Clinical significance and prognostic value of ST segment depression on ECG during exercise treadmill test in asymptomatic patients with moderate or severe aortic stenosis

Objectives. In patients with asymptomatic moderate or severe aortic stenosis (AS), exercise testing is used for evaluating the need for aortic valve intervention. Expert opinions about the clinical significance and prognostic value of ST segment depression on electrocardiography (ECG) during exercise testing in AS is conflicting and there are no large studies exploring this issue. We aimed to explore the association of ST segment depression >5 mm during exercise treadmill test (ETT) with all-cause mortality, aortic valve replacement (AVR) or cardiac-related hospitalization. Design. We performed a retrospective analysis of prospectively collected data of a total of 315 patients (mean age 65 +/- 12 years, 67% men) with asymptomatic moderate (n = 209; 66%) or severe (n = 106; 34%) AS. All patients underwent clinical evaluation, echocardiography and ETT. Results. During a mean follow-up of 34.9 +/- 34.6 months, 29 (9%) patients died and 235 (74%) underwent AVR. The prevalence of ST segment depression (>5 mm) was 13% (n = 41) in the total study population and was comparable in patients with revealed symptoms (17.6%, n = 16) versus without revealed symptoms (11.3%, n = 25; p = .132). ST segment depression on ETT was strongly associated with aortic valve area. In univariate Cox regression analysis, ST segment depression was not associated with cardiac related hospitalizations (HR 1.65; 95% CI 0.89-3.10, p = .113), all-cause mortality (HR 1.37; 95% CI 0.47-3.98, p = .564) or AVR (HR 1.30; 95% CI 0.89-1.91, p = .170). Conclusion. In patients with moderate or severe AS, ST segment depression during ETT is non-specific, carries no prognostic risk and should be used with caution in the clinical interpretation of exercise test.