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• W2002040366 abstract "The relationship between exercise and premature ventricular beats in patients with known arrhythmias at rest was first reported by Bourne1Bourne C An attempt at the clinical classification of premature ventricular beats.Q J Med. 1927; 20: 219-243Crossref Scopus (16) Google Scholar in 1927. In the small number of patients studied, exercise increased the frequency of premature ventricular beats in those patients with coronary disease but had no apparent effect on the frequency in normal patients or in those with rheumatic heart disease. Over the next several decades, several reports in the literature created confusion with regard to the prognostic implications of exercise-associated ventricular arrhythmias.2Porter WB The probably grave significance of premature beats occurring in angina pectoris induced by effort.Am J Med Sci. 1948; 216: 509Crossref PubMed Scopus (2) Google Scholar, 3Mann RH Burchell HB Premature ventricular contractions and exercise.Proc Staff Mayo Clin Meetings. 1952; 27: 383PubMed Google Scholar, 4Master AM Field LE Donoso E Coronary artery disease and the “two step” exercise test.NY State J Med. 1957; 57: 1051PubMed Google Scholar The subsequent development of the motor-driven treadmill, which facilitated on-line electrocardiographic monitoring during exercise, reinforced this diagnostic dilemma, especially since these arrhythmias could not be consistently reproduced. In a small number of patients studied by Mokotoff et al in this issue of Chest (see page 10), complex ventricular arrhythmias were subsequently reproducible in only 50 percent (4/8 patients). Studies from the literature report similar data.5Jelinek MJ Lown B Exercise testing for exposure of cardiac arrhythmias.Prog Cardiovasc Dis. 1974; 16: 497Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 6Faris JV McHenry PL Jordan JW et al.Prevalence and reproducibility of exercise-induced ventricular arrhythmias during maximal exercise testing in normal men.Am J Cardiol. 1976; 37: 617Abstract Full Text PDF PubMed Scopus (65) Google Scholar, 7Blackburn H Taylor HL Hamrell B et al.Premature ventricular complexes induced by stress testing.Am J Cardiol. 1973; 31: 441Abstract Full Text PDF PubMed Scopus (71) Google Scholar This apparent lack of reproducibility is not surprising, since the complex sequence of events necessary for the development of exercise-induced ventricular arrhythmias, such as increased sympathetic tone or the occurrence of an oxygen debt, may be counterbalanced by the mechanism of overdrive suppression due to a rapid heart rate.8DeMaria AN Zakauddin V Amsterdam EA et al.Disturbances of cardiac rhythm and conduction induced by exercise.Am J Cardiol. 1974; 33: 732Abstract Full Text PDF PubMed Scopus (33) Google Scholar It appears that the significance of these arrhythmias is dependent upon the clinical circumstance in which they occur. Intuitively, one would not expect to attach the same significance to the development of a ventricular arrhythmia at a relatively high heart rate in a young athlete as to the development of a similar arrhythmia in a middle-aged man at a relatively low heart rate. Although prior studies suggest that the prevalence of exercise-induced ventricular arrhythmias is significantly greater in patients with known coronary disease, more than 25 percent of the patients with normal coronary arteries may manifest some degree of ventricular ectopy;5Jelinek MJ Lown B Exercise testing for exposure of cardiac arrhythmias.Prog Cardiovasc Dis. 1974; 16: 497Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 9McHenry PL Fisch C Jordan JW et al.Cardiac arrhythmias observed during maximal treadmill exercise testing in clinically normal men.Am J Cardiol. 1972; 29: 331Abstract Full Text PDF PubMed Scopus (97) Google Scholar, 10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar however, in normal subjects, as well as in patients with disease, the prevalence of these arrhythmias tends to increase with age and has been reported to approach 50 percent in both populations by the fifth decade of life.9McHenry PL Fisch C Jordan JW et al.Cardiac arrhythmias observed during maximal treadmill exercise testing in clinically normal men.Am J Cardiol. 1972; 29: 331Abstract Full Text PDF PubMed Scopus (97) Google Scholar Although the less complex ventricular arrhythmias are more prevalent than the more complex variety in both normal subjects and in those with coronary disease, complex arrhythmias (defined by multiformity, frequency, and sustained rhythms) occur significantly more often in the latter.9McHenry PL Fisch C Jordan JW et al.Cardiac arrhythmias observed during maximal treadmill exercise testing in clinically normal men.Am J Cardiol. 1972; 29: 331Abstract Full Text PDF PubMed Scopus (97) Google Scholar, 10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 11Crawford M O'Rourke RA Ramakrishna N et al.Comparative effectiveness of exercise testing and continuous monitoring for detecting arrhythmias in patients with previous myocardial infarction.Circulation. 1974; 50: 301Crossref PubMed Scopus (45) Google Scholar, 12Ryan M Lown B Horn H Comparison of ventricular ectopic activity during 24 hour monitoring and exercise testing in patients with coronary heart disease.N Engl J Med. 1975; 292: 224Crossref PubMed Scopus (156) Google Scholar Ventricular arrhythmias also are more prevalent at heart rates less than 130 beats per minute and during the recovery period after exercise in patients with coronary disease, underlying the importance for continuing electrocardiographic monitoring after exercise has been terminated.5Jelinek MJ Lown B Exercise testing for exposure of cardiac arrhythmias.Prog Cardiovasc Dis. 1974; 16: 497Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 13Anderson MT Lee GB Campion BC et al.Cardiac dysrhythmias associated with exercise stress testing.Am J Cardiol. 1972; 30: 763Abstract Full Text PDF PubMed Scopus (22) Google Scholar When patients with known coronary atherosclerosis are subgrouped according to the extent of disease, the prevalence of exercise-induced ventricular arrhythmias tends to increase with the number of diseased vessels, achieving statistical significance when those patients with multiple-vessel disease are compared to those with single-vessel disease.11Crawford M O'Rourke RA Ramakrishna N et al.Comparative effectiveness of exercise testing and continuous monitoring for detecting arrhythmias in patients with previous myocardial infarction.Circulation. 1974; 50: 301Crossref PubMed Scopus (45) Google Scholar, 14Goldschlager N Cake D Cohn K Exercise-induced ventricular arrhythmias in patients with coronary artery disease.Am J Cardiol. 1973; 31: 434Abstract Full Text PDF PubMed Scopus (98) Google ScholarData from these studies also suggest that exercise-induced ventricular arrhythmias are significantly more frequent in subgroups of patients with coronary atherosclerosis and previous myocardial infarction or left ventricular dysfunction.10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 14Goldschlager N Cake D Cohn K Exercise-induced ventricular arrhythmias in patients with coronary artery disease.Am J Cardiol. 1973; 31: 434Abstract Full Text PDF PubMed Scopus (98) Google Scholar Ventricular arrhythmias at rest which disappear or diminish in frequency with exercise are probably not as benign as have been suspected previously. Recent studies indicate that this response to exercise, when compared to arrhythmias which increase in frequency with exercise5Jelinek MJ Lown B Exercise testing for exposure of cardiac arrhythmias.Prog Cardiovasc Dis. 1974; 16: 497Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 14Goldschlager N Cake D Cohn K Exercise-induced ventricular arrhythmias in patients with coronary artery disease.Am J Cardiol. 1973; 31: 434Abstract Full Text PDF PubMed Scopus (98) Google Scholar, 15Udall JA Ellestad MH Predictive implications of ventricular premature contractions associated with treadmill stress testing.Circulation. 1977; 56: 985Crossref PubMed Scopus (85) Google Scholar, 16Helfant RH Pine R Kabde V et al.Exercise related ventricular premature complexes in coronary heart disease.Ann Intern Med. 1974; 80: 589Crossref PubMed Scopus (44) Google Scholar may be just as predictive for multiple-vessel disease and previous myocardial infarction in patients with known disease. The fact that approximately 50 percent of the 50-year-old patients with coronary disease may manifest some form of ventricular ectopy with exercise does not address the issue of the significance or predictive value of this finding in the individual patient, an issue of major importance to the clinician. Fortunately, various features of these arrhythmias can provide insight in this regard. The tendency towards complexity, appearance at a heart rate of less than 130 beats per minute, concomitant occurrence of significant ST-segment depression, and occurrence in the recovery period all increase the predictive capability of exercise-induced ventricular arrhythmias to diagnose underlying coronary disease.5Jelinek MJ Lown B Exercise testing for exposure of cardiac arrhythmias.Prog Cardiovasc Dis. 1974; 16: 497Abstract Full Text PDF PubMed Scopus (162) Google Scholar, 10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 13Anderson MT Lee GB Campion BC et al.Cardiac dysrhythmias associated with exercise stress testing.Am J Cardiol. 1972; 30: 763Abstract Full Text PDF PubMed Scopus (22) Google Scholar, 14Goldschlager N Cake D Cohn K Exercise-induced ventricular arrhythmias in patients with coronary artery disease.Am J Cardiol. 1973; 31: 434Abstract Full Text PDF PubMed Scopus (98) Google Scholar The precise predictive value, however, would depend upon the a priori likelihood of disease in the individual tested in accordance with Bayesian analysis; that is, given an imperfect diagnostic test with known sensitivity and specificity (such as the provocation of ventricular arrhythmias by exercise), a positive response is more meaningful and less likely to be falsely positive in the patient with the greater estimated likelihood of disease prior to testing. Other factors which also are associated with exercise-induced arrhythmias and which thus may increase the false-positive rate, include the presence of mitral valvular prolapse, idiopathic hypertrophic subaortic stenosis, cardiomyopathy, hypokalemia, or digitalis therapy. Of additional clinical importance, exercise-induced ventricular arrhythmias may provide insight into the extent and severity of disease in patients with known coronary atherosclerosis; for example, provocation of these arrhythmias, when compared to their absence, appears to be more predictive for multiple-vessel disease, previous myocardial infarction, left ventricular dysfunction and sudden coronary death.10McHenry PL Morris SN Kavalier M et al.Comparative study of exercise-induced ventricular arrhythmias in normal subjects and patients with documented coronary artery disease.Am J Cardiol. 1976; 37: 609Abstract Full Text PDF PubMed Scopus (94) Google Scholar, 14Goldschlager N Cake D Cohn K Exercise-induced ventricular arrhythmias in patients with coronary artery disease.Am J Cardiol. 1973; 31: 434Abstract Full Text PDF PubMed Scopus (98) Google Scholar, 15Udall JA Ellestad MH Predictive implications of ventricular premature contractions associated with treadmill stress testing.Circulation. 1977; 56: 985Crossref PubMed Scopus (85) Google Scholar However, in a population of asymptomatic patients, exercise-induced ventricular arrhythmias may carry no increased risk for future coronary events unless the arrhythmias are of the complex type or are associated with significant ST-segment changes.15Udall JA Ellestad MH Predictive implications of ventricular premature contractions associated with treadmill stress testing.Circulation. 1977; 56: 985Crossref PubMed Scopus (85) Google Scholar, 17Froelicher VF Thomas MM Pillow C et al.Epidemiologic study of asymptomatic man screened by maximal treadmill testing for latent coronary artery disease.Am J Cardiol. 1974; 34: 770Abstract Full Text PDF PubMed Scopus (171) Google Scholar It thus appears that in the asymptomatic patient with low risk for disease prior to testing, an exercise-induced ventricular arrhythmia is not an independent predictor for the presence of coronary disease. In contrast, in the patient with known or suspected coronary disease, an exercise-induced ventricular arrhythmia may be an independent predictor for multiple-vessel disease, left ventricular dysfunction, previous myocardial infarction, and sudden coronary death, especially when the arrhythmia is of the complex type and when it occurs at a low external work load." @default.
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• W2002040366 title "The Significance of Exercise-Induced Ventricular Arrhythmias" @default.
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