angiographic correlation. Am J Cardiol 1978; 41: 846–851.PubMedGoogle Scholar
  73. 73.
    Battler A, Froelicher V, Slutsky R, Ashburn W. Relationship of QRS amplitude changes during exercise to left ventricular function and volumes and the diagnosis of coronary artery disease. Circulation 1979; 60: 1004–1013.PubMedGoogle Scholar
  74. 74.
    Cheng SL, Ellestad MH, Selvester RH. Significance of ST-segment depression with R-wave amplitude decrease on exercise testing. Am J Cardiol 1999; 83: 955–969.PubMedGoogle Scholar
  75. 75.
    Hollenberg M, Zoltick JM, Go M, et al. Comparison of a quantitative treadmill exercise score with standard electrocardiographic criteria in screening asymptomatic young men for coronary artery disease. N Engl J Med 1985; 313: 600–606.PubMedGoogle Scholar
  76. 76.
    Wagner S, Cohn K, Selzer A. Unreliability of exercise-induced R wave changes as indexes of coronary artery disease. Am J Cardiol 1979; 44: 1241–1246.PubMedGoogle Scholar
  77. 77.
    Lee JH, Crump R, Ellestad MH. Significance of precordial T-wave increase during treadmill stress testing. Am J Cardiol 1995; 76: 1297–1299.PubMedGoogle Scholar
  78. 78.
    Chikamori T, Doi YL, Furuno T, et al. Diagnostic significance of deep T-wave inversion induced by exercise testing in patients with suspected coronary artery disease. Am J Cardiol 1992; 70: 403–406.PubMedGoogle Scholar
  79. 79.
    Verrier RL, Stone PH. Exercise stress testing for T wave alternans to expose latent electrical instability [editorial]. J Cardiovasc Electrophysiol 1997; 8: 994–997.PubMedGoogle Scholar
  80. 80.
    Hohnloser SH, Klingenheben T, Zabel M, et al. T wave alternans during exercise and atrial pacing in humans. J Cardiovasc Electrophysiol 1997; 8: 987–993.PubMedGoogle Scholar
  81. 81.
    Schwartz PJ, Malliani A. Electrical alternation of the T-wave: clinical and experimental evidence of its relationship with the sympathetic nervous system and with the long Q-T syndrome. Am Heart J 1975; 89: 45–50.PubMedGoogle Scholar
  82. 82.
    Surawicz B, Fisch C. Cardiac alternans: diverse mechanisms and clinical manifestations. J Am Coll Cardiol 1992; 20: 483–499.PubMedGoogle Scholar
  83. 83.
    Zareba W, Moss AJ, le Cessie S, Hall WJ. T wave alternans in idiopathic long QT syndrome. J Am Coll Cardiol 1994; 23: 1541–1546.PubMedGoogle Scholar
  84. 84.
    Salerno JA, Previtali M, Panciroli C, et al. Ventricular arrhythmias during acute myocardial ischaemia in man. The role and significance of R-ST-T alternans and the prevention of ischaemic sudden death by medical treatment. Eur Heart J 1986; 7: 63–75.PubMedGoogle Scholar
  85. 85.
    Rosenbaum DS, Albrecht P, Cohen RJ. Predicting sudden cardiac death from T wave alternans of the surface electrocardiogram: promise and pitfalls. J Cardiovasc Electrophysiol 1996; 7: 1095–1111.PubMedGoogle Scholar
  86. 86.
    Gold MR, Bloomfield DM, Anderson KP, et al. T wave alternans predicts arrhythmia vulnerability in patients undergoing electrophysiology study [abstract]. Circulation 1998; 98(Suppl): 1647–1648.Google Scholar
  87. 87.
    Klingenheben T, Cohen RJ, Peetermans J, Hohnloser SH. Predictive value of T-wave alternans in patients with congestive heart failure. Circulation 1998; 98 (Suppl): 1864.Google Scholar
  88. 88.
    Chikamori T, Kitaoka H, Matsumura Y, et al. Clinical and electrocardiographic profiles producing exercise-induced U-wave inversion in patients with severe narrowing of the left anterior descending coronary artery. Am J Cardiol 1997; 80: 628–632.PubMedGoogle Scholar
  89. 89.
    Choo MH, Gibson DG. U waves in ventricular hypertrophy: possible demonstration of mechano-electrical feedback. Br Heart J 1986; 55: 428–433.PubMedGoogle Scholar
  90. 90.
    Gerson MC, Phillips JF, Morris SN, McHenry PL. Exercise-induced U-wave inversion as a marker of stenosis of the left anterior descending coronary artery. Circulation 1979; 60: 1014–1020.PubMedGoogle Scholar
  91. 91.
    Gerson MC, McHenry PL. Resting U wave inversion as a marker of stenosis of the left anterior descending coronary artery. Am J Med 1980; 69: 545–550.PubMedGoogle Scholar
  92. 92.
    Salmasi AM, Salmasi SN, Nicolaides AN, et al. The value of exercise-induced U-wave inversion on ECG chest wall mapping in the identification of individual coronary arterial lesions. Eur Heart J 1985; 6: 437–443.PubMedGoogle Scholar
  93. 93.
    Grady TA, Chiu AC, Snader CE, et al. Prognostic significance of exercise-induced left bundle-branch block. JAMA 1998; 279: 153–156.PubMedGoogle Scholar
  94. 94.
    Berntsen RF, Gunnes P, Rasmussen K. Pattern of coronary artery disease in patients with ventricular tachycardia and fibrillation exposed by exercise-induced ischemia. Am Heart J 1995; 129: 733–738.PubMedGoogle Scholar
  95. 95.
    dePaola AA, Gomes JA, Terzian AB, et al. Ventricular tachycardia during exercise testing as a predictor of sudden death in patients with chronic chagasic cardiomyopathy and ventricular arrhythmias. Br Heart J 1995; 74: 293–295.PubMedGoogle Scholar
  96. 96.
    Casella G, Pavesi PC, Sangiorgio P, et al. Exercise-induced ventricular arrhythmias in patients with healed myocardial infarction. Int J Cardiol 1993; 40: 229–235.PubMedGoogle Scholar
  97. 97.
    Yang JC, Wesley RC Jr, Froelicher VF. Ventricular tachycardia during routine treadmill testing. Risk and prognosis. Arch Intern Med 1991; 151: 349–353.PubMedGoogle Scholar
  98. 98.
    Califf RM, McKinnis RA, McNeer JF, et al. Prognostic value of ventricular arrhythmias associated with treadmill exercise testing in patients studied with cardiac catheterization for suspected ischemic heart disease. J Am Coll Cardiol 1983; 2: 1060–1067.PubMedGoogle Scholar
  99. 99.
    Sami M, Chaitman B, Fisher L, et al. Significance of exercise-induced ventricular arrhythmia in stable coronary artery disease: a coronary artery surgery study project. Am J Cardiol 1984; 54: 1182–1188.PubMedGoogle Scholar
  100. 100.
    Busby MJ, Shefrin EA, Fleg JL. Prevalence and long-term significance of exercise-induced frequent or repetitive ventricular ectopic beats in apparently healthy volunteers. J Am Coll Cardiol 1989; 14: 1659–1665.PubMedGoogle Scholar
  101. 101.
    Ellestad MH. Chronotropic incompetence. The implications of heart rate response to exercise (com-pensatory parasympathetic hyperactivity?) [editorial]. Circulation 1996; 93: 1485–1487.PubMedGoogle Scholar
  102. 102.
    Hinkle LE Jr, Carver ST, Plakun A. Slow heart rates and increased risk of cardiac death in middle-aged men. Arch Intern Med 1972; 129: 732–748.PubMedGoogle Scholar
  103. 103.
    Hammond HK, Kelly TL, Froelicher V. Radionuclide imaging correlatives of heart rate impairment during maximal exercise testing. J Am Coll Cardiol 1983; 2: 826–833.PubMedGoogle Scholar
  104. 104.
    Heller GV, Ahmed I, Tilkemeier PL, et al. Influence of exercise intensity on the presence, distribution, and size of thallium-201 defects. Am Heart J 1992; 123: 909–916.PubMedGoogle Scholar
  105. 105.
    Beleslin BD, Ostojic M, Stepanovic J, et al. Stress echocardiography in the detection of myocardial ischemia. Head-to-head comparison of exercise, dobutamine, and dipyridamole tests. Circulation 1994; 90: 1168–1176.PubMedGoogle Scholar
  106. 106.
    Marwick TH, Nemec JJ, Pashkow FJ, et al. Accuracy and limitations of exercise echocardiography in a routine clinical setting. J Am Coll Cardiol 1992; 19: 74–81.PubMedGoogle Scholar
  107. 107.
    Hammond HK, Froelicher VF. Normal and abnormal heart rate responses to exercise. Prog Cardiovasc Dis 1985; 27: 271–296.PubMedGoogle Scholar
  108. 108.
    Dyer AR, Persky V, Stamler J, et al. Heart rate as a prognostic factor for coronary heart disease and mortality: findings in three Chicago epidemiologic studies. Am J Epidemiol 1980; 112: 736–749.PubMedGoogle Scholar
  109. 109.
    Paffenbarger RS, Hale WE. Work activity and coronary heart mortality. N Engl J Med 1975; 292: 545–550.PubMedGoogle Scholar
  110. 110.
    Willich SN, Lewis M, Lowel H, et al. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. Engl J Med 1993; 329: 1684–1690.Google Scholar
  111. 111.
    Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Inf-arction Onset Study Investigators. N Engl J Med 1993; 329: 1677–1683.PubMedGoogle Scholar
  112. 112.
    Wilkoff BL, Miller RE. Exercise testing for chronotropic assessment. Cardiol Clin 1992; 10: 705–717.PubMedGoogle Scholar
  113. 113.
    Lauer MS, Pashkow FJ, Larson MG, Levy D. Association of cigarette smoking with chronotropic incompetence and prognosis in the Framingham Heart Study. Circulation 1997; 96: 897–903.PubMedGoogle Scholar
  114. 114.
    Okin PM, Lauer MS, Kligfield P. Chronotropic response to exercise. Improved performance of ST-segment depression criteria after adjustment for heart rate reserve. Circulation 1996; 94: 3226–3231.PubMedGoogle Scholar
  115. 115.
    Lauer MS, Mehta R, Pashkow FJ, et al. Association of chronotropic incompetence with echocardiographic ischemia and prognosis. J Am Coll Cardiol 1998; 32: 1280–1286.PubMedGoogle Scholar
  116. 116.
    Chin CF, Messenger JC, Greenberg PS, Ellestad MH. Chronotropic incompetence in exercise testing. Clin Cardiol 1979; 2: 12–18.PubMedGoogle Scholar
  117. 117.
    Mark AL. The Bezold-Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart. J Am Coll Cardiol 1983; 1: 90–102.PubMedGoogle Scholar
  118. 118.
    Francis GS, Goldsmith SR, Ziesche S, et al. Relative attenuation of sympathetic drive during exercise in patients with congestive heart failure. J Am Coll Cardiol 1985; 5: 832–839.PubMedGoogle Scholar
  119. 119.
    Colucci WS, Ribeiro JP, Rocco MB, et al. Impaired chronotropic response to exercise in patients with congestive heart failure. Role of postsynaptic beta-adrenergic desensitization. Circulation 1989; 80: 314–323.PubMedGoogle Scholar
  120. 120.
    Cole C, Foody J, Blackstone E, Lauer M. Heart rate recovery after submaximal exercise testing as a predictor of mortality in a cardiovascularly healthy cohort. Ann Intern Med 2000; 132: 552–555.PubMedGoogle Scholar
  121. 121.
    Imai K, Sato H, Hori M, et al. Vagally mediated heart rate recovery after exercise is accelerated in athletes but blunted in patients with chronic heart failure. J Am Coll Cardiol 1994; 24: 1529–1535.PubMedGoogle Scholar
  122. 122.
    Schwartz PJ, La Rovere MT, Vanoli E. Autonomic nervous system and sudden cardiac death. Experi-mental basis and clinical observations for post-myocardial infarction risk stratification. Circulation 1992; 85: 177–191.Google Scholar
  123. 123.
    Dlin RA, Hanne N, Silverberg DS, Bar-Or O. Follow-up of normotensive men with exaggerated blood pressure response to exercise. Am Heart J 1983; 106: 316–320.PubMedGoogle Scholar
  124. 124.
    Wilson MF, Sung BH, Pincomb GA, Lovallo WR. Exaggerated pressure response to exercise in men at risk for systemic hypertension. Am J Cardiol 1990; 66: 731–736.PubMedGoogle Scholar
  125. 125.
    Lauer MS, Levy D, Anderson KM, Plehn JF. Is there a relationship between exercise systolic blood pressure response and left ventricular mass? The Framingham Heart Study. Ann Intern Med 1992; 116: 203–210.PubMedGoogle Scholar
  126. 126.
    Irving JB, Bruce RA, DeRouen TA. Variations in and significance of systolic pressure during maximal exercise (treadmill) testing. Am J Cardiol 1977; 39: 841–848.PubMedGoogle Scholar
  127. 127.
    Filipovsky J, Ducimetiere P, Safar ME. Prognostic significance of exercise blood pressure and heart rate in middle-aged men. Hypertension 1992; 20: 333–339.PubMedGoogle Scholar
  128. 128.
    Fagard RH, Pardaens K, Staessen JA, Thijs L. Prognostic value of invasive hemodynamic measure-ments at rest and during exercise in hypertensive men. Hypertension 1996; 28: 31–36.PubMedGoogle Scholar
  129. 129.
    Fagard R, Staessen J, Thijs L, Amery A. Relation of left ventricular mass and filling to exercise blood pressure and rest blood pressure. Am J Cardiol 1995; 75: 53–57.PubMedGoogle Scholar
  130. 130.
    Morrow K, Morris CK, Froelicher VF, et al. Prediction of cardiovascular death in men undergoing non-invasive evaluation for coronary artery disease. Ann Intern Med 1993; 118: 689–695.PubMedGoogle Scholar
  131. 131.
    Mundal R, Kjeldsen SE, Sandvik L, et al. Exercise blood pressure predicts cardiovascular mortality in middle-aged men. Hypertension 1994; 24: 56–62.PubMedGoogle Scholar
  132. 132.
    Mundal R, Kjeldsen SE, Sandvik L, et al. Exercise blood pressure predicts mortality from myocardial infarction. Hypertension 1996; 27: 324–329.PubMedGoogle Scholar
  133. 133.
    Gottdiener JS, Brown J, Zoltick J, Fletcher RD. Left ventricular hypertrophy in men with normal blood pressure: relation to exaggerated blood pressure response to exercise. Ann Intern Med 1990; 112: 161–166.Google Scholar

Copyright information

© Humana Press Inc., Totowa, NJ 2006

Authors and Affiliations

  • Christopher R. Cole
    • 1
  • Michael S. Lauer
    • 2
  1. 1.Colorado Springs CardiologistsColorado Cardiac Alliance Research InstituteColorado Springs
  2. 2.Division of CardiologyWilliam Beaumont HospitalRoyal Oak

Personalised recommendations