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Ejection fraction <40%; (PPA 69%) Exercise time <6 METS, PPA 58% for D, RI, UA, CHF, VA.

Exercise time <6 METS.

aAbbreviations: D, death; RI, reinfarction; UA, unstable angina; CHF, congestive heart failure; VA, ventricular arrhythmia; PPA, positive predictive accuracy; R, revascularization; METS, metabolic equivalents; BP, blood pressure; RR, relative risk; W, Watts; DST/DHR, change in ST-segment depression vs change in heart rate. b490 out of 981 received thrombolytics.

aAbbreviations: D, death; RI, reinfarction; UA, unstable angina; CHF, congestive heart failure; VA, ventricular arrhythmia; PPA, positive predictive accuracy; R, revascularization; METS, metabolic equivalents; BP, blood pressure; RR, relative risk; W, Watts; DST/DHR, change in ST-segment depression vs change in heart rate. b490 out of 981 received thrombolytics.

Fig. 8. Meta-analysis of noninvasive tests in thrombolytic- and nonthrombolytic-treated patients. The positive predictive accuracy for cardiac death, reinfarction rate, and rates of abnormal tests are lower in thrombolytic patients. Reproduced with permission from ref. 95.

Fig. 9. Use of noninvasive testing with exercise (ETT) to risk-stratify lower risk survivors after MI. Submaximal, rather than symptom-limited, testing should be done if exercise is scheduled early (3-5 d) after the index event. APM HR, age-predicted maximum heart rate; METS, metabolic equivalents. Adapted from ref. 96 with permission.

Fig. 9. Use of noninvasive testing with exercise (ETT) to risk-stratify lower risk survivors after MI. Submaximal, rather than symptom-limited, testing should be done if exercise is scheduled early (3-5 d) after the index event. APM HR, age-predicted maximum heart rate; METS, metabolic equivalents. Adapted from ref. 96 with permission.

Table 4

Indications for Exercise Electrocardiography after MI

Recommendations

Class I

1. Before discharge for prognostic assessment, activity prescription, evaluation of medical therapy (submaximal at about 4-7 d).a

2. Early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the predischarge exercise test was not done (symptom-limited/about 14-21 d).a

3. Late after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the early exercise test was submaximal (symptom-limited/about 3-6 wk).a

Class IIa

1. After discharge for activity counseling and/or exercise training as part of the cardiac rehabilitation in patients who have undergone coronary revascularization. Class IIb

1. Patients with the following ECG abnormalities:

a. Complete left bundle-branch block.

b. Pre-excitation syndrome.

c. LV hypertrophy.

d. Digoxin therapy.

e. Greater than 1 mm of resting ST-segment depression.

f. Electronically paced ventricular rhythm.

2. Periodic monitoring in patients who continue to participate in exercise training or cardiac rehabilitation.

Class III

1. Severe comorbidity likely to limit life expectancy and/or candidacy for revascularization.

2. At any time to evaluate patients with AMI who have uncompensated congestive heart failure, cardiac arrhythmia, or noncardiac conditions that severely limit their ability to exercise.

3. Before discharge to evaluate patients who have already been selected for cardiac catheteri-zation. Although a stress test may be useful after catheterization to evaluate or identify ischemia in the distribution of a coronary lesion of borderline severity, stress imaging tests are recommended.

aExceptions are noted under classes lib and III.

Adapted with permission from ACC/AHA Exercise Guidelines (96).

monitoring or spontaneous angina. After 6 mo, median total days hospitalized were 7.5 in the standard stay and 3.6 in the short stay group (p < 0.001). The findings from this study indicate that the reduced hospital stay strategy for low risk patients after AMI is feasible, resulting in a substantial and sustained reduction in hospitalized days without unfavorable psychosocial consequences or adverse risk of cardiac events. The reduced hospital stay strategy also reduced the number of invasive cardiac procedures performed.

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