Negative Exercise Test Research Articles

Epidemiological, Angiographic and Cardiovascular Outcomes of Patients Diagnosed with Myocardial Bridge

Background: Myocardial bridging (MB) is a congenital coronary anomaly that can lead to harmful cardiac consequences if not diagnosed and treated. Objectives: This study aims to evaluate the Epidemiological, angiographic, and cardiovascular outcomes of patients diagnosed with myocardial bridge. Methods: The current research was conducted as a retrospective study in which 151 patients who underwent angiography participated. These patients were admitted between May 2014 and May 2016 at Heshmat and Aria hospitals in Rasht. The collected information in the present study included age, gender, blood pressure history, diabetes mellitus, blood lipid disorders, ischemic changes in ECG, ischemic changes in heart scan, output fraction, ischemic changes in exercise test, number of bridges, name of vessel, length of muscle bridge, and distance from the opening. To analyze the variables, the Chi-square test and independent t-test were used. Results: As a result, we found that myocardial bridging was present in 57 patients, and 95.08% of the bridges were located above LAD. According to this study, there is no significant relationship between the length of the bridge and the distance of the bridge from the vessel opening with the occurrence of ischemic changes in ECG and myocardial perfusion scan (P > 0.05). However, the average distance of the bridge from the vessel opening in patients who had a positive exercise test was lower compared to the patients who had a negative test. They had a negative exercise test, and this difference was statistically significant (P < 0.05). Conclusions: Furthermore, in patients diagnosed with an MB by CAG, the most MB located in the LAD, and this issue can help to better understand the outcome and how to manage these patients.

Association of temperature and absolute humidity with incidence of exercise-induced bronchoconstriction in children.

Exercise test outdoors is widely used to diagnose asthma in children, but it is unclear how much outdoor air factors affect the results. We analysed 321 outdoor exercise challenge tests with spirometry in children 6-16 years conducted due to suspicion of asthma or for assessing the effect of medication on asthma. We studied the association of FEV1 decrease and incidence of exercise-induced bronchoconstriction (EIB) with temperature, relative humidity (RH) and absolute humidity (AH). Asthma was diagnosed in 57% of the subjects. AH ≥5 g/m3, but not RH or temperature, was associated with the EIB incidence (p = 0.035). In multivariable logistic regression, AH ≥5 g/m3 was negatively associated (OR = 0.51, 95% CI [0.28─0.92], p = 0.026) while obstruction before exercise (OR = 2.11, 95% CI [1.16─3.86], p = 0.015) and IgE-mediated sensitisation were positively associated with EIB (OR = 2.24, 95% CI [1.11─4.51], p = 0.025). AH (r = -0.12, p = 0.028) and temperature (r = -0.13, p = 0.023) correlated with decrease in FEV1. In multivariable linear regression, only AH was associated with FEV1 decrease (coefficient = -0.044, 95% CI [-0.085 to -0.004], p = 0.033). AH of outdoor air associates with occurrence and severity of EIB in outdoor exercise tests in children. Care should be taken when interpreting negative outdoor exercise test results if AH of air is high.

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.

Association of anxiety and depression with chronic liver diseases in patients with noncardiac chest pain: A cross-sectional study.

Causes of chest pain can vary from benign to life-threatening conditions, and in many cases not necessary of cardiac origin. A possible reason for noncardiac chest pain could be anxiety or depression caused by chronic liver diseases. The aim of this study was to investigate the association of anxiety and depression with chronic liver disease in patients with noncardiac pain.Patients with chest tightness or pain referred for treadmill exercise testing were recruited from a regional hospital in southern Taiwan. Medical records of the patients were used to define the presence and type of chronic liver disease. Multiple logistic regression analyses were conducted to assess the association of anxiety and depression with chronic liver disease.A total of 2537 patients with liver function test results and abdominal sonography data were analyzed, and 1965 patients showed a negative treadmill exercise testing. The mean age of these 1965 patients was 51.9 years and 54.2% were male. The prevalence of alcoholic liver disease, hepatitis B, hepatitis C, and fatty liver disease was 10.6%, 10.9%, 3.7%, and 27.0%, respectively. Results from multiple logistic regression analyses showed that the risk of anxiety (adjusted odds ratio [aOR] = 1.83, P < .001) and depression (aOR = 1.85, P < .001) was significantly higher in patients with alcoholic liver disease. Anxiety was significantly higher in patients with fatty liver disease (aOR = 1.30, P = .031), and the risk of depression was significantly higher in patients with chronic hepatitis C (aOR = 2.18, P = .005).In conclusion, in patients with noncardiac chest pain, alcoholic liver disease was significantly associated with anxiety and depression, while those with fatty liver and chronic hepatitis C were associated with anxiety and depression, respectively. Clinicians should be vigilant to these correlations in their practice.

P429 PROGNOSTIC IMPACT OF ROUTINE SIX–MONTH EXERCISE STRESS TEST AFTER COMPLEX LEFT MAIN BIFURCATION PCI

Abstract Background/Aim The prognostic value of the exercise stress after complex stenting of left main (LM) coronary artery bifurcations (LM) disease has been poorly investigated in the modern era. Methods We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation diseas, treated using either single versus dual stenting [Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT)] techniques between January 2008 to May 2018. The prognostic impact of an exercise test performed at 6 months during the follow–up period. Results Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–47.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and cardiovascular mortality were observed in 1.2% and 3.6% of cases, respectively. A positive exercise test at 6 months of follow–up was detected in 42 out of 502 patients (8.4%) and correlated with angiographic restenosis in 38 patients (7.6%): 7/171patients in Cross–over group (4.1%), 10/61 patients in T or TAP group (16.4%), 15/98 patients in Culotte group (15.3%) and 6/172 patients in NIT group (3.5%). Multivariate Cox regression analysis demonstrated that Age &amp;gt; 75 years (HR 1.45, 95% CI: 1.33–1.58, p = 0.03), dyslipidaemia (HR: 1.68, 95% CI: 1.58–1.72, p &amp;lt; 0.001), eGFR&amp;lt;30 ml/min/1.73 m2 (HR: 1.44, 95% CI: 1.38–1.52, p = 0.04), presence of a triple vessel disease (HR: 1.89, 95% CI: 1.89, 95% CI: 1.84–1.93, p &amp;lt; 0.001), additional ostial LM lesion (HR: 1.75, 95% CI: 1.76–1.81, p &amp;lt; 0.001), additional LM body lesion (HR: 1.33, 95% CI: 1.28–1.36, o &amp;lt; 0.001), a Syntax score &amp;gt; 25 (HR:1.67, 95% CI: 1.61–1.76, p = 0.01), need of Rotablator (HR: 1.66, 95% CI: 1.61–1.75, p = 0.02) and the number of stents implanted (HR: 1.12, 95% CI: 1.08–1.16, p &amp;lt; 0.001) were independent predictors of a positive stress test. Patients reporting a negative exercise test at 6 months of follow–us had a higher freedom from TLF and improved survival compared to those with positive exercise stress test (Figure 1 Panels A and B). Conclusions A negative exercise performed after 6 months from complex left main stenting predicted excellent outcomes at 3 years follow–up.

Andersen-Tawil syndrome: deep phenotyping reveals significant cardiac and neuromuscular morbidity.

Andersen-Tawil syndrome is a neurological channelopathy caused by mutations in the KCNJ2 gene that encodes the ubiquitously expressed Kir2.1 potassium channel. The syndrome is characterized by episodic weakness, cardiac arrythmias and dysmorphic features. However, the full extent of the multisystem phenotype is not well described. In-depth, multisystem phenotyping is required to inform diagnosis and guide management. We report our findings following deep multimodal phenotyping across all systems in a large case series of 69 total patients, with comprehensive data for 52. As a national referral centre, we assessed point prevalence and showed it is higher than previously reported, at 0.105 per 100 000 population in England. While the classical phenotype of episodic weakness is recognized, we found that a quarter of our cohort have fixed myopathy and 13.5% required a wheelchair or gait aid. We identified frequent fat accumulation on MRI and tubular aggregates on muscle biopsy, emphasizing the active myopathic process underpinning the potential for severe neuromuscular disability. Long exercise testing was not reliable in predicting neuromuscular symptoms. A normal long exercise test was seen in five patients, of whom four had episodic weakness. Sixty-seven per cent of patients treated with acetazolamide reported a good neuromuscular response. Thirteen per cent of the cohort required cardiac defibrillator or pacemaker insertion. An additional 23% reported syncope. Baseline electrocardiograms were not helpful in stratifying cardiac risk, but Holter monitoring was. A subset of patients had no cardiac symptoms, but had abnormal Holter monitor recordings which prompted medication treatment. We describe the utility of loop recorders to guide management in two such asymptomatic patients. Micrognathia was the most commonly reported skeletal feature; however, 8% of patients did not have dysmorphic features and one-third of patients had only mild dysmorphic features. We describe novel phenotypic features including abnormal echocardiogram in nine patients, prominent pain, fatigue and fasciculations. Five patients exhibited executive dysfunction and slowed processing which may be linked to central expression of KCNJ2. We report eight new KCNJ2 variants with in vitro functional data. Our series illustrates that Andersen-Tawil syndrome is not benign. We report marked neuromuscular morbidity and cardiac risk with multisystem involvement. Our key recommendations include proactive genetic screening of all family members of a proband. This is required, given the risk of cardiac arrhythmias among asymptomatic individuals, and a significant subset of Andersen-Tawil syndrome patients have no (or few) dysmorphic features or negative long exercise test. We discuss recommendations for increased cardiac surveillance and neuropsychometry testing.

P5466Exaggerated exercise blood pressure response is accompanied by increased sympathetic activity and arterial stiffness in subjects with high normal blood pressure

Abstract Background/Introduction The clinical importance of a hypertensive response to exercise (HRE) in subjects with high normal blood pressure (BP) is not fully elucidated, while sympathetic overactivity and arterial stiffening are linked with adverse cardiovascular prognosis. Purpose The aim of this study was to assess the relation of HRE with sympathetic drive as assessed by muscle sympathetic nerve activity (MSNA) and arterial stiffness in subjects with high normal BP. Methods 42 subjects with high normal office BP [defined as office systolic BP=130–139 mmHg and office diastolic BP=85–89 mmHg (age: 53±9 years, 29 males, office BP: 134/84 mmHg, 24-hour BP: 114/72 mmHg)] with a negative treadmill exercise test (Bruce protocol) were divided into those with HRE (n=12) (peak exercise systolic BP ≥210mmHg in men and ≥190 mmHg in women) and those without HRE (n=30). Arterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV) values. In all participants sympathetic drive was assessed by MSNA estimations based on established methodology (microneurography). Results Subjects with a HRE compared to those without exhibited higher waist circumference (108.2±5.3 vs 94.7±9.2 cm, p=0.001) and were characterized by greater levels of carotid to femoral PWV (8.5±0.8 vs 7.0±0.9 m/sec, p&lt;0.001) and sympathetic nerve traffic as reflected by MSNA levels (41.1±1.5 vs 32.1±1.9 bursts per 100 heart beats, p&lt;0.001), while did not differ regarding metabolic profile and left ventricular mass index (p=NS). In the total population, peak exercise systolic BP was related to 24-h systolic BP (r=0.229, p&lt;0.05), PWV (r=0.218, p=0.002), and MSNA (r=0.214, p&lt;0.05). Moreover, MSNA was related to waist circumference (r=0.33, p=0.004) and office systolic BP levels (r=0.31, p&lt;0.05) but there was no association with PWV values (p=NS). Conclusion In subjects with high normal BP, a HRE identifies a state of arterial stiffening and sympathetic overdrive, as reflected by increased PWV and MSNA levels respectively. These finding suggest that exercise testing provides additional clinical information regarding the vascular status and modulation of sympathetic tone in this setting.

Exercise electrocardiogram testing in asymptomatic patient with type 2 diabetes and left ventricular diastolic dysfunction

Background: Type 2 diabetes mellitus (DM) is an established risk factor for cardiovascular events and the development of congestive heart failure (HF). Diastolic dysfunction is considered a precursor of HF and may be diagnosed noninvasively by echocardiography. Diastolic dysfunction is common in well-controlled type 2 diabetic patients without clinically detectable heart disease. Left ventricular diastolic dysfunction represents the earliest preclinical dysfunction and that it can progress to asymptomatic HF. Aim of the Work: The aim of the study is to evaluate if diastolic dysfunction in diabetic patients is due to silent ischemia. Methods: This study included 80 asymptomatic patients with type 2 DM. Echocardiography was done to all patients to assess systolic and diastolic functions. Exercise electrocardiogram (ECG) was done for all patients to detect ischemic heart disease. Coronary angiography was done to patients with positive exercise ECG test. Results: The incidence of diastolic dysfunction was 75%; among the studied groups. Impaired relaxation was detected in 87 % and pseudo normal pattern was detected in 13 % of subjects with diastolic dysfunction. Patients with normal diastolic function had negative stress exercise test, while those with diastolic dysfunction, 12 patients had positive exercise stress ECG (40%) and 18 patients had negative exercise stress ECG (60%). Conclusion: These findings indicate that coronary artery disease is not uncommon in diabetic patients with diastolic dysfunction and increase markedly in patients with positive stress exercise electrocardiography.

Association of carotid intima-media thickness with exercise tolerance test in type 2 diabetic patients

AimsAtherosclerosis and ischemic heart disease are more common in diabetic patients. Atherosclerosis process can disturb the normal functioning of the vascular endothelium and increase vessel wall thickness. The aim of this study was the comparison of Carotid intima-media thickness (CIMT) with Exercise tolerance test as an alternative way to evaluate cardiac ischemia in diabetic patients. MethodsIn a cross-sectional study, 30 diabetic patients with positive exercise test and 30 diabetic patients with negative exercise test were enrolled. CIMT of the carotid artery in both groups of patients was measured. ResultCIMT in the patients with positive and negative exercise test were 1.04 ± 0.21 mm and 0.61 ± 0.11 mm, respectively (P < 0.001). CIMT in positive exercise test group was positively associated with age and negatively associated with gender, FBS, HDL and LDL cholesterol and in negative exercise group was negatively associated with gender, age, FBS, HDL and LDL cholesterol. ConclusionConsidering observed significant positive association between CIMT with result of exercise tolerance test (ETT) in type 2 diabetic patients, it may possible to use CIMT as an inexpensive and non-invasive method for evaluation of ischemic heart disease in diabetic patients.

P630Hemodynamic responses of negative treadmil exercise test in relation to cardiovascular risk factors in subjects without previous history of cardiovascular disease

P630Hemodynamic responses of negative treadmil exercise test in relation to cardiovascular risk factors in subjects without previous history of cardiovascular disease

Mental stress test: a rapid, simple, and efficient test to unmask long QT syndrome.

QT prolongation during mental stress test (MST) has been associated with familial idiopathic ventricular fibrillation. In long QT syndrome (LQTS), up to 30% of mutation carriers have normal QT duration. Our aim was to assess the QT response during MST, and its accuracy in the diagnosis of concealed LQTS. All patients who are carrier of a KCNQ1 or KCNH2 mutations without QT prolongation were enrolled. A control group was constituted of patients with negative exercise and epinephrine tests. Electrocardiogram were recorded at rest and at the maximum heart rate during MST and reviewed by two physicians. Among the 70 patients enrolled (median age 41±2.1 years, 46% male), 36 were mutation carrier for LQTS (20 KCNQ1 and 16 KCNH2), and 34 were controls. KCNQ1 and KCNH2 mutation carriers presented a longer QT interval at baseline [405(389; 416) and 421 (394; 434) ms, respectively] compared with the controls [361(338; 375)ms; P < 0.0001]. QT duration during MST varied by 9 (4; 18) ms in KCNQ1, 3 (-6; 16) ms in KCNH2, and by -22 (-29; -17) ms in controls (P < 0.0001). These QT variations were independent of heart rate (P < 0.3751). Receiver operating characteristic curve analysis identified a cut-off value of QT variation superior to -11 ms as best predictor of LQTS. It provided 97% sensitivity and 97% specificity of QT prolongation in the diagnosis of LQTS. We identified a paradoxical response of the QT interval during MST in LQTS. Easy to assess, MST may be efficient to unmask concealed LQTS in patients at risk of this pathology.

Left atrial volume and function in patients with cardiac syndrome X assessed by real time three-dimensional echocardiography.

The aim of this study was to evaluate left atrial (LA) volume and function using real time three-dimensional echocardiography (RT3DE) in patients with cardiac syndrome X (CSX). Fifty patients with CSX (28 females; mean age 50.9±10.9years) and 50 age- and gender-matched healthy controls (30 females; mean age 52.3±9.8years) who had negative treadmill exercise test and normal coronary arteries on invasive coronary angiography were included in the study. Comprehensive two-dimensional (2D), pulsed and tissue Doppler, speckle tracking echocardiography, and RT3DE for the assessment of LA dynamics were performed in all study participants. Cardiac syndrome X and control groups have similar clinical characteristics regarding age, sex, body mass index, hypertension, diabetes, and smoking habit. 2D echocardiographic parameters were also similar between groups. Pulsed- and tissue Doppler parameters, IVRT, A, and Am values, were higher in CSX group, while Em , E/A, and Em /Am ratios were higher in the control group reflecting mild diastolic dysfunction. Regarding RT3DE parameters, LA maximum volume, minimum volume, volume before atrial contraction, LA maximum volume index, total and active stroke volumes were found to be increased in CSX patients. However, LA total stroke fraction, passive stroke volume, passive stroke fraction, peak systolic, and diastolic longitudinal strains were found to be lower in CSX patients. The main finding of this study was that CSX patients had altered LA booster pump, reservoir, and conduit functions. This finding may have clinical implications for early detection of abnormal LA dynamics in CSX patients.

Combination of change in hematological parameters with exercise stress test to predict coronary artery disease.

Treadmill exercise stress testing for identifying patients with a higher likelihood of coronary artery disease (CAD) before elective coronary angiography is recommended in the current guidelines. In this study, we aimed to evaluate the changes in the hematological parameters before and after exercise stress test in relation with the presence of CAD. A total of 113 patients with chest pain who underwent treadmill exercise testing and coronary angiography were included in this study. Neutrophil count (4.38±0.99 vs 5.19±0.93, P<.001), and neutrophil to lymphocyte ratio (NLR) (2.04±0.63 vs 2.41±0.78, P<.001) were significantly elevated after treadmill exercise test in all the patients. Increase in the NLR after exercise test was significantly higher in patients with positive exercise test (n=68) than negative exercise test (n=45) (0.49±0.58 vs 0.19±0.44, P=.016). The sensitivity and specificity of treadmill exercise testing according to coronary angiography was 79% and 64%, respectively. A cut-off point of 0.2 for the change in the NLR in addition to positive treadmill exercise testing had 91% sensitivity and 92% specificity in predicting significant coronary artery stenosis (AUC:0.913, 95% CI: 0.805-1.000, P<.001). Neutrophil to lymphocyte ratio is an important inflammatory marker that can contribute to treadmill ECG testing in predicting CAD.

PS 11-66 HEART RATE RECOVERY AFTER EXERCISE AND BLOOD PRESSURE RESPONSE DURING EXERCISE TESTING IN PATIENTS WITH CARDIAC SYNDROME X.

Objective: The syndrome of angina pectoris with a normal coronary arteriogram, often termed cardiac syndrome X (CSX), is an important clinical entity, however, its causes are still unclear. Autonomic dysfunction is one of the possible causes, so we aimed to investigate the parasympathetic dysfunction assessed by heart rate recovery (HRR) and increased sympathetic activity assessed by exaggerated blood pressure (BP) response to exercise (EBPR) in CSX. Design and Method: A total of 1393 consecutive patients without significant coronary artery disease (CAD) with anginal chest pain underwent both ergonovine provocation test and a treadmill exercise test between Jan. 2008 and Feb. 2015. Among them, the patients without significant coronary artery spasm (<70%) and positive exercise stress test with uniform ST depression ≥1 mm were enrolled as CSX. EBPR was defined as a peak exercise systolic BP ≥210 mmHg in men and ≥190 mmHg in women. HRR was defined as peak heart rate minus heart rate after a 1-minute recovery; blunted HRR was defined as ≤12 beats/min. These parameters were compared between patients with CSX and the controls. Results: A total of 15.1% (211/1393) patients were diagnosed as CXS documented by negative ergonovine provocation test and positive exercise test (68.7% female) and 787 patients with negative ergonovine test and normal exercise test were compared as controls. HRR was significantly reduced in patients with CSX compared to the controls (27.6 ± 20.1 vs. 31.7 ± 22.9, p = 0.015) and maximal systolic BP during exercise was significantly increased in patients with CSX (176.6 ± 23.7 vs. 171.4 ± 19.9, p < 0.001). The proportion of blunted HRR (32.7% vs. 26.0%, p = 0.034) and EBBR (21.3% vs. 11.6%, p < 0.001) were significantly higher in patients with CSX than those without CSX. Conclusions: Blunted HRR and EBBR were associated with CSX, which suggests a link between CSX and autonomic dysregulation.

Factors Affecting Exercise Test Performance in Patients After Liver Transplantation.

BackgroundCardiovascular diseases are a leading cause of morbidity and mortality in solid organ transplant recipients. In addition, low physical activity is a risk factor for cardiac and cerebrovascular complications.ObjectivesThis study examined potential relationships between physical activity, health-related quality of life (HRQoL), risk factors for cardiovascular disease, and an exercise test in liver-graft recipients.Patients and MethodsA total of 107 participants (62 men/45 women) who had received a liver transplantation (LT) at least 6 months previously were evaluated. Physical activity was assessed using three different questionnaires, while HRQoL was assessed using the medical outcomes study short form (SF)-36 questionnaire, and health behaviors were evaluated using the health behavior inventory (HBI). The exercise test was performed in a standard manner.ResultsSeven participants (6.5%) had a positive exercise test, and these individuals were older than those who had a negative exercise test (P = 0.04). A significant association between a negative exercise test and a higher level of physical activity was shown by the Seven-day physical activity recall questionnaire. In addition, HRQoL was improved in various domains of the SF-36 in participants who had a negative exercise test. No correlations between physical activity, the exercise test and healthy behaviors, as assessed via the HBI were observed.ConclusionsExercise test performance was affected by lower quality of life and lower physical activity after LT. With the exception of hypertension, well known factors that affect the risk of coronary artery disease had no effect on the exercise test results.

Value of index of microcirculatory resistance in the diagnosis of cardiac syndrome X

Objective To explore the correlation between the index of microcirculatory resistance (IMR) and the corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) in patients with cardiac syndrome X (CSX), and to discuss the value of IMR in the diagnosis of CSX. Methods This study selected 28 patients with positive treadmill exercise test (CSX group), and another 28 patients with negative treadmill exercise test (normal control group). First, the baseline CTFC (B-CTFC), and hyperemic CTFC (H-CTFC) were measured. The ratio of B-CTFC and H-CTFC was recorded as CFRCTFC. IMR was calculated by method of thermodilution. Results Proportion of patients with hypertension and diabetes in CSX group was significantly higher than that of normal control group (75% vs 46.4%, 60.7% vs 28.6%, P<0.05). IMR in the CSX group was significantly higher than that in the normal group (39.5±27.6 vs 16.1±5.9, P<0.01). H-CTFC in the CSX group was significantly higher than that in the normal group (13.0±4.2 vs 9.5±2.4, P<0.01). CFRCTFCin the CSX group was significantly lower than that in the normal group (2.0±0.5 vs 2.6±0.5, P<0.01). IMR has significant correlation with CFRCTFC (r=-0.62, P<0.01). Conclusions IMR has a notable association with CFRCTFC calculated from CTFC.IMR can provide clinical application in the evaluation of coronary microcirculation dysfunction, and can be used in the diagnosis of CSX. Key words: Capillary resistance; Microcirculation; Microvascular angina/DI

Negative Treadmill Exercise Test does not Rule out Coronary Artery Disease

Negative Treadmill Exercise Test does not Rule out Coronary Artery Disease

Age-Related Left Ventricular Changes and Their Association with Leukocyte Telomere Length in Healthy People

IntroductionWith advancing age the left ventricle (LV) undergoes structural and functional changes, thereby creating the substrate for the development of diseases. One possible mechanism of the ageing heart is a cellular senescence. Leukocyte telomere length (LTL) is a marker of replicative ageing. The purpose of this study was to evaluate the structure and function of the LV in people of different ages free of cardiovascular diseases (CVD) and regular drug medication and to assess their relationship with LTL. We hypothesized that age-related changes in LV myocardium are associated with telomere length.MethodsThe study population consisted of 150 healthy, non-obese volunteers aged 28 to 78 years without history of CVD, significant deviations by 12-lead electrocardiogram and negative exercise test (treadmill stress test). All the participants underwent standardized transthoracic echocardiography using an available system (iE33; Philips). The LTL was measured by real-time quantitative polymerase chain reaction. We determined the relative ratio of telomere repeat copy number (T) to single-copy gene copy number (S).ResultsIn the older people there was a higher wall thickness than in the younger (1.03±0.09 vs. 0.88±0.10, p<0.01), whereas LV mass index was comparable between them (85.8±15.40 vs. 83.1±11.8, p = 0.20). There was a decrease in LV dimensions with advancing age (p<0.001). Older subjects had impairment in LV relaxation. LTL was associated with decreased E/A, Em/Am ratio (β = -0.323, p = 0.0001) after adjusting for age, sex and risk factors. There is no relation between the LTL and the structure of LV.ConclusionsOur data suggest that the ageing process leads to changes in LV structure and diastolic function and is linked with a phenotype of concentric LV remodeling. Telomere attrition is associated with age-related LV diastolic dysfunction. Telomere length appears to be a biomarker of myocardial ageing.

17 Striving for a Safe and Streamlined HSTNT Negative Chest Pain Pathway

<h3>Objective</h3> This study aimed to assess whether an initial high-sensitivity troponin (HsTnT) value of &lt;3 ng/l or a negative repeat value (&lt;14 ng/l) at 3 h, could be used in conjunction with a validated cardiac risk score (HEART) and a normal 12 lead ECG to risk-stratify, reassure and discharge patients with low-risk presentations. <h3>Background</h3> Many A&amp;E departments still rely on a 12-hour negative HsTnT result for reassurance. Recent publications have demonstrated that a HsTnT value of 3 ng/l at presentation has a high negative predictive value for ruling out acute coronary syndromes with a &lt;1% chance of major adverse cardiac events (MACE) at 1 year documented in one study. <h3>Methods</h3> In a retrospective cohort study we followed up all patients who presented to the A&amp;E department with an initial negative HsTnT (value &lt;14 ng/l) over a three week period. We calculated a validated cardiac risk score for chest pain presentations (HEART). This was compiled for each patient based on their age, cardiac risk factors and the nature of the chest pain recorded in A&amp;E, as well as by reviewing the serial ECGs taken on that presentation. We reviewed each patient’s clinical records at three months and cross-referenced each form of electronic record to identify and review any subsequent cardiac admissions/investigations over that period. <h3>Results</h3> Of 291 patients 121 (41.6%) were admitted. 2 (0.7%) patients in this group had a raised HsTnT at 12 h and were thus classed as NSTEMIs. Both of these had an abnormal ECG and a HEART score of &gt;4 on arrival to A&amp;E. Of the remaining 119 patients admitted, none (0%) had any MACE at 3 months. 15 of the 119 HsTnT-negative patients underwent inpatient cardiac investigation (angiogram/stress ECHO/exercise tolerance testing/CT coronary angiogram), all of which were negative for significant coronary artery disease. Of the 170 (58.4%) patients discharged from A&amp;E none (0%) have had any MACE at 3 months. 53 of these 170 (31.2%) patients were referred into the Rapid Access Chest Pain Clinic. Of these 53, 10 patients underwent a negative stress echo, 11 patients undertook a negative exercise test and the remainder were discharged following a re-evaluation of their history, risk factors and 12 lead ECG. All 53 have had no MACE at 3 months. <h3>Conclusions</h3> All of the patients in this study who had a negative HsTnT value on arrival to A&amp;E, a normal ECG and a low clinical risk score (HEART score &lt;4) have had no MACE as of three months. Many patients underwent further investigation and all of the results were negative for significant coronary artery disease. The data supports the use these criteria in risk-stratifying, reassuring and discharging such patients in a timely manner. It has been used to develop a new chest pain pathway in our local centre. We plan to evaluate the patients through direct patient contact at 6 months to assess MACE rate and exclude loss to another centre.

Is an exaggerated blood pressure response to exercise in hypertensive patients a benign phenomenon or a dangerous alarm?

A hypertensive response to exercise is associated with high cardiovascular risk, whereas scarce data are available about its relation to surrogates of subclinical atherosclerosis. Endothelial dysfunction and intima-media thickness (IMT) have been demonstrated in atherosclerotic patients. The purpose of this study was to investigate the relationships between a hypertensive response to exercise and IMT as well as endothelial function as surrogates of subclinical atherosclerosis. A total of 52 untreated males with stage I essential hypertension and a negative treadmill exercise test for exercise-induced myocardial ischemia were divided into two groups: group I which included 21 patients with a hypertensive response to exercise (peak exercise systolic blood pressure ≥210 mm Hg) and group II which included 31 individual with normal blood pressure response. Flow-mediated dilatation (FMD) and dilatation ratio (as markers of endothelial function) and measurements of carotid IMT were done for both groups. Group I patients showed significant reduction in FMD (5.61 ± 5.25 vs 10.52 ± 4.78, p = 0.026) and dilatation ratio (50.28 ± 26.03 vs 94.8 ± 40.06, p < 0.001) compared to group II. Moreover, Group I patients also showed significant increase in IMT compared to group II (0.102 ± 0.033 vs 0.089 ± 0.03, p = 0.047). Hypertensive response to exercise in patients with untreated stage I essential hypertension is associated with endothelial dysfunction and increased carotid IMT. It seems that this phenomenon is not a benign one but rather a dangerous alarm.