Exercise ECG Stress Research Articles

Elevated high‐sensitive troponin T in negative stress test individuals

The exercise ECG stress test (EST) is still the first step of work-up in intermediate risk patients in many clinical scenarios. High-sensitive cardiac troponin T (hs-cTnT) elevation is related to future cardiovascular events in the general population and in patients with ischaemic heart disease. The relation between these 2 tests is not well described. A total of 2780 participants from the Tel-Aviv Medical Center Inflammation Survey cohort (mean age 49 years, 79% men) were analysed. Multiple physiologic and metabolic parameters including hs-cTnT were collected. All participants completed an EST manually reviewed by a cardiologist. A positive EST was documented in 224 subjects (8%). The majority (91%) of participants with hs-cTnT levels of 5-14 ng/L had a negative EST as well as 89.3% of subjects with levels >14 ng/L. The proportion of subjects with a positive EST and detectable hs-cTnT levels (>5 ng/L) was not significantly greater compared to those with a negative EST (53.1% vs 46.2%, respectively, P = .09). Among subjects referred for EST as part of an annual health survey, we found no significant association between EST results to hs-cTnT detection.

PP.28.28] IMPACT OF HYPERTENSION ON LEFT VENTRICULAR MECHANICS ASSESSED BY TWO-DIMENSIONAL SPECKLE-TRACKING ECHOCARDIOGRPHY IN ASYMPTOMATIC MIDDLE-AGED PATIENTS WITH TYPE 2 DIABETES MELLITUS

Objective: The aim of the study was to evaluate an impact of hypertension on left ventricular (LV) mechanics in asymptomatic middle-aged patients (pts) with type 2 diabetes mellitus (T2DM) assessed by two-dimensional speckle-tracking echocardiogrphy (2D-STE). Design and method: In total, 150 consecutive middle-aged (<60 years) subjects (50 healthy controls, 48 normotensive and 52 hypertensive T2DM pts) who underwent 2D-STE were enrolled into the study. Inclusion criteria for the T2DM pts were no cardiac history, absence of typical angina, normal LV ejection fraction, and negative exercise ECG stress test/myocardial perfusion imaging or coronary angiography. Exclusion criteria were reduced LV ejection fraction, serious arrhythmias, cardiomyopathy, valvular heart disease, hepatopathy, and alcohol abuse. Global longitudinal peak systolic strain (GLS) was measured from two- and four-chamber cines using feature tracking. Results: Mean GLS was significantly lower in middle-aged asymptomatic T2DM pts compared with normal subjects of the same age (−17.5 ± 2.1% vs −21.8 ± 2.6%; p < .05). On the other side, GLS was worst in hypertensive T2DM pts, with significant difference against normotensives (−15.2 ± 1.8% vs −18.2 ± 1.5%; p < .05) and control subjects (−15.2 ± 1.8% vs −21.8 ± 2.6%; p < .001). Conclusions: In conclusion, T2DM significantly influence LV mechanics assessed by 2D-STE. Hypertension has an additive unfavourable impact on GLS in asymptomatic middle-aged pts with T2DM. The results of the study suggest that more strong correction of blood pressure on appropriate values in asymptomatic middle-aged diabetics might represent one of the potential pathways of the prevention of diabetic cardiomyopathy in forthcoming future.

The Relation of Arm Exercise Peak Heart Rate to Stress Test Results and Outcome.

Arm exercise is an alternative to pharmacologic stress testing for >50% of patients unable to perform treadmill exercise, but no data exist regarding the effect of attained peak arm exercise heart rate on test sensitivity. Thus, the purpose of this investigation was to characterize the relationship of peak arm exercise heart rate responses to abnormal stress test findings, coronary revascularization, and mortality in patients unable to perform leg exercise. From 1997 until 2002, arm cycle ergometer stress tests were performed in 443 consecutive veterans age 64.1 yr (11.0 yr) (mean (SD)), of whom 253 also underwent myocardial perfusion imaging (MPI). Patients were categorized by frequency distributions of quartiles of percentage age-predicted peak heart rate (APPHR), heart rate reserve (HRR), and peak heart rate-systolic blood pressure product (PRPP). Exercise-induced ST-segment depression, abnormal MPI findings, coronary revascularization, and 12.0-yr (1.3 yr) Kaplan-Meier all-cause and cardiovascular mortality plots were then characterized by quartiles of APPHR, HRR, and PRPP. A reduced frequency of abnormal arm exercise ECG results was associated only with the lowest quartile of APPHR (≤69%) and HRR (≤43%), whereas higher frequency of abnormal MPI findings exhibited an inverse relationship trend with lower APPHR (P = 0.10) and HRR (P = 0.12). There was a strong inverse association of APPHR, HRR, and PRPP with all-cause (all P ≤ 0.01) and cardiovascular (P < 0.05) mortality. The frequency of coronary revascularization was unrelated to APPHR or HRR. Arm exercise ECG stress test sensitivity is only reduced at ≤69% APPHR or ≤43% HRR, whereas arm exercise MPI sensitivity and referral for coronary revascularization after arm exercise stress testing are not adversely affected by even a severely blunted peak heart rate. However, both all-cause mortality and cardiovascular mortality are strongly and inversely related to APPHR and HRR.

A prognostic scoring system for arm exercise stress testing

ObjectiveArm exercise stress testing may be an equivalent or better predictor of mortality outcome than pharmacological stress imaging for the ≥50% for patients unable to perform leg exercise. Thus, our...

Abstract 14308: Parameters of Exercise Stress Testing Are Associated With Incident Major Cardiovascular Event independent of Risk Factors and Coronary Artery Calcification - The Heinz Nixdorf Recall Study

Objective: To assess the prognostic value of parameters of autonomic cardiac function and cardiovascular fitness, as derived from exercise stress ECG testing, in addition to traditional risk factors and the anatomic information of coronary artery calcification (CAC)-score. Methods: Participants from the population based Heinz Nixdorf Recall Study without known cardiovascular disease and without heart rate lowering therapy were included. CAC-score was quantified from non-contrast electron beam CT. From bicycle stress ECG testing peak heart rate (HR), HR recovery (decline of HR 1 minute after peak exercise), exercise capacity, exercise duration, and chronotropic incompetence (chronotropic response of ≤80%) were assessed. We determined gender differences of exercise parameters. Associations with cardiovascular events (myocardial infarction, stroke, cardiovascular death) were evaluated using multivariable Cox regression. Results: We included 2349 subjects (age 58.1 ± 7.4 years, 48% male). Exercise duration and exercise capacity were higher in men (11.6 ± 3.0 vs. 7.6 ± 1.9 min, p&lt;0.0001 and 8.9 ± 1.9 vs. 6.5 ± 1.3 METs, p&lt;0.0001), while peak HR, HR recovery, and frequency of chronotropic response were not significantly different between gender (p&gt;0.05). During a median (Q1; Q3) follow-up of 10.6 (10.2; 11.4) years, 118 cardiovascular events occurred. Adjusting for Framingham risk score, peak HR (0.70 (0.52-0.95), p=0.02), HR recovery (0.70 (0.50-0.98), p=0.04), exercise capacity (0.64 (0.45-0.92), p=0.01), and chronotopic incompetence (2.62 (1.35-5.06), p=0.004) were associated with events in women, while only exercise duration was significantly associated in men (0.77 (0.60-0.99), p=0.04). When ancillary adjusting for CAC-score, exercise duration was associated with events in both genders (women: 0.67 (0.47-0.96), p=0.03, men: 0.61 (0.43-0.87), p=0.007), while chronotropic incompetence (2.43 (1.25-4.70), p=0.01) and exercise capacity (0.69 (0.48-0.99), p=0.04) were significantly associated in women only. Conclusion: Parameters of exercise stress ECG testing are associated with incident major cardiovascular events, independent of traditional risk factors and coronary artery calcification, especially in female subjects.

Assessment of the left ventricular systolic function in cardiac syndrome X using speckle tracking echocardiography.

Objective:The aim of this study was to evaluate left ventricular (LV) systolic strain by speckle tracking echocardiography (STE) and real-time three-dimensional echocardiography (3-DE) for the early detection of myocardial dysfunction in patients with cardiac syndrome X (CSX).Methods:We compared 34 patients with CSX (18 females, mean age 47.9±10.0 years) with 41 healthy persons as a control group (23 females, mean age 50.6±9.9 years). Inclusion criteria for CSX were typical angina, a positive exercise ECG stress test, and angiographically documented normal coronary arteries. Exclusion criteria for both groups were hypertension, valvular heart disease, cardiomyopathies, inflammatory diseases, myocarditis, vasculitis, arthropathies, Tietze's syndrome, gastrointestinal diseases, aortic diseases, hormone replacement therapy, arrhythmias, liver diseases, and alcohol use. All subjects underwent two-dimensional STE and 3-DE to assess resting LV function. STE measures were taken from the basal septum, mid-septum, apical septum, apex, apicolateral, mid-lateral, basal lateral, anteroseptal, anterior, anterolateral, inferolateral, inferior, and inferoseptal walls. Student's t-test, Mann–Whitney U test, and chi-square test were used to statistically analyze data.Results:LV echo ejection fraction (EF) and systolic wave peak velocity were similar for both groups. Regional mean longitudinal strain (-17.7±2.5% vs. -19.8±1.8%; p<0.0001) was significantly lower in patients with CSX than in healthy control patients. However, regional mean circumferential strain values (-22.0±1.6% vs. -22.2±2.3%; p=0.78) did not differ significantly between the two groups.Conclusion:Significant impairment of LV longitudinal myocardial systolic function was detected with STE in patients with CSX, although normal 3-D EF and tissue Doppler imaging systolic parameters were observed. Arteriosclerosis of small coronary arteries and microvascular dysfunction may affect myocardial longitudinal strain.

Noise processing in exercise ECG stress test for the analysis and the clinical characterization of QRS and T wave alternans

The aim of this study is to analyze different sources of noise in ECG recordings from stress tests in order to obtain reliable parameters and measurements for the analysis of T-wave and QRS-complex alternans (TWA & QRSA). Simple methods for eliminating common sources of noise like power-line interference, baseline drift and electromyographic noise were used. The pre-processing phase considered the detection of steep slope/spike, low amplitude signal, and flat line or missing lead artefacts. The detection of TWA and QRSA was based on Principal Component Analysis indices and wave amplitudes considering all the leads.A particular database of 106 ECG records during stress testing was considered. The signal quality analysis performed in this study has permitted to obtain reliable and noise-tolerant measurements of TWA and QRSA indices. The different diagnostic groups were used for the evaluation of the clinical significance of the alternans. Men have significantly higher values of QRSA than women. Smokers have significantly higher TWA values as compared with non-smokers. Significant negative correlation was obtained between age and both TWA and QRSA. Correlations between TWA and QRSA and the double product of arterial hypertension and the maximal heart rate during the stress test were statistically significant, positive and relatively strong.

Diagnostic performance and cost of CT angiography versus stress ECG — A randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE)

BackgroundCoronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested. MethodsCT-COMPARE was a randomized, single-center trial of low–intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n=322) or ExECG (n=240). Primary endpoints were diagnostic performance for ACS, and hospital cost at 30days. Secondary endpoints were time-to-discharge, admission rates, and downstream resource utilization. ResultsACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity of 83% [95% CI: 36, 99.6%], specificity of 91% [CI: 86, 94%], and ROC AUC of 0.87 [CI: 0.70, 1]. CCTA (>50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity of 100% [CI: 81.5, 100], specificity of 94% [CI: 91.2, 96.7%], and ROC of 0.97 [CI: 0.92, 1.0; p=0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30day per-patient cost was significantly lower for CCTA ($2193 vs $2704, p<0.001). Length of stay for CCTA was significantly reduced (13.5h [95% CI: 11.2–15.7], ExECG 19.7h [95% CI: 17.4–22.1], p<0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30days. ConclusionsCCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.

Added value of hybrid myocardial perfusion SPECT and CT coronary angiography in the diagnosis of coronary artery disease.

Hybrid single photon emission computed tomography (SPECT)/coronary computed tomography angiography (CCTA) has only been evaluated for its diagnostic accuracy as a single test in patients suspected of significant coronary artery disease (CAD). Added value of hybrid SPECT/CCTA beyond usual clinical work-up, or use of each of these tests separately, remains unclear. We evaluated the added value of hybrid myocardial perfusion SPECT (SPECT) and CCTA, beyond pre-test likelihood and exercise stress ECG (X-ECG), in the diagnosis of CAD. Two hundred and five patients with stable angina pectoris and intermediate-to-high pre-test likelihood were prospectively included. All patients underwent clinical history and examination, X-ECG, stress and rest SPECT, coronary calcium scoring (CCS) and CCTA. Fractional flow reserve measurement <0.80 or a lesion >50% on coronary angiography (CA) served as reference standard for significant CAD. Multiple imputation was used to correct for missing test results (17-20%). Added value of hybrid SPECT/CCTA to the basic model of pre-test likelihood plus X-ECG was quantified using logistic regression analysis. Model differences were then assessed using differences in C-index and in net reclassification improvement (NRI). The basic model had a C-index of 0.73 (95%CI 0.66-0.80). This significantly increased to 0.85 (95%CI 0.80-0.91) by addition of only SPECT, to 0.90 (95%CI 0.85-0.94) when adding only CCTA, and to 0.96 (95%CI 0.92-0.99) when adding hybrid SPECT/CCTA. The accompanying NRIs were 0.82 (95%CI 0.62-1.02), 0.86 (95%CI 0.66-1.06) and 1.57 (95%CI 1.11-1.59) respectively. Current analysis resembles clinical routine of layered testing and shows that hybrid SPECT/CCTA imaging has a substantially higher yield than standalone SPECT or CCTA in the diagnostic workup of patients suspected of significant CAD.

Rate–pressure product-derived global coronary flow reserve (CFR): An unrecognized parameter available during all standard exercise ECG stress tests and conventional exercise SPECT myocardial perfusion studies (exMPS)

Rate–pressure product-derived global coronary flow reserve (CFR): An unrecognized parameter available during all standard exercise ECG stress tests and conventional exercise SPECT myocardial perfusion studies (exMPS)

CT Coronary Angiography is a Useful Diagnostic Test Following Equivocal Exercise Stress ECG in Troponin-Negative Chest Pain

Background: Exercise stress ECG (ETT) is commonly the first-line investigation in troponin-negative chest pain patients. Inconclusive results are common and often lead to repeated functional testings. CT coronary angiography (CTCA) has excellent negative predictive value for coronary artery disease detection and may play an important role in their diagnostic workup. Methods: We retrospectively identified consecutive troponin-negative chest pain patients undergoing CTCA (320-slice Aquillon ONE, Toshiba Medical Systems), referred following “equivocal” stress ECG (ETT), from August 2011 to February 2013. Stress ECGs were reviewed blinded to the CTCA results. The prevalence of obstructive coronary disease, as well as their clinical and ETT predictors, are identified. Results: 346 patients (age 57± 11, female 54%, BMI 28± 5) underwent CTCA after equivocal (49%), positive (30%), non-diagnostic (10%) or negative (11%) ETTs. Average exercise duration was 8.7± 2.9min. CTCA identified obstructive coronary artery disease in 20%, nonobstructive atherosclerosis in 35%, and normal coronary arteries in 41%. Significant predictors for obstructive coronary artery disease included advanced age, male gender (29% vs. 13%, p= 0.0001), abnormal ETT findings (positive vs. equivocal vs. negative); but not exercise duration. In women, ETT findings (equivocal vs. positive vs. nondiagnostic) did not predict obstructive disease. Conclusion: In the patient cohort referred for CTCA following “equivocal” ETT, obstructive coronary disease prevalence is 20%. In this diagnostic pathway, CTCA appearsuseful inestablishingdefinitivediagnosis inmany while avoiding further functional testings. In women, ETT findings did not predict the presence or absence of obstructive disease.

Are We Reaching Target LDL-Cholesterol (LDL-C) Levels After Acute Myocardial Infarction (AMI)

Background: Exercise stress ECG (ETT) is commonly the first-line investigation in troponin-negative chest pain patients. Inconclusive results are common and often lead to repeated functional testings. CT coronary angiography (CTCA) has excellent negative predictive value for coronary artery disease detection and may play an important role in their diagnostic workup. Methods: We retrospectively identified consecutive troponin-negative chest pain patients undergoing CTCA (320-slice Aquillon ONE, Toshiba Medical Systems), referred following “equivocal” stress ECG (ETT), from August 2011 to February 2013. Stress ECGs were reviewed blinded to the CTCA results. The prevalence of obstructive coronary disease, as well as their clinical and ETT predictors, are identified. Results: 346 patients (age 57± 11, female 54%, BMI 28± 5) underwent CTCA after equivocal (49%), positive (30%), non-diagnostic (10%) or negative (11%) ETTs. Average exercise duration was 8.7± 2.9min. CTCA identified obstructive coronary artery disease in 20%, nonobstructive atherosclerosis in 35%, and normal coronary arteries in 41%. Significant predictors for obstructive coronary artery disease included advanced age, male gender (29% vs. 13%, p= 0.0001), abnormal ETT findings (positive vs. equivocal vs. negative); but not exercise duration. In women, ETT findings (equivocal vs. positive vs. nondiagnostic) did not predict obstructive disease. Conclusion: In the patient cohort referred for CTCA following “equivocal” ETT, obstructive coronary disease prevalence is 20%. In this diagnostic pathway, CTCA appearsuseful inestablishingdefinitivediagnosis inmany while avoiding further functional testings. In women, ETT findings did not predict the presence or absence of obstructive disease.

Risk Stratification of Patients Presenting to the Emergency Department of the Gold Coast Hospital with Possible Cardiac Chest Pain: A Clinical Audit

Background: Coronary CT angiography (CTCA) has high sensitivity to rule out coronary artery disease (CAD). However, there are little data comparing CTCA and exercise stress ECG as part of a standard of care (SOC) chest pain assessment in the Emergency Department (ED). Methods: In a single Australian tertiary hospital, 565 low-to-intermediate CAD risk patients with chest pain (meanage51years, 57%male)wereprospectively enrolled and randomised to CCTA or SOC using exercise stress ECG. Randomisation occurred after a first negative troponin. Primary endpoints were length of hospitalisation, admission rates, downstream testing, and cost-utilisation ($AUD). Statistical tests used non-parametric testing and logistic regression for analysis. Result: Length of stay was significantly reduced in the CCTA arm [13.5 h (95% CI 11.2–15.7)] compared to the SOC [20.5 h (95%CI 17.9–23.1), p< 0.0001].Hospital admission rates were similar (CCTA 10.2% versus SOC 11.2%, odds ratio (OR) 1.1, p= 0.7). CCTA increased rates of downstream cardiac testing (10.8% versus 5.8%, OR 2.0, p= 0.04), predominantly from invasive coronary angiography (7.1% vs 3.3%, odds 2.2, p= 0.045). Mean radiation exposure forCCTAwas 4.8mSv (95%CI 4.4–5.2mSv). Representation was not statistically different (13.3% vs 10.0%, OR 1.2, p= 0.2). Per-patient cost was significantly lower in the CCTA arm [$2193 (95%CI 1997–2389) vs $2704 (95%CI 2555–2853)], particularly in patients who did not require inpatient management [$1669 (95%CI 1612–1726) vs $2459 (95%CI 2397–2521)]. Conclusion:Forpatientspresenting to theEDwithacute chest pain, CCTA results in significantly reduced length of stay but similar admission rates compared to the SOC usingexercise stressECG.Despite increased rate of downstream testing forCCTA, per-patient costwas significantly reduced.CCTA in theEDsetting is faster and cheaper than the most widely available standard of care, exercise stress ECG.

CT Coronary Angiography is a Useful Diagnostic Test Following Equivocal Exercise Stress ECG in Troponin-negative Chest Pain

Background: Exercise stress ECG (ETT) is commonly the first-line investigation in troponin-negative chest pain patients. Inconclusive results are common and often lead to repeated functional testings. CT coronary angiography (CTCA) has excellent negative predictive value for coronary artery disease detection and may play an important role in their diagnostic workup. Methods: We retrospectively identified consecutive troponin-negative chest pain patients undergoing CTCA (320-slice Aquillon ONE, Toshiba Medical Systems), referred following “equivocal” stress ECG (ETT), from August 2011 to February 2013. Stress ECGs were reviewed blinded to the CTCA results. The prevalence of obstructive coronary disease, as well as their clinical and ETT predictors, are identified. Results: 346 patients (age 57 ± 11, female 54%, BMI 28 ± 5) underwent CTCA after equivocal (49%), positive (30%), non-diagnostic (10%) or negative (11%) ETTs. Average exercise duration was 8.7 ± 2.9 min. CTCA identified obstructive coronary artery disease in 20%, non-obstructive atherosclerosis in 35%, and normal coronary arteries in 41%. Significant predictors for obstructive coronary artery disease included advanced age, male gender (29% vs. 13%, p = 0.0001), abnormal ETT findings (positive vs. equivocal vs. negative); but not exercise duration. In women, ETT findings (equivocal vs. positive vs. non-diagnostic) did not predict obstructive disease. Conclusion: In the patient cohort referred for CTCA following “equivocal” ETT, obstructive coronary disease prevalence is 20%. In this diagnostic pathway, CTCA appears useful in establishing definitive diagnosis in many while avoiding further functional testings. In women, ETT findings did not predict the presence or absence of obstructive disease.

Transient Myocardial Ischemia During Acetylcholine-Induced Coronary Microvascular Dysfunction Documented by Myocardial Contrast Echocardiography

A 77-year-old white woman was referred for diagnostic coronary angiography after a 6-month history of exertional breathlessness and back pain. Her cardiovascular risk factors were hypercholesterolemia (low-density lipoprotein, 153 mg/dL) and a positive family history for cardiovascular disease (father died at 73 years of age because of a peripheral artery occlusive disease event). Furthermore, the patient was overweight (body mass index, 28.8 kg/m2). Exercise ECG stress testing had to be stopped after 75 W as a result of limiting symptoms (breathlessness) but without ST-segment depression. Diagnostic coronary angiography revealed a 50% plaque in the distal circumflex coronary artery and diffuse minor irregularities in the remaining epicardial vessels (Figure 1). However, there was no flow-limiting epicardial stenosis. Left ventricular angiography showed normal left ventricular function without any wall motion abnormalities at rest, although left ventricular end-diastolic pressure was elevated at 25 mmHg. To further investigate the cause of the patient’s symptoms, intracoronary acetylcholine …

Asymptomatic Ischemic Heart Disease in a 45-year-old Male Athlete: A Case Report

Abstract Background: The primary purpose of pre-participation screening is identifying the cohort of athletes affected by unsuspected cardiovascular diseases, such as coronary artery disease (CAD) as well as preventing sudden cardiac death (SCD) during sports competitions or training, through appropriate intervention. Case Report: This case report describes the recent history of a middle-aged marathon runner suffering from asymptomatic ischemic heart disease at high risk for SCD and illustrates the clinical pathway. An exercise ECG stress testing was positive for subendocardial ischemia. Computerized tomography (CT) coronary angiogram subsequently showed critical narrowing of the left anterior descending artery. Invasive coronary angiography was performed following angioplasty procedure. One month later an exercise ECG stress testing was normal, indicative of complete myocardial revascularization. Conclusions: Silent myocardial ischemia (SMI) is not such a rare event in athletes, especially in endurance sports athletes. In fact, even though they are asymptomatic this does not exclude the presence of a severe coronary artery disease. Exercise stress testing is safe and affordable non-invasive screening for detecting asymptomatic coronary artery disease in athletes. Myocardial revascularization procedure is to re-establish the athlete’s state of fitness for competitive sports.

Anomalous Origin of the Right Coronary Artery From the Left Sinus of Valsalva in an Elderly Man

A 77-year-old man underwent left lower-lung lobectomy for lung cancer in August 2009. He was free of angina before surgery. He presented to our hospital with exertional chest pain in September 2010. Exercise stress ECG revealed ST-segment depression in leads II, III, aVF, V5, and V6 with chest pain (Figure 1). Computed tomographic coronary angiography revealed a severe stenosis at the right coronary artery (RCA) ostium without atherosclerotic plaque that originated from the left sinus of Valsalva and coursed between the aortic root and the pulmonary artery (Figure 2). Compared with the prelobectomy chest computed tomography, the pulmonary artery was larger than before surgery (Figure 3). Estimated right ventricular systolic pressure measured by Doppler echocardiography was also higher than before surgery (32 versus 23 mm Hg). We thought that his worsening angina might be caused by extrinsic mechanical compression of the RCA between the aortic root and the dilated pulmonary artery after the left lower-lung lobectomy. Coronary artery angiography revealed an RCA with an anomalous origin from the left sinus …

Appropriateness of referrals for single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in a developing community: A comparison between 2005 and 2009 versions of ACCF/ASNC appropriateness criteria

IntroductionAppropriateness of referrals for myocardial perfusion imaging (MPI) in developing countries has not been extensively studied. Our study was conducted to describe the ordering practices of physicians and appropriateness of MPI referrals in Iran. MethodWe prospectively applied 2005 and 2009 versions of the Appropriateness Use Criteria published by the American College of Cardiology Foundation (ACCF) and the American Society of Nuclear Cardiology (ASNC) to 291 consecutive patients (age 55.3 ± 10.3 years) who underwent SPECT-MPI. For this purpose, we convened a panel, consisting of two academic cardiologists, one academic clinician in internal medicine, and one academic clinician in nuclear medicine. The panelists were invited for a face-to-face meeting to judge appropriateness of SPECT-MPI and independently assign a specific indication (scenario), whenever possible, for each case in accordance with ACCF/ASNC appropriateness scenarios. ResultsBased on the 2005 ACCF/ASNC criteria, SPECT-MPI studies were judged appropriate for 211 (72.5%), uncertain for 36 (12.4%), inappropriate for 32 (11.0%), and unclassifiable for 12 (4.1%) referrals. The same figures based on the 2009 version were 219 (75.3%), 15 (5.2%), 49 (16.8%), and 8 (2.7%) patients, respectively. Overall agreement between the 2005 and 2009 versions was good (κ 0.63). Lack of chest pain and age below 60 years were significant indicators increasing the likelihood of inappropriate referrals by 2.9-3.4 fold. Absence of diabetes mellitus and hypertension, a normal lipid profile, lack of a past history of myocardial infarction or cardiovascular interventions (CABGs or PCI), as well as lack of application and exercise ECG stress test as the gate keeper (keeping abnormal ETT or inability of the patient to perform exercise as the appropriate indication for SPECT-MPI referral) were significant indicators, decreasing the odds of appropriate referrals. Generally a higher percentage of referrals with inappropriate indications had normal MPI. ConclusionOur study provides an evidence for the fact that SPECT-MPI ordering practices in our developing community largely parallel the ACCF/ASNC recommendations. The implementation of appropriateness criteria is feasible in clinical settings and might provide an alternative to utilization management.

Correlation between serum osteoprotegerin and atherosclerotic vascular disorders in rheumatoid arthritis patients

Aim of the workThe aim of the present study was to investigate the association of serum osteoprotegerin (OPG) level with the presence of angiographically documented asymptomatic coronary artery disease (CAD) in patients with rheumatoid arthritis (RA) and to evaluate its relationship with plasma thrombomodulin (TM), as a marker of endothelial dysfunction and with carotid artery intima media thickness (IMT), as a marker of atherosclerosis. Patients and methodsThe study included 20 rheumatoid patients without CAD (negative results on exercise ECG stress test) and other 20 rheumatoid patients with CAD (positive results on exercise ECG stress test and confirmed by coronary angiography). In addition, 20 age and sex matched normal control subjects were studied. Serum OPG and plasma TM levels were measured and carotid artery IMT was determined. ResultsThe study revealed that serum OPG levels were significantly higher in rheumatoid patients with and without CAD than in controls (P<0.001, P<0.01; respectively) and were positively correlated with age, duration of disease, Disease active score 28(DAS28), Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and carotid IMT in rheumatoid patients with and without CAD. Serum OPG level was correlated significantly with plasma TM only in rheumatoid patients with CAD (P<0.001). ConclusionOsteoprotegerin is a clinically important molecule independently associated with the presence of coronary artery disease and may be a good indicator of atherosclerotic vascular damage and macroangiopathy in asymptomatic rheumatoid patients. Hence, measurement of serum OPG merits further investigation as a simple test for improving early diagnosis of asymptomatic CAD in rheumatoid patients.

Key role of the molecular autopsy in sudden unexpected death

Sudden Cardiac Death (SCD) is a major and tragic complication of a number of cardiovascular diseases. While in the older populations, SCD is most frequently caused by underlying coronary artery disease and heart failure, in those aged under 40 years, the causes of SCD commonly include genetic disorders, such as inherited cardiomyopathies and primary arrhythmogenic diseases. As part of the evaluation of families in which SCD has occurred, the role of genetic testing has evolved as an important feature in both establishing an underlying diagnosis and in screening at-risk family relatives. Specifically, in cases where no definitive cause is identified at postmortem, i.e. Sudden Unexpected Death (SUD), the "molecular autopsy" has emerged as a key process in the investigation of the cause of death. The combination of clinical and genetic evaluation of families in which SUD has occurred provides a platform for early initiation of therapeutic and prevention strategies, with the ultimate goal to reduce sudden death among the young in our communities.