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Association of Electrocardiographic Morphology of Exercise-Induced Ventricular Arrhythmia with Mortality

Robert E. Eckart, DO; Michael E. Field, MD; Tomasz W. Hruczkowski, MD; Daniel E. Forman, MD; Sharmila Dorbala, MBBS; Marcelo F. Di Carli, MD; Christine E. Albert, MD, MPH; William H. Maisel, MD, MPH; Laurence M. Epstein, MD; and William G. Stevenson, MD
[+] Article, Author, and Disclosure Information

From Brooke Army Medical Center, San Antonio, Texas; Brigham and Women's Hospital, Boston Veterans Administration Medical Center, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; and the University of Alberta, Edmonton, Alberta, Canada.

Potential Financial Conflicts of Interest:Honoraria: L.M. Epstein (Medtronic, Boston Scientific, St. Jude). Grants received: L.M. Epstein (Medtronic, Boston Scientific, Biosense Webster).

Reproducible Research Statement:Study protocol: Available from Brigham and Women's Hospital Institutional Review Board, 75 Francis Street, Boston, MA 02115. Statistical code: Available from Dr. Eckart (e-mail, robert.eckart@us.army.mil). Data set: Certain portions of the analytic data set are available to approved individuals through written agreements with Dr. Eckart (e-mail, robert.eckart@us.army.mil).

Requests for Single Reprints: MAJ Robert E. Eckart, MC, USA, Arrhythmia Service (ATTN: MCHE-MDC), 3851 Roger Brooke Drive, Brooke Army Medical Center, San Antonio, TX 78234; e-mail, robert.eckart@us.army.mil.

Current Author Addresses: Dr. Eckart: Arrhythmia Service (ATTN: MCHE-MDC), 3851 Roger Brooke Drive, Brooke Army Medical Center, San Antonio, TX 78234.

Dr. Field: Cardiovascular Consultants of Maine, P.A., 96 Campus Drive, Suite 1, Scarborough, ME 04074.

Dr. Hruczkowski: Cardiology Arrhythmia Services, 2C1.16 Walter Mackenzie Centre, University of Alberta, Edmonton, Alberta T6G 2B7, Canada.

Drs. Forman, Dorbala, Di Carli, Albert, Epstein, and Stevenson: Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Dr. Maisel: Cardiovascular Division, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Baker 4, Boston, MA 02215.

Author Contributions: Conception and design: R.E. Eckart, M.E. Field, C.E. Albert, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.

Analysis and interpretation of the data: R.E. Eckart, M.E. Field, T.W. Hruczkowski, M.F. Di Carli, C.E. Albert, W.H. Maisel.

Drafting of the article: R.E. Eckart, M.E. Field, T.W. Hruczkowski, M.F. Di Carli, W.H. Maisel, L.M. Epsteìn.

Critical revision of the article for important intellectual content: R.E. Eckart, S. Dorbala, M.F. Di Carli, C.E. Albert, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.

Final approval of the article: R.E. Eckart, S. Dorbala, M.F. Di Carli, W.H. Maisel, L.M. Epsteìn, W.G. Stevenson.

Provision of study materials or patients: R.E. Eckart, S. Dorbala, M.F. Di Carli, L.M. Epsteìn.

Statistical expertise: R.E. Eckart, W.H. Maisel.

Obtaining of funding: R.E. Eckart.

Administrative, technical, or logistic support: R.E. Eckart.

Collection and assembly of data: R.E. Eckart, T.W. Hruczkowskì, M.F. Di Carli.

Ann Intern Med. 2008;149(7):451-460. doi:10.7326/0003-4819-149-7-200810070-00005
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We reviewed the records of all patients undergoing exercise stress testing at Brigham and Women's Hospital, Boston, Massachusetts, between January 2001 and March 2006 for the presence or absence of pathologic arrhythmia during testing. A cardiologist interpreted all tests and specified in the report whether any pathologic arrhythmia was observed. We prospectively defined pathologic arrhythmia (that is, complex ventricular arrhythmia) as a minimum of ventricular couplets, triplets, or multifocal ventricular ectopy (that is, >1 QRS morphologic characteristic of ventricular ectopy) associated with exercise testing. Investigators who were blinded to the results of other testing reviewed the test results that met this definition. We recorded tracings at a paper speed of 25 mm/s and a gain of 10 mm/mV. To assess background incidence of ectopic burden, we reviewed complete tracings of monitoring during patient resting periods through completion of recovery. We excluded participants with intraventricular aberrancy from analysis because this finding could alter clinical management.

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Figure 1.
Study flow diagram.

EIVA = exercise-induced ventricular arrhythmia.

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Figure 2.
Unadjusted Kaplan–Meier survival in the study cohort.

The death rate for those without exercise-induced ventricular arrhythmia (EIVA) was 2.0% during the period of observation compared with 5.5% for those with EIVA (P < 0.001). The mortality rate statistically significantly differed for patients with right bundle-branch block (RBBB)–morphology EIVA (6.8%; P < 0.001) and those with multiple-morphology EIVA (8.3%; P < 0.001) but not for those with left bundle-branch block (LBBB)– morphology EIVA (2.6%; P = 0.60) compared with patients who did not have EIVA.

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Summary for Patients

Type of Exercise-Induced Arrhythmia on Exercise Test and Risk for Death

The summary below is from the full report titled “Association of Electrocardiographic Morphology of Exercise-Induced Ventricular Arrhythmia with Mortality in Patients Referred for Exercise Testing.” It is in the 7 October 2008 issue of Annals of Internal Medicine (volume 149, pages 451-460). The authors are R.E. Eckart, M.E. Field, T.W. Hruczkowski, D.E. Forman, S. Dorbala, M.F. Di Carli, C.E. Albert, W.H. Maisel, L.M. Epstein, and W.G. Stevenson.


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