Skip to main content
SpringerLink
Log in

Is an Exercise Tolerance Test Indicated Before Beginning Regular Exercise? A Decision Analysis

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND AND OBJECTIVE

The present study, using a decision analysis, evaluates whether an exercise tolerance test (ETT) is indicated before initiating regular physical activity to reduce the risk of sudden death during exercise training.

DESIGN

The study encompasses a decision tree, Monte Carlo simulation, and utility analysis for adults at low to high risk for coronary disease, with a time horizon of five years, with or without routine ETT screening before initiating physical activity.

MEASURES

Mortality in Monte Carlo simulation; expected values in utility analysis.

RESULTS

Routine screening decreases mortality in intermediate to high-risk populations but not in low-risk persons. At all risk levels, the number of exercise-induced deaths prevented is less than the added number of deaths from angiography. Utility analysis indicates inferiority of routine screening, regardless of risk. Personal preferences (perceived stigma from having coronary disease and perceived benefit of regular exercise on quality of life) have a strong influence on the optimal choice.

CONCLUSION

Routine screening before initiating regular exercise is not recommended for the purpose of reducing the risk of sudden death during exercise training.

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

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

References

  1. United States Public Health Service Office of the Surgeon General. Physical activity and health: a report of the Surgeon General. Pittsburg, PA: U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention; 1996.

  2. In Collaboration With the American College of Sports Medicine, Thompson PD, Franklin BA, et al. Exercise and Acute Cardiovascular Events: Placing the Risks Into Perspective: A Scientific Statement From the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115:2358–68.

    Article  PubMed  Google Scholar 

  3. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000; 343: 1355–61.

    Article  PubMed  CAS  Google Scholar 

  4. Reddy PR, Reinier K, Singh T, et al. Physical activity as a trigger of sudden cardiac arrest: The Oregon Sudden Unexpected Death Study. Int J Cardiol. 2009; 131: 345–9.

    Article  PubMed  Google Scholar 

  5. Eckart RE, Field ME, Hruczkowski TW, et al. Association of Electrocardiographic Morphology of Exercise-Induced Ventricular Arrhythmia with Mortality. Ann Intern Med. 2008; 149: 451–60.

    PubMed  Google Scholar 

  6. Katzel LI, Sorkin JD, Goldberg AP. Exercise-induced silent myocardial ischemia and future cardiac events in healthy, sedentary, middle-aged and older men. J Am Geri Soc. 1999; 47: 923.

    CAS  Google Scholar 

  7. Laukkanen JA, Makikallio TH, Rauramaa R, Kurl S. Asymptomatic ST-segment depression during exercise testing and the risk of sudden cardiac death in middle-aged men: a population-based follow-up study. Eur Heart J. 2009; 30: 558–65.

    Article  PubMed  Google Scholar 

  8. U. S. Preventive Services Task Force. Screening for Coronary Heart Disease: Recommendation Statement. Ann Intern Med. 2004;140:569–572.

    Google Scholar 

  9. Gibbons RJ, Balady GJ, Timothy Bricker J, et al. 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). J Am Coll Cardiol. 2002; 40: 1531–40.

    Article  PubMed  Google Scholar 

  10. Byberg L, Melhus H, Gedeborg R, et al. Total mortality after changes in leisure time physical activity in 50 year old men: 35 year follow-up of population based cohort. BMJ. 2009;338:b688-.

    Google Scholar 

  11. Hippisley-Cox J, Coupland C. Effect of statins on the mortality of patients with ischaemic heart disease: population based cohort study with nested case-control analysis. Heart. 2006; 92: 752–8.

    Article  PubMed  CAS  Google Scholar 

  12. Critchfield GC, Willard KE. Probabilistic analysis of decision trees using Monte Carlo simulation. Med Decision Making. 1986; 6: 85–92.

    Article  CAS  Google Scholar 

  13. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA. 2004; 291: 1238–45.

    Article  PubMed  Google Scholar 

  14. Douglas PS, Redberg RF, Blumenthal RS, Ambrose M. Imaging for coronary risk assessment: Ready for prime time? J Am Coll Cardiol Img. 2008; 1: 263–5.

    Google Scholar 

  15. Anderson HV, Shaw RE, Brindis RG, et al. A contemporary overview of percutaneous coronary interventions: The American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). J Am Coll Cardiol. 2002; 39: 1096–103.

    Article  PubMed  Google Scholar 

  16. Scanlon PJ, Faxon DP, Audet A-M, et al. ACC/AHA guidelines for coronary angiography: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography) developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol. 1999; 33: 1756–824.

    Article  PubMed  CAS  Google Scholar 

  17. Rogers WJ, Canto JG, Lambrew CT, et al. Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999: The National Registry of Myocardial Infarction 1, 2 and 3. J Am Coll Cardiol.. 2000; 36: 2056–63.

    Article  PubMed  CAS  Google Scholar 

  18. Hallqvist J, Moller J, Ahlbom A, Diderichsen F, Reuterwall C, Faire Ud. Does heavy physical exertion trigger myocardial infarction? A case-crossover analysis nested in a population based case-referent study. Am. J. Epidemiol.. 2000; 151: 459–67.

    PubMed  CAS  Google Scholar 

  19. Williams PT. Physical fitness and activity as separate heart disease risk factors: a meta-analysis. Med Sci Sports Exercise. 2001; 33: 754–61.

    CAS  Google Scholar 

  20. Antithrombotic Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002;324:71–86.

    Google Scholar 

  21. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med. 1996; 335: 1001–9.

    Article  PubMed  CAS  Google Scholar 

  22. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000;342:145–53.

    Google Scholar 

  23. Macera A, Jones DA, Yore MM, et al. Prevalence of physical activity, including lifestyle activities among adults—United States, 2000–2001. MMWR Morb Mortal Wkly Rep. 2003; 52: 764–69.

    Google Scholar 

  24. Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med. 2001; 345: 892.

    Article  PubMed  CAS  Google Scholar 

  25. Suaya JA, Shepard DS, Normand S-LT, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007; 116: 1653–62.

    Article  PubMed  Google Scholar 

  26. Center for Evaluation of Value and Risk in Health. Cost-Effectiveness Analysis Registry (CEA); Formerly: Standardizing the Methods and Practices of Cost-Effectiveness Analysis at the Harvard Center for Risk Analysis. Currently available at: https://research.tufts-nemc.org/cear/ Accessed May 26, 2008.

  27. Elley CR, Kerse N, Arroll B, Robinson E. Effectiveness of counselling patients on physical activity in general practice: cluster randomised controlled trial. BMJ. 2003; 326: 793.

    Article  PubMed  Google Scholar 

  28. Laforge RG, Rossi JS, Prochaska JO, Velicer WF, Levesque DA, McHorney CA. Stage of regular exercise and health-related quality of life. Prev Med. 1999; 28: 349–60.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgment

None applicable.

Conflict of interest statement

None disclosed.

Author information

Authors and Affiliations

  1. Department of Internal Medicine E, Tel-Aviv Sourasky Medical Center, Ichilov Hospital, Tel-Aviv, Israel

    Dror Lahav MD

  2. Faculty of Management and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

    Moshe Leshno MD

  3. Center for Health Policy, Stanford University, Palo Alto, CA, USA

    Mayer Brezis MD, MPH

  4. Center for Primary Care and Outcomes Research, Stanford University, Palo Alto, CA, USA

    Mayer Brezis MD, MPH

  5. Center for Clinical Quality & Safety, Hadassah Hebrew University Medical Center, Jerusalem, Israel

    Mayer Brezis MD, MPH

Authors
  1. Dror Lahav MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Moshe Leshno MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mayer Brezis MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mayer Brezis MD, MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Lahav, D., Leshno, M. & Brezis, M. Is an Exercise Tolerance Test Indicated Before Beginning Regular Exercise? A Decision Analysis. J GEN INTERN MED 24, 934–938 (2009). https://doi.org/10.1007/s11606-009-1029-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-009-1029-2

KEY WORDS

Search

Navigation