Exercise Stress Echocardiogram Research Articles

Is dyspnea the new angina?

Abstract Introduction The exercise stress echocardiogram is a highly valuable tool for evaluating patients with dyspnea as the main symptom (without angina) and suspected coronary artery disease (CAD). This involves a large volume of patients in daily practice, and etiological orientation is often difficult, especially in patients with high cardiovascular risk. Objective This study aims to define the likelihood of inducible ischemia in this population concerning their pretest probability described in the literature, as well as to compare the exercise workload achieved during the test with the predicted workload. Methods We performed a retrospective analysis of 116 consecutive diagnostic exercise stress echocardiograms (2021-2023) conducted on patients with dyspnea as the main symptom (14.55% of the total exercise stress echocardiograms). Results The average age was 67.93 years (standard deviation [SD] 9.99), and the average body mass index (BMI) was 28.87 (SD 4.37). Baseline characteristics included hypertension (79 patients, 68.1%), diabetes (39 patients, 33.6%), dyslipidemia (76 patients, 65.5%), smoking (46 patients, 39.7%), and known pulmonary disease (21 patients, 18.1%). Among the patients, 104 (89.7%) had an intermediate pretest probability of CAD. The main reason for test termination was dyspnea in 78 patients (67.2%). The average maximum workload achieved was 7.28 METs (SD 2.34), compared to a predicted maximum workload of 6.58 METs (SD 1.78), resulting in an actual/predicted METs ratio of 1.14. The stress echocardiogram was positive for inducible ischemia in 8 cases (6.9%), with no significant differences between diabetic and non-diabetic patients (6.49% positive in non-diabetics, 7.89% positive in diabetics, p = 0.781). Conclusions Patients referred for dyspnea as the main symptom demonstrated greater functional capacity than predicted, suggesting both a challenging assessment of functional class in clinical consultations and a possible underestimation of age-predicted functional capacity formulas in the current population. Additionally, the positivity rate for ischemia was lower than described in the literature for a population with predominantly intermediate pretest probability of CAD. Salgo le characteristics

Unmasking Obstruction in Hypertrophic Cardiomyopathy With Postprandial Resting and Treadmill Stress Echocardiography

Latent left ventricular outflow tract obstruction (LVOTO) is an important cause of symptoms in patients with hypertrophic cardiomyopathy (HCM) but can be challenging to provoke. To examine the value of postprandial resting and stress echocardiography and utilization of invasive or enhanced drug therapies (surgical myectomy, alcohol septal ablation, disopyramide, and mavacamten) in patients with postprandial LVOTO. Consecutive HCM patients without LVOTO underwent routine and postprandial echocardiography at rest, with provocation (Valsalva and standing) and after symptom-limited treadmill stress. Among 252 patients (mean age, 58years, 39% women), postprandial LVOT gradients were higher compared with routine echocardiography at rest (median, 9.0 [0-38.0] vs 0 [0-14.0] mm Hg; P<.0001) and with provocation (18.5 [0-70.3] vs 1.5 [0-41.0] mm Hg; P<.0001). Postprandial exercise stress echocardiogram (PPXSE) gradients were higher in a subset of 44 patients who underwent both postprandial and fasting stress echocardiography (47.0 [5.3-81.0] vs 17.5 [0-46.0] mm Hg; P<.0001). In total, 49 (19.5%) patients achieved the ≥50mm Hg threshold under routine conditions (rest/provocation); 90 (35.7%) additional patients achieved postprandial gradients ≥50mm Hg (rest/provocation/exercise), 38 (15.1%) with PPXSE alone. A total of 71 patients were treated with 91 invasive or enhanced drug therapies, 32 (45.1%) of whom had gradients ≥50mm Hg only after eating (rest/provocation) and 8 (11.3%) only with PPXSE, with symptom relief in the majority. Postprandial echocardiography was useful at unmasking LVOTO in more than one-third of patients who did not have high gradients otherwise. Eating before echocardiography is a powerful provocative tool in the evaluation of patients with HCM.

Abstract 18379: Implementation of a Fully Automated Procedural Reporting System for Cardiology Fellowship

Introduction: Contemporary cardiovascular fellowship training is based in the principles of competency-based medical education (CBME). Inclusive of CBME, core cardiovascular training statements suggest a minimum number of procedures necessary to achieve levels of training. However, current platforms for procedure logging create an onerous burden on trainees and program leadership which can result in incomplete data capture. There is a paucity of experience with automated case logging tools across training programs. Herein, we present the experience of fully automating trainee case logging within the echo lab at a large cardiovascular fellowship program. Methods: Structured trainee procedure attribution data (patient age, gender, and procedure type) were captured during routine clinical activity within our EHR structured reporting module (Epic Cupid). Attribution was extracted from the EHR reporting warehouse (Epic Clarity) and summarized for trainees weekly via email. Following a weeklong buffer period to allow for corrections, the data were uploaded to the institutional educational reporting platform (MedHub) via a web application programming interface. All stages of this workflow were fully automated. Results: During the post-intervention period (June 2022 to May 2023), 32 cardiovascular fellows participated. Attribution was initially captured for transthoracic and transesophageal echocardiograms and later expanded to include exercise and dobutamine stress echocardiograms. A monthly average of 584 procedures were captured for trainees. There were no attribution errors reported. The intervention was uniformly perceived as helpful by both trainees and leadership with requests for expansion to other cardiovascular procedure types. Conclusion: Fully automated educational experience reporting is feasible in a large cardiovascular training program and can be implemented without change to clinical workflows or administrative burden.

Outcomes of right heart dysfunction in the acutely and severely unwell: protocol for a prospective, longitudinal observational study using multimodal assessment

IntroductionThe relationship of acute right heart dysfunction (RHD) with long-term cardiopulmonary dysfunction and its’ associated morbidity has not been clearly elucidated. We propose a prospective, observational study to assess the...

An initiative to promote value-based stress test selection in primary care and cardiology clinics: A mixed methods evaluation.

Exercise stress echocardiograms (stress echos) are overused, whereas exercise stress electrocardiograms (stress ECGs) can be an appropriate, lower-cost substitute. In this post hoc, mixed methods evaluation, we assessed an initiative promoting value-based, guideline-concordant ordering practices in primary care (PC) and cardiology clinics. Change in percent of stress ECGs ordered of all exercise stress tests (stress ECGs and echos) was calculated between three periods: baseline (January 2019-February 2020); Period 1 with reduced stress ECG report turnaround time + PC-targeted education (began June 2020); and Period 2 with the addition of electronic health record-based alternative alert (AA) providing point-of-care clinical decision support. The AA was deployed in two of five PC clinics in July 2020, two additional PC clinics in January 2021, and one of four cardiology clinics in February 2021. Nineteen primary care providers (PCPs) and five cardiologists were interviewed in Period 2. Clinicians reported reducing ECG report turnaround time was crucial for adoption. PCPs specifically reported that value-based education helped change their practice. In PC, the percent of stress ECGs ordered increased by 38% ± 6% (SE) (p < 0.0001) from baseline to Period 1. Most PCPs identified the AA as the most impactful initiative, yet stress ECG ordering did not change (6% ± 6%; p = 0.34) between Periods 1 and 2. In contrast, cardiologists reportedly relied on their expertise rather than AAs, yet their stress ECGs orders increased from Period 1 to 2 to a larger degree in the cardiology clinic with the AA (12% ± 5%; p = 0.01) than clinics without the AA (6% ± 2%; p = 0.01). The percent of stress ECGs ordered was higher in Period 2 than baseline for both specialties (both p < 0.0001). This initiative influenced ordering behaviour in PC and cardiology clinics. However, clinicians' perceptions of the initiative varied between specialties and did not always align with the observed behaviour change.

Wide QRS Complexes Following Ablation for Reentrant Tachycardia

Scenario: A 25-year-old man was referred from a cardiology clinic for an acute exacerbation of supraventricular tachycardia (SVT) during an exercise stress echocardiogram. He has a history of dilated cardiomyopathy (50% left ventricular ejection fraction [LVEF]), wall motion abnormalities, and long QT syndrome. In the clinic before admission, an SVT event was captured during an electrocardiogram (ECG) recording and resolved with a carotid sinus massage. The patient was fully conscious during the event. A few days later, he underwent an electrophysiology (EP) study with radio frequency ablation for atrioventricular reentrant tachycardia (AVRT). He was transferred to the cardiac step-down unit after the EP procedure, and his blood pressure was 94/56 mm Hg, heart rate 87/min, respiratory rate 21/min (regular), oxygen saturation 94% via room air, and body temperature 37 °C (99 °F). The 12-lead ECG below was taken 6 hours after admission to the unit.Normal sinus rhythm, frequent premature ventricular complexes (PVCs) in a quadrigeminy pattern, prolonged QTc interval.Generally, wide QRS complexes (>120 milliseconds) represent electrical activity that originates from the ventricles. Exceptions are aberrantly conducted supraventricular beats, preexcitation associated with an accessory pathway, bundle branch block, and electrolyte imbalance. Given the AVRT diagnosis with recent ablation treatment, these PVCs may be mistaken for preexcitations associated with an accessory pathway, especially as the PVC QRSs appear slurred (ie, “pseudo” delta wave), a characteristic associated with an accessory pathway. However, some features support PVC as the cause. First, the wide QRS complexes are premature, albeit only slightly at first glance. However, if calipers are used, or even on careful visual inspection, one can appreciate that these beats are indeed premature. In this case, the P waves fall just before the PVC but should not be confused with a delta wave. Furthermore, there is a complete compensatory pause after the PVCs because the timing of the sinus node is not interrupted. In contrast, a supraventricular beat (eg, aberrancy, premature atrial complex) would typically have a P wave before the QRS complex, and one would see an incomplete pause because these beats usually enter the sinus node and reset its timing.PVCs can be monomorphic, as in this case, or polymorphic (multiple QRS morphologies). Interestingly, the morphology of the PVC can be used to determine the ventricle of origin (ie, left or right) by examining lead V1. In this example, the morphology resembles a left bundle branch block (ie, negative wide QRS complex). This pattern indicates that the ectopic impulse is moving away from lead V1 and travels toward the left ventricle (ie, deep S wave). The QRS complex is wide because the ventricular impulse travels slowly from the right ventricle, outside the normal conduction system, to the left ventricle, slowing depolarization.Premature beats, including PVCs, can trigger reentrant tachyarrhythmias when an accessory pathway is present. Although PVCs were not documented as the source of the AVRT events in this patient, they are a likely source. This patient’s history of cardiomyopathy may be contributing to the occurrence of PVCs, which may also need to be treated with ablation. Considering that this patient has a prolonged QTc and other significant risk factors (postablation, AVRT, cardiomyopathy, and reduced EF), medications that prolong the QT/QTc should be closely reviewed and adjusted if necessary to prevent torsades de pointes. This patient was discharged home and was followed up by outpatient cardiology.

Exercise-induced Brugada pattern and ventricular tachycardia during Capecitabine treatment

We report the case of a 59-year-old female patient with no previous cardiovascular disease treated for Breast cancer with Capecitabine. Shortly after starting treatment, she developed recurrent angina. An exercise stress echocardiogram was performed, which induced a type 1 Brugada pattern 12 s of a non-sustained pleomorphic ventricular tachycardia ensued.

Exercise Stress Echocardiography in Kawasaki Disease Patients with Coronary Aneurysms

The most significant sequelae of Kawasaki disease (KD) are coronary artery aneurysms, which can lead to risk of future myocardial ischemia. Exercise stress echocardiography allows for non-invasive assessment of myocardial dysfunction. We reviewed our single center experience with exercise stress echocardiography in patients with previous history of KD with coronary aneurysms. We reviewed the records of 53 KD patients who underwent exercise stress echocardiography from 2000 to 2020. Abnormal stress echocardiograms were defined as those showing no increase in biventricular systolic function post-exercise or regional wall motion abnormalities. Computed tomography angiography and cardiac magnetic resonance imaging were reviewed for patients with abnormal stress echocardiograms. Clinical data were reviewed and correlated with stress echocardiogram results. Of the 53 patients, three (5.7%) had an abnormal exercise stress echocardiogram. All three patients were classified as AHA Risk Level 4 or 5 by coronary Z-score (internal dimension normalized for body surface area) and were confirmed to have coronary aneurysms, stenosis, or myocardial tissue perfusion defects on advanced cardiac imaging that could account for the results seen on stress echocardiogram. Exercise stress echocardiography detected signs of myocardial ischemia in a subset of high-risk patients with Kawasaki disease and coronary aneurysms and may be considered as a useful screening tool for this complex patient cohort.

Phase III impact of telerehabilitation in patients with coronary heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiac rehabilitation (CR) in coronary heart disease (CAD) has been shown to improve physical capability and health-related quality of life, reducing morbimortality. However, CR accessibility is still low and patient adherence remains poor. It has been hypothesized that using mobile applications to telemonitor exercise-based CR would increase patient adherence to CR, improving results. Hybrid cardiac telerehabilitation (HCTR) is a new concept that includes center and home interventions. Objectives Investigate the effects of HCTR program on improving physical activity, quality of life and reducing cardiovascular risk factors among patients with CAD 1 year after CR phase II. Materials and methods Longitudinal retrospective study with patients who attended phase 2 CR program (CRP) at a hospital center between august 2018-november 2020. They were divided in 2 groups: group 1 completed conventional CRP (CCRP), 12 weeks of monitored hospital physical exercise and educational sessions; group 2 participated on HCTR program (CCRP associated to a tele-monitorization platform consisting of a mobile application, MOVIDA.eros, with medical prescription of physical exercise and remote interaction). Group 2 maintained use of MOVIDA.eros on phase 3. Evaluations were performed on T0 – phase 2 onset, T1 – end of phase 2, T2 – 1 year after T1, with registration of age, gender, occupation, body mass index (BMI), exercise stress testing, echocardiogram (evaluation of left ventricular ejection fraction [LVEF]), LDL, HDL cholesterol, triglycerides, NTproBNP levels, and application of EuroQol-5D questionnaire (EQ5D), International Physical Activity Questionnaire – Short Form (IPAQ). Statistical analysis was completed through software SPSS v28. p-values &amp;lt;0.05 were considered statistically significant. Results We analyzed 68 patients, 46 on group 1 and 22 on group 2. Variable analysis revealed similar group characteristics, except for age (p=0.011) and LVEF (p=0.005). There was an association between HCTR adherence and occupation (p=0.002; greater proportion of intellectual professionals on group 2). We observed a significant IPAQ (p=0.018) and EQ-5D index (p=0.034) improvement between T0 to T1 in both groups, but only in group 2 persisted till T2. In exercise stress testing, both groups revealed an increase in METs at T1 and decrease at T2, without significant differences between them. Regarding lipid profile, HbA1c, NTproBNP and BMI, both groups improved from T0 to T1 maintaining it till T2 with no differences between them, however in group 2 HDL cholesterol levels were greater and HbA1c levels were lower than group 1. In both groups, LVEF increased from T0 to T1 and from T1 to T2 in both groups, with faster and higher improvement in group 2. Conclusions HCTR outperformed CCRP improving physical activity, patient quality of life, HDL cholesterol and faster improvement of LVEF. These findings encourage the use of a mobile platform in CR.

Exercise-Induced Pulmonary Hypertension Is Associated with High Cardiovascular Risk in Patients with HIV.

Background and Aim: Pulmonary hypertension (PH) at rest can be preceded by the onset of exercise-induced PH (ExPH). We investigated its association with the cardiovascular (CV) risk score in patients with human immunodeficiency virus (HIV). Methods: In 46 consecutive patients with HIV with low (n = 43) or intermediate (n = 3) probability of resting PH, we evaluated the CV risk score based on prognostic determinants of CV risk. Diagnosis of ExPH was made by cardiopulmonary exercise test (CPET) and exercise stress echocardiogram (ESE). Results: Twenty-eight % (n = 13) of the enrolled patients had ExPH at both CPET and ESE, with good agreement between the two methods (Cohen’s kappa = 0.678). ExPH correlated directly with a higher CV score (p < 0.001). Patients with a higher CV score also had lower CD4+ T-cell counts (p = 0.001), a faster progression to acquired immunodeficiency syndrome (p < 0.001), a poor immunological response to antiretroviral therapy (p = 0.035), higher pulmonary vascular resistance (p = 0.003) and a higher right atrial area (p = 0.006). Conclusions: Isolated ExPH is associated with a high CV risk score in patients with HIV. Assessment of ExPH may better stratify CV risk in patients with HIV.

The Cost of Return to Play Protocols in Collegiate Athletes Recovering from Coronavirus Disease 2019.

SARS-CoV-2 infection (COVID-19) can result in myocarditis. Protocols were developed to allow competitive athletes to safely return to play (RTP) after a COVID-19 infection, but the financial impact of these protocols is unknown. Our objective was to determine the differential cost of post-COVID-19 RTP protocols for competitive collegiate athletes. This multicenter retrospective cohort study of clinical evaluation of 295 athletes after COVID-19 infection was performed at four institutions with three RTP protocols. Costs were calculated using adjusted Center for Medicare and Medicaid Services pricing. All athletes underwent electrocardiogram and clinical evaluation. A tiered approach performed cardiac imaging and biomarker analysis for major symptoms. A universal transthoracic echocardiogram (TTE) approach performed TTE and biomarkers for all athletes. A universal exercise stress echocardiogram (ESE) approach performed ESE and biomarkers for all athletes. The cost per athlete was $632.51 ± 651.80 ($44,908 total) in tiered group (n = 71), $1,072.30 ± 517.93 ($87,928 total) in the universal TTE group (n = 82), and $1357.38 ± 757.05 ($192,748 total) in the universal ESE group (n = 142) (P < 0.001). Extrapolated national costs for collegiate athletes would be $39 to 64 million higher for universal imaging approaches versus a tiered approach. Only seven athletes had probable/possible myocarditis with no significant difference between approaches. Cardiac screening in collegiate athletes after COVID-19 infection resulted in significant cost to the health care system. A tiered-based approach was more economical, and a universal exercise echocardiogram group detected slightly more myocardial abnormalities by cardiac magnetic resonance imaging. The clinical consequences of these approaches are unknown.

Prevalence and clinical impact of latent obstruction in hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Hypertrophic cardiomyopathy (HCM) is characterized by varying degrees of left ventricular outflow tract obstruction (LVOTobs). We aim to define the prevalence, clinical profile and impact of LVOTobs under physiological exercise in HCM patients (pts). METHODS Single center retrospective study of consecutive HCM pts without LVOTobs at rest (resting gradient &amp;lt;30mmHg), referred for exercise stress echocardiogram (ESE) between 2015 and 2019. Significative latent obstruction was defined as a LVOT gradient ≥50 mmHg during exercise or at early recuperation. RESULTS A total of 56 pts were included (64% men, mean age 57 ± 11 years, 61% septal HCM). The majority of pts (47; 84%) were in NYHA I functional class, 20 (36%) had history of syncope or pre-syncope (S/pS) and 7 (13%) had an implantable cardioverter defibrillator (ICD). Twelve (21%) pts had systolic anterior motion (SAM) of the mitral valve at rest. Thirty-five (63%) pts performed ESE under beta-blocker (BB) therapy. Mean exercise time was 8 ± 3 min. During ESE, 2 (4%) pts developed a LVOT gradient between 30 to 50 mmHg and 17 pts (30%) developed a significative LVOTobs gradient (mean 85 ± 18 mmHg). Pts with significative latent LVOTobs had more previous complaints of S/pS (59% vs 26%, p=.017), a tendency for a higher NYHA functional class (p=.082) and were more frequently on BB therapy (82% vs 18%, p=.043). Mean septum thickness was similar between groups (17 ± 0.7 vs 16 ± 0.6 mm, p=.536). The presence of SAM at rest was more frequent in the significative latent LVOTobs pts (p&amp;lt;.001). No differences were noted in exercise tolerance (p=.526). During a median follow-up of 43 (IQR 15-53) months, 7 (41%) pts with significative latent LVOTobs had a pre-syncope, 3 (18%) were diagnosed with atrial fibrillation and 2 (12%) had a cardiovascular admission . There was up-titration/initiation of BB therapy in 5 (29%) pts, referral for septal myectomy in 3 (18%) and ICD implantation for primary prevention in 3 (18%) pts. No proper ICD shocks, sustained ventricular arrythmias or deaths occurred. Comparing significative latent to non LVOTobs pts, the first ones had more ICD implantation (log rank p =.04) and performed a surgical myectomy more frequently (log rank p= .018) during the follow-up. CONCLUSION In our study, significative latent LVOTobs was observed in 30% of pts. Its presence can have clinical implications in HCM pts approach and should be suspected in more symptomatic pts and when SAM is present at rest.

Impact of an inconclusive exercise stress echocardiogram on cardiovascular outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Background Exercise stress echocardiography (ESE) is used for the assessment of suspected or known coronary artery disease (CAD); however, a certain percentage of ESE studies are inconclusive. We aim to evaluate the prognostic impact of an inconclusive ESE on cardiovascular outcomes. Methods Single-center retrospective study of consecutive patients (pts) who performed an ESE between 2018 and 2019 for diagnosis or stratification of CAD. All pts performed a symptom-limited Bruce protocol. ESE was considered inconclusive when 85% of age-predicted maximum HR was not reached. Primary endpoint was a composite of admission for acute coronary syndrome (ACS), coronary revascularization and cardiovascular death during the follow-up. Results A total of 141 pts were included (76% male; mean age 60 ± 9 years). ESE was inconclusive in 51 (36%) pts, positive in 11 (8%) and negative in 79 (56%). The mean exercise time of pts with inconclusive ESE was 7 ± 2 minutes and 76% had normal functional capacity. Fatigue (25 pts; 49%) and lower extremities pain (11 pts; 22%) were the main reasons for ESE stopping. Five pts (10%) complained of chest pain during exam. Pts with an inconclusive ESE were more diabetic (inconclusive 43%, positive 9%, negative 13%; p=.001), had more chronic obstructive pulmonary disease (COPD) (14%, 0%, 2.5%; p=.026), performed more frequently the exam under beta blocker (BB) therapy (59%, 27%, 18%; p=.041) and had less ST-segment depression fulfilling electrocardiographic criteria for ischemia (10%, 64%, 27%, p&amp;lt;.001). Their functional capacity was worse than negative ESE pts (p&amp;lt;.001). During a median follow up of 22 months (IQR 15-27), 13 (9.2%) pts had the primary endpoint, including 5 pts (3.5%) with ACS. Pts with an inconclusive ESE had a lower incidence of the primary outcome than pts with a positive ESE and a higher incidence of events than pts with negative results (figure). In multivariate analysis, after adjusting for functional capacity and electrocardiographic criteria for ischemia, an inconclusive ESE was an independent predictor of the primary endpoint (HR 9.7, IC95% 1.1-87,6 p= .042) Conclusions The frequency of inconclusive ESE is not negligible (36%). These pts had more diabetes and COPD and performed the exam under BB therapy more frequently, highlighting the importance of proper patient selection. An inconclusive ESE was associated to a higher risk of cardiovascular events compared to negative ESE. Abstract Figure.

Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review.

An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.

Average Exercise Capacity in Men and Women >75 Years of Age Undergoing a Bruce Protocol Exercise Stress Test

Exercise stress testing is routinely performed to evaluate suspected coronary artery disease in older adults. However, the available data to predict and compare relative exercise capacity in the general population were developed using predominantly younger, healthy cohorts with few or no women. This study aimed to describe the exercise capacity of patients older than 75 years who underwent a clinically indicated Bruce protocol exercise stress test. This was a retrospective, cross-sectional study of 2,041 consecutive patients older than 75 years who performed a Bruce protocol exercise stress echocardiogram that was terminated because of maximal effort without ischemia at Columbia University Medical Center between April 10, 2009, and July 30, 2020. The analytic sample included 2,041 exercise stress tests in 786 women (median [interquartile range] age 79 [77 to 81] years) and 1,255 men (median [interquartile range] age 79 [77 to 82] years). Cardiovascular risk factors and clinical coronary disease were common and more prevalent in men than women. The median exercise time for men aged 76 to 80 years was 7:22 (minutes:seconds) and for women was 6:00 and significantly decreased in both genders as age increased (p <0.001). The mean (SD) METs achieved for women and men were 6.5 (1.6) and 7.7 (1.7), respectively. Most women (85%) and men (95%) completed the first stage, whereas only 32% of women and 64% of men completed the second stage. It was uncommon for women (3%) or men (15%) to complete the third stage. Fewer than 1% of patients completed the fourth stage, and none completed the fifth stage. At all ages, women had a lower exercise capacity than men. These data allow physicians to compare the exercise capacity of older patients who underwent a Bruce protocol exercise stress test more accurately to a representative sample of similarly aged adults.

Abstract 13064: Sex-Related Differences in Chest Pain and Asymptomatic Myocardial Ischemia Experienced During Exercise Stress Echocardiogram

Background: Coronary artery disease (CAD) continues to account for significant morbidity and mortality for both men and women. Women present with greater variability in symptoms from coronary artery disease than men. This study seeks to describe the potential differences between men and women in the association between stress test-related chest pain and obstructive CAD. Methods: Patients with an exercise stress test who underwent a coronary angiogram from September 2013 to January 2019 were included in our analyses. The patients’ clinical characteristics, symptoms, coronary angiography and ECGs were analyzed to determine the relationship between ischemia, chest pain, and obstructive coronary artery disease (CAD; stenosis &gt; 70%). T-tests and chi-square tests described differences in continuous and categorical variables, respectively. Logistic regression was used to adjust for demographic, imaging, and stress testing factors. Results: A total of 368 patients were included in our analyses: 297 patients had a positive stress echocardiogram or ECG; 71 patients had negative stress tests but continued to have persistent symptoms. The study population had a mean age of 63 years and included 29% female, 11% African-American, and 61% obstructive CAD. In those with obstructive CAD, only 39% of women experienced chest pain during stress (p&gt;0.2), but in men, 48% experienced stress test related chest pain (p&lt;0.001). Adjusting for baseline demographics in sex-stratified models, echo-based ischemia and ECG-based ischemia were significantly associated with obstructive CAD in women, but stress-test related chest pain was not (p=0.02; p&lt;0.001; p&gt;0.2, respectively). In men, echo-based ischemia, ECG-based ischemia, and stress-test related chest pain all associated with obstructive CAD (p&lt;0.001; p&lt;0.001; p=0.008, respectively). These changes persisted with adjustment for stress test performance (METS, heart rate achieved) as well as baseline left ventricular ejection fraction. Conclusion: In women, stress test-related chest pain during stress testing was not associated with obstructive CAD. Further studies are needed to understand the role, significance, and management of potential myocardial ischemia without chest pain in women.

Comparing downstream consequences of normal exercise stress echocardiograms and cardiac computed tomography angiography scans in patients suspected of having of obstructive coronary artery disease: a retrospective cohort study of Tricare beneficiaries

To compare overall number of downstream tests and total costs between negative exercise stress echocardiograms (ESE) or cardiac computed tomography angiography scans (CCTA) in symptomatic Tricare beneficiaries suspected of having coronary artery disease (CAD). This is a retrospective cohort study examining 651 propensity-matched patients who underwent ESE or CCTA with normal results between 2008 and 2014 at the United States’ largest Department of Defense hospital. The total number of additional downstream tests over the next five years was determined. The total costs associated with each arm, inclusive of the initial test and all subsequent tests, were calculated using the 2018 Medicare Physician Fee Schedule. 18.5 percent of patients with a normal ESE result underwent some additional form of cardiac testing over the five years after initial testing compared to 12.8 percent of patients with a normal CCTA. The absolute difference in total number of downstream tests between both study groups was 5.7 percent (p = 0.03). When factoring the costs of the initial test as well as the downstream tests, the ESE group was associated with overall lower costs compared to the CCTA group, 351 United States Dollars (USD) versus 496 USD (p < 0.0001). This study demonstrates that, when compared to CCTA, ESE is associated with a higher total number of downstream tests, but overall lower total costs when chosen as initial testing strategy for suspected CAD.

Power walking based outpatient cardiac rehabilitation in patients with post-coronary angioplasty: Randomized control trial.

The purpose of this trial was to compare the effectiveness of standardized outpatient cardiac rehabilitation combined with treadmill power walking versus standardized outpatient cardiac rehabilitation alone on health-related quality of life (HQoL), functional exercise capacity (FEC), left ventricular ejection fraction (LVEF) and metabolic equivalent of tasks (METs) in patients who went post coronary angioplasty (CA). Further this study evaluated the association between average numbers of steps taken with above clinical outcomes. In a pragmatic sequential randomized clinical trial, 24 patients were randomized into two groups (n=12) and participated in a standardized outpatient cardiac rehabilitation program (SOCRP) with treadmill power walking as an intervention group and SOCRP alone in control group. Scores obtained before and after 4 weeks of intervention, that is, after 12 treatment sessions were assessed using a HQoL questionnaire and 6-min walk test (6 MWT). Average number of steps taken throughout the 4 weeks, METs and LVEF values were obtained by pedometer, exercise stress testing and echocardiogram respectively. Significant improvements were found in intergroup and intragroup comparison after 4 weeks of cardiac rehabilitation (p<0.05). Scores of 6 MWT and LVEF significantly improved in the intervention group (p<0.003) compared to the control group (p<0.032). HQoL components that is, global and physical, MET values and average number of steps were significantly higher in the intervention group compared to the control group (p<0.001). SOCRP with power walking was more effective in improving HQoL, FEC, LVEF, METs and average numbers of steps than SOCRP alone although both interventions were significant after 4 weeks in patients underwent CA and completed cardiac rehabilitation program. Positive significant associations were found between the average number of steps taken with scores of METs and scores of global and physical domains of HQoL.

302 Biomarker Profiling for Obstructive Coronary Artery Disease: A PROMISE Substudy

Coronary artery disease (CAD) is a prevalent condition, frequently diagnosed by imaging studies. Laboratory-based adjuncts would be useful but currently play a limited role in diagnosis. We hypothesized that a multimarker blood-based panel could exclude obstructive CAD such that further noninvasive imaging would not be required. We used banked samples from the randomized PROMISE trial. Patients were symptomatic outpatients without diagnosed CAD referred for noninvasive cardiovascular testing for suspected CAD who were randomized to either coronary computed tomography (CT) or functional testing (exercise ECG or stress echocardiogram or SPECT imaging). Traditional clinical CAD risk factor information was collected including age, sex, race, and a history of hypertension, diabetes, dyslipidemia smoking, or family history of CAD. Baseline blood samples were collected, banked, and tested for a panel of 13 cardiovascular risk biomarkers (high sensitivity troponin I (hsTn), Cystatin C, Galectin-3, NT-pro-BNP, Creatinine, Homocysteine, Beta2, Lipoprotein A, Glucose, Insulin, ALT, Free T3, and Uric Acid) using least absolute shrinkage and selection operator (LASSO) regression analysis with 10-fold nested cross validation to estimate prediction performance. Our endpoint was obstructive CAD as defined by >70% stenosis on coronary CT. CT scans were read at a core lab for study purposes. We compared models using only clinical variables to those using all biomarker variables, hsTn alone, or either of these plus clinical variables. The PROMISE biomarker repository included 1,716 patients who were randomized to and received an evaluable coronary CT, with mean age 60.2 years, 52.5 % female and 87.3% white. On average, patients had 2.4 clinical risk factors for CAD and a ASCVD score of 14. A total of 102 patients had obstructive CAD; these patients were mostly male (71.6%) and smokers (65.7%). A predictive model using only clinical variables had similar negative predictive value (NPV), AUC, and Youden index (sensitivity + specificity -1) compared to a biomarker + clinical model. Similar results were found for hsTn in combination with clinical variables (Table 1). A biomarker-only model and hsTn alone had lower AUC and Youden index, with the former superior to the latter. In this population of symptomatic outpatients being evaluated for suspected CAD, clinical variables had only modest overall accuracy but good negative predictive value. A biomarker panel of 13 different analytes also had modest overall accuracy but was inferior to clinical factors alone, or hsTN alone. Combining the biomarkers with clinical data did not provide significant incremental accuracy to exclude CAD.Table 1Model Performance Summary for Obstructive CAD.ModelAUC (95% CI)NPV %, (95% CI)PPV %, (95% CI)YoudenSensitivity %, (95% CI)Specificity %, (95% CI)Clinical0.681 (0.630, 0.732)88.2% (85.6, 89.3%)11.1% (10.1, 16.3%)0.33866.0% (55.8, 75.2%)67.8% (65.5, 70.0%)Biomarkers0.604 (0.547, 0.662)85.7% (82.6, 87.0%)7.2% (6.6, 11.2%)0.17570.8% (60.7, 79.7%)46.7% (44.2, 49.1%)Clinical + Biomarkers0.691 (0.64, 0.743)89.2% (86.6, 90.2%)10.2% (9.3, 15.8%)0.34771.7% (61.4, 80.6%)63.0% (60.6, 65.4%)Hs Troponin I alone0.651 (0.598, 0.703)85.0% (81.9, 86.5%)8.8% (8.0, 12.9%)0.23762.7% (52.6, 72.1%)61.0% (58.7, 63.4%)Clinical + Hs Troponin I0.695 (0.642, 0.747)(85.2, 89.0%)88.0%10.7% (9.8, 16.2%)0.35871.4% (61.4, 80.1%)64.4% (62.0, 66.7%) Open table in a new tab

Patent ductus venosus and exercise related pulmonary hypertension: a case of a young adult with successful surgery closure

The patent ductus venosus is an embryological portosystemic shunt that connects the umbilical vein to the inferior vena cava and it can be diagnosed incidentally or in subjects suffering from hepatic encephalopathy, hypoxemia or hypoglycaemia. Sometimes it can be found in patients with cardiac defects or hypoxia caused by pulmonary arteriovenous shunting.Case presentationA 34-year-old male patient was referred to our medical centre for further evaluation of abdominal pain and moderate exertional dyspnoea. An exercise stress echocardiogram was performed in order to understand the mechanism of the exertional dyspnoea. The test was interrupted due to dyspnoea and desaturation and an estimated pulmonary pressure value of 65 mmHg was detected. Exercise pulmonary hypertension (PH) seems to represent the hemodynamic manifestation of early pulmonary vascular disease, acting as a possible transitional phase anticipating resting PH.An MRI of the abdomen showed the presence of a portosystemic shunt from a patent ductus venosus, associated with stenosis of the celiac tripod artery. A CT scan, of the pulmonary circulation, showed a normal pulmonary venous return,mediastinal vessel a normal pulmonary artery. Subsequently, taking into consideration the large size (> 25 mm) of the duct, treatment (closure) of the patent ductus venosus with the help of a detachable vascular plug device was not feasible and open surgery rather than a percutaneous invasive approach would be advisable.ConclusionPersistent ductus venous can lead to pulmonary arteriovenous shunt fistula and exercise related pulmonary hypertension. Percutaneous or surgical closure requires detailed planning and an anatomical and physiological evaluations.