When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT

One Overlooked Pitfall on TMT

  • Dmitri Muhammad Rifanda General Practitioner, Jakarta Heart Center, Jakarta, Indonesia
  • M. A. L. Parama General Practitioner, Jakarta Heart Center, Jakarta, Indonesia
  • Teuku Muhammad Haykal Putra Cardiologist, Jakarta Heart Center, Jakarta, Indonesia
  • Wishnu Aditya Widodo Cardiologist, Jakarta Heart Center, Jakarta, Indonesia
Keywords: Treadmill Test; Hypokalemia; Coronary artery disease


When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT



Particular ischemic process that portrayed in Electrocardiogram (ECG) changes bear similar depiction to different conditions, one of them is hypokalemia. On the other hand, Treadmill Test (TMT) has been used for decades for risk stratifying and diagnosing coronary artery disease as a non-invasive, safe and affordable screening test. However, using ECG changes as interpretation, TMT could have incidence of false positive results reported in various conditions, one of which is hypokalemia. The aim is to report a case of positive ischemic response resemblance in TMT of patient with severe hypokalemia.


Case Illustration:

A-43-years-old female with history of unstable angina pectoris with risk factors of diabetes mellitus and hypertension underwent several examinations. Computed Tomography Coronary Angiography (CTCA) showed a 60% stenosis lesion in Left Anterior Descending (LAD) coronary artery. Within 3 minutes of TMT the ECG showed ST-segment depression in lead II, III, aVF, V1-V6 and prominent elevation in lead aVR. Fear of left main coronary artery occlusion, the test was terminated and the patient was immediately planned for urgent Percutaneous Coronary Intervention (PCI). The result indicated non-significant coronary lesion. Potassium concentration of 1.87 mmol per liter and troponin levels were normal. Unbeknownst before, the patient had multiple episodes of vomiting for a whole day and felt dehydrated prior to the TMT. Patient then treated for potassium implementation and discharged uneventfully.



Hypokalemia could induce widespread ST-Segment depression or ST-Segment elevation in right limb lead. Peculiarly in context of stress testing or accompanied with chest pain, it is difficult to differentiate ECG changes in hypokalemia with true myocardial ischemia. Hypokalemia should be considered when TMT result is not concordance with true myocardial ischemia.



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1. Attar, A., Mehrzadeh, A., Foulad, M., Aldavood, D., Fallahzadeh, M. A., Assadian Rad, M., & Khosropanah, S. (2017). Accuracy of exercise tolerance test in the diagnosis of coronary artery disease in patients with left dominant coronary circulation. Indian Heart Journal, 69(5): 624-627.
2. Vilcant V, Zeltser R. Treadmill Stress Testing. 2021 Jul 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29763078.
3. Bittencourt, M. S., Hulten, E., Polonsky, T. S., Hoffman, U., Nasir, K., Abbara, S., di Carli, M., & Blankstein, R. (2016). European Society of Cardiology–Recommended Coronary Artery Disease Consortium Pretest Probability Scores More Accurately Predict Obstructive Coronary Disease and Cardiovascular Events Than the Diamond and Forrester Score. Circulation, 134(3): 201-211.
4. Kharabsheh, S. M., Al-Sugair, A., Al-Buraiki, J., & Farhan, J. (2006). Overview of Exercise Stress Testing. Annals of Saudi Medicine, 26(1):1-6.
5. Fitzgerald, B. T., Scalia, W. M., & Scalia, G. M. (2019). Female False Positive Exercise Stress ECG Testing – Fact Versus Fiction. Heart, Lung and Circulation, 28(5):735-741.
6. Wang X, Han D, Li G. Electrocardiographic manifestations in severe hypokalemia. Journal of International Medical Research. 2018;48(1):030006051881105.
7. Chua, C. E., Choi, E., & Khoo, E. Y. H. (2018). ECG changes of severe hypokalemia. QJM: An International Journal of Medicine, 111(8):581-582
8. Diercks, D. B., Shumaik, G. M., Harrigan, R. A., Brady, W. J., & Chan, T. C. (2004). Electrocardiographic manifestations: electrolyte abnormalities. The Journal of Emergency Medicine, 27(2):153-160
9. Petrov, D., Sardovski, S., & Milanova, M. (2012). Severe Hypokalemia Masquerading Myocardial Ischemia. Cardiology Research, 3(5):236-238.
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How to Cite
Rifanda, D., Parama, M. A. L., Putra, T., & Widodo, W. (2022). When Positive Ischemic Response on Treadmill Test Implies Otherwise: One Overlooked Pitfall on TMT. Indonesian Journal of Cardiology, 43(1), 30-6. https://doi.org/10.30701/ijc.1197