Exercise Testing Score for Myocardial Ischemia Gradation

Introduction Scores aimed at contributing to the optimization of exercise testing (ET) have been developed and the experience with their application in coronary artery disease (CAD) has proven to be favorable1. Although there is debate on the use of scores in clinical practice, those that stand for it argue that they may decrease the rate of undiagnosed CAD, besides reducing the number of patients without disease that undergo highly expensive tests2. Additionally, scores may be helpful, in a more consistent and organized fashion, in prognosis evaluation and in the adoption of an appropriate plan of action for the triage of this disease in the general population. Besides improving diagnostic and prognostic accuracy, scores remove interpretation biases and reduce variability in the decision-making process. Physicians frequently make clinical decisions based on their personal experience, instead of following a rational decision-making process, in addition to trusting more the results from more expensive tests, such as perfusion imaging or echocardiography. Using scores has shown great results, as good as or even better than the formerly mentioned tests3, but the complex nature of equations intimidate physicians to make a routine use of them. Although many scores adopt particular features of electrocardiographic responses in their composition, there are no references for a proposal to graduate myocardial ischemia documented in ET. Most cardiologists divide the wide spectrum of electrocardiographic alterations into just two categories (normal/abnormal), which still lack a clearer definition. Such lack of a proper categorization for ischemic response, determines an inappropriate comparison of results from large studies, thus promoting interpretation biases. To this moment, no line of research has turned primarily toward the CAD evaluation through ET, enabling a view beyond the simple dichotomy (negative/positive test), to provide more objective data about the degree of myocardial ischemia documented during the test. In this article, we propose an electrocardiographic score for myocardial ischemia graduation during the exercise testing. This is a conceptual proposition and clinical studies must be designed to validate the new score among many populations and clinical conditions. Interobserver variations studies and comparisons with other scoring systems and diagnostic methods will help the medical community to evaluate the reliability and better understand the clinical relevance of the new exercise testing ischemic score.