# Arm Exercise versus Pharmacologic Stress Testing for Clinical Outcome Prediction

> **NIH VA I01** · ST. LOUIS VA MEDICAL CENTER · 2021 · —

## Abstract

Treadmill exercise capacity and other physiologic responses to leg exercise are powerful
predictors of mortality and provide important clinical and diagnostic information. However, many
Veterans cannot perform treadmill exercise because of lower extremity or other disabilities. For
many years, pharmacologic myocardial perfusion imaging (MPI) has been the standard of care
for their evaluation but fails to provide powerful prognostic and clinically relevant information of
exercise testing, requires exposure to ionizing radiation, and is several times more expensive
than exercise electrocardiography (ECG). With a recently completed Merit Review award, we
obtained substantial retrospective observational evidence that arm exercise ECG stress testing
scores are at least equivalent to pharmacologic MPI for robust prediction of mortality and other
measures of clinical outcome in Veterans who cannot perform leg exercise. Major hypotheses
for the current proposal are: 1) arm exercise ECG stress testing scores or best fit models
without or with coronary artery calcium scoring (-/+ CACS) are non-inferior to the Duke
Treadmill Score -/+ CACS, best fit model treadmill ECG and regadenoson (r) MPI stress testing,
all performed in the same Veterans in randomized order, as an initial evaluation for obstructive
coronary artery disease (oCAD), and 2) arm exercise ECG stress testing scores or best fit
models -/+ CACS are non-inferior to the Duke Treadmill Score -/+ CACS, best fit model
treadmill ECG and rMPI stress testing in the same Veterans for predicting the primary clinical
endpoint (composite of cardiovascular (CV) mortality, myocardial infarction, or 90-day post-
stress test coronary revascularization) and secondary clinical endpoints of all-cause mortality
and CV mortality. Our specific aim for all Veterans referred to the St. Louis Veterans
Administration (VA) stress testing laboratory and are without exclusions for exercise or
regadenoson stress testing or cardiac computed tomographic angiography (CTA), is to perform
a single site prospective clinical trial comparing arm exercise ECG stress test scores and best
models -/+ CACS with the Duke Treadmill Score -/+ CACS if able to perform treadmill exercise,
and best fit treadmill ECG and rMPI models, all performed in the same Veterans, for
identification of the diagnostic endpoint of oCAD, defined as a severely (≥70%) occluded
epicardial, graft, or ≥50% left main coronary artery lumen, determined by cardiac CTA or
invasive coronary arteriography, and prediction of the primary and secondary clinical endpoints
described above. The arm exercise scoring system to be evaluated incorporates the variables
arm exercise capacity in resting metabolic equivalents, 1-minute heart rate recovery and arm
exercise-induced ST depression ≥1 mm. Regadenoson MPI variables to be evaluated include
an abnormal MPI study and best fit models of summed stress and difference scores, transient
ischemic dilatation, gated left ventricular e...

## Key facts

- **NIH application ID:** 9932925
- **Project number:** 5I01CX001345-03
- **Recipient organization:** ST. LOUIS VA MEDICAL CENTER
- **Principal Investigator:** Wade Hampton Martin
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2021
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2018-07-01 → 2021-04-05

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9932925

## Citation

> US National Institutes of Health, RePORTER application 9932925, Arm Exercise versus Pharmacologic Stress Testing for Clinical Outcome Prediction (5I01CX001345-03). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/9932925. Licensed CC0.

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