Early exercise testing after treatment with thrombolytic drugs for acute myocardial infarction: importance of reciprocal ST segment depression

BMJ 1994;308:1189-1192 (7 May)

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Early exercise testing after treatment with thrombolytic drugs for acute myocardial infarction: importance of reciprocal ST segment depression

R N Stevenson, V Umachandran, K Ranjadayalan, R H Roberts, A D Timmis

Department of Cardiology, London Chest Hospital, London E2 9JX Department of Cardiology, Newham General Hospital, London E13 8SL Correspondence to: Dr Robert N Stevenson, Huddersfield Royal Infirmary, Huddersfield HD3 3EA.

Abstract

Objective : To investigate the clinical importance of reciprocalST depression induced by exercise testing early after acutemyocardial infarction in patients treated with thrombolysis.
Design : Prospective observational study.
Setting : District general hospital in London.
Subjects : 202 patients (170 men) aged 33-69 with acute myocardialinfarction treated with thrombolysis.
Main outcome measures : All patients underwent exercise testingand coronary arteriography. ST depression induced by exercisewas classified as either reciprocal (associated with ST elevation)or isolated (occurring on its own). The relation between reciprocalST depression and the following end points was studied: characteristicsof the infarct, left ventricular ejection fraction, extent ofcoronary artery disease on arteriography, and presence of anginainduced by exercise.
Results : Reciprocal ST depression occurred almost exclusivelyin Q wave infarctions and was associated with a lower overallejection fraction than isolated ST depression. It tended tobe associated with persistent occlusion of the coronary arteryrelated to the infarct and did not indicate remote ischaemiadue to multivessel coronary disease. Unlike isolated ST depression,reciprocal ST depression was not associated with angina inducedby exercise.
Conclusions : Reciprocal ST depression induced by exerciseis usually associated with extensive Q wave infarctions andpersistent occlusion of the artery related to the infarct. Itdoes not seem to indicate reversible ischaemia and should notbe used as a non-invasive marker of multivessel disease in theassessment of requirements for further investigation soon afteracute myocardial infarction.

Clinical implications

Clinical implications
Treadmill exercise testing is widely used to select patients for coronary angiography after myocardial infarction
Little information is available on the importance of reciprocal ST depression during exercise testing after infarction
In this study reciprocal ST depression occurred almost exclusively in Q wave infarctions and was associated with a lower ejection fraction than isolated ST depression
Reciprocal ST depression tended to be associated with an occluded coronary artery related to the infarct and was not associated with multivessel coronary disease
Reciprocal ST depression occurring during exercise testing after infarction does not seem to indicate reversible ischaemia

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Dominguez, H, Torp-Pedersen, C, Koeber, L, Rask-Madsen, C (2001). Prognostic value of exercise testing in a cohort of patients followed for 15 years after acute myocardial infarction. Eur Heart J 22: 300-306 [Abstract]
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