Positive Exercise Electrocardiogram Research Articles

Screening Sportsmen and Sportswomen Over Age 35: The Relevance of an Exercise Electrocardiogram. Data From the SEEPRED Study.

The importance of exercise electrocardiogram (ECG) is still controversial in the prevention of cardiovascular events among sportsmen and sportswomen. The aim of this study was to assess the relevance of exercise ECG as a screening tool to prevent cardiovascular events when any cardiovascular disease (CVD) risk factors are present. The study included leisure time asymptomatic sportsmen and sportswomen over age 35 evaluated from 2011 to 2016 at the University Hospital of Saint-Etienne (France). Major adverse cardiovascular events (MACE) and atrial fibrillation were collected at 3 years. Of the cohort of 2457 sportsmen and sportswomen (mean age 50.2 ± 9.4 years), 50 (2%) had a high-risk SCORE2. A total of 256 exercise ECGs (10%) were defined as positive, most of them due to silent myocardial ischemia (SMI) (n = 196; 8%). These 196 SMI cases led to 33 coronary angiograms (1%), which revealed 23 significant coronary stenoses requiring revascularization. In multivariate logistic regression analysis, having at least two CVD risk factors was independently associated with (1) positive exercise ECG (OR = 1.80 [95% CI: 1.29-2.52], p = 0.0006), with (2) suspected SMI (OR = 2.57 [95% CI: 1.10-6.02], p = 0.0304), with (3) confirmed SMI (OR = 8.20 [95% CI: 3.46-19.46], p < 0.0001) and with (4) cardiovascular events (MACE or atrial fibrillation) (OR = 6.95 [95% CI: 3.49-13.81], p < 0.0001) at 3 years (median). The study supports the European recommendations for the use of exercise ECG in evaluation of asymptomatic leisure time sportsmen over age 35. Having at least two CVD risk factors was the best predictor for presence of coronary artery stenosis that may increase the risk for adverse events. ClinicalTrials.gov Identifier: NCT06024863.

Optimising screening of intermediate to high-risk asymptomatic sportsmen with exercise electrocardiogram. The SEEPRED study

Abstract Funding Acknowledgements Type of funding sources: None. Background The importance of exercise electrocardiogram (ECG) is still controversial in the prevention of cardiovascular events among sportsmen. The aim of this study was to assess the relevance of exercise ECG as a significant prognostic marker for cardiovascular events when any CVD risk factors are present. Methods The SEEPRED cohort study included leisure time asymptomatic sportsmen over 35 years old, referred from 2011 to 2016 in the Sports Medicine Unit of our university hospital. Major adverse cardiovascular events (MACE) and atrial fibrillation were collected 5 years after exercise ECG using a phone questionnaire. Multivariate logistic regression models were performed to predict positive exercise ECG, suspected and confirmed silent myocardial ischemia (SMI) and cardiovascular events. Results Of the cohort of 2457 sportsmen (1898 men; mean age 50.2 ± 9.4 years; physical activity level 29.4 ± 25.1 MET-h/week), 1482 (60%) had at least one cardiovascular disease (CVD) risk factor and 52 (2%) had a SCORE&amp;gt;5%. A total of 256 exercise ECGs (10%) were defined as positive, most of them due to SMI (n = 196; 8%). SMI was an indication for coronary angiography in 43 cases, leading to 33 documented SMIs (1%), including 23 significant stenoses requiring revascularization. In multivariate logistic regression analysis, having at least 2 CVD risk factors was independently associated with (1) positive exercise ECG [OR=1.80 (CI 95%: 1.29-2.52), p=0.0006], with (2) suspected SMI [OR=2.57 (CI 95%: 1.10-6.02), p=0.0304], with (3) confirmed SMI [OR=8.20 (CI 95%: 3.46-19.46), p&amp;lt;0.0001] and with (4) cardiovascular events (MACE or atrial fibrillation) [OR=6.95 (CI 95%: 3.49-13.81), p&amp;lt;0.0001]. Conclusions The study supports the European recommendations for the use of exercise ECG in evaluation of asymptomatic leisure time sportsmen over 35 years. Having at least 2 CVD risk factors was the best predictors for presence of coronary lesions at risk for events.

Acute Electrocardiographic Changes during Smoking and Tobacco Chewing

Background: Smoking increases the risk of coronary artery disease. Very few studies have evaluated the temporal relationship of electrocardiographic changes with smoking. We sought to study and compare the electrocardiogram (ECG) changes during smoking and tobacco chewing in current smokers and tobacco chewers presenting with atypical chest pain with either negative or mild positive exercise ECG test (treadmill test [TMT]). Materials and Methods: We screened male smokers and tobacco chewers with atypical chest pain with TMT. A total of 60 patients, 30 in each group in whom TMT was either negative or mildly positive, underwent a 24-h Holter monitoring. We asked patients to note down their time of smoking and tobacco chewing along with the timing of symptoms if any. Results: All patients were male with an average age of 45 years in smokers and 42 years in the tobacco chewer group. The mean number of cigarettes consumed was 6 ± 2.8 and tobacco chewed was 5 ± 4.7 g/day. Heart rate (HR) in smokers increased from 82.5 ± 14.56/min 10 min before smoking to 90.63 ± 15.34/min, during smoking with peak HR achieved at the time of smoking (P &lt; 0.0001). HR in the tobacco chewers peaked at 10 min after chewing from 80.62 ± 13.52/min 10 min before to 87.89 ± 13.86/min 10 min after chewing (P &lt; 0.0001). Smoking was associated with a significant increase in supraventricular ectopics (VEs) from 3.98/h before smoking to 7.43/h during and 6.92/h after smoking (P &lt; 0.0001). Two patients in the smoker subgroup had spontaneous smokeless tobacco -T changes lasting for 10–25 min. Smoking was associated with a significant decrease in HR variability (HRV) index than the controls (P = 0.023). Tobacco chewing was not associated with any significant changes in the HRV parameter. Conclusions: Smoking and tobacco chewing both significantly increase the HR acutely. Smoking leads to an increase in both supraventricular and VEs. We observed reduced HRV in patients who smoked cigarettes.

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.

Analysis of elective coronary angiography findings in patients with suspected angina pectoris in the cardiocenter Hradec Králové – Real-life clinical practice in light of the guidelines

IntroductionCoronary angiography (CA) is a gold standard of diagnosis of occlusive coronary atherosclerosis in patients with high pre-test probability of IHD (PTP) and in patients with medium pre-test probability, in whom a prognostically significant ischemia was detected during a stress test. The imaging stress tests are preferred to the stress electrocardiogram due to higher sensitivity and specificity. The aim of this work was to analyze the profile of patients undergoing the elective CA due to suspected IHD. Study population and methodsPopulation of 184 patients who underwent elective CA due to suspected ischemic heart disease between April and August 2016 was retrospectively analyzed in the cardiocenter at the University Hospital Hradec Králové. The patient risk profile and use of cardiac stress tests and their relation to the CA findings were evaluated. The CA result was evaluated as positive if stenosis of coronary artery of ≥50% in at least one of the main coronary arteries was found. ResultsPatients with medium PTP prevailed in our study population – 154 (84%), there were 6 (3%) patients with low and 24 (13%) with high PTP. 112 (61%) patients had negative and 72 (39%) positive CA finding. Stress test was performed in 43 cases (23%) and the stress electrocardiograms predominated significantly over the imaging stress tests: 37 (86%) versus 6 (14%). In the medium-risk group, a stress test was performed in 36 (23%) patients, in 92% it consisted of stress electrocardiogram. None of the patients with low PTP had positive CA, in the medium-risk group the CA was positive in 38% and in the high-risk group in 54%. In the patients with positive exercise electrocardiogram, the CA was positive only in 10% of cases. 44% of patients with positive and 39% of patients with negative CA had typical angina pectoris. ConclusionMost of the patients referred for elective CA had medium risk of IHD. The patient medical history alone was not a reliable predictor of IHD. The stress tests for detection of ischemia were performed scarcely with the dominance of stress electrocardiogram, which was not reliable in the ischemia detection in the clinical practice. The imaging stress tests were not used to a sufficient extent and the rate of negative elective CAs was high in the analyzed study population.

Exercise electrocardiogram in middle-aged and older leisure time sportsmen: 100 exercise tests would be enough to identify one silent myocardial ischemia at risk for cardiac event

BackgroundThe importance of exercise electrocardiogram (ECG) has been controversial in the prevention of cardiac events among sportsmen. The aim of this study was to determine the frequency of silent myocardial ischemia (SMI) from an exercise ECG and its relationship with induced coronary angiographic assessment and potentially preventable cardiac events. MethodsThis prospective cohort study included leisure time asymptomatic sportsmen over 35years old, referred from 2011 to 2014 in the Sports Medicine Unit of the University Hospital of Saint-Etienne. ResultsOf the cohort of 1500 sportsmen (1205 men; mean age 50.7±9.4years; physical activity level 32.8±26.8MET-h/week), 951 (63%) had at least one cardiovascular disease (CVD) risk factor. Family history, medical examination and standard resting 12-lead were collected. A total of 163 exercise ECGs (10.9%) were defined as positive, most of them due to SMI (n=129, 8.6%). SMI was an indication for coronary angiography in 23 cases, leading to 17 documented SMIs (1.1%), including 11 significant stenoses requiring revascularization. In multivariate logistic regression analysis, a high risk of CVD (OR=2.65 [CI 95%: 1.33–5.27], p=0.005) and an age >50years (OR=2.71 [CI 95%: 1.65–4.44], p<0.0001) were independently associated with confirmed SMI. ConclusionsThe association of positive exercise ECG with significant coronary stenosis was stronger among sportsmen with CVD risk factors and older than 50years. Screening by exercise ECG can lower the risk of cardiac events in middle-aged and older sportsmen. One hundred tests would be enough to detect one silent myocardial ischemia at risk for cardiac event.

Exercise Electrocardiogram Neither Predicts Nor Excludes Coronary Artery Disease in Women with Low to Intermediate Risk.

The value of exercise electrocardiogram (ExECG) in symptomatic female patients with low to intermediate risk for significant coronary artery disease (CAD) has been under debate for many years, and nondiagnostic or even erroneous test results are frequently encountered. Cardiac-CT may be more appropriate to exclude CAD in women. This study compares the results of ExECGs with those of cardiac-CTs, performed within a time frame of 1 month in an all-comers female chest pain population. Five hundred fifty-one consecutive female patients from a patient registry were included. ExECGs were negative in 324 (59%), positive in 14 (3%), and nondiagnostic in 213 (39%) patients. CAD was revealed by cardiac-CT in 57% of the women with negative ExECG. No signs of CAD were present on cardiac-CT in 64% of the women with a positive ExECG. Cardiac-CT showed presence of CAD in 268/551 (49%) patients, of whom 56/268 (21%) was diagnosed with ≥50% stenosis. The ExECG of the latter group was negative in 26 (46%), inconclusive in 29 (52%), and positive in 1 (2%). Considering ≥50% stenosis at cardiac-CT as the reference, sensitivity, specificity, PPV, and NPV of ExECG for the present population were 3.7%, 95.7%, 7.1%, and 91.7%, respectively. Similar diagnostic performance was calculated when considering ≥70% stenosis at cardiac-CT as the reference. ExECG failed to detect CAD in more than half of this cohort and in almost half of women with >50% stenosis at cardiac-CT. Importantly, no CAD was detected by cardiac-CT in 64% of women with a positive ExECG. ExECG is therefore questionable as a diagnostic strategy in women with low-to-intermediate risk of CAD, although prospective studies are warranted to determine whether replacing ExECG by cardiac-CT provides better prognoses.

Prognostic value of demographic factors, pre-test probability scoring, exercise test diagnosis, and inability to exercise in patients with recent onset suspected cardiac chest pain

To assess the prognostic value of an inconclusive exercise test or inability to exercise in patients with recent onset suspected cardiac chest pain and to determine the independent predictors of events in these patients. This was an observational follow-up study of patients presenting to a rapid access chest pain clinic with a history of recent-onset suspected cardiac chest pain as referred by the family practitioner. The main outcome measure was a composite endpoint of death and acute coronary syndrome hospital admission. The study cohort consisted of 1851 patients in whom a total of 147 events were recorded during a mean follow-up period of 4.1 ± 1.1 years. Those with events were significantly older (65.1 ± 12.5 years versus 56.4 ± 13.2 years, p < 0.001), had higher mean pre-test probability of coronary artery disease (CAD), and had higher prevalence of diabetes (18.4% vs. 13.6%, p < 0.001), hypertension (55.8% vs. 38.7%, p < 0.001), and smoking (36.7% vs. 25.4%, p = 0.03) than those without events. These patients were also more likely to have a positive exercise electrocardiogram (ECG) (15.6% vs. 8.6%, p < 0.001) or not have a diagnostic exercise test because of an inconclusive result or inability to exercise (60.5% vs. 28.6%, p < 0.001). Cox multivariate regression analysis showed that age (hazard ratio, HR 1.03, p < 0.001), pre-test probability of CAD (HR 1.08, p = 0.04), positive exercise ECG (HR 2.94, p < 0.001), and an inconclusive test or inability to exercise (HR 3.45, p < 0.001) were independent predictors of events. In patients with recent onset suspected cardiac chest pain, not having a diagnostic exercise ECG because of an inconclusive test or inability to exercise is an independent predictor of events and has similar prognostic implications to a positive exercise ECG. In addition, pre-test probability estimation at baseline is a robust indicator of clinical outcome. Future models of care need to incorporate early and increased access to non-exercise cardiac imaging techniques in order to meet the needs of this high-risk subgroup of patients.

Group support to improve psychosocial well-being and primary-care demands among women with cardiac syndrome X

Background Women with angina pectoris, a positive exercise electrocardiogram (ECG) for myocardial ischemia and angiographically smooth coronary arteries (cardiac syndrome X), are often characterized by unresolved symptomatology and a poor quality of life. Psychological morbidity and quality of life appear to be related to social support and social isolation. An investigation of group support as an aid to treatment for cardiac syndrome X was therefore undertaken.Methods Forty-nine women with cardiac syndrome X (mean ± standard deviation 61.8 ± 8 years) were randomized to 12 monthly support group meetings or usual care control. The Health Anxiety Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), SF-36, York Angina Beliefs scale, ENRICHD Social Support Instrument (ESSI) and a demographic information scale, along with hospital admissions, general practitioner (GP) or cardiologist appointments were measured at baseline, 6 months and 12 months.Results Support group participants maintained higher levels of social support than controls (ESSI score, 17.18 ± 5.35 vs. 14.45 ± 6.98, p == 0.008). Near significant improvements in health beliefs total score (p == 0.068) and threat perception (p == 0.062) were found among the support group compared to the control; 29%% of support patients had made one or more GP visits over the duration of the study, compared with 54%% of the control group (p == 0.06).Conclusion Support group participation maintains social support and may reduce health-care demands and misconceived health beliefs among patients with cardiac syndrome X.

ASSESMENT OF PERFUSION AND KINETICS OF THE LEFT VENTRICLE AT REST AND EXERTION IN PATIENTS WITH MICROVASCULAR ANGINA USING SPECT CT: PP.11.437

Objectives: Patients with Microvascular angina (MA) fulfil the three big criteria: angiographically smooth coronary arteries, angina pectoris and positive exercise electrocardiogram. The most manifest clinical symptom in those patients is chest pain. Aim of the study is to investigate the changes in the LV perfusion and kinetics at rest and exertion, reversible or not reversible, in patients with MA using gated SPECT CT. Design and Method: A prospective randomized study including 18 consecutively hospitalized patients (women) at the mean age 55,29 ± 9,47 who fulfilled criteria for MA. All patients underwent a quantitative gated SPECT examination and the total defect in perfusion and kinetics of the left ventricle (LV) was calculated. There were defined: summed difference score (SDS), the rest and exertion parameters of the LV function: ejection fraction (EF), end systolic volume (ESV), max velocities of filling and ejection of the LV: peak filling rate (PFR), peak empting rate (PER). Results: In 10 (55.6%) patients there were different degree of perfusion abnormalities at exertion: SDS max 9, min 2, mean 3.6 ± 2.497. From patients with SDS > 0, 6 (60%) recovered at rest and 2 (20%) normalized after receiving nitrates. Changes in the LV kinetics were found in 3 patients (16.7%): 2 with perfusion defect (1 with no change at rest) and 1 without such a defect. In perfusion defects there was no significant increase of EF (p 0,235) and no significant change of the ESV (p 0,498) at exertion. There was a preserved reaction of the PER (p 0,05) at exertion in those patients, but no significant difference of the PFR (p 0,674). Conclusion: In patients with criteria for MA there were more marked changes in the myocardial perfusion than changes in the kinetics. In those patients there was no adequate increase of the EFLV as a reaction to exertion which is probably related to the disturbed diastolic function assessed by PFR.

It hurts so bad like a needle through the heart

A 62-year-old male patient with no cardiovascular risk factors was followed in our Cardiology outpatient clinic for 2 years because of some episodes of chest pain that resembled angor pectoris. He underwent several treadmill tests with mild positive exercise electrocardiograms in lateral leads in the latter stages (ischaemic threshold at 9 min and maximum exercise …

Characteristics of stress tests and symptoms in patients with myocardial bridge and coronary artery spasm

A relationship between coronary artery spasm (CAS) and myocardial bridge (MB) has been noticed. This study was designed to investigate the differences of stress tests and symptoms between CAS patients with or without MB. Two hundred and sixteen patients with atypical chest pain who underwent coronary angiography and acetylcholine provocation test were divided into MB group (n=68) and nonmyocardial bridge group (NMB, n=148). The results of acetylcholine test, treadmill exercise electrocardiography, myocardial scintigraphy, and levels of plasma endothelin-1 and nitric oxide were compared between the two groups. Among these atypical chest pain patients, CAS was induced by acetylcholine in 85% MB patients and 53% NMB patients (P<0.001). A positive exercise electrocardiogram was identified in 71% MB patients and 8% NMB patients (P<0.001). Myocardial scintigraphy revealed ischemic changes in 67% MB patients and 9% NMB patients (P<0.001) and reverse redistribution in 87 and 69% (P<0.01), respectively. MB patients experienced exertional chest pain as well as at rest more frequently than NMB patients. Endothelin-1 levels were elevated in MB group complicated with CAS (P<0.01), whereas nitric oxide levels were reduced in the same cohort (P<0.05) compared with NMB group. MB might predispose to CAS in which endothelial dysfunction may play a part. CAS patients with MB usually present mixed chest pain and positive stress tests as well as reversal redistribution on myocardial scintigraphy whereas CAS patients without MB displayed chest pain at rest, negative stress test and reversal redistribution.

Arm exercise testing predicts clinical outcome

Treadmill exercise testing provides prognostic and clinical information that is not available for patients with lower extremity disabilities who undergo pharmacologic stress tests. We sought to determine whether arm ergometer (AXT) exercise capacity in resting metabolic equivalents (METs) and hemodynamic and electrocardiographic responses to AXT are predictors of survival, myocardial infarction (MI), or coronary revascularization, individually or as a composite. A prospective cohort of 359 veterans aged 63 +/- 11 (SD) years, who were unable or unwilling to perform treadmill exercise, underwent AXT stress testing for clinical reasons between 1997 and 2002 and were followed for 63 +/- 24 months to an end point of death or December 31, 2006. Average annual mortality, MI, revascularization, and combined event rates were 5.2%, 1.7%, 2.2%, and 7.1%, respectively. By univariate analysis, AXT METs were highly predictive of survival (P < .01; hazard ratio 0.58, 95% confidence interval 0.46-0.70). A greater delta (peak-rest) heart rate, peak exercise systolic blood pressure, and rate pressure product were associated with survival and event-free outcome (all P < .02). A positive exercise electrocardiogram was predictive of death, revascularization, and combined events (all P < .01), and borderline predictive of MI (P = .058). By Wald chi(2) analysis, age, clinical variables, exercise capacity in METs, a positive exercise electrocardiogram, and delta heart rate all had statistically significant incremental prognostic value (P < .05) for survival. In older veterans with lower extremity disabilities and more comorbidities than most study populations, arm exercise capacity, delta heart rate, and a positive electrocardiogram were independently predictive of survival and/or adverse cardiovascular outcomes.

Noninvasive Techniques to Assess Myocardial Ischemia in Hypertensive Patients

Hypertensive patients are more affected by coronary artery disease (CAD) than normotensive patients. Currently, established techniques are able to diagnose myocardial ischemia/CAD in hypertensive patients with suspected CAD. An irrevocable role remains for exercise electrocardiogram (ECG) owing to the many parameters evaluated under physiologic conditions. However, the suboptimal specificity of a positive exercise ECG demands further examination of hypertensive patients with either myocardial single-photon emission computed tomography (SPECT) or stress echocardiography, both more specific than exercise ECG in diagnosing CAD. The high specificity of imaging techniques also makes them highly predictive of cardiac events. Additional techniques to help diagnose CAD are available. Tissue Doppler imaging, strain and other echo-derived techniques may add quantitative elements to recognize CAD in hypertensive hearts. The accuracy of MRI is improving to study myocardial function and perfusion. Positron emission tomography and multislice computed tomography, also in-built with fusion scanners, are playing roles in combining coronary angiography and myocardial function/ischemia assessment. However, no significant application of these additional techniques is available for hypertensive patients. Epicardial CAD assessed by coronary angiography remains the gold standard to decide for revascularization procedures. The presence of microcirculatory dysfunction, a symptom typical of hypertensive hearts, is opening up new areas of noninvasive diagnostic techniques for the detection of coronary flow reserve (CFR) and related myocardial ischemia. The quantification of CFR may render this parameter pivotal to deciding the need for revascularization procedures of intermediate coronary stenosis and it may become an additional gold standard in evaluating coronary vessels. Moreover, even with normal epicardial coronary arteries, microcirculation dysfunction bears prognostic stratification capabilities for hypertensive patients and it may become a promising therapeutic target in the near future.

Role of Coronary Spasm for a Positive Noninvasive Stress Test Result in Angina Pectoris Patients Without Hemodynamically Significant Coronary Artery Disease

A positive noninvasive stress test result is often considered as a false-positive indicator of coronary artery disease (CAD) when coronary angiography reveals no hemodynamically significant CAD. From January 2001 through December 2004, 5474 patients scheduled to undergo exercise electrocardiogram (ECG) [exercise ECG without imaging or exercise ECG with thallium-201 (201Tl) single photon emission tomography (SPECT)] or dipyridamole 201Tl tomography at our outpatient clinic because of chest oppressive sensation were included in this prospective study. Coronary angiography was performed when a noninvasive test result was positive for ischemia or when ischemic chest pain was suspected. Intracoronary methylergonovine testing was performed when spastic angina was suspected and coronary angiography showed no hemodynamically significant CAD. Noninvasive stress testing was positive in 113 (67%) patients with coronary spasm. Of the 53 patients who had positive exercise ECG (exercise ECG with or without imaging), ST depression was found in 50 patients and ST elevationin in 3 patients. Multivessel spasm was found in 6 (15%), 6 (15%), and 7 (21%) of the patients with a positive result on exercise ECG without imaging, exercise ECG with 201Tl SPECT, and dipyridamole 201Tl SPECT, respectively. There was no significant difference in the results of noninvasive stress testing and the number of vessels with coronary spasm (1-vessel spasm versus multivessel spasm) among these 3 noninvasive stress testing groups. Intracoronary ergonovine testing induced coronary spasm in over 50% of patients who had suspected ischemic chest pain, a positive noninvasive stress test, and no hemodynamically significant CAD.

Predicting Breast Attenuation in Patients Undergoing Myocardial Perfusion Scintigraphy: A Digital X-Ray Study

Attenuation artifacts are the most common sources of error in myocardial single-photon emission computed tomography (SPECT) imaging. Breast artifacts are the most frequent causes of false positive planar images in female subjects. The purpose of this study was to predict breast adverse attenuation by measuring breast tissue thickness with digital x-ray. Sixty-five consecutive female patients with angina pectoris, who were referred to myocardial perfusion scintigraphy were enrolled in this study. Eighteen patients with normal perfusion imaging and normal coronary angiography composed the first group, whereas the second group consisted of 28 patients with a positive exercise electrocardiogram with anterior ischemia on myocardial perfusion imaging and greater than 50% left anterior descending artery stenosis on angiography. Nineteen patients in the third group had normal exercise electrocardiograms and normal coronary angiographies, but anterior ischemia on perfusion imaging. Digital x-ray records were obtained for measuring breast tissue thickness and Hounsfield density. The rate of breast adverse attenuation was 40% (19/47) in patients with anterior ischemia. The sensitivity and specificity of the prediction of breast adverse attenuation (lateral density less than 550 Hounsfield) were 79% and 11%, respectively. When breast attenuation for a breast thickness greater than 6 cm measured in the left anterior oblique view was predicted, the sensitivity and specificity were 79% and 93%, respectively. In conclusion, breast thickness greater than 6 cm measured from the left anterior oblique view with digital x-ray can predict breast adverse attenuation in female patients, and thereby may decrease the number of unnecessary invasive diagnostic procedures to be performed.

Diagnostic work-up of unselected patients with suspected coronary artery disease: complementary role of multidetector computed tomography, symptoms and electrocardiogram stress test

We evaluated the accuracy of multidetector computed tomography in detecting coronary artery disease and how it could change the indication to coronary angiography in patients with suspected cardiac chest pain. We enrolled 142 consecutive patients who had already performed an exercise electrocardiogram test referred to our hospital and scheduled for coronary angiography for chest pain. According to the characteristics of chest pain and the results of exercise electrocardiogram, patients were divided into four groups: atypical chest pain and negative exercise electrocardiogram (group 1); typical chest pain and negative exercise electrocardiogram (group 2); atypical chest pain and positive exercise electrocardiogram (group 3); and typical chest pain with positive exercise electrocardiogram (group 4). We evaluated the accuracy of multidetector computed tomography and whether it could reduce the number of unnecessary coronary angiography in the study groups. Of 1801 segments larger than 1.5 mm, 1696 (94%) were assessable. In a segment based-model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 81% (95% confidence interval 75-89%), 94% (95% confidence interval 90-98%), 96% (95% confidence interval 93-98%), 75% (95% confidence interval 69-82%) and 91% (95% confidence interval 89-93%), respectively. In a patient-based model, sensitivity, specificity, negative predictive value, positive predictive value and accuracy were 95% (95% confidence interval 91-99%), 78% (95% confidence interval 67-89%), 88% (95% confidence interval 79-97%), 89% (95% confidence interval 83-95%) and 89% (95% confidence interval 84-94%). Unnecessary coronary angiography may be avoided by multidetector computed tomography results particularly in group 2 (16%) and group 3 (24%), whereas in groups 1 and 4 the role of multidetector computed tomography in facilitating the correct indication to coronary angiography was less relevant. Multidetector computed tomography is a particularly helpful technique in patients with discordance between the clinical features of chest pain and stress-test results. This technique may be introduced in the diagnostic work-up of patients with suspected coronary artery disease and may potentially reduce the number of unnecessary coronary angiography.

Thematic review series: The Pathogenesis of Atherosclerosis. An interpretive history of the cholesterol controversy, part IV: The 1984 Coronary Primary Prevention Trial ends it—almost

As of the early 1980s, despite the wealth of evidence from experimental animal models, the extensive epidemiologic evidence, the powerful genetic evidence, and the strongly suggestive clinical intervention trial results, most clinicians still remained unpersuaded regarding the relevance of the lipid hypothesis. What was needed was a well-designed, large-scale, long-term, double-blind study demonstrating a statistically significant impact of treatment on coronary heart disease events. The National Institutes of Health (NIH) had laid the groundwork for such a study as early as 1970, but the study was not completed and the results published until 1984. This study, the Coronary Primary Prevention Trial, showed that treatment with a bile acid binding resin reduced major coronary events in hypercholesterolemic men by 19%, with a P value of 0.05. The NIH followed this up with a national Consensus Development Conference on Lowering Blood Cholesterol to Prevent Heart Disease. For the first time, the NIH now went on record advocating screening for hypercholesterolemia and urging aggressive treatment for those at high risk. The Institute initiated a national cooperative program to that end, the National Cholesterol Education Program. For the first time, preventing coronary heart disease became a national public health goal.

Cardiac syndrome X

Cardiac syndrome X, the triad of angina pectoris, a positive exercise electrocardiogram for myocardial ischaemia and angiographically smooth coronary arteries, is frequently associated with debilitating symptomology, increased psychological morbidity and a poor quality of life. While various avenues of research have been undertaken, there are as yet no definitive conclusions regarding the exact pathogenesis of the condition. A number of physiological mechanisms have been explored, including the existence of underlying myocardial ischaemia, suggested endothelial dysfunction, abnormal pain perception, hormonal irregularities and insulin resistance, while the psychological impact of the condition has also been explored. Various treatment regimens have also been the subject of research with varying degrees of success. The heterogeneous nature of the patient population suggests that the mechanistic pathway may be multifactorial, while a comprehensive treatment regimen including both psychosocial and pharmacological interventions may offer the best outcome for patients with cardiac syndrome X.

Can Adoption of Regular Exercise Later in Life Prevent Metabolic Risk for Cardiovascular Disease?

To determine the impact of chronic exercise training initiated later in life upon development of metabolic markers of cardiovascular disease risk. Two inception cohorts of previously sedentary healthy adults aged 55-75 years at baseline (1989), one initiating regular supervised physical exercise training and the other a geographical similar sedentary control, were assessed for anthropometric, biochemical, and clinical markers of the metabolic syndrome and comorbidity over 10 years. At baseline, active individuals aged 68 years compared with sedentary individuals aged 67 years had similar fitness levels (5.7 vs. 5.8 metabolic equivalents). At follow-up, complete data were obtained for 161 active and 136 sedentary subjects. Drop out occurred primarily because of failure to adhere to the exercise regimen and poor physical health for active and sedentary individuals, respectively. More metabolic abnormalities were seen in the sedentary group than in the active group for one or two (64 vs. 36%, P < 0.001) and three or more (35 vs. 22%, P < 0.003) abnormalities, respectively. In those assessed at follow-up, the sedentary group compared with the active group had lower fitness levels (5.0 [13.8% decrease] vs. 5.9 [3.5% increase] metabolic equivalents), had a greater likelihood of a positive exercise electrocardiogram or symptom (32 vs. 10%, P < 0.001), and had more comorbid conditions (Charlson Comorbidity Index score 0.9 vs. 0.4, P < 0.01). Higher fitness achieved over 10 years of regular exercise training in older adults was associated with reduced development of metabolic risk factors for cardiovascular disease, fewer exercise-induced cardiac abnormalities, and reduced comorbidity.