To compare four recently proposed methods of analyzing the exercise electrocardiogram with the conventional analysis of ST segment depression, 303 consecutive patients without myocardial infarction who had been referred for coronary arteriography underwent stress electrocardiography and stress thallium imaging. The specificity for the prediction of a greater than 50% coronary obstruction of 0.5, 1.0, 1.5 and 2.0 mm ST segment depression measured in the conventional way was 0.59, 0.73, 0.88 and 0.94, respectively. The specificity of a thallium perfusion defect was 0.79. Sensitivities of the conventional ST depressions, thallium defect, the change in the sum of the R amplitudes and the slope adjusted for heart rate increase were calculated and compared at the cited levels of specificity. R wave changes had a significantly lower sensitivity than did the conventionally analyzed ST depression at each level of specificity. Slope-adjusted ST depression had a slightly higher sensitivity than that of conventional ST depression only at a specificity of 0.73 (0.68 versus 0.65, p = 0.07). R wave-adjusted ST depression was significantly more sensitive than conventional ST depression only at a specificity of 0.94 (0.45 versus 0.36, p = 0.01). Heart rate-adjusted ST depression was more sensitive than conventional ST depression at all of the specificities except 0.59. This pattern of superior accuracy of heart rate-adjusted ST depressions was preserved for the prediction of multivessel coronary disease. Heart rate adjustment is a simpler and more accurate modification of the conventional electrocardiographic analysis than are the other three methods studied.