Exercise stress testing has traditionally been thought of as a means of diagnosing hemodynamically significant obstructive coronary artery disease (CAD), with primary attention paid to the behavior of the ST segment during and immediately after exercise.19 Gibbons R.J., Balady G.J., Beasley J.W. , et al. ACC/AHA Guidelines for Exercise Testing: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 1997 ; 30 : 260-311
Cliquez ici pour aller à la section Références Although extensive literature has demonstrated that exercise testing has some value for diagnostic purposes, particularly in patients with an intermediate pretest likelihood for having disease,16 Fletcher G.F., Balady G., Froelicher V.F. , et al. Exercise standards: A statement for healthcare professionals from the American Heart Association: Writing Group Circulation 1995 ; 91 : 580-615
Cliquez ici pour aller à la section Références, 19 Gibbons R.J., Balady G.J., Beasley J.W. , et al. ACC/AHA Guidelines for Exercise Testing: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing) J Am Coll Cardiol 1997 ; 30 : 260-311
Cliquez ici pour aller à la section Références recent work has drawn attention to three serious limitations of exercise testing as a diagnostic modality. First, when compared to results of coronary angiography, ST-segment changes have only a modest sensitivity and specificity for detecting or excluding obstructive coronary lesions.18 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 [cross-ref]
Cliquez ici pour aller à la section Références Second, almost every study done has suffered from sequential work-up bias, or verification bias, by which the performance of the gold standard coronary angiogram is at least in part determined by the results of the exercise test. This verification bias leads to overestimation of sensitivity and underestimation of specificity.7 Sensitivity and specificity of a single diagnostic test in the presence of work-up bias J Clin Epidemiol 1992 ; 45 : 581-586
Cliquez ici pour aller à la section Références, 52 Roger V.L., Pellikka P.A., Bell M.R. , et al. Sex and test verification bias. Impact on the diagnostic value of exercise echocardiography Circulation 1997 ; 95 : 405-410
Cliquez ici pour aller à la section Références Indeed, a large recent study reported that the true sensitivity of exercise testing in a population free of work-up bias was only 40% to 50%.17 Froelicher V.F., Lehmann K.G., 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
Cliquez ici pour aller à la section Références Third, the gold standard itself, namely coronary angiography, suffers from its own inherent deficiencies, limiting its usefulness for accurately assessing severity of disease.60 Tsuji H., Venditti F.J., Manders E.S. , et al. Reduced heart rate variability and mortality risk in an elderly cohort. The Framingham Heart Study Circulation 1994 ; 90 : 878-883
Cliquez ici pour aller à la section Références
Over the past 10 to 15 years, increasing attention has been focused on the exercise test as a prognostic modality. As reviewed by Hlatky,28 Hlatky M.A. Exercise testing to predict outcome in patients with angina J Gen Intern Med 1999 ; 14 : 63-65 [cross-ref]
Cliquez ici pour aller à la section Références relatively few studies of prognosis have been reported because of the need for large sample sizes and long follow-up periods. Nonetheless, a number of groups have successfully followed large cohorts of patients who have undergone stress testing in a variety of settings and have been able to identify powerful markers of risk.1 Alexander K.P., Shaw L.J., Shaw L.K. , et al. Value of exercise treadmill testing in women [published erratum appears in J Am Coll Cardiol January 1999; 33:289] J Am Coll Cardiol 1998 ; 32 : 1657-1664 [cross-ref]
Cliquez ici pour aller à la section Références, 20 Gibbons R.J., Hodge D.O., Berman D.S. , et al. Long-term outcome of patients with intermediate-risk exercise electrocardiograms who do not have myocardial perfusion defects on radionuclide imaging Circulation 1999 ; 100 : 2140-2145
Cliquez ici pour aller à la section Références, 34 Lauer M.S., Okin P.M., Larson M.G. , et al. Impaired heart rate response to graded exercise. Prognostic implications of chronotropic incompetence in the Framingham Heart Study Circulation 1996 ; 93 : 1520-1526
Cliquez ici pour aller à la section Références, 38 Lauer M.S., Francis G.S., Okin P.M. , et al. Impaired chronotropic response to exercise stress testing as a predictor of mortality JAMA 1999 ; 1999 : 524-529 [cross-ref]
Cliquez ici pour aller à la section Références, 42 Mark D.B., Shaw L., Harrell F.E. , et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease N Engl J Med 1991 ; 325 : 849-853 [cross-ref]
Cliquez ici pour aller à la section Références, 46 Morrow K., Morris C.K., Froelicher V.F. , et al. Prediction of cardiovascular death in men undergoing noninvasive evaluation for coronary artery disease Ann Intern Med 1993 ; 118 : 689-695
Cliquez ici pour aller à la section Références, 47 Nishime E.O., Cole C.R., Blackstone E.H. , et al. Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG JAMA 2000 ; 284 : 1392-1398 [cross-ref]
Cliquez ici pour aller à la section Références, 48 Okin P.M., Anderson K.M., Levy D. , et al. Heart rate adjustment of exercise-induced ST segment depression. Improved risk stratification in the Framingham Offspring Study Circulation 1991 ; 83 : 866-874
Cliquez ici pour aller à la section Références, 62 Weiner D.A., Ryan T.J., 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 [cross-ref]
Cliquez ici pour aller à la section Références This review will focus on three measures that are routinely available in the vast majority of stress tests: the Duke exercise treadmill score,41 Mark D.B., Hlatky M.A., Harrell F.E. , et al. Exercise treadmill score for predicting pregnosis in coronary artery disease Ann Intern Med 1987 ; 106 : 793-800
Cliquez ici pour aller à la section Références, 42 Mark D.B., Shaw L., Harrell F.E. , et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease N Engl J Med 1991 ; 325 : 849-853 [cross-ref]
Cliquez ici pour aller à la section Références the chronotropic response to exercise,35 Lauer M.S., Pashkow F.J., Larson M.G. , et al. Association of cigarette smoking with chronotropic incompetence and prognosis in the Framingham Heart Study Circulation 1997 ; 96 : 897-903
Cliquez ici pour aller à la section Références, 38 Lauer M.S., Francis G.S., Okin P.M. , et al. Impaired chronotropic response to exercise stress testing as a predictor of mortality JAMA 1999 ; 1999 : 524-529 [cross-ref]
Cliquez ici pour aller à la section Références and heart rate recovery immediately after exercise.8 Cole C.R., Blackstone E.H., Pashkow F.J. , et al. Heart-rate recovery immediately after exercise as a predictor of mortality N Engl J Med 1999 ; 341 : 1351-1357 [cross-ref]
Cliquez ici pour aller à la section Références, 9 Cole C.R., Foody J.M., Blackstone E.H. , et al. Heart rate recovery after submaximal exercise testing as a predictor of mortality in a cardiovascularly healthy cohort Ann Intern Med 2000 ; 132 : 552-555
Cliquez ici pour aller à la section Références, 47 Nishime E.O., Cole C.R., Blackstone E.H. , et al. Heart rate recovery and treadmill exercise score as predictors of mortality in patients referred for exercise ECG JAMA 2000 ; 284 : 1392-1398 [cross-ref]
Cliquez ici pour aller à la section Références
Le texte complet de cet article est disponible en PDF.
© 2001
W. B. Saunders Company. Publié par Elsevier Masson SAS. Tous droits réservés.© 1996
© 1999
© 2000
© 1999
© 1999
© 1999
© 2000
Article précédent
