Correspondence
Exercise-Induced Premature Ventricular Depolarizations
N Engl J Med 2001; 344:383-384February 1, 2001
- Article
To the Editor:
Jouven et al. report on the long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations (Sept. 21 issue).1 In 1977, a colleague and I reported the results of a similar study involving 6500 patients, although most of them had chest pain as an indication for exercise testing.2 We also found that premature ventricular depolarizations (contractions) were predictive of coronary events, especially when combined with ST-segment depression. The risk of death in a five-year follow-up study increased from 8 percent when premature ventricular depolarizations were induced by exercise to 22 percent when ST-segment depression was also present. In an editorial accompanying the report by Jouven et al., Dr. Calkins states that this is the first report on the risk associated with exercise-induced premature ventricular depolarizations.3 For the record, many others reported on this issue before we did.2
The low incidence of premature ventricular depolarizations is of interest. Although we counted premature ventricular depolarizations before, during, and after exercise, 20 percent of our patients had this abnormality. Froelicher et al. reported that 35 percent of 1390 active-duty airmen had premature ventricular depolarizations.4 According to several reports,5 in the absence of evidence of ischemia, premature ventricular depolarizations have almost no power to predict coronary disease, a finding that seems to conflict with that reported by Jouven et al. The much longer follow-up period in the study by Jouven et al. may explain this discrepancy. Over the years, most cardiologists have largely ignored premature ventricular depolarizations during exercise testing, a practice that should probably change.
A final comment may be of interest. A colleague and I recently correlated ST-segment depression in premature ventricular depolarizations with abnormalities on coronary angiograms.6 If this finding can be confirmed, the predictive value of these arrhythmias, which are usually overlooked, may be more robust than heretofore believed.
6 ReferencesM.H. Ellestad, M.D.
L.B. Memorial Heart Institute, Long Beach, CA 908011
Jouven X ,Zureik M ,Desnos M ,Courbon D ,Ducimetiere P . Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med 2000;343:826-833
Full Text | Web of Science | Medline2
Udall JA ,Ellestad MH . Predictive implications of ventricular premature contractions associated with treadmill stress testing. Circulation 1977;56:985-989
Web of Science | Medline3
Calkins H . Premature ventricular depolarizations during exercise. N Engl J Med 2000;343:879-880
Full Text | Web of Science | Medline4
Froelicher VF Jr ,Thomas MM ,Pillow C ,Lancaster MC . Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 1974;34:770-776
CrossRef | Medline5
Gooch AS . Exercise testing for detecting changes in cardiac rhythm and conduction. Am J Cardiol 1972;30:741-746
CrossRef | Web of Science | Medline6
Rasouli L, Ellestad MH. Does ST depression in premature ventricular contractions predict ischemia? Am J Cardiol (in press).
Author/Editor Response
The authors reply:
To the Editor: Although the opposite has been described by many authors, premature ventricular depolarizations were found to be predictive of coronary events and of coronary lesions in patients with known or suspected cardiovascular disease in many studies that we cited and others that we did not cite.
However, the new information provided by our study was that frequent premature ventricular depolarizations during exercise were associated with an increased rate of mortality from cardiovascular causes in middle-aged men who were free of known cardiovascular disease, and as Dr. Ellestad pointed out, this finding is at variance with the results of previous studies. Moreover, the design of our study probably explains the relatively low proportion of subjects with premature ventricular depolarizations or ST-segment depression, or both, during exercise.
As Dr. Ellestad mentioned, an analysis of ST-segment depression in relation to premature ventricular depolarizations might provide additional information about coronary disease. However, in our study, very few subjects with frequent premature ventricular depolarizations also had signs of ischemia during exercise, and the subjects with an exercise test that was positive for ischemia and those who had frequent premature ventricular depolarizations during exercise apparently did not have the same pattern of risk factors.
Finally, we agree with Dr. Ellestad and with Dr. Calkins that physicians should probably be more concerned than before about frequent premature ventricular depolarizations during exercise.
Xavier Jouven, M.D., Ph.D.
Hôpital Européen Georges Pompidou, 75015 Paris, FrancePierre Ducimetière, Ph.D.
Hôpital Paul Brousse, Villejuif, FranceAuthor/Editor Response
The editorialist replies:
To the Editor: Ellestad's letter calls attention to the study in which he and a colleague evaluated the predictive implications of premature ventricular depolarizations associated with stress testing in patients referred for a clinically indicated stress test.1 The follow-up period ranged from 6 to 60 months. The incidence of a cardiac event was 1.7 percent among patients without premature ventricular depolarizations or ischemia, 6.4 percent among patients with premature ventricular depolarizations but without ischemia, and 11.4 percent among those with both premature ventricular depolarizations and ischemia. Patients in whom premature ventricular depolarizations increased during exercise were more likely to have a cardiac event during follow-up than those in whom premature ventricular depolarizations decreased with exercise.
Although Ellestad claims that the study by Jouven et al. was similar to the previous study that he reported with a colleague, this does not appear to be the case. Whereas in the study by Udall and Ellestad stress tests were performed for clinical indications in patients with known or suspected cardiac disease, the study by Jouven et al. involved subjects without known or suspected cardiovascular disease. Udall and Ellestad reported that they followed most patients for 2 years or less, as compared with a 23-year follow-up period in the study by Jouven et al. It is because of this difference in follow-up that I concluded that the study by Jouven et al. was the first to evaluate the long-term prognostic implications of premature ventricular depolarizations that occur during exercise stress testing.
Before the study by Jouven et al., it was generally accepted that premature ventricular depolarizations during stress testing do not have prognostic importance in apparently healthy persons.1-3 Therefore, the finding that frequent premature ventricular depolarizations during exercise in apparently healthy persons are associated with a 2.6-fold increase in long-term mortality from cardiovascular causes is new.
3 ReferencesHugh Calkins, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21287-04091
Udall JA ,Ellestad MH . Predictive implications of ventricular premature contractions associated with treadmill stress testing. Circulation 1977;56:985-989
Web of Science | Medline2
McHenry PL ,Fisch C ,Jordan JW ,Corya BR . Cardiac arrhythmias observed during maximal treadmill exercise testing in clinically normal men. Am J Cardiol 1972;29:331-336
CrossRef | Web of Science | Medline3
Fleg JL ,Lakatta EG . Prevalence and prognosis of exercise-induced nonsustained ventricular tachycardia in apparently healthy volunteers. Am J Cardiol 1984;54:762-764
CrossRef | Web of Science | Medline
