ST elevation on the exercise ECG in patients presenting with chest pain and no prior history of myocardial infarction

Objective: To assess the aetiology, and prognosis of ST-segment elevation (STE) on the exercise electrocardiogram in patients with chest pain without a prior history of myocardial infarction (MI). Methods: Between January 1998 and December 2005, 14 941 exercise stress tests were performed to assess chest pain in patients without a prior history of MI. Those who developed STE were identified. Results: STE occurred in 0.78% (116/14 941). Coronary angiography was performed in 108 patients. All patients had at least one severe coronary artery stenosis (>70%). The site of STE on exercise ECG was shown to be 95.4% predictive of a severe stenosis in the coronary artery supplying that area. Lateral STE was rare (1/116). Ninety-eight patients underwent revascularisation; 67 patients had percutaneous coronary intervention (PCI) and 31 underwent coronary artery bypass grafting (CABG). Follow-up included recording of death, MI, cerebrovascular event, heart failure and target vessel revascularisation. The projected 7-year event-free survival probability was 62.1% for those undergoing CABG, 77.1% for those who had PCI and 68.6% for those not undergoing revascularisation (no difference between these three groups, log rank p = 0.802). Conclusions: STE on the exercise ECG is rare but specific for ischaemic heart disease and is predictive of a severe stenosis in the corresponding coronary artery. Prognosis is favourable following revascularisation.