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Angina can usually be diagnosed from a proper history When atypical features are present such as prolonged duration (hours or days) or darting, knifelike pains at the apex or over the precordium ischemia is less likely Anterior chest wall syndrome is characterized by sharply localized tenderness of intercostal muscles Inflammation of the chondrocostal junctions, which may be warm, swollen, and red, may result in diffuse chest pain that is also reproduced by local pressure (Tietze s syndrome) Intercostal neuritis (due to herpes zoster, diabetes mellitus, etc) also mimics angina Cervical or thoracic spine disease involving the dorsal roots produces sudden sharp, severe chest pain suggesting angina in location and radiation but related to specific movements of the neck or spine, recumbency, and strain-

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present at rest is detected by precipitation of typical chest pain or ST-segment depression (or, rarely, elevation) Exercise testing is often combined with imaging studies (nuclear, echocardiography, or MRI [see below]), but in patients without baseline ST segment abnormalities or in whom anatomic localization is not necessary, the exercise ECG remains the recommended initial procedure because of considerations of cost and convenience Exercise testing can be done on a motorized treadmill or with a bicycle ergometer A variety of exercise protocols are utilized, the most common being the Bruce protocol, which increases the treadmill speed and elevation every 3 minutes until limited by symptoms At least two ECG leads should be monitored continuously 1 Precautions and risks The usually quoted risk of exercise testing is one infarction or death per 1000 tests, but individuals who continue to have pain at rest or minimal activity are at higher risk and should not be tested Many of the traditional exclusions, such as recent myocardial infarction or CHF, are no longer used if the patient is stable and ambulatory, but aortic stenosis remains a contraindication Although most tests are carried to a symptomlimited end point (except submaximal testing early postinfarction), the test should be terminated when hypotension, significant ventricular or supraventricular arrhythmias, more than mild to moderate angina, or more than 3- to 4-mm ST-segment depression occurs 2 Indications Exercise testing is used (1) to confirm the diagnosis of angina; (2) to determine the severity of limitation of activity due to angina; (3) to assess prognosis in patients with known coronary disease, including those recovering from myocardial infarction, by detecting groups at high or low risk; (4) to evaluate responses to therapy; and (5) less successfully, to screen asymptomatic populations for silent coronary disease The latter application is controversial Because false-positive tests often exceed true positives, leading to much patient anxiety and self-imposed or mandated disability, exercise testing of asymptomatic individuals should be done only for those at high risk (usually a strong family history of premature coronary disease or hyperlipidemia), those whose occupations place them or others at special risk (eg, airline pilots), and older individuals commencing strenuous activity 3 Interpretation The usual ECG criterion for a positive test is 1 mm (01 mV) horizontal or downsloping STsegment depression (beyond baseline) measured 80 milliseconds after the J point By this criterion, 60 80% of patients with anatomically significant coronary disease will have a positive test, but 10 30% of those without significant disease will also be positive False positives are uncommon when a 2-mm depression is present Additional information is inferred from the time of onset and duration of the ECG changes, their magnitude and configuration, BP and heart rate changes, the duration of exercise, and the presence of associated symptoms In general, patients exhibiting more severe ST-segment depression (> 2 mm) at low workloads (< 6 minutes on the Bruce protocol) or heart rates (< 70% of age-predicted maximum) espe-.

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