Abnormal Exercise Test Research Articles

Long-term outcomes of ischaemia with no obstructive coronary artery disease (INOCA): a systematic review and meta-analysis

BackgroundThe prognosis of myocardial ischaemia with no obstructive coronary artery disease (INOCA) and its underlying vasomotor disorders, vasospastic angina (VSA) and microvascular angina (MVA), is not well defined. The aim...

A retrospective study of accuracy and usefulness of electrophysiological exercise tests

ObjectivesThis study aimed to determine the usefulness of electrophysiological exercise tests. The significance of slightly abnormal exercise tests was also examined.MethodsWe identified all the patients who had undergone exercise testing between February 2007 to June 2022 in Tampere University Hospital, Finland. Their medical records after diagnostic workup and exercise test reports were reviewed. A binary logistic regression was performed to evaluate the association between positive test result in short exercise test, long exercise test, or short exercise test with cooling and genetically confirmed skeletal muscle channelopathy or myotonic disorder.ResultsWe identified 256 patients. 27 patients were diagnosed with nondystrophic myotonia, periodic paralysis, myotonic dystrophy type 1, myotonic dystrophy type 2, or other specified myopathy. 14 patients were suspected to have a skeletal muscle channelopathy, but pathogenic variants could not be identified. The remaining 215 patients were diagnosed with other conditions than skeletal muscle channelopathy or myotonic disorder. The combined sensitivity of exercise tests was 59.3% and specificity 99.1%. Abnormal exercise test result was associated with increased risk of skeletal muscle channelopathy or myotonic disorder (OR 164.3, 95% CI 28.3–954.6, p < 0.001).ConclusionsElectrophysiological exercise test is not optimal to exclude skeletal muscle channelopathy. It may be useful if a skeletal muscle channelopathy is suspected and genetic testing is negative or indeterminate and further evidence is required. Slightly abnormal exercise test results are possible in various conditions and result from different aetiologies. There is a demand for neurophysiological studies with higher sensitivity to detect skeletal muscle channelopathies.

Long-term outcomes of patients with ischemia and no obstructive coronary artery disease (INOCA) - a systematic review and meta-analysis

Abstract Background Myocardial ischemia with no obstructive coronary artery disease (INOCA) is an increasingly recognized syndrome that encompasses coronary vasomotor disorders such as coronary microvascular dysfunction (CMD) and coronary vasospasm. However, the prognosis of patients with INOCA is not well defined. Purpose To perform a systematic review and meta-analysis of previous studies evaluating the long-term prognosis of patients with INOCA stratified by the underlying vasomotor disorder. Methods We searched Medline, Embase, Web of Science, and Cochrane databases combining terms for INOCA and outcomes to identify observational studies evaluating the prognosis of patients with INOCA published between 1984 and 2021. The primary outcomes were composite of all-cause death and MI, and major adverse cardiovascular events (MACE) at annual intervals for up to 5-year follow-up. Meta-analytic averages with 95% confidence intervals (CI) of the incidence of primary outcomes for INOCA, each INOCA endotype, and by method used to determine the diagnosis were calculated using the random effect models. Results We identified a total of 52 studies (19765 patients) meeting eligibility criteria. Of those, 22 included patients with vasospastic angina and 34 with microvascular angina. The rate of all-cause death and MI in the vasospastic angina group was 0.7 (95% CI 0.4-1.0)/100 patient-years [Figure 1] and the rate of MACE was 1.1 (95% CI 0.6-1.9)/100 patient-years [Figure 2]. For patients with microvascular angina the rate of all cause death and MI was 1.2 (95% CI 0.7-1.7)/100 patient-years [Figure 1] and the rate of MACE was 2.8 (95% CI 1.8-4.0)/100 patient-years [Figure 2]. Patients with evidence of microvascular dysfunction by non-invasive (CFR) or invasive (CFR, IMR, TIMI frame count) criteria had 2.7 times higher all-cause death and MI rates than patients whose diagnosis was established solely based on an abnormal exercise or imaging stress test (2.6 (95% CI, 0.8-5.1) vs. 0.7(95% CI, 0.4-1.2)/100 patient-years, p=0.034). Conclusions Overall, patients with INOCA have a low rate of MACE events or death, although there is heterogeneity based on the underlying phenotype. Patients with vasospastic angina have a relatively benign long-term prognosis, whereas patients with microvascular angina have a significantly higher rate of MACE at long-term follow-up. Among patients with microvascular angina, those with objective evidence of abnormal microvascular function (such as reduced CFR) had 2.7 times higher rates of all-cause death and MI.Incidence of all cause death and MIIncidence of MACE

Reference equations for breathlessness during incremental cycle exercise testing.

Exertional breathlessness is commonly assessed using incremental exercise testing (IET), but reference equations for breathlessness responses are lacking. We aimed to develop reference equations for breathlessness intensity during IET. A retrospective, consecutive cohort study of adults undergoing IET was carried out in Sweden. Exclusion criteria included cardiac or respiratory disease, death or any of the aforementioned diagnoses within 1 year of the IET, morbid obesity, abnormally low exercise capacity, submaximal exertion or an abnormal exercise test. Probabilities for breathlessness intensity ratings (Borg CR10) during IET in relation to power output (%predWmax), age, sex, height and body mass were analysed using marginal ordinal logistic regression. Reference equations for males and females were derived to predict the upper limit of normal (ULN) and the probability of different Borg CR10 intensity ratings. 2581 participants (43% female) aged 18-90 years were included. Mean breathlessness intensity was similar between sexes at peak exertion (6.7±1.5 versus 6.4±1.5 Borg CR10 units) and throughout exercise in relation to %predWmax. Final reference equations included age, height and %predWmax for males, whereas height was not included for females. The models showed a close fit to observed breathlessness intensity ratings across %predWmax values. Models using absolute W did not show superior fit. Scripts are provided for calculating the probability for different breathlessness intensity ratings and the ULN by %predWmax throughout IET. We present the first reference equations for interpreting breathlessness intensity during incremental cycle exercise testing in males and females aged 18-90 years.

The Prevalence and Association of Exercise Test Abnormalities With Sudden Cardiac Death and Transplant-Free Survival in Childhood Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) can be associated with an abnormal exercise response. In adults with HCM, abnormal results on exercise stress testing are predictive of heart failure outcomes. Our goal was to determine whether an abnormal exercise response is associated with adverse outcomes in pediatric patients with HCM. In an international cohort study including 20 centers, phenotype-positive patients with primary HCM who were <18 years of age at diagnosis were included. Abnormal exercise response was defined as a blunted blood pressure response and new or worsened ST- or T-wave segment changes or complex ventricular ectopy. Sudden cardiac death (SCD) events were defined as a composite of SCD and aborted sudden cardiac arrest. Using Kaplan-Meier survival, competing outcomes, and Cox regression analyses, we analyzed the association of abnormal exercise test results with transplant and SCD event-free survival. Of 724 eligible patients, 630 underwent at least 1 exercise test. There were no major differences in clinical characteristics between those with or without an exercise test. The median age at exercise testing was 13.8 years (interquartile range, 4.7 years); 78% were male and 39% were receiving beta-blockers. A total of 175 (28%) had abnormal test results. Patients with abnormal test results had more severe septal hypertrophy, higher left atrial diameter z scores, higher resting left ventricular outflow tract gradient, and higher frequency of myectomy compared with participants with normal test results (P<0.05). Compared with normal test results, abnormal test results were independently associated with lower 5-year transplant-free survival (97% versus 88%, respectively; P=0.005). Patients with exercise-induced ischemia were most likely to experience all-cause death or transplant (hazard ratio, 4.86 [95% CI, 1.69-13.99]), followed by those with an abnormal blood pressure response (hazard ratio, 3.19 [95% CI, 1.32-7.71]). Exercise-induced ischemia was also independently associated with lower SCD event-free survival (hazard ratio, 3.32 [95% CI, 1.27-8.70]). Exercise-induced ectopy was not associated with survival. Exercise abnormalities are common in childhood HCM. An abnormal exercise test result was independently associated with lower transplant-free survival, especially in those with an ischemic or abnormal blood pressure response with exercise. Exercise-induced ischemia was also independently associated with SCD events. These findings argue for routine exercise testing in childhood HCM as part of ongoing risk assessment.

Assessment of Exercise Function in Children and Young Adults with Hypertrophic Cardiomyopathy and Correlation with Transthoracic Echocardiographic Parameters.

Exercise function is well characterized in adults with hypertrophic cardiomyopathy (HCM); however, there is a paucity of data in children and young adults with HCM. Here we sought tocharacterize exercise function in young people with HCM, understand limitations in exercise function by correlating exercise function parameters with echocardiogram parameters and identify prognostic value of exercise parameters. We performed aretrospective, single-center cohort study characterizing exercise function in patients < 26years old with HCM undergoing cardiopulmonary exercise testing (CPET). Patients with syndromic HCM or submaximal effort were excluded. We compared exercise function in this cohort to population normal values and measured changes in exercise function over time. We correlated exercise function parameters with echocardiographic parameters and investigated the relationship between exercise test parameters and a clinical composite outcome comprised of significant ventricular arrhythmia, death, or heart transplantation. We identified 229 CPETs performed by 117 patients (mean age at time of first CPET 15.6 ± 3.2years). Mean %-predicted peak VO2, O2 pulse, and peak heart rate were statistically significantly depressed compared to population normal values and exercise function gradually worsened over time. Abnormal exercise testing correlated closely with echocardiographic indices of diastolic dysfunction. There was a trend toward increased incidence of poor clinical outcome in patients with abnormal exercise function.While adverse clinical outcomes were rare, normal exercise function appears to be a marker of low risk for adverse clinical outcomes in this population.

Exercise test for patients with new-onset paroxysmal kinesigenic dyskinesia.

The pathogenesis of primary paroxysmal kinesigenic dyskinesia (PKD) remains unclear, and channelopathy is a possibility. In a pilot study, we found that PKD patients had abnormal exercise test (ET) results. To investigate the ET performances in patients affected by PKD, and the role of the channelopathies in the pathogenesis of PKD, we compared the ET results of PKD patients, control subjects, and hypokalemic periodic paralysis (HoPP) patients, and we analyzed ET changes in 32 PKD patients before and after treatment. Forty-four PKD patients underwent genetic testing for the PRRT2, SCN4A, and CLCN1 genes. Sixteen of 59 (27%) patients had abnormal ET results in the PKD group, while 28 of 35 (80%) patients had abnormal ET results in the HoPP group. Compared with the control group, the PKD group showed a significant decrease in the compound muscle action potential (CMAP) amplitude and area after the long ET (LET), while the HoPP group showed not only greater decreases in the CMAP amplitude and area after the LET but also greater increases in the CMAP amplitude and area immediately after the LET. The ET parameters before and after treatment were not significantly different. Nine of 44 PKD patients carried PRRT2 mutations, but the gene abnormalities were unrelated to any ET parameter. The PKD group demonstrated an abnormal LET result by electromyography (EMG), and this abnormality did not seem to correlate with the PRRT2 variant or sodium channel blocker therapy.

3D speckle tracking echocardiographic strain pattern in Hypertrophic Cardiomyopathy and its relation with Sudden Cardiac Death risk markers

ContextSudden cardiac death (SCD) predictability for assessing the need for primary insertion of Implantable Cardioverter Defibrillator (ICD) in patients with Hypertrophic cardiomyopathy (HCM) is difficult though there are several conventional risk markers. The role of deformation indices in predicting SCD in HCM is less addressed. ObjectivesTo analyse the 3D speckle tracking echocardiographic strain parameters of HCM patients and its relation with SCD risk markers. Design and study methodologyIt was a cross-sectional observation study done over a period of one year with a follow up period of one year. Fifty HCM patients were included after screening eighty-two patients. Their global LV strain parameters, Global Longitudinal Strain (GLS), Global Circumferential Strain (GCS), Global Radial Strain (GRS) and Global area strain (GAS) were analysed with respect to their age and gender-matched controls. The various strain parameters were correlated with the conventional SCD risk markers and the ESC SCD risk score among these HCM patients. ResultsAll the global strain parameters were significantly low in HCM patients compared to their controls {GLS -7.30 ± 3.424 vs −18.78 ± 2.342, p < 001; GCS -11.26 ± 2.754 vs −25.08 ± 3.542, p < 001; GRS 20.56 ± 8.929 vs 39.70 ± 7.546, p < 001}. On subgroup analysis of HCM patients with LV thickness >30 mm, abnormal exercise test, family history of SCD, LVOT gradients >30mmHgand more than one SCD risk marker had significantly low values for all global deformation parameters, when compared with their control HCM cohort. The ESC risk score also had significant inverse correlation with all deformation parameters (GLS 0.496, p < 0.001; GCS 0.491, p < 0.001; GRS -0.529, p < 0.001; GAS 0.519, p < 0.001). On follow up, only one event was recorded in this cohort. ConclusionThere exists a possible linear correlation between conventional SCD risk markers and 3D deformation parameters, which may be utilized for risk stratification and SCD predictability in HCM patients after confirmation with further large prospective studies.

Quality of life was similar in children with congenital diaphragmatic hernia and oesophageal atresia and related to respiratory morbidity.

To assess quality of life (QoL) in children with congenital diaphragmatic hernia (CDH) and to compare it with oesophageal atresia (OA). A cross-sectional study in CDH children (≥7years) was conducted in Lille University Hospital, France, from January 2013 to April 2014. History, lung function (rest, exercise) and Pediatric Quality of Life Inventory questionnaires (PedsQoL 4.0) were collected. Data of OA children were previously published. Fifty-four CDH patients (male: 53%, median age: 11years, IQR 9-14) were compared to 54 OA patients (male: 61%, median age: 13years, IQR: 11-15). CDH children had significantly more frequent history of pneumonia (30% vs 13%), exercise limitation (54% vs 35%) and chest deformity (39% vs 11%); 46% had an obstructive pattern and 66% an abnormal cardiopulmonary exercise test. The median PedsQoL total score in children was 81 (IQR 73-90) in CDH and 81 (IQR 72-91) in OA (P=.8). In CDH, duration of neonatal oxygen therapy, hospitalisation for respiratory disease, exercise limitation, inhaled corticosteroids treatment, chest deformity, abnormal cardiopulmonary exercise test and lower forced expiratory volume in one second were significantly associated with lower QoL scores. PedsQoL scores remained satisfactory in CDH children with CDH, with no difference compared to OA. Patients with respiratory morbidity and lung function impairment, who displayed lower scores, should be identified in order to optimise their management in reference centres.

Subclinical coronary artery disease in veteran athletes: is a new preparticipation methodology required?

ObjectivePreparticipation evaluation of veteran athletes should focus on accurate cardiovascular (CV) risk stratification and subclinical detection of coronary artery disease (CAD), which is the main cause of sudden cardiac death...

Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection.

There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, (Equation is included in full-text article.)O2peak), and blood pressure. Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection. Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured (Equation is included in full-text article.)O2peak was <36% predicted normative values (19.2 mL·kgmin vs 29.3 mLkgmin, P < .0001); the most marked impairment in (Equation is included in full-text article.)O2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups. We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. (Equation is included in full-text article.)O2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.

Abnormal Exercise Test or CVD History on Weight Loss or Fitness: the Look AHEAD Trial.

Obesity and type 2 diabetes are associated with an increased risk of cardiovascular disease (CVD) and the combination of weight loss and increased physical exercise are commonly recommended to reduce CVD. This study examined whether people with obesity and type 2 diabetes with an abnormal graded exercise tolerance test (GXT) or a history of CVD would have less success in achieving weight loss and improved fitness, compared to adults without these conditions. The Look AHEAD Study examined whether an intensive lifestyle intervention (ILI) compared with diabetes support and education (DSE) reduced cardiovascular events in adults with overweight/obesity and type 2 diabetes. Participants underwent a baseline maximal GXT and provided medical history data. Weight loss and fitness change were examined in 5011 participants over four years in those with or without an abnormal baseline GXT and/or history of CVD. After four years, weight loss in both ILI and DSE were significantly greater in those without a prior history of CVD than in those with a CVD history (6.69% vs 5.98%, p=0.02, in ILI and 0.73 vs -.07% (weight gain), p=0.01, in DSE). Likewise, those without a prior history of CVD experienced greater improvements in fitness in both ILI and DSE relative to those with a history of CVD. Having an abnormal GXT at baseline did not affect weight loss or fitness. A history of CVD at baseline modestly lessened weight loss and fitness changes at 4 years, whereas having any abnormality on the baseline GXT did not affect these outcomes. Thus, weight loss and improved fitness are achievable in adults with a history of CVD or ECG abnormalities.

Coronary microvascular function in athletes with abnormal exercise test results.

AimsIn asymptomatic athletes, abnormal exercise test (ET) results have a poor positive predictive value. It is unknown whether abnormal ET results in the absence of obstructive coronary artery disease (CAD) are related to coronary microvascular dysfunction. It is also unknown whether they should be considered false-positive ET results or a consequence of physiological adaptation to sport. In our study, we evaluated whether athletes with abnormal ET results and documented myocardial ischaemia in the absence of obstructive CAD have an attenuated microvascular function and whether coronary microvascular dysfunction is related to endothelial dysfunction.Methods and resultsNine athletes with concordant abnormal ET and myocardial perfusion scintigraphy (MPS) results without obstructive CAD were compared with age- and gender-matched individuals with a low-to-intermediate a priori risk of CAD. Coronary flow reserve was assessed by Rubidium-82 positron emission tomography (PET) imaging. Endothelin‑1 concentrations were measured to evaluate endothelial function. Coronary flow reserve was significantly lower in athletes (3.3 ± 0.8 versus 4.2 ± 0.6, p = 0.014 respectively). Endothelin‑1 levels were significantly higher in athletes (1.3 ± 0.2 pg/ml versus 1.0 ± 0.2 pg/ml, p = 0.012 respectively). There was no correlation between endothelin‑1 concentrations and mean global coronary flow reserve (r = 0.12).ConclusionAthletes with abnormal ET and MPS outcomes indicative for myocardial ischaemia and no obstructive CAD have a lower coronary flow reserve compared with non-athletes with low-to-intermediate a priori risk of CAD, suggesting an attenuated coronary microvascular function. Higher endothelin‑1 concentrations in athletes suggest that endothelial-dependent dysfunction is an important determinant of the attenuated microvascular function.

The Ability of the Toe-Brachial Index to Predict the Outcome of Treadmill Exercise Testing in Patients with a Normal Resting Ankle-Brachial Index

Peripheral arterial disease (PAD) in the presence of a normal ankle-brachial index (ABI) can be diagnosed noninvasively by measuring a postexercise ABI or by measuring the toe-brachial index (TBI). This was a prospective comparative study. Over a period of 30months, a total of 415 patients who were referred with the suspicion of vascular claudication and resting values of 0.91≤ABI<1.40 were further evaluated for the resting TBI and postexercise ABI by treadmill testing. A total of 325 (39%) of the 830 investigated limbs had a low TBI (≤0.70), and 505 (61%) had a normal TBI. Of the limbs with a low TBI, 160 (49%) had PAD according to a postexercise ABI versus 165 (33%) of the limbs with normal TBI. The overall agreement in PAD classification between the two methods was 500/830 (60%) with a Cohen's kappa=0.166 (95% CI: 0.096-0.232). The data showed an inverse correlation between the magnitude of the TBI decrease, as well as the resting ABI, and the probability of an abnormal postexercise ABI. On average, limbs with a low TBI had a lower resting ABI than patients with a normal TBI (1.07±0.09 vs. 1.13±0.10, P<0.001). The groups with a low TBI had a significantly higher ratio of abnormal test results than patients with a normal TBI, in limbs with ABI (0.96-1.00) and ABI >1.10 (P≤0.022 for both), but there were no statistically significant differences found in other ABI intervals (P>0.200 for all). The magnitude of the TBI reduction correlates with an increased probability of an abnormal postexercise ABI. However, this is due in part to limbs with a low TBI having a lower resting ABI on average than limbs with a normal TBI, which also correlates with the probability of an abnormal exercise test result. This study shows that the TBI and the postexercise ABI are not interchangeable for establishing a PAD diagnosis.

Decreased heart rate recovery may predict a high SYNTAX score in patients with stable coronary artery disease.

An impaired heart rate recovery (HRR) has been associated with increased risk of cardiovascular events, cardiovascular, and all-cause mortality. However, the diagnostic ability of HRR for the presence and severity of coronary artery disease (CAD) has not been clearly elucidated. Our aim was to investigate the relationship between HRR and the SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score in patients with stable CAD (SCAD). A total of 406 patients with an abnormal treadmill exercise test and ≥50% coronary stenosis on coronary angiography were included. The HRR was calculated by subtracting the HR in the first minute of the recovery period from the maximum HR during exercise. The SYNTAX score ≥23 was accepted as high. Correlation of HRR with SYNTAX score and independent predictors of high SYNTAX score were determined. A high SYNTAX score was present in 172 (42%) patients. Mean HRR was lower in patients with a high SYNTAX score (9.8 ± 4.5 vs. 21.3 ± 9, p < 0.001). The SYNTAX score was negatively correlated with HRR (r: -0.580, p < 0.001). In multivariate logistic regression analysis, peripheral arterial disease (OR: 13.3; 95% CI: 3.120-34.520; p < 0.001), decreased HRR (OR: 0.780; 95% CI: 0.674-0.902; p = 0.001), peak systolic blood pressure (OR: 1.054; 95% CI: 1.023-1.087; p = 0.001), and peak HR (OR: 0.950; 95% CI: 0.923-0.977; p < 0.001) were found to be independent predictors of a high SYNTAX score. Our results showed that HRR is significantly correlated with the SYNTAX score, and a decreased HRR is an independent predictor of a high SYNTAX score in patients with SCAD.

The influence of LV geometry on the occurrence of abnormal exercise tests in athletes

BackgroundPrevious studies revealed a high rate of abnormal exercise test (ET) results in the absence of obstructive coronary artery disease (CAD) in asymptomatic athletes. The physiological background of this phenomenon is not well established. In particular, it is unclear whether sports-induced morphological cardiac adaptations are determinants of abnormal ET results. The main objective of this study was to investigate if healthy asymptomatic recreational and competitive athletes with abnormal ET results without obstructive CAD have a higher LV mass when compared with athletes with normal ET results.MethodsSeventy-three athletes with abnormal ET results without presence of obstructive CAD underwent echocardiographic assessment of LV mass, systolic and diastolic measurements. These data were compared with data from 73 athletes with normal ET results, matched for gender, age, body composition, sports characteristics and exercise capacity.ResultsNo significant increase in LV mass (161.9 ± 39 g vs. 166.9 ± 42.1 g, p = 0.461) was found between groups. Athletes with abnormal ET results had a significant thicker IVSd (9.7 ± 1.8 mm vs. 9.0 ± 1.7 mm, p = 0.014), higher IVSd/PWTd ratio (1.08 ± 0.20 vs. 1.00 ± 0.12, p = 0.011) and deceleration time (DT) was prolonged ((225.14 ± 55.08 vs. 199.96 ± 34.65, p = 0.003).ConclusionAthletes with abnormal ET result did not show a higher in LV mass when compared to athletes with a normal ET result. However, a pattern of asymmetric cardiac remodeling, together with altered diastolic function is present. Due to small differences, cardiac remodeling only plays a limited role in the occurrence of positive ET results in athletes.

O2 Pulse Patterns in Male Master Athletes with Normal and Abnormal Exercise Tests.

The clinical relevance of abnormal exercise testing (ET) results (at least 0.1 mV ST segment depression measured during exercise or recovery in three consecutive beats) in athletes without obstructive coronary artery disease (CAD) is not well understood. It is unknown whether this phenomenon reflects a physiological adaptation to sport or a truly ischemic response and a concomitant attenuated stroke volume (SV) response. The aim of this study was to investigate if athletes with abnormal ET results without obstructive CAD showed signs of an attenuated SV response using cardiopulmonary ET parameters. A total of 78 male master athletes with abnormal ET results without obstructive CAD underwent cardiopulmonary ET. ΔO2 pulse/Δwork rate (WR), ΔV˙O2/ΔWR, and Δheart rate (HR)/ΔWR were assessed and compared with data from 78 male master athletes with normal ET results, matched for age, sports characteristics, and exercise capacity. The ΔO2 pulse/ΔWR ratio beyond anaerobic threshold in athletes with abnormal ET results was lower than that in athletes with normal ET results (0.73 ± 0.41 vs 1.12 ± 0.54, respectively, P < 0.001). The ΔV˙O2/ΔWR ratio was also lower in athletes with abnormal ET results (0.9 ± 0.2 vs 1.0 ± 0.3, respectively, P = 0.041). Furthermore, these athletes showed a greater increase in HR in the last 2 min of exercise (ΔHR/ΔWR ratio: 1.19 ± 0.5 vs 0.80 ± 0.6, P < 0.001). Athletes with abnormal ET results without obstructive CAD showed an attenuated O2 pulse slope, decreased ΔV˙O2/ΔWR ratio, and increased ΔHR/ΔWR ratio beyond anaerobic threshold when compared with athletes with a normal ET result. These results support the hypothesis that at least a part of the athletes with an abnormal ET in absence of obstructive CAD have an attenuated SV response at high-intensity exercise.

Discrepancy between abnormal ECG exercise test and scintigraphy without ischemia in suspected or known coronary artery disease patients

Only few data exist on discrepancies between positive ECG exercise test (ExT) results and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) without ischemia, in patients with suspected or known coronary artery disease (CAD). The aim was to assess coronary angiography results and early clinical outcome in patients with suspected or known CAD with discrepancy between an abnormal ECG ExT and a MPI without ischemia. In total, 30,620 consecutive patients with suspected or known CAD referred between May 2010 and October 2016 for exercise SPECT MPI with CZT camera were retrospectively evaluated. “True discrepancy” was defined in presence of exercise ECG changes highly suggestive of ischemia in contrast to SPECT MPI without ischemia. Significant stenosis on coronary angiography (CAG) performed within 3 months after MPI and major cardiovascular events (cardiac death, nonfatal myocardial infarction and revascularization) during follow-up were collected. The Kaplan–Meier and log-rank test was used to compare the time to cardiac event-free survival. Among 270 patients with true discrepancy, invasive coronary angiography and coronary CT angiography data were available in 142 patients with suspected (S group; 60 patients) or known (K group; 89 patients) CAD. No significant coronary stenosis and significant stenosis was present in 30 patients (50%) versus 30 patients (50%) in S group and in 42 patients (47%) versus 47 patients (55%) in K group, respectively. Major cardiac event rate was significantly different between patients with or without revascularization after CAG in S group (respectively, 17% versus 0%; P = 0.003), contrary to K group (15% versus 9.5%; P = 0.49). True discordant results occurred in 1% of exercise SPECT MPI and half of patients with anatomy assessment were associated in 50% of the cases with the presence of significant coronary stenosis.

Validity of tortuosity severity index in chest pain patients with abnormal exercise test and normal coronary angiography.

BackgroundCoronary tortuosity (CT) had different definitions and scores in literature with unclear pathophysiological impact.ObjectivesTo study degree of CT and it's relation to ischemic changes in patients with angina but normal coronary angiography (CA).MethodsWe conducted a prospective study at University hospitals between May 2016 and January 2017. We included 200 consecutive patients who underwent CA due to chest pain assumed to be of cardiac origin, and their CA was normal (no diameter stenosis >30%, nor myocardial bridging). Patients were prospectively divided into 2 groups based on the presence (n = 113) or absence (n = 87) of ischemic changes during stress study and compared for clinical, echocardiographic and CA characteristics. A newly proposed Tortuosity Severity Index (TSI) was developed into significant (mild/moderate CT with more than 4 curvatures in total, or severe/extreme CT with any number of curvatures) or not significant TSI (mild CT with curvatures less than or equal to 4 curvatures in total).ResultsPatients with ischemic changes had the highest rate of CT (76.5 vs 18%, p = 0.004) compared to those without. CT mostly affects the left anterior descending (LAD) coronary artery in mid and distal segments. Females, elderly, and hypertensives with left ventricular hypertrophy were strongly related to CT. Multivariate logistic regression analysis identified CT with significant TSI as the only predictor of ischemic changes in these patients (OR = 6.2, CI = 2.5–15.3, P = <0.001).ConclusionsCoronary tortuosity is a strong predictor of anginal pain among patients with normal CA, despite positive stress study. This finding is more pronounced among elderly, hypertensive female patients.

Deconditioning, fatigue and impaired quality of life in long-term survivors after allogeneic hematopoietic stem cell transplantation.

Long-term survivors after allogeneic hematopoietic stem cell transplantation (allo-HSCT) are at high risk for treatment-related adverse events, that may worsen physical capacity and may induce fatigue and disability. The aims of this prospective study were to evaluate exercise capacity in allotransplant survivors and its relationship with fatigue and disability. Patient-reported outcomes and exercise capacity were evaluated in 71 non-relapse patients 1 year after allo-HSCT, using validated questionnaires, cardiopulmonary exercise testing (CPET) with measure of peak oxygen uptake (peakVO2) and deconditioning, pulmonary function testing, echocardiography and 6-min walk test. A high proportion (75.4%) of allo-HSCT survivors showed abnormal cardiopulmonary exercise testing parameters as compared to predicted normal values, including 49.3% patients who exhibited moderate to severe impairment in exercise capacity and 37.7% patients with physical deconditioning. PeakVO2 values were not accurately predicted by 6-min walk distances (r = 0.53). Disability and fatigue were strongly associated with decreased peakVO2 values (p = 0.002 and p = 0.008, respectively). Exercise capacity was reduced in most allo-HSCT long-term survivors. Because reduced exercise capacity was associated with fatigue, disability and a decrease in quality of life, cardiopulmonary exercise testing should be performed in every patient who reports fatigue and disability.