Exercise Electrocardiography Research Articles

Exercise-Induced Electrocardiography Changes in Pulmonary Arterial Hypertension

Cardiopulmonary exercise testing (CPET) is an important tool in assessing the functional status of patients with pulmonary arterial hypertension (PAH). During CPET, continuous electrocardiography (ECG) is used as a marker of exercise-induced ischemia or arrhythmia. We hypothesize that ECG changes with exercise may be an early indicator of clinical worsening in PAH and could predict adverse outcomes. Clinical, hemodynamic, and CPET data of 155 children and young adult patients with PAH who underwent CPET between 2012 and 2019 in our pulmonary hypertension (PH) center were included in this retrospective analysis. ECGs were analyzed for ST depressions and T-wave inversions, along with coincident hemodynamic data. These data were correlated with adverse outcomes divided into 2 categories: severe worsening (death or receiving lung transplant) and mild to moderate worsening (PAH medication escalation, hospitalization, shunt creation, or listing for lung transplant). The median age was 19years (range 7 to 40years), 69% were female, and the average follow-up time was 5years (range 1 to 8years). A total of 63 patients (41%) had at least 1 adverse outcome. A total of 39 patients (25%) demonstrated significant ST-T-wave changes with exercise. Patients with ST-T-wave changes were 20% more likely to die or need lung transplant than those without. The multiple linear regression found that ST-T-wave changes were a predictor of elevated mean pulmonary arterial pressure (mPAP) found on catheterization (R=0.489, p=0.003), although not of pulmonary vascular resistance index (R=-0.112, p=0.484). An mPAP of 55mm Hg was the most sensitive and specific point in identifying when ST-T-wave changes with exercise begin to appear. In conclusion, ST-T-wave changes on exercise ECG are significantly associated with adverse outcomes in PH in a medium-term follow-up study, and the presence of ST-T-wave changes correlates with higher mPAP. These ECG changes with exercise may be used as early indicators of clinical worsening in PH and predictors of adverse outcomes.

Which Biomarker(s) Augment the Diagnostic Value of the Positive Exercise Electrocardiography Test: Systemic Inflammatory Index, Plasma Atherogenic Index, or Monocyte/HDL-C Ratio?

The exercise electrocardiography test (EET) is still used before coronary angiography in the diagnosis of chronic coronary syndromes. This study aimed to demonstrate the value of the combination of a positive EET with the systemic inflammatory index (SII), the plasma atherogenic index (PAI), and the monocyte/HDL-C ratio (MHR) in the determination of obstructive coronary artery disease (CAD). This single-center, retrospective study included 540 patients who underwent coronary angiography after ETT. The patients were separated into Group 1, comprising 434 patients with normal coronary arteries and non-obstructive CAD, and Group 2, including 106 with obstructive CAD. In Group 2, the patients were separated into SYNTAX ≤ 22 or ≥23. Glucose, low-density lipoprotein, white blood cells, and MHR were determined to be significantly higher in Group 2 (p < 0.05). According to the multivariate logistic regression analysis, age, gender, diabetes mellitus, and low-density lipoprotein were determined to be independent predictors of CAD. In the ROC curve analysis, a cut-off value of 12 for the MHR in the determination of obstructive CAD had a sensitivity of 60.4% and a specificity of 53.0%. The main result of this study was that a high MHR is an indicator of obstructive CAD in patients with positive EET and suspected CAD.

Exercise ECG must be considered in conjunction with conventional SPECT

Exercise ECG must be considered in conjunction with conventional SPECT

Capabilities of the Treadmill Test in Modern Cardiological Practice

Many publications in recent years have been dedicated to the search for the best preliminary method of diagnosing coronary artery disease (CAD), where the availability of technology and staff experience are the determining factors. According to the National Cardiovascular Data Registry of the American College of Cardiology, 58.4% of patients referred for coronary angiography after functional testing do not have significant coronary artery stenoses. European guidelines for the diagnosis and management of patients with chronic coronary syndrome recommend the use of imaging diagnostic tests instead of exercise electrocardiography for the diagnosis of obstructive CAD.&#x0D; The aim. To analyze the capabilities of the exercise electrocardiography test for patients in modern cardiological practice.&#x0D; Materials and methods. A treadmill test was performed on 406 patients, among whom 317 (78.07%) were men, 89 (21.9%) were women, the mean age was 44.7±17.3 years. The test was carried out according to the Bruce protocol on the Valiant Ergometric Treadmill.&#x0D; Results. The patients were divided into groups depending on the area of diagnostic search: verification of CAD in cardiac pain (n=184); evaluation of the long-term results of cardiac surgery (n=74); visualization of myocardial ischemia in borderline stenoses of coronary arteries (n=4); screening in the presence of additional CAD risk factors (n=49); in the case of heart rhythm disorders in order to decide on further treatment tactics and evaluation of the effectiveness of the antiarrhythmic treatment (n=34); evaluation of the coronary artery in patients with congenital heart defects (n=7); determination of tolerance to physical exertion (n=54). Among the examined patients, there were 48 (11.8%) with positive, 246 (60.5%) with negative, and 112 (27.5%) with doubtful treadmill test. Among 48 patients with a positive treadmill test, myocardial revascularization was performed in 41 (85.4%) cases.&#x0D; Conclusions. Exercise electrocardiography is an affordable tool for diagnostic research which, with its high-quality performance and interpretation, can be an alternative to modern imaging techniques.

Using Coronary Artery Calcium Score as Diagnostic Tool in Symptomatic Chronic Coronary Syndrome Patients in a Real-Life Setting.

The coronary artery calcium (CAC) score can be used to increase (CAC score > 0) or decrease (CAC score = 0) the likelihood of coronary artery disease (CAD). We compared the CAC score with the pre-test probability (PTP) for CAD (low, intermediate, and high). Furthermore, we compared the CAC score with exercise electrocardiography (ECG) and compared both tests with coronary angiography. We retrospectively identified patients with angina and/or dyspnea for whom CAC score was used to increase or decrease the likelihood of CAD. Of 882 patients, majority had low (45%) or intermediate (44%) PTP. Patients with higher PTP had significantly higher CAC scores (Cramer's V = 0.29, p < 0.0001). Most patients (57%) had a CAC score of zero, especially those with low (73%) and intermediate (49%) PTP. However, 20% of patients with high PTP had CAC score of zero. Higher CAC scores were observed in patients with abnormal exercise ECG, but association was weak and not significant (Cramer's V = 0.13, p = 0.08). Moreover, more than 40% of patients with an abnormal exercise ECG had CAC score of zero. Higher CAC scores were associated with more severe abnormalities on coronary angiography (Cramer's V = 0.43, p < 0.0001), whereas there was no association between results of exercise ECG and coronary angiography (Cramer's V = 0.11, p = 0.91). CAC score can be used in addition to PTP to increase or decrease the likelihood of CAD, and it might be more useful than exercise ECG in the diagnostic work-up of chest pain.

Exercise Test Predicts Both Noncardiovascular and Cardiovascular Death in a Primary Prevention Population

ObjectiveTo identify specific causes of death and determine the prevalence of noncardiovascular (non-CV) deaths in an exercise test referral population while testing whether exercise test parameters predict non-CV as well as CV deaths. Patients and MethodsNon-imaging exercise tests on patients 30 to 79 years of age from September 1993 to December 2010 were reviewed. Patients with baseline CV diseases and non-Minnesota residents were excluded. Mortality through January 2016 was obtained through Mayo Clinic Records and the Minnesota Death Index. Exercise test abnormalities included low functional aerobic capacity (ie, less than 80%), heart rate recovery (ie, less than 13 beats/min), low chronotropic index (ie, less than 0.8), and abnormal exercise electrocardiogram (ECG) of greater than or equal to 1.0 mm ST depression or elevation. We also combined these four abnormalities into a composite exercise test score (EX_SCORE). Statistical analyses consisted of Cox regression adjusted for age, sex, diabetes, hypertension, obesity, current and past smoking, and heart rate–lowering drug. ResultsThe study identified 13,382 patients (females: n=4736, 35.4%, 50.5±10.5 years of age). During 12.7±5.0 years of follow-up, there were 849 deaths (6.3%); of these 162 (19.1%) were from CV; 687 (80.9%) were non-CV. Hazard ratios for non-CV death were significant for low functional aerobic capacity (HR, 1.42; 95% CI, 1.19 to 1.69; P<.0001), abnormal heart rate recovery (HR, 1.36; 95% CI, 1.15 to 1.61; P<.0033), and low chronotropic index (HR, 1.49; 95% CI, 1.26 to 1.77; P<.0001), whereas abnormal exercise ECG was not significant. All exercise test abnormalities including EX_SCORE were more strongly associated with CV death versus non-CV death except abnormal exercise ECG. ConclusionNon-CV deaths predominated in this primary prevention cohort. Exercise test abnormalities not only predicted CV death but also non-CV death.

Ultra-High-Resolution Electrocardiography Enables Earlier Detection of Transmural and Subendocardial Myocardial Ischemia Compared to Conventional Electrocardiography.

The sensitivity of exercise ECG is marginally sufficient for the detection of mild reduction of coronary blood flow in patients with early coronary atherosclerosis. Here, we describe the application of a new technique of ECG registration/analysis-ultra-high-resolution ECG (UHR ECG)-for early detection of myocardial ischemia (MIS). The utility of UHR ECG vs. conventional ECG (C ECG) was tested in anesthetized rats and pigs. Transmural MIS was induced in rats by the ligation of the left coronary artery (CA). In pigs, subendocardial ischemia of a variable extent was produced by stepwise inflation of a balloon within the right CA, causing a 25-100% reduction of its lumen. In rats, a reduction in power spectral density (PSD) in the high-frequency (HF) channel of UHR ECG was registered at 60 s after ischemia (power 0.81 ± 0.14 vs. 1.25 ± 0.12 mW at baseline, p < 0.01). This was not accompanied by any ST segment elevation on C ECG. In pigs, PSD in the HF channel of UHR ECG was significantly decreased at a 25% reduction of CA lumen, while the ST segment on C ECG remained unchanged. In conclusion, UHR ECG enabled earlier detection of transmural MIS compared to C ECG. PSD in the HF channel of UHR ECG demonstrated greater sensitivity in the settings of subendocardial ischemia.

Exercise electrocardiography for pre-test assessment of the likelihood of coronary artery disease

ObjectivesTo develop a tool including exercise electrocardiography (ExECG) for patient-specific clinical likelihood estimation of patients with suspected obstructive coronary artery disease (CAD).MethodsAn ExECG-weighted clinical likelihood (ExECG-CL) model was developed in...

Sex-related beneficial effects of exercise on cardiac function and rhythm in autistic rats.

Cardiovascular diseases are prevalent in autistic patients. As exercise is useful in the treatment of medical conditions, this study aimed to identify the effect of low-intensity endurance exercise (LIEE) and moderate-intensity endurance exercise (MIEE) on cardiovascular events in autistic rats. Valproic acid (VPA) was administrated once on gestational day 12.5 to pregnant rats to produce autism-like symptoms in offspring. Thirty-day-old offspring were divided into 12 groups: Male-CTL, Male-VPA, Male-CTL + LIEE, Male-CTL + MIEE, Male-VPA + LIEE, Male-VPA + MIEE, Female-CTL, Female-VPA, Female-CTL + LIEE, Female-CTL + MIEE, Female-VPA + LIEE, and Female-VPA + MIEE. LIEE and MIEE were performed 5 days a week for 30 days. Twenty-four hours after the last exercise session, electrocardiogram and hemodynamic and cardiac function indices were recorded. The results indicated that +dp/dt max and contractility index (CI) decreased in the Female-VPA group compared to the Female-CTL group. LIEE increased these parameters in the Female-VPA + LIEE group. However, MIEE normalized CI in the Male-VPA + MIEE compared to the Male-VPA group. Tau increased in the Female-VPA group compared to the Female-CTL group and it decreased in the Female-VPA + MIEE group compared to the Female-VPA group. LIEE and MIEE recovered the reduction of heart rate and the increase in P, R, and T amplitudes in Male-VPA group. LIEE and MIEE increased heart rate variability in the Male-VPA and Female-VPA groups. The findings showed that LIEE and MIEE alleviated cardiac dysfunction and disturbances in heart rhythm in the autistic offspring. Exercise may be recommended as a routine program for autistic patients to prevent and treat the harmful cardiovascular consequences of autism.

Interpretation and management of premature ventricular beats in athletes: An expert opinion document of the Italian Society of Sports Cardiology (SICSPORT)

Premature ventricular beats (PVBs) are recorded in a sizeable proportion of athletes during pre-participation screening, especially if the evaluation includes both resting and exercise ECG. While in the majority of cases no underlying heart disease is present, in others PVBs may be the sign of a condition at risk of sudden cardiac death, including cardiomyopathies, congenital, coronary artery, heart valves and ion channels diseases. In this expert opinion document of the Italian Society of Sports Cardiology, we propose a multiparametric interpretation approach to PVBs in athletes and a stepwise diagnostic algorithm. The clinical work-up should include the assessment of the probable site of origin based on the ECG pattern of the ectopic QRS and of the arrhythmia behavior (including the number of different PVB morphologies, complexity, response to exercise and reproducibility), as well as first-line tests such as echocardiography. Based on this initial evaluation, most athletes can be reassured of the benign nature of PVBs and cleared for competition under periodical follow-up. However, when the clinical suspicion is high, further investigations with non-invasive (e.g. cardiac magnetic resonance, cardiac computed tomography, genetic testing) and, in very selected cases, invasive (e.g. endocardial voltage mapping and endomyocardial biopsy) tests should be carried out to rule out a high-risk condition. Importantly, such advanced tests should be performed in centers with a consolidated experience not only in the technique, but also in evaluation of athletes.

The Value of Exercise Electrocardiography in Outpatients with Stable Chest Pain and Low Pre-Test Probability of Significant Coronary Artery Disease.

The role of exercise electrocardiography (ECG) in the investigation of stable chest pain has been questioned. The American Heart Association guidelines suggest the use of exercise ECG in patients with stable chest pain and low pre-test probability (PTP) of significant coronary artery disease, while the European Society of Cardiology Guidelines does not. This retrospective observational study aimed to assess the usefulness of exercise ECG in the low-PTP population with stable chest pain. We reviewed the medical records for all outpatient exercise ECGs conducted because of stable chest pain at the Department of Medicine and Emergency, Sahlgrenska University Hospital, Mölndal, Sweden, during 2016-2018. The identified patients were categorized in low-, intermediate-, or high-risk pre-test probability of significant coronary artery disease. All low-PTP patients were followed for one year post investigation for the incidence of acute coronary syndrome and all-cause mortality. Thus, 505 patients (mean age 60 years, 56% women) with low PTP were included in the study. Only four patients (0.6%) experienced incident myocardial infarction (three patients) or all-cause mortality (one patient). The negative predictive value of exercise ECG was 99.7%, and the positive predictive value was 28.6%. In this low-PTP population, exercise ECG yields a good negative predictive value and a poor positive predictive value.

Correlation between QT Interval Prolongation or Dispersion in Positive Exercise ECG Patients and severity of coronary artery disease

Correlation between QT Interval Prolongation or Dispersion in Positive Exercise ECG Patients and severity of coronary artery disease

Heart Rate Recovery as a Predictor of Long-Term Adverse Events after Negative Exercise Testing in Patients with Chest Pain and Pre-Test Probability of Coronary Artery Disease from 15% to 65.

The prognosis of patients with chest pain after a negative exercise test is good, but some adverse events occur in this low-risk group. The aim of our study was to identify predictors of long-term adverse events after a negative exercise test in patients with chest pain and a lower intermediate (15-65%) pre-test probability of coronary artery disease (CAD) and to assess the prognostic value of exercise electrocardiography and exercise stress echocardiography in this group of patients. We identified from our stress test laboratory database 862 patients with chest pain without previously known CAD and with a pre-test probability of CAD ranging from 15 to 65% (mean 41 ± 14%) who underwent exercise testing. Patients were followed for the occurrence of death, non-fatal myocardial infarction (MI) and clinically guided revascularization. During the median follow-up of 94 months, 87 patients (10.1%) had an adverse event (AE). A total of 30 patients died (3.5%), 23 patients suffered non-fatal MI (2.7%) and 34 patients (3.9%) had clinically guided revascularization (20 patients percutaneous and 14 patients surgical revascularizations). Male gender, age, the presence of diabetes and a slow heart rate recovery (HRR) in the first minute after exercise were independently related to the occurrence of AEs. Adverse events occurred in 10.3% of patients who were tested by exercise stress echocardiography and in 10.0% of those who underwent stress electrocardiography (p = 0.888). The risk of AEs after negative exercise testing in patients with a pre-test probability of CAD of 15-65% is low. Male patients with a history of diabetes and slow HRR in the first minute after exercise have an increased risk of an adverse outcome.

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).

Diagnostic Strategies for the Assessment of Suspected Stable Coronary Artery Disease : A Systematic Review and Meta-analysis.

There is uncertainty about which diagnostic strategy for detecting coronary artery disease (CAD) provides better outcomes. To compare the effect on clinical management and subsequent health effects of alternative diagnostic strategies for the initial assessment of suspected stable CAD. PubMed, Embase, and Cochrane Central Register of Controlled Trials. Randomized clinical trials comparing diagnostic strategies for CAD detection among patients with symptoms suggestive of stable CAD. Three investigators independently extracted study data. The strongest available evidence was for 3 of the 6 comparisons: coronary computed tomography angiography (CCTA) versus invasive coronary angiography (ICA) (4 trials), CCTA versus exercise electrocardiography (ECG) (2 trials), and CCTA versus stress single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) (5 trials). Compared with direct ICA referral, CCTA was associated with no difference in cardiovascular death and myocardial infarction (relative risk [RR], 0.84 [95% CI, 0.52 to 1.35]; low certainty) but less index ICA (RR, 0.23 [CI, 0.22 to 0.25]; high certainty) and index revascularization (RR, 0.71 [CI, 0.63 to 0.80]; moderate certainty). Moreover, CCTA was associated with a reduction in cardiovascular death and myocardial infarction compared with exercise ECG (RR, 0.66 [CI, 0.44 to 0.99]; moderate certainty) and SPECT-MPI (RR, 0.64 [CI, 0.45 to 0.90]; high certainty). However, CCTA was associated with more index revascularization (RR, 1.78 [CI, 1.33 to 2.38]; moderate certainty) but less downstream testing (RR, 0.56 [CI, 0.45 to 0.71]; very low certainty) than exercise ECG. Low-certainty evidence compared SPECT-MPI versus exercise ECG (2 trials), SPECT-MPI versus stress cardiovascular magnetic resonance imaging (1 trial), and stress echocardiography versus exercise ECG (1 trial). Most comparisons primarily rely on a single study, many studies were underpowered to detect potential differences in direct health outcomes, and individual patient data were lacking. For the initial assessment of patients with suspected stable CAD, CCTA was associated with similar health effects to direct ICA referral, and with a health benefit compared with exercise ECG and SPECT-MPI. Further research is needed to better assess the relative performance of each diagnostic strategy. None. (PROSPERO: CRD42022329635).

The use of a new ECG patch for exercise and prolonged monitoring: usability, evaluation of signal quality and utility to detect arrhythmias

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA. Background Accurate detection of myocardial ischemia and arrhythmia’s during free-living exercise could play a pivotal role in optimizing screening and monitoring of individuals with underlying cardiovascular disease. Although remote electrocardiogram (ECG) solutions are emerging rapidly, these applications are generally not designed nor validated for continuous use during vigorous exercise. Purpose In this proof-of-concept study, we evaluated the usability, signal quality and arrhythmia detection of a new self-adhesive dry electrode ECG patch, the Nighthawk Vital Signs patch, during exercise and prolonged continuous ECG monitoring in individuals with chronic coronary syndrome (CCS). Methods Six consecutive CCS patients scheduled for an exercise stress test as part of routine cardiac follow-up were recruited. The traditional 12-lead exercise ECG was combined with monitoring with the 1-lead patch. Following the exercise test, the subjects continuously wore the sensor for five days. Intraclass correlation coefficients (ICC) and Wilcoxon signed-rank tests were used to assess the utility to detect arrhythmias with the patch. Signal quality for ECG recording was evaluated by using a signal quality indicator (SQI) based on the average QRS complex. Connection time and signal-to-noise ratio (SNR) were additionally calculated for prolonged ECG monitoring. Comfort and usability of the patch were evaluated by an online questionnaire. Results Six male patients with CCS (mean age 69.8 ± 6.2 years) completed the protocol. The mean time the patch was worn, was 118.3 hours (SD 5.6). The level of agreement between the patch and the 12-lead ECG was excellent for amount of premature atrial contractions (PAC’s) and premature ventricular contractions (PVC’s) during exercise stage, recovery stage and total test duration (ICC = 0.998, 0.998, 1.000, 1.000, 0.998, 1.000). There were no significant differences in the total amount of PAC’s and PVC’s detected with both methods during the exercise test (p = 0.785 and 0.180, respectively). One episode of atrial fibrillation was detected identically on both recorded ECG’s. Signal quality based on average QRS SQI during exercise did decrease slightly during (sub)maximal effort. Total connection time during recording was above 88% in all subjects and the SNR was above the target limit of 18dB. There were no reports on skin irritation, erythema or pain. Conclusion The Nighthawk Vital Signs ECG patch based on self-adhesive dry electrodes technology can be used for accurate arrhythmia detection during vigorous exercise. The sensor is also usable for prolonged ECG monitoring in free-living conditions and can therefore be of potential use in cardiac rehabilitation and telemonitoring for prevention of exercise-related cardiovascular events. However, more research is needed in order to analyze the signal quality over time together with a larger-scale validation study focusing on both arrhythmia and ischemia detection.

Does right ventricular remodeling in elite athletes persist years after training cessation?

Abstract Funding Acknowledgements Type of funding sources: None. Background Intense and prolonged exercise training induces morpho-functional cardiac changes, known as "athlete’s heart". The physiologic nature of this cardiac remodeling has been questioned and data on reversibility of cardiac remodeling, especially of the right ventricle (RV), after the suspension of high intensity training are scarce. Purpose To describe cardiac morpho-functional changes by echocardiography in a group of Olympic athletes prior the Olympic games (T1) and years after cessation of their competitive athletic career (T2). Methods Endurance athletes evaluated prior their participation to the Olympic games (edition 2004-2008-2012) and after cessation of their athletic career (&amp;gt; 3 years of cessation of intensive exercise training) were invited to be evaluated at our Institute. 12-lead ECG, exercise ECG test and echocardiogram were performed. Echocardiogram parameters at T1 and T2 were compared including left ventricle (LV) and RV dimension, systolic and diastolic function. Results 25 athletes were enrolled (mean age 47±2 years). The mean time from the end of their agonistic activity was 12 ± 7 years. No differences in terms of LV dimensions and function were observed (Table). Veterans showed a significant decrease in RV dimensions and improvement in function at T2 compared to T1. Conclusion After suspension of competitive training, Veteran athletes showed reverse remodeling of the right ventricle compared with the evaluation during the peak training by echocardiography.

P50 ODD CONNECTIONS

Abstract A 40 yo man was admitted to the ER due to typical oppressive chest pain at rest; he had no previous medical history and he denied any cardiovascular risk factor, including family history of cardiac disease. He was actually a sportsman, practicing martial arts. The basal ECG showed sinus rhythm, and an early repolarization pattern with no pathological features. Physical examination revealed a continuous cardiac murmur (2/6) along the sternal border and no other pathological signs. Three consecutive HsTnI determinations resulted negative. He was evaluated by the cardiologist, and a bedside echocardiogram resulted unremarkable. Due to the typical characteristics of the symptoms, an exercise ECG was performed, and the results were suspicious for inducible ischemia at high workloads. He was then admitted to our Cardiology ward, where he underwent a coronary angiography that showed a really surprising and unexpected anatomy: numerous coronary fistulas arising from various tracts (mid–LAD, intermediate coronary artery, conal branch of RCA, and distal Cx). A CT coronary angiogram was then performed, showing some ectasic vascular malformations between different coronary arteries, between coronaries and the pulmonary artery, and also a vascular anomaly connecting a bronchial artery with the right pulmonary artery. We subsequently performed a full body CT angiogram and a cerebral MR angiography, that excluded the presence of extrathoracic arteriovenous malformations. This case shows an extremely rare coronary congenital anomaly (accounting for 0.08–0.4% of all congenital heart disease), that generally goes underdetected in the first decades of life of these subjects. In this case, the typical anginal symptoms (probably due to coronary “steal” mechanism) arose suspicion that lead to the, albeit least expected, odd diagnosis. The treatment of symptomatic coronary fistulas is percutaneous/surgical closure. The patient was referred to our Tertiary Centre GUCH department, where a multidisciplinary discussion will decide the best therapeutic strategy.

P170 WHICH DIAGNOSTIC PROCEDURE IN CANCER SURVIVORS WITH CHEST PAIN? DESCRIPTION OF A CLINICAL CASE

Abstract Introduction Cancer and CVD often share common risk factors and pathophysiological mechanisms, the relationship can be amplified by oncological treatment. In the case of aromatase inhibitors (AIs), used for a long time in breast cancer (BC) expressing the estrogen receptor there is a significant association with dyslipidemia, metabolic syndrome, ischemic heart disease and heart failure. For this reason the ESC guidelines on Cardio–oncology (LG–CO) recommend the evaluation of the baseline CV risk using SCORE2 or SCORE2–OP and aggressive control of CV risk factors (RF) to be integrated with the management of cancer. In case of suspicion of coronary artery disease (CAD), ESC LG–CO recommended the adoption of ESC 2019 guidelines for CAD. We present a case of atypical chest pain (LG 2019 ESC CAD pre–test probability &amp;lt; 15%) in a woman at very high CV risk and in adjuvant therapy with AI for BC Clinical case August 2022: 63–year–old female with multiple RF (premature family history of CAD, smoke, hypertension and dyslipidemia) in adjuvant treatment with Exemestane (Letrozole not tolerated) for BC (2020: T2N0M0 ER 99%, PGr– HER2– Ki67 20%) presents in ER for chest pain typical for site, character and irradiation (constricting – burdening, retrosternal radiating to the neck and shoulders) mainly at rest, in the evening, very rarely induced by rapid efforts. Statin therapy was discontinued after initiation of letrozole therapy for arthralgias – myalgias. At the most recent evaluation of blood chemistry: LDL cholesterol 185 mg/dl, Hb, glycemia and thyroid hormones were normal. ECG and rest, troponin, echocardiogram and exercise ECG were normal. Non–synchronized CT with ECG, performed for tumor staging, showed the presence of multiple calcifications on DA, CX and CD (Figure 1). The CGF confirmed the presence of a critical stenosis on the right coronary artery (Figure 2) and a non–critical stenosis on the DA (Figure 3). Successfully performed PTCA with DES implant and started DAPT + high intensity statin with Ezetimibe in addition to antihypertensive therapy obtaining asymptomaticity and optimal control of CV risk factors (FR) Conclusions Aggressive control of CV RF is mandatory in women with BC on AI therapy and high CV risk; the onset of symptoms suggestive of CAD must not be overlooked and in this context coronary CT can be a valid tool for estimating the atherosclerotic burden and to establish the diagnosis.

Comparative effectiveness of exercise electrocardiography versus exercise echocardiography in women presenting with suspected coronary artery disease: a randomized study.

There is a paucity of randomized diagnostic studies in women with suspected coronary artery disease (CAD). This study sought to assess the relative value of exercise stress echocardiography (ESE) compared with exercise electrocardiography (Ex-ECG) in women with CAD. Accordingly, 416 women with no prior CAD and intermediate probability of CAD (mean pre-test probability 41%), were randomized to undergo either Ex-ECG or ESE. The primary endpoints were the positive predictive value (PPV) for the detection of significant CAD and downstream resource utilization. The PPV of ESE and Ex-ECG were 33% and 30% (P = 0.87), respectively for the detection of CAD. There were similar clinic visits (36 vs. 29, P = 0.44) and emergency visits with chest pain (28 vs. 25, P = 0.55) in the Ex-ECG and ESE arms, respectively. At 2.9 years, cardiac events were 6 Ex-ECG vs. 3 ESE, P = 0.31. Although initial diagnosis costs were higher for ESE, more women underwent further CAD testing in the Ex-ECG arm compared to the ESE arm (37 vs. 17, P = 0.003). Overall, there was higher downstream resource utilization (hospital attendances and investigations) in the Ex-ECG arm (P = 0.002). Using National Health Service tariffs 2020/21 (British pounds) the cumulative diagnostic costs were 7.4% lower for Ex-ECG compared with ESE, but this finding is sensitive to the cost differential between ESE and Ex-ECG. In intermediate-risk women who are able to exercise, Ex-ECG had similar efficacy to an ESE strategy, with higher resource utilization whilst providing cost savings.