Duke Treadmill Score Research Articles

Negative long-term prognostic value of stress echocardiography in patients with incomplete revascularization after successful primary PCI

Abstract Background The role of stress echocardiography (SECHO) in a risk stratification of patients with incomplete revascularization after primary percutaneous coronary intervention (pPCI) has not been extensively documented. The Aim The aim of our study was to assess the negative long-term prognostic value of SECHO after successful pPCI and incomplete revascularization of non-culprit lesions. Methods Our study consisted of 194 patients (mean age 59±10years, male 136; 70.1%) successfully treated with pPCI, who performed SECHO according to Bruce protocol in order to assess residual ischemia in coronary artery with non-culprit lesion other than treated vessel. Lesion severity of non-culprit coronary arteries was assessed by quantitative coronary angiography. Duke treadmill score, functional capacity (Metabolic Equivalents - METs), achieved target heart rate (THR), chronotropic incompetence, heart rate recovery (HRR), wall motion score index (WMSI) and ejection fraction were calculated in all patients. Slow HRR was defined as ≤18 beats/min. Median follow up of the patients was 96 ± 32.5 months for the occurrence of all-cause mortality and non-fatal myocardial infarction (MI). Results Out of 194 patients, 38 (19.6%) had positive SECHO test, and 7 patients (3.6%) were lost to follow up so they were excluded from further analysis. During the follow-up period 29 out of 149 patients (18.8%) had an adverse event (20 deaths and 9 non-fatal MI). Negative predictive value of SECHO test was 81.2%. Median time from MI to SECHO test was 8 months. Using the Cox regression analysis, univariate predictors of adverse events were slow HRR (HR 3.750 [95% CI 1.620-8.679], p=0.002), Duke score (HR 0.866 [95% CI 0.755-0.994], p=0.040) and chronotropic incompetence (HR 0.310 [95% CI 0.107-0.895], p=0.030). In the multivariate analysis only the slow HRR remained an independent predictor of adverse events (HR 3.329 [95% CI 1.417-7.825], p=0.006). Using the Kaplan-Meier survival curve we see that the patients with slow HRR had much shorter event-free time (slow HRR 117.2 ± 13.4 months vs normal HRR test 139.4 ± 4.2 months, Log Rank 4.988, p=0.026). (Figure 1.) Conclusion SECHO test has excellent negative long-term prognostic value in patients with incomplete revascularization of non-culprit lesions after successful pPCI while patients with slow HRR have more pronounced risk for the occurrence of adverse events.Figure 1.Kaplan-Meier survival curve

Sildenafil’s effectiveness in the primary coronary slow flow phenomenon: a pilot randomised controlled clinical trial

BackgroundOn the one hand, the primary coronary slow flow phenomenon (CSFP) can cause recurrence of chest pain, prompting medical examinations and further healthcare costs, while on the other hand, it...

Abstract 12224: Long Term Mortality in Patients With Low-Risk Myocardial Perfusion Imaging

Introduction: Stress testing is utilized for diagnosis and risk stratification for coronary artery disease, with low-risk myocardial perfusion imaging (MPI) indicating less than 1% cardiac mortality per year. We aimed to determine the long-term cardiac mortality in these patients. Methods: We performed a retrospective observational study of 1,300 patients with low-risk MPI in 2015, including pharmacological and exercise studies in a tertiary care center in Central Massachusetts, USA. Each patient was followed from the time of the MPI study for a total duration of 7 years. All-cause mortality and cardiac death were identified. We calculated the pharmacologic and exercise MPI percentage in patients with cardiac death. A cardiac mortality graph was plotted to observe trends over seven years. Results: Out of the 1,300 patients, 3.2% [n=42; mean age 74.6+/-20 years, 78% male (n=32)] of patients had a cardiac death in the follow-up period of 7 years. The pharmacological MPI group had 5% (n=41) cardiac deaths as compared to 0.2% (n=1) in the exercise MPI with the low Duke Treadmill Score group (p-value 0.04) [Figure 1a]. The cardiac death trend over the seven years revealed the highest mortality in year 6 (19%, n= 8) and the lowest in year 4 (7.1%, n=3) [Figure 1b]. Conclusions: The incidence of long-term cardiac deaths is less than 0.5% each year in patients with low-risk MPI, in both groups. Cardiac mortality was higher in patients who underwent pharmacological stress tests indicating appropriate assessment of underlying cardiac pathology. Exercise MPI depends on multiple variables to be optimal, while all patients undergoing pharmacological MPI are maximally stressed. Extensive, multi-center, controlled studies are necessary to evaluate the differences in risk stratification of low-risk MPI between exercise and pharmacological stress tests.

Duke Treadmill Score Predicts Coronary Artery Disease Severity in Diabetics and Non-Diabetics

Coronary artery disease (CAD) is a significant cause of mortality and morbidity on a global scale. The Duke Treadmill Score (DTS) is a clinical evaluation that uses exercise stress testing to determine the severity of coronary artery disease (CAD). Objective: This study was to see how well DTS predicted the severity of CAD in diabetic and non-diabetic individuals. Methods: A prospective cohort study was conducted in the Department of Cardiology, PIMS, Islamabad, from March 2023 to September 2023. Total 450 patients were separated into diabetes (225) and non-diabetic (225) groups. Diabetes was diagnosed using American Diabetes Association criteria. The validated DTS scores exercise duration, ST-segment deviation, and angina symptoms to predict severe CAD. -11 or above is high risk, -10 to +4 is moderate, and +5 or more is low risk. Results: A study of 450 patients comprised 282 (62.6%) male and 168 (37.3%) female, with an average age of 58.4±13.2years. On coronary angiography, 170 diabetics (75.6%) and 130 non-diabetics (57.8%) had substantial CAD. Hypertension was 52.9% in diabetics and 49.3% in non-diabetics (p=0.920). Diabetics had 10.6% dyslipidemia and non-diabetics 9.3% (p=0.058). Conclusions: DTS may predict CAD severity in diabetics and non-diabetics, according to one study. Diabetes is a key risk factor for CAD, and DTS may aid in risk estimation. DTS findings and CAD risk assessment may potentially be affected by patient characteristics, exercise capacity, and treadmill technique.

Effectiveness of Device-Guided Breathing in Chronic Coronary Syndrome: A Randomized Controlled Study.

Chronic coronary syndrome (CCS) is one of the most life-restricting coronary artery diseases, and symptom relief is the main goal in CCS patients who suffer from angina. To assess the potential benefits of device-guided breathing in CCS patients with angina in this randomized, controlled, single-blinded study. Fifty-one patients with CCS received device-guided breathing for 7 days/8 weeks. Exercise capacity [exercise stress test], cardiac function [transthoracic echocardiography], and angina severity [Canadian Cardiovascular Society Classification] were evaluated initially and after the training. Device-guided breathing was performed at the lowest resistance of the device (POWERbreathe® Classic LR) for the control group (n = 17). The low load training group (LLTG; n = 18) and high load training group (HLTG; n = 16) were trained at 30% and 50% of maximal inspiratory pressure. Baseline characteristics were compared using one-way ANOVA and Kruskal-Wallis test. Categorical data were compared using the chi-square test. ANCOVA was performed to compare changes between three groups. A p value < 0.05 was considered statistically significant. Metabolic equivalent values were significantly improved in both HLTG and LLTG groups (p < 0.001, p = 0.003). The Duke treadmill score significantly improved and shifted to low-risk both in the HLTG (p < 0.001) and LLTG (p < 0.001) groups. Angina severity significantly alleviated after the training in both HLTG and LLTG groups (p < 0.001, p = 0.002). An 8-week long program of short-term respiratory muscle training provided positive gains in exercise capacity and angina severity in CCS patients with angina. The effects of long-term training programs on CCS patients should be investigated clinically because of the possibility of helping to decrease the need for invasive treatments.

An experimental study to diagnose coronary artery disease using five treadmill scores

Objectives: Exercise is the first step of a cardiovascular stress test, including electrocardiography (ECG) and blood pressure monitoring. Typically, a treadmill or bicycle is used to carry out the exercise for this stress test. Computer-derived criteria and a scoring system have been proposed and tested in hopes of improving the diagnostic accuracy of the exercise ECG for diagnosing coronary artery disease (CAD). Many treadmill scores have not been compared with one another in the same population, so questions remain concerning their diagnostic accuracy. The study aimed to correlate the diagnostic accuracy of ST segment response with various treadmill scores. Material and Methods: A total of 100 consecutive patients with suspected CAD referred for exercise testing at ACS Medical College and Hospital, Chennai, Tamil Nadu, between December 2021 and June 2022 were included in the study. The Institutional Review Board approved the study protocol at our institution, and all patients provided written informed consent. A treadmill test was conducted using commercially available equipment. All patients were subjected to symptom-limited exercise testing following the standard Bruce and modified Bruce protocols. A series of five scores were calculated using data collected from the patients to calculate the probability of CAD occurrence. Results: The study included 100 patients with an average age of 48.4 ± 1 years. Obesity (41%), hypertension (80%), diabetes (86%), current smokers (62%), family history of CAD (46%), and hypercholesterolemia (46%) were all observed in the study. The receiver operator characteristic (ROC) plot’s area under the curve (AUC) (standard error) for the Detrano score was 0.46 ± 0.59. This was significantly lower than the AUC of each treadmill score. The AUC of the ROC plots of the Duke treadmill score (DTS), veterans affairs (VA), and consensus scores were 0.47 ± 0.58, 0.63 ± 0.56, and 0.61 ± 0.57, respectively. Conclusion: The Morise score remains helpful in our study population for detecting CAD and determining risk strata. DTS and Detrano had comparable accuracy when calculated from intermediate and high probability scores and ST responses (44% and 43%, respectively). VA and consensus had lower accuracy than others (37% and 29%, respectively).

Consensus statement on cardiovascular risk stratification and aggressive management of chronic coronary syndromes

Cardiovascular diseases (CVDs) are responsible for 17.5 million deaths globally, and India is more susceptible to coronary artery disease (CAD) than its western counterparts because of certain challenges such as suboptimal management, increased healthcare costs, and physicians undermining the extent of limitation in angina patients. All of these could be resolved by employing strategies starting with accurate diagnosis to timely implementation of aggressive management techniques to contain morbidity and mortality. Pan India, experts from the field of cardiology came together in order to discuss risk stratification and aggressive management of chronic coronary syndromes (CCS). The expert consensus laid down a path of recommendations considering the prevailing healthcare service infrastructure, local evidence-based studies and key international guidelines. With the wide diversity in terms of geographical distribution in India and the risk factors presented across various divisions of the population, risk stratification is necessary for prompt identification and subsequent management of CCS. In this consensus, various risk stratification techniques such as risk stratification based on ventricular function, electrocardiogram (ECG), stress echocardiography (ECHO), the Duke treadmill score (DTS), and myocardial perfusion imaging (MPI) were discussed. After risk stratification, the consensus focused on aggressive management of CVDs with therapeutic optimization for various types of patient profiles such as revascularization for stable angina and angina with comorbidities (diabetes and renal failure), apart from emphasis on various medications and their roles in ameliorating disease symptoms.

Age, Hypertension, and Exercise Capacity are Independently Associated with Likelihood of Multi-Vessel Disease in Patients Referred for Treadmill Exercise Testing: The Intermediate-High-Workload Treadmill Score (IHWTS).

To identify factors that increase the specificity of the treadmill exercise test (TMET), and develop a novel scoring system which accounts for functional capacity to aid in determining the need for further testing. We retrospectively evaluated the electronic health records of 600 patients who had positive TMET results and follow-up stress echocardiography from 1-January-2004, through 31-December-2016. Correlations between clinical and aerobic variables and multivessel disease (MVD) were determined. Duke Treadmill Score (DTS) was calculated and compared with a novel scoring system titled the Intermediate-High-Workload Treadmill Score (IHWTS) that used variables associated with MVD. In total, 124 of 600 patients (21%) had coronary catheterization, and 51 of these patients (41%) had MVD. Mean (SD) DTS was -2.10 (6.3) among patients with MVD vs -0.16 (5) among patients without MVD (p = 0.06). Mean (SD) functional aerobic capacity (FAC) was 76% (20%) among patients with MVD vs 90% (21%) among patients without MVD (p 0.001). Mean (SD) metabolic equivalent (MET) was 7 (2) among patients with MVD vs 8 (2) among patients without MVD (p = 0.002). Only 6 (12%) of patients with MVD achieved 9 MET or greater on TMET. DTS less than 4 did not distinguish between patients with and without MVD (p = 0.67). Age, hypertension and FAC were independently associated with MVD (all p 0.05). Our novel scoring system IHWTS utilized age, hypertension, and FAC appeared comparable to DTS to risk-stratify patients regardless of baseline symptoms. Clinical parameters such as hypertension along with exercise functional capacity should be considered when evaluating a positive TMET result in patients that achieve an intermediate-high workload 5 Metabolic Equivalents (METs).

Correlation of Duke Treadmill Score with Coronary angiographic Findings in Patients with Stable Ischemic Heart Disease

Aim: To determine the correlation of Duke treadmill score with angiographically determined obstructive coronary artery disease (CAD) Study design: observational cross sectional study, comparative type Place and duration: The study was done at Cardiac Center Bahawalpur from August 2020 to July 2021. Methods: The patients who had stable angina and underwent exercise tolerance testing as well as coronary angiography were included in the study. The data was collected on a predesigned proforma. The difference in the prevalence of obstructive CAD with regards to Duke treadmill score (DTS), gender, diabetes mellitus, hypertension, smoking and family history was determined with Chi square test using SPSS 20; ap value of &lt; 0.05 was taken as significant. Results: Total 71 patients were enrolled for study. Mean ageof the participants was 48.25 ± 8.7 years. It was a male dominant population. A significant difference in the prevalence of obstructive CADwas noted in low, intermediate and high risk groups according to DTS. The prevalence of obstructive coronary artery disease was not significantly different with regards to gender, diabetes mellitus, hypertension, smoking and family history. However obstructive CAD was more prevalent in those who presented with typical angina as compared to those who had atypical symptoms. Conclusion: Obstructive CAD significantly differs in low, intermediate and high risk groups according to DTS. Keywords: Duke treadmill score, coronary artery disease

Can high-sensitive troponin levels within the normal range predict positivity in treadmill test?

This study aimed to determine whether a high level of high-sensitivity troponin T (hsTnT) predicts a positive treadmill test in patients with suspected stable ischemic heart disease (SIHD). In all, 366 patients with suspected SIHD were included in the study. We measured the serum hsTnT levels before the treadmill test. The treadmill test was performed according to the Bruce protocol. Of the 366 patients, 97 had positive treadmill tests. The hsTnT levels were significantly higher in the positive group than in the negative group. In the binary logistic regression analysis, hsTnT, pretest probability, metabolic equivalents (METs), target heart rate (THR) percentage, and Duke treadmill score (DTS) were independent predictors of a positive treadmill test [hsTnT odds ratio (OR): 2.178, P < 0.001; pretest probability OR: 1.036, P = 0.007; METs OR: 0.755, P = 0.008; THR OR: 0.773, P < 0.001; DTS OR: 2.661, P = 0.012]. In the receiver operating characteristic (ROC) curve analysis, the area under the curve (AUC) value of the model with the combined parameters of hsTnT, pretest probability, METs, THR, and DTS was statistically significant in predicting a positive treadmill test [combined model AUC: 0.945 (0.922-0.968), P < 0.001]. In sum, high pretest hsTnT levels predicted a positive treadmill test in patients with suspected SIHD. Analysis of the hsTnT levels before the treadmill test can increase the sensitivity and specificity of the treadmill test. The methods for measuring hsTnT levels are cheap and easily accessible and can be used before the treadmill test in patients with suspected SIHD.

Clinical significance of the hemodynamic gain index in patients undergoing exercise stress testing and coronary computed tomography angiography

BackgroundMany hemodynamic parameters provide limited information regarding obstructive coronary artery disease (CAD) during exercise stress testing particularly when exercise is suboptimal. Hemodynamic gain index (HGI) is a recent sensitive indicator of ischemia and has been associated with increased mortality. This study evaluated the clinical impact of HGI in patients who underwent concomitant exercise stress testing and coronary computed tomography angiography (CCTA).MethodsA total of 284 consecutive patients from the executive health program between 2010 and 2018 were identified. Resting and peak heart rate (HR) as well as systolic blood pressure (SBP) measurements were recorded. Framingham risk score (FRS), Duke treadmill score (DTS) and HGI (frac{{{text{HRpeak}} times {text{SBPpeak}} - {text{HRrest}} times {text{SBPrest}}}}{{{text{HRrest}} times {text{SBPrest}}}}) were calculated. The latter was divided into quartiles. CCTA was used as a reference test to detect any CAD. Multivariate analysis and artificial neural network were used to determine the independent predictors of obstructive CAD.ResultsMean age was 53 ± 12 years with 83% male. Mean HGI was 1.74 ± 0.67, with cut-off value of severely blunted HGI ≤ 1.25 (Quartile 4). Patients with severely blunted HGI were older, had higher FRS, and worse DTS. Patients with obstructive CAD had lower HGI when compared to those with normal CCTA/non-obstructive CAD (1.36 ± 0.53 vs. 1.77 ± 0.67, P = 0.005), and showed a higher prevalence of severely blunted HGI (44% vs. 22%, P = 0.019). After adjusting for traditional risk factors, HGI remained an independent predictor of obstructive CAD while severely blunted HGI was associated with threefold increased odds of having obstructive CAD (P = 0.05). Using artificial intelligence analysis, severely blunted HGI independently predicted obstructive CAD with an area under the curve of 0.83 and 0.96, and normalized importance of HGI of 100% and 63%, respectively for different models.ConclusionsAmong patients who underwent concomitant exercise stress testing and CCTA, severely blunted HGI independently predicted obstructive CAD after multivariate adjustment for traditional risk factors.

Relationship Between Duke Treadmill Score and Severity of CAD in Suspected Patients

Nowadays, cardiovascular disease, including coronary artery disease, is the leading cause of death around the world. Duke Treadmill Score (DTS) is used as a prognostic score for patients suspected of coronary artery disease. Investigating the Relationship between DTS and syntax score (SxScore) as an indicator of complexity and severity of coronary artery disease in patients with intermediate and high Duke Score. This cross-sectional study was conducted at the exercise test unit of Heshmat Hospital in Rasht from September 2017 to December 2018. Among 1033 patients that passed exercise cardiac stress testing (EST), 118 patients who had positive exercise testing for CAD were enrolled. Coronary angiography was performed, and SxScore, a marker of CAD complexity, was determined. The relationship between DTS and SxScore was then evaluated. The data were analyzed by SPSS version 21. The risk of positive EST raised age more than 61 years (OR=1.072; 95%; CI=1.046-1.099), Hypertension (OR=3.235; 95%; CI=2.097-4.992), Hyperlipidemia (OR=2.109; 95%; CI=1.371-3.242) and Diabetes Mellitus (OR=2.15; CI=1.22-3.14). The presence of the following factors reduced positive EST: female (OR=0.377;95%; CI=0.133-1.068), retired (OR=0.128;95%; CI=0.045-0.361). The results of the present study showed that there was no significant difference between the degree of coronary artery involvement based on syntax with Duke scores (P=0.328). Although both DTS and Syntax scores are useful in evaluating coronary artery disease, there isn't a significant relationship between these scores, and they don't coincide. In other words, we cannot use DTS to predict the Syntax score.

Significance of Rate-Pressure Product and Duke Treadmill Score in Predicting Disease Severity in Patients with Coronary Artery Disease: A Cross-sectional Study

Introduction: Exercise electrocardiography is a well-established and cost-effective investigation for evaluating Coronary Artery Disease (CAD). The Rate-pressure Product (RPP), which is the product of maximal Systolic Blood Pressure (SBP) and peak Heart Rate (HR) during exercise, is a widely accepted parameter reflecting cardiac work and evaluating ventricular function. The use of Duke Treadmill Score (DTS) improves the diagnostic accuracy of exercise-induced ST-segment depression and has been observed to provide independent prognostic information. It has been shown that DTS provides information about the complexity of coronary artery lesions assessed by invasive coronary artery testing. Aim: To determine the significance of RPP and DTS in predicting the severity and complexity of angiographic lesions in patients with Stable Ischemic Heart Disease (SIHD) and a positive Treadmill Test (TMT). Materials and Methods: This study involved 100 consecutive patients with a positive TMT but no prior history of Acute Coronary Syndrome (ACS) who underwent coronary angiography at Government Medical College, Kottayam, Kerala, India, between March 2018 and March 2019 after obtaining ethical clearance from the Institutional Review Board. The DTS and RPP were calculated for these patients. All patients then underwent coronary angiography, and their SYNTAX scores were calculated. Correlation analysis was performed to assess the relationship between DTS, RPP, and SYNTAX score using Spearman's correlation coefficient. The Kruskall-Wallis test was used to compare risk factors among groups. Results: A total of 100 patients were evaluated, ranging in age from 40 to 74 years with an average age of 57 years. The average SYNTAX score was 15, ranging from 2 to 56. The average Duke TMT score was -5.2, ranging from 6 to -22. There was a significant negative correlation between DTS and angiographic severity determined by SYNTAX score (r=-0.702, p=0.001). The average RPP was 22174, ranging from 14000 to 37620. The study showed a significant negative correlation between RPP and SYNTAX score (r=-0.201, p=0.04). Diabetic patients had a significantly higher SYNTAX score compared to non-diabetics (r=-0.602, p=0.013). Additionally, a significant negative correlation was observed between the Metabolic Equivalents (METs) attained, duration of exercise, and the SYNTAX score. Conclusion: DTS and RPP derived from the exercise treadmill test have a significant negative correlation with the severity and complexity of CAD as determined by the SYNTAX score in coronary angiography.

Rate-pressure product from exercise treadmill test corresponds to Duke treadmill score

Duke treadmill score (DTS) (sum of exercise duration, ST segment deviation and angina index) from exercise treadmill test (ETT) is validated for prediction of severe coronary artery disease (CAD). Rate-pressure product (RPP) (of peak heart rate and peak systolic blood pressure) is another composite score from ETT reflecting the exercise stress on the heart.

Abstract 13469: A Risk Score Model to Identify Patients With High Likelihood of Left Main or 3-vessel Coronary Artery Disease

Introduction: Revascularization improves outcomes only for stable coronary artery disease (CAD) patients with high-risk coronary anatomy (HRCA). While exercise stress test (EST) is the screening modality for CAD, identifying HRCA noninvasively is challenging. We aimed to derive a prediction model, incorporating clinical and EST characteristics, to screen for HRCA. Methods: We included adult patients who underwent EST followed by elective invasive coronary angiography (ICA) at our center between 2017 and 2019. HRCA was defined as left main (LM) or 3-vessel disease on ICA. Significant CAD was defined as ≥50% stenosis in the LM and/or ≥70% stenosis in the 3 main vessels. We excluded patients with acute coronary syndrome or ejection fraction &lt;50%. Variables with p&lt;0.1 at univariable analysis were selected as candidates to enter a multivariable stepwise backward regression model to derive a HRCA risk model. Results: 304 consecutive patients met inclusion criteria (64[13]years, 81.6% M). 15.5% were found to have HRCA on ICA. Median time from EST to ICA was 11[31]days. The following hit the threshold for inclusion into the multivariable model: hypertension, maximal predicted heart rate (MPHR), diabetes, rate pressure product, metabolic equivalents, exercise time, chronotropic response index ≥0.8, heart rate recovery, Duke Treadmill Score (DTS). After backward selection, hypertension (OR 17.08, p=0.008), MPHR (0.98, p=0.048), and very abnormal DTS (8.26, p=0.001) were the only significant predictors of HRCA ( Fig.1A ). The fully adjusted model showed good discrimination for HRCA (AUC 0.74, p&lt;0.001, Fig.1B ). Conclusions: In an era of declining emphasis on EST in favor of imaging stress test, we identified a risk model based on clinical and EST-derived parameters, that can accurately predict likelihood of HRCA, enabling personalized risk-stratification. Further studies are needed to externally validate our model.

The Prognostic Value of Duke Treadmill Score in Prediction of MPI Result

Abstract Objective This study was designed to reinforce the duke treadmill score of anginas during the treadmill stress test through a comparative study between the result of SPECT MPI study and the duke treadmill score of the suspected CAD since many centers and cardiology units have no capability of MPI study and eventually, that improve the early detection and the management of the high-risk cases in the limited units. Background Coronary artery disease is the leading cause of death worldwide and in our country Egypt. The diagnosis of CAD can be difficult to make. Frequently, the disease is diagnosed only after the patient has had a heart attack as symptoms of CAD range from unstable angina to no symptoms at all. Duke treadmill score (DTS) is well recognized as a simple prognostic score in patients with suspected coronary artery disease (CAD). Patients and Methods A retrospective review of the studies patients underwent stress treadmill test MPI between January to October 2020 were consecutively included in our study. The study was conducted in ALFA Scan Radiology Center, Cairo, Egypt. Results There was a highly statistically significant difference between the high risk and the other 2 groups (low &amp; moderate) regarding the inability to continue the test. Where High-risk group showed an increased incidence of early inability to continue and there was a significant relation between the duke treadmill score and Aston summed stress score among the studied patients (P= 0.018). Conclusion Duke's score is valid in predicting coronary arterial disease. High-risk Duke's score patients need to be referred directly to coronary angiography for they usually have significant coronary disease. DTS can provide pre-processing guidance about revascularization for physicians before the procedure. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Additive negative prognostic value of coronary flow reserve in patients with left bundle branch block without inducible ischemia and without known coronary artery disease

Abstract Background Left bundle branch block (LBBB) can be isolated thing, but it is also often associated with underlying coronary artery disease (CAD). Stress echocardiography (SECHO) is widely used as an imaging method for the diagnosis of CAD. However, the diagnostic value of stress echocardiography in patients (pts) with LBBB is limited. Purpose To evaluate negative prognostic value of coronary flow reserve (CFR) in pts with LBBB without inducible ischemia and without known CAD. Methods This retrospective study included 224 pts (98, 43.8% male gender, average age 66±11 years) with LBBB and without known CAD. All the pts had negative SECHO test according the Bruce protocol. Risk factors for CAD (diabetes, smoking, hypertension, high cholesterol and positive family history of CAD), Duke treadmill score, functional capacity (Metabolic Equivalents - METs) were recorded in all pts. Out of 224 pts, in 64 (29.5%) coronary flow reserve on the left anterior descending artery was assessed using pulsed Doppler echocardiography with adenosine in a dose of 140μcg/kg/body weight during 3 minutes. As the normal value we took value of CFR ≥2. Median follow up of the pts was 72 months (IQR 56.25–132 months) for the occurrence of MACE (cardiovascular death (CVD), non-fatal myocardial infarction (nfMI), coronary artery bypass graft (CABG) and percutaneous coronary revascularization (PCI). Results Out of 224 pts, 6 (2.7%) had positive SECHO test, 2 pts (0.9%) had died due to non-cardiac causes and 11 pts (4.9%) were lost to follow up so they were excluded from further analysis. The remaining 204 pts were divided in 2 groups: 1. pts with only negative SECHO (n=144, 68.8%); 2. pts with negative SECHO and normal CFR (n=64, 31.2%). During the follow-up period 22 out of 205 pts (10.7%) had an adverse event (6 CVD, 6 nfMI, 5 CABG, 8 PCI). Between the two groups there was no significant difference in risk factors and parameters of the SECHO test. Pts with CFR had significantly lower rate of MACE compared to the pts with only SECHO test (2, 3.1% vs 20, 14.2%, p=0.018, respectively). Using the Cox regression analysis, univariate predictors of MACE were insulin dependent diabetes (HR 10.851 [95% CI 2.095–56.220], p=0.004), Duke score (HR 0.603 [95% CI 0.414–0.878], p=0.008), and MET (HR 0.393 [95% CI 0.209–0.737], p=0.004). In the multivariate analysis only the insulin dependent diabetes remained an independent predictor of MACE (HR 6.906 [95% CI 1.100–43.363], p=0.039). Using the Kaplan-Meier survival curve we see that the pts with SECHO test and CFR had shorter event-free time compared to the pts with SECHO test (136.3±3.6 months vs 149.8±2.9 months, Log Rank 4.022, p=0.045) (Figure 1). Conclusion Normal value of CFR has good negative prognostic value in pts with LBBB without inducible ischemia and without known CAD, while pts with insulin dependent diabetes have more pronounced risk for the occurrence of adverse events. Funding Acknowledgement Type of funding sources: None.

Clinical significance of the hemodynamic gain index in patients undergoing exercise stress testing and coronary computed tomography angiography

Abstract Background Many hemodynamic parameters are used during exercise stress testing but provide limited information regarding obstructive coronary artery disease (CAD) when exercise is suboptimal. Hemodynamic gain index (HGI) is a recently developed and sensitive indicator of ischemia which has been associated with increased mortality. Purpose This study sought to evaluate the clinical impact of HGI in patients who underwent concomitant exercise testing and coronary computed tomography angiography (CCTA). Methods Consecutive patients from the executive health program between 2010 and 2018 were identified. Resting and peak heart rate (HR) and systolic blood pressure (SBP) were recorded. Framingham risk score (FRS), Duke treadmill score (DTS) and HGI [(HRpeak × SBPpeak) − (HRrest × SBPrest)] / (HRrest × SBPrest) were calculated. The latter was divided into quartiles. The presence or absence of any CAD on CCTA was confirmed. Multivariate analysis and artificial neural network were used to determine the independent predictors of obstructive CAD. Results There were 284 patients (mean age 53 years, 83% male). Mean HGI was 1.74±0.67, with severely blunted HGI cut-off of ≤1.25 (Quartile 4). Patients with blunted HGI were older, had higher FRS, and worse DTS. Patients with obstructive CAD showed lower HGI when compared to control (1.36±0.53 vs. 1.77±0.67, P-value 0.005) and had more prevalence of severely blunted HGI ≤1.25 (44% vs. 22%, P-value 0.019). In the multivariate analysis, after adjusting for traditional risk factors, HGI remained independent predictor of obstructive CAD while severely blunted HGI ≤1.25 was associated with 3-fold increased odds of obstructive CAD (P-value 0.05). Using artificial intelligence analysis, blunted HGI remained an independent predictor of obstructive CAD an area under the curve of 0.83 and 0.96, and normalized importance of HGI of 100% and 63%, respectively for different models. Conclusions Among patients who underwent concomitant exercise testing and CCTA, blunted HGI ≤1.25 was strongly associated with obstructive CAD after adjusting for traditional risk factors. HGI is robust, practical, and allows clinicians to reclassify patients, change management, and thus improve prognosis. Funding Acknowledgement Type of funding sources: None.

Ranolazine Versus Allopurinol for Eligible Symptomatic Patients With a History of Angioplasty: Comparative Efficacy Study.

Recurrent angina, which is defined as a return of chest pain or chest discomfort, occurs in many patients undergoing coronary interventions. This study aims to compare the antianginal efficacy of ranolazine versus allopurinol for eligible symptomatic patients with a history of angioplasty. A total of 62 eligible symptomatic patients with a history of angioplasty were randomly allocated into two groups. For group A, 300 mg of allopurinol was administered twice daily, while for group B, 1000 mg of ranolazine daily was prescribed for a duration of 4 weeks. An initial screening visit was done for all participants where patients' medical history was recorded and a physical examination was given; electrocardiography, blood pressure, and heart rate measurements were done as well. The patients were also given a blood and exercise test. At the end of the medication period, participants were revisited, and the tests were done again. All the required data were collected via a researcher-made form, and data analysis was conducted using SPSS. The study was approved by a formal ethics committee. The mean age of participants in the two groups (A and B) was 57.36 (SD 8.36) and 60.27 (SD 9.17) years, respectively. Among the 62 patients, 34 (59%) were men, while 28 (41%) were women. Creatinine, fasting blood sugar, C-reactive protein, N-terminal prohormone of brain natriuretic protein, uric acid, white blood cell, and hemoglobin levels of participants were not significantly different between groups (P>.05). Both allopurinol and ranolazine increased the total exercise time and decreased the ST depression of the patients. Additionally, they both improved the chest pain severity and Duke Treadmill Score of patients. At the same time, ranolazine had a statistically greater effect on ST depression reduction (mean 2.64, SD 0.74 vs mean 1.57, SD 0.49), while allopurinol showed better efficacy in reducing chest pain severity (mean 1.86, SD 0.37 vs mean 0.59, SD 0.21) and the Duke Treadmill Score (mean -14.77, SD 3.65 vs mean -6.88, SD 1.93). Based on the results, the antianginal efficacy of allopurinol and ranolazine was approved but with different effects on ST depression, chest pain severity, and the Duke Treadmill Score. Therefore, the precise differences in their effects need to be explored further.

The Value of Stress Echocardiography Imaging and Functional Parameters in Patients with aVR Lead ST-Segment Elevation during an Exercise Stress Test to Detect Significant Left Main Stenosis.

To evaluate the role of functional and imaging parameters during exercise stress echocardiography (SE) in the presence of ST-segment elevation (ST-E) in aVR leads to predict significant left main/left main equivalent/or ostial left anterior descending (LAD) stenosis (LM+). The study population included 548 patients with ECG and echo markers of myocardial ischemia, in whom diagnostic coronary angiography was performed. We analyzed the patients' clinical characteristics, ECG changes, wall motion score index (WMSI) by stress echocardiography (SE), as well as functional capacity during exercise (METs) and Duke treadmill score. aVR ST-segment elevation was found in 60/548 (11%) patients, whereas aVR ST-E was found in 23/57 patients with left main LM stenosis (Sn 40%, Sp 92%, PPV 38%, NPV 93%). When aVR ST-E was combined with other functional/imaging parameters, patients with aVR ST-E and LM+ had significantly worse functional capacity in METs (5.0±2.2 vs. 6.7±2.3, P=0.005), lower Duke score (-6.8±6.8 vs. -3.6±4.1, P=0.049), and higher deterioration of WMSI (0.51±0.24 vs. 0.39±0.24, P=0.046). Significant multivariable predictors of the left main (LM) stenosis were aVR ST-E and positive SE in LAD territory in the whole group of patients, and Delta WMSI, Duke score and METs achieved in patients presented with aVR ST-E during exercise. The aVR ST-segment alone has intermediate sensitivity in detecting significant LM stenosis in patients referred to SE testing for chest pain. When combined with other functional and imaging parameters, including poor exercise functional capacity in METs, lower Duke score or greater WMA in the territory of LAD, its diagnostic power to detect LM significantly increases.