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Rehabilitation of the Exercise Electrocardiogram

Paul Kligfield, MD
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The New York Hospital-Cornell Medical Center; New York, NY 10021. Requests for Reprints: Paul Kligfield, MD, Division of Cardiology, Department of Medicine, The New York Hospital-Cornell Medical Center, 525 East 68th Street, New York, NY 10021.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;128(12_Part_1):1035-1037. doi:10.7326/0003-4819-128-12_Part_1-199806150-00015
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Evaluation of the electrocardiographic ST-segment response to exercise has been the most widely used laboratory method for the assessment of ischemic heart disease for half a century. The availability, accessibility, and relatively simple technological requirements of exercise electrocardiography make it a useful tool for the general internist as well as the subspecialist, but the limitations of standard test criteria are well recognized. Sensitivity for the detection of coronary disease is poor, particularly when only modest obstruction is present, and test responses are often indeterminate in the presence of upsloping ST-segment depression [12]. As an inevitable consequence of low sensitivity and imperfect specificity for coronary obstruction, the positive predictive value of the standard exercise test is poor when disease prevalence is low [3]. This Bayesian principle has become so entrenched in the contemporary medical literature that the perception has evolved that the exercise electrocardiogram cannot be improved and that attempting to improve it is presumptuous.

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