ST-segment deviation during 24-hour ambulatory electrocardiographic monitoring and exercise stress test in healthy male subjects 51 to 75 years of age: The Copenhagen City Heart Study

doi:10.1016/S0002-8703(99)70364-9

American Heart Journal

Volume 137, Issue 6, June 1999, Pages 1070-1074

https://doi.org/10.1016/S0002-8703(99)70364-9 Get rights and content

Abstract

Background Although ST-segment deviation has been evaluated and used during many years both on continuous electrocardiographic Holter monitoring and during exercise stress testing, considerable controversy still remains concerning the prevalence and diagnostic significance of fortuitously discovered ST-segment deviation in asymptomatic healthy persons. Methods and Results The occurrence of ST-segment deviation was studied in a population of 63 clinically healthy male subjects 51 to 75 years of age, with the use of 24-hour Holter monitoring and exercise stress testing. The subjects were recruited from the Copenhagen City Heart Study and were without cardiovascular risk factors, chronic diseases, or medication and without cardiovascular events during 5 to 12 years before and 3 to 5 years after admission. The specificity, that is, the probability of displaying a negative test result in healthy subjects without disease, was 1.0 when using as criterion for significant ST-segment deviation a horizontal or descending ST-segment depression of >0.20 mV or ST-segment elevation ≥0.15 mV during Holter monitoring, and acceptable, for example, 0.95, when using as criterion a horizontal or descending ST-segment depression of ≥0.15 mV during Holter monitoring or at the exercise test, respectively. Furthermore, the specificity was 0.95 when a horizontal or downsloping ST-segment depression of 0.1 mV was displayed in both the Holter and exercise electrocardiographic recording system. Conclusions Thus in asymptomatic persons, the usual criterion for significant ST-segment depression of 0.1 mV can be applied when occurring in both electrocardiographic recording systems. However, if one test alone is used, the criterion of significant ST-segment depression should be 0.15 mV. Absence of ST-segment deviation during Holter monitoring and exercise stress testing, indicated with a specificity of 1.0 or 0.95 according to choice of criterion, implies that the person is in a healthy state. (Am Heart J 1999;137:1070-4.)

Section snippets

Study population and protocol

The Copenhagen City Heart Study6, 7 is a prospective cardiovascular epidemiologic survey of 19,662 persons ≥20 years of age, examined in the periods 1976 to 1978 and 1981 to 1983, selected from a well-defined specific area of Copenhagen with a total adult population of 87,172. The subjects were monitored by a population-based register for death and hospitalization. A total of 3419 men 51 to 75 years of age were included in the Copenhagen City Heart Study. The subjects were considered for

Results

Mean age of the included 63 men was 62 years (range 51 to 75). The analyzable Holter recording time was 1427 ± 136 minutes (mean ± SD). One subject had only 420 minutes of applicable recording time. The minimum and maximum times of the rest were 1200 and 1495 minutes, respectively.

Discussion

The current study demonstrated that the probability of displaying a negative test result in healthy subjects without disease, for example specificity is 1.0 when using as criterion for significant ST-segment deviation a horizontal or descending ST-segment depression of >0.20 mV or ST-segment elevation ≥0.15 mV during Holter monitoring, and acceptable, for example, 0.95 when using as criterion a horizontal or descending ST-segment depression of ≥0.15 mV during Holter monitoring or at the

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Continuous 12-lead electrocardiographic monitoring in an emergency department chest pain unit: An assessment of potential clinical effect
2003, Annals of Emergency Medicine
Citation Excerpt :
In settings other than the ED, the serial ECG has been found to aid in the detection of acute coronary syndrome by capturing transient episodes of ST-segment changes. Serial ECG monitoring has been used to diagnose cardiac ischemia in the ambulatory outpatient population,19-22 to identify coronary occlusion in postthrombolytic and postsurgical patients,5,23,24 and to detect reperfusion in patients receiving thrombolytic therapy for acute myocardial infarction.6,25-28 In ED patients with nondiagnostic 12-lead ECGs, serial ECG might increase the sensitivity of the initial ECG29 and might assist in safely discharging patients with nonischemic causes of chest pain.30
Study objectives: Continuous 12-lead serial ECG monitoring has been proposed to assist in the evaluation of patients with acute coronary syndrome and nondiagnostic ECG in an emergency department chest pain unit. However, the ability of serial ECG to detect acute coronary syndrome and its benefit in addition to a standard protocol has not been established. We evaluate the ability of continuous 12-lead ECG to detect acute coronary syndrome, assess the incremental benefit of the serial ECG in association with a set protocol in an ED chest pain unit, and evaluate whether serial ECG changes could be considered as prognostic factors. Methods: Patients who met Agency for Health Care Policy and Research guidelines for intermediate risk for short-term cardiovascular event unstable angina were prospectively studied in the chest pain unit. Patients were monitored with the Mortara Instruments ELI 100 STM continuous 12-lead ECG system with ST-segment analysis. ST-segment changes of greater than 100 μV in 2 or more contiguous leads or greater than 200 μV in 1 lead were considered positive. Data were compared with serial serum cardiac markers, cardiac function study results, angiographic results, and 30-day outcome results. Results: One hundred nineteen patients had serial ECG applied. The median duration of monitoring was 4.2 hours. Forty patients were given a diagnosis of acute coronary syndrome. Chest pain unit protocol detected 52 patients, and 23 were given a diagnosis of acute coronary syndrome (sensitivity 58%; specificity 63%). Sixteen patients had ST-segment changes of greater than 100 μV or greater than 200 μV, and 9 were given a diagnosis of acute coronary syndrome. The addition of the serial ECG to the chest pain unit protocol increased the sensitivity to 65% and decreased the specificity to 58%. Two patients with ST-segment changes but none without ST-segment changes had an adverse cardiac event, yielding a sensitivity of 100% and a specificity of 88%. Conclusion: Serial ECG is of limited value in the diagnostic evaluation of intermediate-risk patients managed in the chest pain unit with a standard protocol. However, when ST-segment changes are present, they indicate an increased likelihood for an adverse cardiac event. [Ann Emerg Med. 2003;41:342-351.]
Electrocardiographic ST segment depression
2001, American Journal of Emergency Medicine
Citation Excerpt :
A combination of 2 diagnostic criteria have typically been required in at least one electrocardiographic lead to diagnose subendocardial injury - ie, myocardial ischemia: (1) at least 1.0 mm (0.10 mV) depression at the J point and, (2) either horizontal or downward sloping ST segment depression.4 Some investigators have postulated that patients with a “low probability” of coronary artery disease (ie, minimal cardiac risk factors) may need a stricter criteria of STSD - such as greater than 1.5mm or even greater than 2.0 mm of depression - to be regarded as significant.5,6 However, these criteria are based on several small studies of otherwise healthy, asymptomatic patients; the applicability of this criteria to patients presenting with acute cardiopulmonary symptoms is unclear.
Traditionally, ST segment depression has been associated with acute coronary syndromes; this electrocardiographic pattern may also be found in patients with nonischemic events, such as left bundle branch block (LBBB), left ventricular hypertrophy (LVH), and those with therapeutic digitalis levels. Using the ECG as an adjunct in distinguishing those patients with acute coronary syndromes from those with more “benign,” nonacute causes of STSD will obviously lead to divergent treatment and management plans. The following cases illustrate the use the ECG in patients presenting with chest pain and electrocardiographic ST segment depression attributable to an ACS, LVH, LBBB, or digitalis. (Am J Emerg Med 2001;19:303-309. Copyright © 2001 by W.B. Saunders Company)
Diagnostic accuracy of ST changes detected by exercise testing and ambulatory electrocardiographic monitoring in apparently healthy individuals
1999, American Heart Journal
Fifteen-year risk of major coronary events predicted by Holter ST-monitoring in asymptomatic middle-aged men
2005, European Journal of Cardiovascular Prevention and Rehabilitation
Ambulatory electrocardiogram monitoring (Holter) with ST-analysis as a measure of myocardial ichemia has in populations with coronary heart disease been shown to predict major coronary events: death, myocardial infarction or coronary revascularization. There has, however, been conflicting evidence regarding the usefulness of this technique in identification of healthy subjects with increased risk for coronary heart disease. The aim of this study was to assess if Holter monitoring with ST-analysis could be used to predict future major coronary events in asymptomatic middle-aged men with a defined aggregation of traditional risk factors for coronary heart disease.
One hundred and fifty-five asymptomatic participants from the city of Malmö, Sweden, with known levels of conventional cardiovascular risk factors underwent Holter monitoring for analysis of transient ST-segment depression at the age of 55 years. Fifteen years after the Holter monitoring, hospital records, diagnosis and death registries were revisited for major coronary events.
An ST-segment depression of 1 mm or greater (0.1 mV) was considered significant for myocardial ischemia and was found in 54 of the 155 men. There were no significant differences in risk factors in the two groups at baseline. The 15-year incidence of a first major coronary event was significantly higher in men with ST-segment depression (39%) than in men without ST-segment depression (20%) (P<0.015). A Holter electrocardiogram could predict future major coronary events with a positive and negative predictive value of 35 and 80%, respectively.
Holter monitoring can be used as a complement to conventional risk factor evaluation in deciding whether or not to treat risk factors for CHD in asymptomatic subjects.
The diagnostic accuracy of exercise electrocardiography in asymptomatic recreational and competitive athletes
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^☆: Reprint requests: Merete Vaage-Nilsen, MD, Laboratory of Cardiology, Department of Cardiology B, Rigshospitalet University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark.

^☆☆: 0002-8703/99/$8.00 + 0 4/1/95081

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ST-segment deviation during 24-hour ambulatory electrocardiographic monitoring and exercise stress test in healthy male subjects 51 to 75 years of age: The Copenhagen City Heart Study☆,☆☆

Abstract

Section snippets

Study population and protocol

Results

Discussion

Am J Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

The ST segment of the ambulatory electrocardiogram in a normal population

Br Heart J

Ambulatory electrocardiographic ST segment changes in healthy volunteers

Br Heart J

Prevalence and prognostic significance of exercise-induced silent myocardial ischemia detected by thallium scintigraphy and electrocardiography in asymptomatic volunteers

Circulation