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LETTERS: Kevin Barraclough Sensitivity and specificity of exercise ECG in heart disease BMJ 2008; 337: a3098 [Full text]

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False negative exercise ECG: are we using the wright tool?

Riccardo Bigi   (26 January 2009)

False negative exercise ECG: are we using the wright tool? 26 January 2009
Riccardo Bigi, Senior Clinical Researcher Department of Cardiovascular Sciences,University School of Medicine, via Parea 4, 20138 Milan, Italy Send response to journal: Re: False negative exercise ECG: are we using the wright tool?	I read with great interest this article and I agree with the Authors on the major clinical relevance of the unsatisfactory sensitivity of exercise ECG in heart disease. However, an important remark should be done, in my opinion, concerning the criteria to define a test as negative. Despite several markers of ischemia are available from exercise ECG testing, the use of fixed magnitude of ST- segment depression has been the leading approach in the majority of clinical studies to distinguish between positive and negative response. The intrinsic limitation of such a dichotomous interpretation is well known. Two main theoretical assumptions have supported the evolution of ST- segment analysis during the last years. The first hypothesizes that the examination of the peak rate of ST depression as a function of the increase in heart rate during developing ischemia should more accurately reflect the severity of disease than does ST depression alone. The second suggests that, since the relationship of ST-segment depression to myocardial oxygen demand is non-linear during early recovery, the resolution of ST depression during this phase lags behind its development during exercise in case of significant coronary artery disease. Both these assumptions have produced diagnostic indexes which proved to be more accurate markers of myocardial ischemia than ST depression alone. The combination of these with established clinical markers is expected to significantly reduce the number of false negative results. Surprisingly, no prospective study has been designed so far to assess this hypothesis. In the meanwhile, the lack of confidence in the clinical utility of exercise ECG is generating an increasing recourse to more expensive, less available and sometimes less safe procedures. References 1. 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;25:1726-35 2. Bigi R, Cortigiani L, Gregori D, Bax JJ, Fiorentini C. Prognostic value of combined exercise and recovery electrocardiographic analysis. Arch Intern Med 2005;165:1253-1258 Competing interests: None declared