Use of electrocardiographic depolarization abnormalities for detection of stress-induced ischemia as defined by myocardial perfusion imaging.

High-frequency mid-QRS (HFQRS) analysis was recently introduced as a tool for identification of stress-induced ischemia. The diagnostic performance of this electrocardiographic technique has not been determined in a large cohort of patients. This study compared the diagnostic performance of HFQRS analysis to conventional ST-segment analysis in detecting exercise-induced ischemia. The study included 996 patients (56 ± 10 years of age, 670 men) referred for exercise myocardial perfusion imaging (MPI), which served as the gold standard of ischemia. High-resolution electrocardiogram was used for computer analysis of HFQRS signals. Number of electrocardiographic leads with ≥50% decrease of HFQRS intensity (L(50%)) was used as an index of ischemia. Perfusion images were evaluated semiquantitatively. Receiver operating characteristic analysis demonstrated an L(50%) ≥3 as the criterion that yielded optimal sensitivity and specificity for diagnosing moderate/severe ischemia. Compared to ST-segment analysis HFQRS analysis was more sensitive (69% vs 39%, p <0.005) and more specific (86% vs 82%, p <0.05). L(50%) correlated with amount of MPI ischemia (R(2) = 0.75, p <0.0001). Multivariate logistic regression analysis demonstrated a significant incremental diagnostic value for the addition of HFQRS data to a model containing pretest and conventional exercise parameters. L(50%) was the best predictor of mild or moderate/severe MPI ischemia. In conclusion, computerized HFQRS analysis improved the diagnostic performance of conventional stress electrocardiogram in detecting exercise-induced ischemia. Thus, this technique might aid in the noninvasive evaluation of coronary artery disease.

[1]  E. Antman,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). , 2002, Journal of the American College of Cardiology.

[2]  O Pahlm,et al.  Changes in high-frequency QRS components are more sensitive than ST-segment deviation for detecting acute coronary artery occlusion. , 2000, Journal of the American College of Cardiology.

[3]  R. Gibbons,et al.  Assessment of the exercise electrocardiogram in women versus men using tomographic myocardial perfusion imaging as the reference standard. , 2001, The American journal of cardiology.

[4]  G Germano,et al.  Prediction of myocardial infarction versus cardiac death by gated myocardial perfusion SPECT: risk stratification by the amount of stress-induced ischemia and the poststress ejection fraction. , 2001, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[5]  S. Abboud,et al.  Simulation of high-resolution QRS complex using a ventricular model with a fractal conduction system. Effects of ischemia on high-frequency QRS potentials. , 1991, Circulation research.

[6]  M. Yamaki,et al.  Decrease in the high frequency QRS components depending on the local conduction delay. , 1998, Japanese circulation journal.

[7]  Paul Kligfield,et al.  Exercise Electrocardiogram Testing: Beyond the ST Segment , 2006, Circulation.

[8]  S Abboud.  Subtle alterations in the high-frequency QRS potentials during myocardial ischemia in dogs. , 1987, Computers and biomedical research, an international journal.

[9]  S. Akselrod,et al.  Effects of coronary occlusion on high-frequency content of the epicardial electrogram and body surface electrocardiogram. , 1987, Circulation.

[10]  F. L. Lucas,et al.  Temporal Trends in the Utilization of Diagnostic Testing and Treatments for Cardiovascular Disease in the United States, 1993–2001 , 2006, Circulation.

[11]  D. Berman,et al.  Separate acquisition rest thallium-201/stress technetium-99m sestamibi dual-isotope myocardial perfusion single-photon emission computed tomography: a clinical validation study. , 1993, Journal of the American College of Cardiology.

[12]  L. Shaw,et al.  Current Economic Evidence Using Noninvasive Cardiac Testing , 2003 .

[13]  E. Antman,et al.  ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionucl , 2003, Journal of the American College of Cardiology.

[14]  K. Zou,et al.  Receiver-Operating Characteristic Analysis for Evaluating Diagnostic Tests and Predictive Models , 2007, Circulation.

[15]  A L Goldberger,et al.  Effect of Myocardial Infarction on High‐frequency QRS Potentials , 1981, Circulation.

[16]  W. Vach,et al.  Diagnostic accuracy of myocardial perfusion imaging in a study population without post-test referral bias , 2005, Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology.

[17]  Robert Califf,et al.  Value of the History and Physical in Identifying Patients at Increased Risk for Coronary Artery Disease , 1993, Annals of Internal Medicine.

[18]  R J Cohen,et al.  Detection of transient myocardial ischemia by computer analysis of standard and signal-averaged high-frequency electrocardiograms in patients undergoing percutaneous transluminal coronary angioplasty. , 1987, Circulation.

[19]  V Hombach,et al.  Standards for analysis of ventricular late potentials using high-resolution or signal-averaged electrocardiography: a statement by a task force committee of the European Society of Cardiology, the American Heart Association, and the American College of Cardiology. , 1991, Journal of the American College of Cardiology.

[20]  R. Cohen,et al.  A spectral analysis of the high frequency QRS potentials observed during acute myocardial ischemia in dogs. , 1990, International journal of cardiology.

[21]  T Sharir,et al.  Evaluation of an attenuation correction method for thallium-201 myocardial perfusion tomographic imaging of patients with low likelihood of coronary artery disease , 1998, Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology.

[22]  Leif Sörnmo,et al.  High-frequency QRS electrocardiogram analysis during exercise stress testing for detecting ischemia. , 2008, International journal of cardiology.

[23]  C. Dennis,et al.  The Electrocardiographic Exercise Test in a Population with Reduced Workup Bias: Diagnostic Performance, Computerized Interpretation, and Multivariable Prediction , 1998, Annals of Internal Medicine.

[24]  S Abboud,et al.  High-frequency electrocardiogram analysis of the entire QRS in the diagnosis and assessment of coronary artery disease. , 1993, Progress in cardiovascular diseases.

[25]  Y. Benjamini,et al.  THE CONTROL OF THE FALSE DISCOVERY RATE IN MULTIPLE TESTING UNDER DEPENDENCY , 2001 .

[26]  J. Higgins,et al.  Electrocardiographic exercise stress testing: an update beyond the ST segment. , 2007, International journal of cardiology.

[27]  S. Abboud,et al.  Detection of stress-induced myocardial ischemia from the depolarization phase of the cardiac cycle--a preliminary study. , 2009, Journal of electrocardiology.

[28]  D. Berman,et al.  Comparison of the Short‐Term Survival Benefit Associated With Revascularization Compared With Medical Therapy in Patients With No Prior Coronary Artery Disease Undergoing Stress Myocardial Perfusion Single Photon Emission Computed Tomography , 2003, Circulation.