Positive Exercise Tolerance Test Research Articles

Cardiac ischemic symptoms among diabetic patients with their exercise tolerance test findings at a tertiary care hospital of Bangladesh

Background: Cardiovascular disease is the leading cause of death among diabetic patients. Diabetics who experience chest pain should get a full cardiac evaluation. Exercise tolerance test (ETT) is a noninvasive, less costly and relatively accurate test for evaluation of ischemic heart diseases. This study aimed to describe cardiac ischemic symptoms among diabetic patients and their ETT findings. Methods: This cross-sectional study was carried out among 82 diabetic patients with ischemic symptoms, in the Department of Cardiology, BIRDEM General Hospital, Dhaka from July to December 2018. Results: The mean±SD age was 60.91±11.68 years with male predominance (67%). The respondents had diabetes for an average of 8.34±4.92 years. Two-thirds of research participants were on insulin. The majority of the resting ECG results were ST-T changes (86.58%); mostly in anterior leads (54.9%) and ‘T’ inversion was predominant feature (64.2%) among all ST-T changes. The ETT result was positive in 69.72% of the individuals. During the ETT test, 57.31% of the individuals reached their goal heart rate. Test was terminated owing to tiredness in the majority of the individuals (86.58%). Chest pain and shortness of breath were significantly higher (p 0.042 and 0.011 respectively) in ETT positive participants. Aside from diabetes, the ETT positive participants had risk factors such as dyslipidaemia, hypertension, a family history of IHD and smoking (18.3%, 8.53%, 14.63% and 13.42% respectively). Conclusion: Over two-thirds of the diabetic patients with suspected IHD had positive ETT findings in this study. BIRDEM Med J 2023; 13(2): 67-75

Evaluation of Risk Factors Associated with Positive Exercise Tolerance Test

Objective: To determine the potential risk factors in patients aged under 40 years with a positive Exercise Tolerance Test (ETT).Study Design: Prospective study.Place and Duration of Study: The study was carried out at the Department of Cardiology Choudhary Pervaiz Elahi Institute of Cardiology (CPEIC), Multan, Pakistan, from 1st January 2021 to 1st March 2022.Materials and Methods: The study included 285 patients with positive ETT, selected through non-probability consecutive sampling. Patients were grouped into two age brackets: 20-30 and 31-40. Patients were advised to stop taking nitrates, calcium channel blockers and beta blockers a day before the test. The patients were investigated for potential risk factors that caused the positivity of EET.Results: The study was conducted on 285 patients. The age of the participants was 30.12±5.64 years. There were 185 (64.9%) males and 100 (35.1%) females. The BMI was .32±1.38 kg/m2. Obesity was recorded in 38 (13.3%) patients, 85 (29.8%) had a family history, 63 (22.1%) had dyslipidemia, hypertension in 58 (20.4%), 32 (11.2%) had a smoking history, and 56 (19.6%) had diabetes mellitus. Diabetes Mellitus (p=0.00) and dyslipidemia (p=0.004) were found to be the most significant risk factors in patients aged between 31-40 years with positive EET.Conclusion: Diabetes mellitus and dyslipidemia are the most significant causes of positive EET in patients aged between 31-40 years.

EXERCISE TOLERANCE TEST (ETT), AN EFFECTIVE TOOL FOR PREVELANCE AND ESTIMATION OF CORONARY HEART DISEASE

Objectives: Exercise tolerance test (ETT) is utilized for diagnostic and prognostic reasons in patients with chest pain and suspected coronary artery disease (CAD). The main objective is to know the nature of chest pain, either it is cardiac or non-cardiac. By using the exercise tolerance test tool we can evaluate the prevalence of ischemic heart disease (IHD) in patients with chest pain.
 Methodology: This cross-sectional study was carried among 572 male and female patients 30 to 65 years of age with chest pain. Their exercise tolerance test was performed using Bruce protocol and then the ECG findings and cardiopulmonary responses were studied at the Tertiary Care Cardiac Centre of Karachi.
 Results: From 572 profiles only 177 were found positive ETT. The prevalence of IHD was found to be 30.94 %. We studied all ETT-positive patients and found that IHD was most common in hypertensive patients, which was 33.89%. Dyslipidemia, diabetes, obesity, smoking habit, and positive family history were also found to be the leading factors of ischemic heart disease.
 Conclusion: Our results conclude that there is a high incidence of heart disease in patients with hypertension, dyslipidemia, diabetes, positive family history of heart disease, obesity, and smoking. Our study establishes that if someone is coming with chest pain must be further evaluated, and the easy way is to perform the exercise tolerance test. Those with positive ETT should be treated properly and advised for regular follow-up by a cardiologist, control diet, regular exercise, no smoking, and a healthy lifestyle.

Transaortic flow rate to predict short and long term outcomes in individuals with asymptomatic aortic stenosis

Abstract Background Echocardiographic derived transaortic flow rate (TFR), defined as stroke volume over left ventricular ejection time, has been shown to be associated with increased mortality in asymptomatic mild to severe aortic stenosis (AS) and superior to stroke volume index (SVi) in individuals with symptomatic discordant AS undergoing aortic valve replacement. However, TFR has not been explored alongside SVi in asymptomatic moderate to severe AS, who are a group of interest in risk stratifying for early intervention. Moreover, there is no data where TFR is indexed to body surface area (TFRi). Purpose We explored the prognostic value of TFR, TFRi and SVi in a homogenous cohort of asymptomatic patients with moderate to severe AS. Methods Subjects with asymptomatic moderate to severe AS were prospectively recruited to the Prognostic Importance of Microvascular Dysfunction in asymptomatic patients with AS (PRIMID) study, a multi-centre observational study in the UK conducted between April 2012 and November 2014. All subjects underwent extensive phenotyping with transthoracic echocardiography, bicycle exercise testing and cardiovascular magnetic resonance (CMR) imaging, with blinded core-lab analysis. Patients were followed up in person for a minimum of 12 months, and through health records thereafter. The composite outcome of interest was: cardiovascular mortality, AVR for symptoms and major adverse cardiovascular events (hospitalisation with heart failure, myocardial infarction, syncope and arrhythmia) at one-year and at five years. A cox proportional hazards model was used to calculate a hazard ratio (HR) and 95% confidence intervals (95% CI). Known co-variables associated with the composite outcome were added into the multivariable model. Results Overall, 173 individuals were included with a mean age of 66.3—-±13.3 years and 76.4% were male. Most individuals had severe AS (71.1%, n=123). There were 47 (64.4%) primary outcome events at one-year and 110 (63.6%) events at five-years. Age, sex, N-terminal pro brain natriuretic peptide (NT-pro-BNP), peak aortic velocity (AV Vmax), a positive exercise tolerance test (ETT), myocardial perfusion reserve and right ventricular ejection fraction measured on cardiac magnetic resonance were included in the multivariable model in addition to TFR or TFRi or SVi. Decreasing TFR and TFRi remained independently associated with one-year and five-year composite outcome (Figure 1). However, SVi was only associated with the composite outcome at five-years. AV Vmax (HR: 4.36, 95% CI: 2.59, 7.34, p<0.01) and a positive ETT (HR: 1.87, 95% CI: 1.03, 3.37, p=0.04) were independently associated with the primary outcome at one-year. Conclusion Both TFR and TFRi have a potential role in risk stratifying asymptomatic patients with AS and identifying those for earlier intervention, and may be superior to SVi. However, further prospectively designed studies are needed before this becomes part of the routine clinical practice. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Independent research from a Post-Doctoral Fellowship supported by the National Institute for Health Research (NIHR-PDF 2011-04-51 Geral P McCann).

Role of SPECT Myocardial Perfusion Imaging, in Assessment and Early Diagnosis of Asymptomatic Coronary Artery Disease; An Analytical Study Conducted in a Tertiary Care Hospital of Islamabad, Pakistan

Exercise Tolerance Test (ETT) and Myocardial Perfusion Imaging (MPI) are known non-invasive modalities to detect coronary artery disease (CAD). Aim of this study was to find out better modality for early detection of asymptomatic CAD. Material and Methods: 25 asymptomatic individuals with one or more cardiac risk factors were enrolled. Probability of CAD was calculated, using Framingham scoring; patients classified as low, intermediate and high-risk group. Each (n=25) underwent ETT and MPI. ETT response was categorized as normal, ischemic or equivocal. MPI results as normal, mild, moderate to severe degree defects. 18 patients had follow-up angiograms. Results: Risk stratification showed 14 patients were in intermediate group, 4 had high and 7 had low risk of CAD. In intermediate group, 6 patients had ischemic ETT changes, 10 had perfusion defects on scan and all 10 patients had ≥ 70% stenosis on coronary angiograms. In high-risk group; 2 subjects had positive ETTs, 3 had positive scans and all 3 showed significant vascular involvement on coronary angiogram. In low risk group 3 patients had positive ETT and MPS, 2 had mild vascular stenosis. Considering angiography as gold standard, we observed that MPI had sensitivity (86.66%) and specificity (90%), whereas ETT had 66.6% and 70% respectively. Positive and negative predictive values of MPI were 92.8% and 81.8 % respectively. Post-test probability of MPI was i.e. 0.72-0.88; compared to ETT which was 0.55-0.78. Conclusion: MPI is a better modality than ETT for early diagnosis of occult CAD, especially in intermediate and high risk group.

Gauging the Positive Predictive Value of Exercise Tolerance Test Using Angiographic Evaluation: A Cross-Sectional Analysis From a Developing Country.

BackgroundExercise tolerance test (ETT) and angiographic evaluation are important tools to evaluate patients presenting with ischemic cardiac pathologies. Angiographic evaluation is regarded as the gold standard diagnostic modality to diagnose coronary artery disease (CAD). Our study aims to evaluate the positive predictive value (PPV) of ETT to diagnose CAD using coronary angiography.MethodsWe conducted a cross-sectional study that analyzed 94 patients with a positive ETT test after the application of strict inclusion and exclusion criteria. All 94 patients were referred for angiography after a positive ETT test. Data collection was performed using a structured proforma, and analysis was carried out on Statistical Package for Social Sciences (SPSS) version 23 (IBM Corp., Armonk, NY). PPV for various demographic characteristics was calculated.ResultsOut of 94 patients, 76 were males and 18 were females with a mean age of 52.28 ± 7.55 years. A total of 35.1% of the patients had type-2 diabetes, and 31.9% were hypertensive. On coronary angiography, only 25 patients had normal findings, and 69 patients had a significant occlusion in at least one of the major coronary arteries. The overall PPV of the ETT against angiographic evaluation was 73.40%. The PPV for females, hypertensives, non-smokers, and non-diabetics was lower than the PPV of males, smokers, non-hypertensives, and diabetics.ConclusionAngiographic evaluation of patients with positive ETT findings has a high likelihood of false positivity especially among females, non-smokers, hypertensives, and non-diabetics. The results of ETT must be interpreted with caution in these subsets of the population. Invasive radiological modalities can be used for diagnosis; however, such modalities do not elucidate the functioning of myocardium under stress.

Novel Scoring System for Prediction of Cardiac Syndrome X in Women with Typical Angina and a Positive Exercise Tolerance Test.

A major diagnostic challenge for cardiologists is to distinguish cardiac syndrome X (CSX) from obstructive coronary artery disease in women with typical angina and a positive exercise tolerance test (ETT). We performed this study to develop a scoring system that more accurately predicts CSX in this patient population. Data on 976 women with typical angina and a positive ETT who underwent coronary angiography at our center were randomly divided into derivation and validation datasets. We developed a backward stepwise logistic regression model that predicted the presence of CSX, and a scoring system was derived from it. The derivation dataset (809 patients) was calibrated by uing a Hosmer-Lemeshow goodness-of-fit test (8 degrees of freedom; χ2=12.9; P=0.115), and the area under the curve was 0.758. The validation dataset (167 patients) was calibrated in the same way (8 degrees of freedom; χ2=9.0; P=0.339), and the area under the curve was 0.782. Independent predictors of CSX were age <55 years; negative histories of smoking, diabetes mellitus, hyperlipidemia, hypertension, or familial premature coronary artery disease; and highly positive ETTs. A total score >9.5 was the optimal cutoff point for differentiating CSX from obstructive coronary artery disease. Our proposed scoring system is a simple, objective, and accurate system for distinguishing CSX from obstructive coronary artery disease in women with typical angina and positive ETTs. It may help determine which of these patients need invasive coronary angiograms or noninvasive tests like computed tomographic coronary angiography.

IMPACT OF SMOKING STATUS ON SHORT TERM CLINICAL OUTCOMES OF DRUG ELUTING STENTS IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE

Objective: To evaluate the impact of smoking status on short-term clinicaloutcomes of Drug Eluting Stents (DES) in patients with stable coronary arterydisease. Methodology: This cross sectional study was carried out at the Department ofCardiology, Lady Reading Hospital Peshawar from April 2011 to July 2012. Itincluded all patients with stable coronary disease undergoing DES implantation.Smoking status was assessed on the basis of information obtained from hospitalmedical records at the time of first medical examination and rechecked bytelephone interview. All patients were classified as non-smokers and smokers.Clinical outcomes (Myocardial infarction [MI], unstable angina [UA], and positiveETT) at three months stratified by smoking status were measured in patients whoreceived DES for coronary artery lesions. All patients were followed andreassessed after 3 months from the index procedure. Exercise Tolerance Test(ETT) was performed on every patient and recorded on proforma. Data analysiswas done using SPSS version 16. Result: A total of 376 patients were enrolled in this study. The mean age was57±9.313 years. Males were 271(72.1%). Among 376 patients who werefollowed up, 70 of them were smokers (18.6%) at the index procedure, 306patients (81.4%) were non-smokers. The frequency of dyslipidemia and diabetesmellitus was higher in smokers as compared to non-smokers. Mean stent lengthin smokers was 27.824±6.23mm as compared to 26.592±4.73mm in nonsmokers.Mean stent diameter was 2.91±0.347mm in smoker group while itwas 3.01±0.141mm in non-smoker group. Most of the patients in both groupsunderwent DES implantation to LAD and LCx arteries. There were significantlyhigher rates of myocardial infarction (7.1% vs 2%, p<0.036),unstable angina(22.9% vs 3.3%, p<0.001) and positive ETT (30% vs 5.2%, p<0.001) in thesmoker group as compared to non-smoker group. Conclusion: This study provides evidence that smokers treated with DESexperience higher rates of myocardial infarction, unstable angina and positiveETT at three months as compared to non-smokers, particularly in the setting ofstable coronary artery disease. Key Words: Smokers, Coronary artery disease, Drug eluting stent

Presence of coronary artery disease in diabetic and non diabetic South Asian immigrants

IntroductionSouth Asian Immigrants (SAIs) are the second fastest growing Asian immigrant population in the US, and at a higher risk of type 2 diabetes (diabetes) and coronary artery disease (CAD) than the general US population. Objectives: We sought to determine in SAIs the; 1) the prevalence of CAD risk factors in diabetics and non-diabetics; and b) the high possibility of CAD in diabetic SAIs. We also assessed the prevalence of sub-clinical CAD in both diabetics and non-diabetics SAIs using common carotid artery Intima-media thickness (CIMT) as a surrogate marker for atherosclerosis. MethodsIn a cross-sectional study design, 213 first generation SAIs were recruited and based on the history, and fasting glucose levels were divided into two subgroups; 35 diabetics and 178 non-diabetics. 12-hour fasting blood samples were collected for glucose and total cholesterol levels. Exercise Tolerance Test (ETT) was performed to determine the possibility of CAD. ResultsBoth diabetics and non-diabetics SAIs in general, share a significant burden of CAD risk factors. The prevalence of hypertension (p=0.003), total cholesterol ≥200mg/dl (p<0.0001) and family history of diabetes (p<0.0001) was significantly was significantly higher in diabetics compared to non-diabetics. Of the 22/29 diabetic participants without known history of CAD, 45% had positive ETT (p<0.001). Similarly, 63.1% of diabetics and 51.8 % of non-diabetics were positive for sub-clinical CAD using CIMT as a marker. ConclusionThe susceptibility to diabetes amongst SAIs promotes an adverse CAD risk, as evident by this small study. Further research, including larger longitudinal prospective studies, is required to validate the current small study findings with investigation of the temporal association.

Impact of stent length and diameter on short term clinical outcomes of drug eluting stents in patients with stable coronary artery disease

Background & Objective:The risk of restenosis and other adverse cardiovascular events with bare-metal stents have increased with smaller stent diameters and longer stent lengths. However, the exact impact of stent size on the short-term outcomes of drug-eluting stent (DES) implantations has not been much classified in Pakistani population. This study was designed to evaluate the impact of size (length and diameter) of Drug Eluting Stents on Clinical outcomes in patient with stable coronary artery disease at three months of implantation in Pakistani Population.Methods:This is a prospective study which was carried out in the Department of Cardiology, Lady Reading Hospital Peshawar from April 2011 and July 2012. All consecutive patients with stable coronary disease undergoing Percutaneous Intervention (PCI) with DES implantation at Cardiology Unit Lady Reading Hospital, were included prospectively. Clinical outcomes (Myocardial infarction [MI], unstable angina[UA], and positive ETT) at three months stratified by 3 tertiles of stent length and diameter each, were measured in patients who underwent PCI with DES for coronary artery lesions. All patients were followed and reassessed after three months from the index procedure. Exercise Tolerance Test(ETT) was performed on every patient and recorded on proforma. Data analysis was done using SPSS software version 16.Results:A total of 376 patients were included prospectively in this study. The mean age was 57±9.313 years. Male patients were 271(72.1%). Mean length of drug eluting stent was 27.313±7.235 mm while mean diameter of stent was 2.90±0.2483mm. There were slightly higher rates of MI, U.A and positive ETT in the longest stent length tertile(>28mm) compared with the shortest stent length tertile (<22mm) at three months, but they were statistically not significant. We also observed that for DES, there was no clear relationship between stent diameter and outcome for any of the clinical outcome variables.Conclusion:In our single-center prospective study, stent length and diameter defined in tertiles, had no impact on the short-term clinical outcomes of DES in patients with stable coronary artery disease.

221 Comparing Erectile Dysfunction with Traditional Vascular Risk Factors in the Prediction of Coronary Artery Disease in Patients Presenting with Chest Pain

<h3>Introduction</h3> Erectile dysfunction (ED) is the persistent inability to attain or maintain an erection and affects up to 52% of men between the ages of 40 and 70. ED is an independent predictor of clinically overt cardiovascular (CV) events, coronary artery disease (CAD), stroke and all-cause mortality, preceding these by 2–5 years. ED has not been evaluated in patients referred to a rapid access chest pain clinic (RACPC) for suspected CAD. <h3>Purpose</h3> To prospectively investigate ED in patients referred to the RACPC and to assess ED as an independent predictor of CAD in these patients. <h3>Methods</h3> All male patients attending RACPC between October 2012 and February 2014 were eligible. ED was measured using a well validated 5-item International Index of Erectile function (IIEF-5) questionnaire, with ED being defined as IIEF-5 of ≤21 out of 25. ED was further categorised into mild-moderate (IIEF-5: 11–21) and severe (IIEF-5: ≤10). All patients underwent an exercise tolerance test (ETT) according to Bruce protocol where appropriate as a first line investigation. When this was not possible, patients underwent a functional imaging (stress echocardiography [SE] or myocardial perfusion scintigraphy [MPS]). Patients with positive or inconclusive studies went on to have coronary angiography (CA). Patients were considered to have CAD if they had a positive ETT, SE, MPS or CA. Results were analysed using Chi-squared test for categorical data and one-way ANOVA for continuous data. Stepwise Binary logistic regression model was used to determine the contribution of traditional risk factors and the presence of ED to the prediction of CAD. P-value less than 0.05 was considered significant. <h3>Results</h3> Our study cohort constituted 181 patients. Of these, 26 (14%) could not complete IIEF-5. Of the remaining 155 participants, 53 (34%) had normal erectile function (IIEF-5: ≥22). Of 102 (66%) ED patients, 55 (36%) had mild-moderate ED and 47 (30%) had severe ED. Patients with ED reported more risk factors than patients without ED, including smoking (68% vs. 55%, p = 0.004), diabetes (9% vs. 23%, p = 0.029), and hypertension (30% vs. 56%, p = 0.002). More patients with ED had CAD (47% vs. 25%, p = 0.014). Using stepwise Binary logistic regression including hypertension, hypercholesterolemia, smoking, diabetes, family history and ED as covariates, hypercholesterolemia (p = 0.045) and ED (p = 0.007) were significant independent predictors of CAD (r2=0.135, p = 0.001). <h3>Conclusions</h3> ED may be a more powerful predictor of CAD in male patients with chest pain when compared to traditional vascular risk factors.

Comparison of Clinical Efficacy and Cost of a Cardiac Imaging Strategy Versus a Traditional Exercise Test Strategy for the Investigation of Patients With Suspected Stable Coronary Artery Disease

We evaluated the clinical efficacy and cost of a cardiac imaging strategy versus a traditional exercise tolerance test (ETT) strategy for the investigation of suspected stable coronary artery disease (CAD). We retrospectively collected data of consecutive patients seen in rapid access chest pain clinics at 2 UK hospitals for a period of 12 months. Hospital A investigated patients by performing ETT. Hospital B investigated patients using cardiac imaging test; 483 patients from hospital A and 295 from hospital B were included. In hospital A, 209 patients (43.3%) had contraindication to ETT. Of those who had ETT, 151 (55.1%) had negative ETT, 68 (24.8%) had equivocal ETT, and 55 (20.1%) had positive ETT, of which 53 (96.4%) had invasive coronary angiography (ICA), and of these 23 (43.4%) had obstructive CAD. In hospital B, 26 patients (8.8%) with low pretest probability had calcium score and 3 (11.5%) were positive leading to computed tomography coronary angiography; 98 patients (33.2%) with intermediate pretest probability had computed tomography coronary angiography and 5 (5.1%) were positive; 77 patients (26.1%) had stress echocardiogram and 6 (7.8%) were positive; and 57 patients (19.3%) had myocardial perfusion scintigraphy and 11 (19.3%) were positive. Hospital A performed 127 ICA (26.3% of population) and 52 (40.9%) had obstructive CAD. Hospital B performed 63 ICA (21.4% of population) and 32 (50.8%) had obstructive CAD. The average cost per patient in hospital A was £566.6 ± 490.0 ($875 ± 758) and in hospital B was £487.9 ± 469.6 ($750 ± 725) (p <0.001). In conclusion, our results suggest that a cardiac imaging pathway leads to fewer ICA and a higher yield of obstructive CAD at lower cost per patient.

A NOVEL SCORING SYSTEM FOR PREDICTION OF CARDIAC SYNDROME X IN WOMEN WITH TYPICAL ANGINA AND POSITIVE EXERCISE TOLERANCE TEST: IMPLICATIONS FOR NON-INVASIVE IMAGING

About 40% of women with typical angina and positive exercise tolerance test (ETT) have normal coronary angiographies. We performed this study to construct a scoring system for better distinguishing patients with cardiac syndrome × (CSX) than those with obstructive coronary artery disease (CAD)

Prognostic Value of Normal Exercise Echocardiography in a One-Year Follow-up

Background: Exercise echocardiography is a well-validated technique for the diagnosis of coronary artery disease. In addition to the diagnostic role, it also provides useful prognostic information. Objectives: The aim of this cross sectional study was to assess the prognosis of patients with negative exercise echocardiographic results over a one-year period follow-up. Patients and Methods: The outcomes of 336 patients who had normal exercise echocardiograms were examined. All clinical and exercise echocardiogram parameters were recorded. Patients were followed up for 1 year. End points were defined as cardiac death, non-fatal myocardial infarction, hospital admission for coronary artery disease, and coronary revascularization. Results: Mean age was 54.55 ± 10.34 years. 63.4 % were women. The most frequent risk factor was hypertension. There was no significant statistical difference between men and women regarding the prevalence of systemic hypertension, diabetes mellitus, and history of coronary artery bypass grafting. 5.67% of men and 8.9 % of women had positive exercise tolerance test for ischemia. Hemodynamic parameters, diastolic function, severity of mitral regurgitation, pulmonary artery pressures, peak strain rate were not significantly different between men and women, but rest strain rates were significantly lower in women. Total exercise times and exercise capacity were higher in men. After a 1-year follow-up there was no cardiac events and mortality. Conclusions: Patients with normal exercise echocardiogram results regardless of ischemia or chest pain during the test had excellent outcomes over a one-year follow-up.

Cardiovascular disease and kidney transplantation‑evaluation of potential transplant recipient

Cardiovascular evaluation of a potential kidney transplant recipient remains controversial. The burning issue is the lack of clear guidelines as well as the fact that patients with a low probability of cardiovascular disease undergo numerous unnecessary screening procedures and false‑positive results are common. In general, the standard procedure involves clinical data collection, physical examination, electrocardiography, chest‑X ray, measurement of the lipid profile and fasting glycemia, cardiac ultrasonography, followed by coronary angiography. An exercise tolerance test is not recommended because it has low sensitivity and is difficult to perform and interpret. Cardiac ultrasonography should be performed after a hemodialysis session to avoid an effect on hypervolemia. All noninvasive diagnostic imaging and isotope tests are usually of limited value and, to a large extent, are facility- and operator‑dependent. Coronary angiography should be considered in patients with positive exercise tolerance test results and a history of acute coronary syndrome, unstable coronary artery disease, and high cardiovascular risk. However, a decision regarding therapy, ie, percutaneous coronary intervention, stenting (type of stent), or coronary artery bypass grafting should be made during the meeting of a cardiac team. The guidelines also discuss cardiac contraindications to kidney transplantation. It should be stressed that a patient scheduled for a kidney transplant is sick at the time of evaluation and that his or her condition may change after several years on the waiting list. Therefore, cardiac reevaluation may be needed. Preemptive transplantation as well as short dialysis therapy before transplantation (<6 months) are associated with better patient and graft survival and thus with lower incidence of cardiovascular complications and better quality of life. The current review discusses the available guidelines on the evaluation of the potential kidney transplant recipient.

The efficacy and safety of ivabradine hydrochloride versus atenolol in Chinese patients with chronic stable angina pectoris.

The aim of this study was to assess the efficacy and safety of ivabradine (Iva) noninferiority to atenolol (Aten) in Chinese patients with chronic stable angina pectoris. In this double-blind, double-dummy trial, patients with symptomatic angina pectoris and positive exercise tolerance test were randomized into the Iva [5 or 7.5 mg bis in die (BID)] or Aten group (12.5 or 25 mg BID) according to computer-generated random numbers for 12 weeks. One hundred and sixty-eight patients were randomized to the Iva group and 166 to the Aten group. In a full analysis set, increases in the total exercise duration (TED) were 54.3 ± 120.1 seconds with Iva 5 mg and 58.8 ± 114.7 seconds with Aten 12.5 mg at the fourth week, and at the 12th week, TED improved by 84.1 ± 130.5 seconds with Iva and 77.8 ± 126.6 seconds with Aten (95%CI: -21.4-34.1 seconds, p = 0.0011 for noninferiority). The analysis of per protocol set yielded similar results (95%CI: -31.4-33.0 seconds, p = 0.0131 for noninferiority). Heart rate was reduced in both groups at rest and during peak exercise. There were small, nonsignificant differences in the number of adverse events between the two groups (66 in Iva and 73 in Aten, p > 0.05). Nine patients (5.42%) were reported to develop phosphenes/luminous phenomena and blurred vision in the Iva group (p = 0.0035). Iva is effective in reducing heart rates and improving exercise capacity and noninferior to Aten in Chinese patients with chronic stable angina pectoris. Iva is well tolerated and safe.

Screening modalities for an asymptomatic cardiovascular disease in type 2 diabetics mellitus patients

Background: Asymptomatic myocardial ischemia is more common in diabetic than in the normal individual. Therefore, it becomes necessary to screen cardiovascular disease as early as possible.Objective: The present study was aimed to assess non-invasive procedures for the detection of asymptomatic myocardial ischemia and other coexistent risk factors in type 2 diabetics.Methods: A total of 76 patients with type 2 diabetes mellitus (T2DM) with no clinical history of coronary heart disease were included in the study and evaluated for silent myocardial ischemia by stress cardiac exercise tolerance test (ETT), echocardiography and electrocardiogram (ECG). Baseline clinical characteristic such as age, gender, Smoking, duration of diabetes, hemoglobin A1C (HbA1c) %, urinary microalbuminuria, hypertension, dyslipidemia and retinopathy were evaluated and reported. The clinical characteristic of ischemic ETT and normal ETT patients were compared.Results: The ETT showed an ischemic pattern in 22 patients (28.94%), the ECG was suggestive of ischemia in six patients (7.89%), echocardiography showed diastolic dysfunction in 18 (23.68%). Patients with microalbuminuria, hypertension, dyslipidemia and smoking and/or diastolic dysfunction were more prone than others to have ischemic ETT and patients with diastolic dysfunction had a higher prevalence of ischemic ETT. The prevalence of microalbuminuria, hypertension, dyslipidemia and smoking were found significantly higher in ischemic ETT when compared to normal ETT patients. The body mass index, HbA1c% and duration of diabetes were not shown significant deference in patients with positive ischemic ETT when compared to normal ischemic ETT patients.Conclusion: The cardiac ETT was found to be most helpful for detecting asymptomatic myocardial ischemia in T2DM patients on outpatient department basis. Study provides evidence for prevalence of asymptomatic myocardial infarction (MI) in diabetic patients. Moreover, this study will help to other diabetes care center for screening and prevention of asymptomatic MI in T2DM patients.

Diagnostic Yield of Implantable Loop Recorders in Patients with Unexplained Syncope

of patients in sinus rhythm at one and two year follow up. These results are comparable to international reports. Follow up at 12 months Follow up at ≥24 months Total (n= 65) Paroxysmal AF (n= 37) Nonparoxysmal AF (n= 28) Total (n= 36) Paroxysmal AF (n= 20) Nonparoxysmal AF (n= 16) Success without drugs Single procedure (%) 53.8 56.8 50.0 50.0 55.0 43.8 Success with or without drugs Single procedure (%) 58.5 59.5 57.1 50.0 55.0 43.8 Success without drugs ≥1 procedure (%) 69.2 67.6 71.4 69.4 70.0 68.8 Success with or without drugs ≥1 procedure (%) 89.2 91.9 85.7 86.1 90.0 81.3 http://dx.doi.org/10.1016/j.hlc.2012.03.098 Diagnostic Yield of Implantable Loop Recorders in Patients with Unexplained Syncope J. Swampillai ∗, R.F. Allen, S. Levings, M.R.Webber, C.M. Wade, M.K. Stiles, S.C. Heald Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: The implantable loop recorder (ILR) is a subcutaneous, electrocardiographic monitoring device used for diagnosis in patients with recurrent, infrequent Use of Exercise Tolerance Test in Intermediate Risk nonST Elevation Acute Coronary Syndrome P. Tamuno ∗, J. Mazhar, J. Swampillai, V. Pera, A. Kerr, G. Devlin Department of Cardiology, Waikato Hospital, Hamilton, New Zealand Background: Exercise tolerance test (ETT) is recommended for initial risk stratification in patients with Non ST Elevation Acute Coronary Syndrome (NSTEACS) in the absence of high risk features. We reviewed current practice at Waikato Hospital, the regional tertiary centre. Methods:FromtheACUTEPREDICTregistrywe identified 716 patients admitted with NSTEACS and TIMI score 0–4 between January 2008 and January 2010. After excluding143patientswhoweremanagedmedically (20%)due to co-morbidities, the remaining 573 patients were analysed in two groups: Group A had ETT prior to angiography; Group B had angiography without ETT. Results: There were 244 (43%) patients in Group A (mean age 64± 12 years, 72% males) and 329 (57%) in Group B (mean age 64± 13 years, 66% males). Compared togroupA,GroupBhadmorepatientswithTIMI score 3–4 (63%vs. 53%,P= 0.02) andNSTEMI (66%vs. 44%,P≤ 0.01). Results are summarised in the tables below. Only 20% of patients risk-stratified by ETT did not undergo inpatient angiography (Tables 1 and 2). symptoms with a suspected arrhythmic aetiology. We aimed to establish the diagnostic yield of ILR in patients with unexplained syncope. Methods: We identified all patients who had an ILR implanted at Waikato Hospital from March 2007 to November 2011. Previous investigations, arrhythmias detected by the device and outcomes were recorded. Results: Thirty-one patients (17 men; mean age 46± 24 years) underwent ILR implantation. The mean number of cardiac investigations prior to ILR was 4± 1; duration of implant 16± 12 months. Arrhythmias were detected in 13 patients; eight tachycardias, five bradycardias. Time to diagnosis was 7± 6 months and specific treatment was guided by ILR analysis in these patients. Pacemakers were implanted in four patients, two received implantable cardioverter defibrillators, two were given anti-arrhythmic drugs, four had an electrophysiological study (two were normal and two underwent catheter ablation). Neurocardiogenic syncope was diagnosed in one patient and symptoms resolved. Sinus rhythm was documented during syncope in five patients. Death from non-arrhythmic causes occurred in twopatients (onemyocardial infarction and cardiogenic shock, one stroke). No arrhythmias have been detected so far in 11 patients remaining under follow up (mean implant duration 9± 7 months). Conclusion: More than half of patients had an arrhythmic causeof syncopediagnosed (13) or excluded (5) by ILR. This confirms their usefulness in selected patients with unexplained syncope despite normal preliminary investigations. http://dx.doi.org/10.1016/j.hlc.2012.03.099 Table 1. Summary of coronary interventions and outcomes. Group A N= 244 Group B N= 329 P value Inpatient angiogram 195 (80%) 329 (100%) <0.01 PCI 109 (45%) 180 (55%) 0.02 CABG 23 (9%) 24 (7%) NS Length of stay in days (mean±SD) 6.8± 6 6.1± 5 0.09 Stroke/TIA (in-hospital) 0 3 Death (in-hospital) 1 1 Table 2. Angiograms performed in relation to ETT results. Positive ETT N= 167 (68%) Negative ETT N= 42 (18%) Inconclusive ETT N= 35 (14%) In-patient angiogram, N (%) 159 (95%) 10 (24%) 26 (74%) Angiogram in 6-month F/U, N (%) 6 (4%) 7 (17%) 2 (6%) Conclusions: The majority of patients admitted with NSTEACS and TIMI score ≤4 underwent inpatient angiography regardless of the use of ETT as a risk stratification tool for intermediate risk scores. No difference was evident in early events. http://dx.doi.org/10.1016/j.hlc.2012.03.100

Effect of high-dose allopurinol on exercise in patients with chronic stable angina: a randomised, placebo controlled crossover trial

SummaryBackgroundExperimental evidence suggests that xanthine oxidase inhibitors can reduce myocardial oxygen consumption for a particular stroke volume. If such an effect also occurs in man, this class of inhibitors could become a new treatment for ischaemia in patients with angina pectoris. We ascertained whether high-dose allopurinol prolongs exercise capability in patients with chronic stable angina.Methods65 patients (aged 18–85 years) with angiographically documented coronary artery disease, a positive exercise tolerance test, and stable chronic angina pectoris (for at least 2 months) were recruited into a double-blind, randomised, placebo-controlled, crossover study in a hospital and two infirmaries in the UK. We used computer-generated randomisation to assign patients to allopurinol (600 mg per day) or placebo for 6 weeks before crossover. Our primary endpoint was the time to ST depression, and the secondary endpoints were total exercise time and time to chest pain. We did a completed case analysis. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 82040078.FindingsIn the first treatment period, 31 patients were allocated to allopurinol and 28 were analysed, and 34 were allocated to placebo and 32 were analysed. In the second period, all 60 patients were analysed. Allopurinol increased the median time to ST depression to 298 s (IQR 211–408) from a baseline of 232 s (182–380), and placebo increased it to 249 s (200–375; p=0·0002). The point estimate (absolute difference between allopurinol and placebo) was 43 s (95% CI 31–58). Allopurinol increased median total exercise time to 393 s (IQR 280–519) from a baseline of 301 s (251–447), and placebo increased it to 307 s (232–430; p=0·0003); the point estimate was 58 s (95% CI 45–77). Allopurinol increased the time to chest pain from a baseline of 234 s (IQR 189–382) to 304 s (222–421), and placebo increased it to 272 s (200–380; p=0·001); the point estimate was 38 s (95% CI 17–55). No adverse effects of treatment were reported.InterpretationAllopurinol seems to be a useful, inexpensive, well tolerated, and safe anti-ischaemic drug for patients with angina.FundingBritish Heart Foundation.

Use of exercise tolerance test and thallium stress test in the diagnosis of ischemic heart disease in soldiers.

To determine the role of Exercise Tolerance Test (ETT) and Thallium Stress Test (TST) in the detection of Coronary Artery Disease (CAD) among soldiers. Descriptive study. This study was conducted at Combined Military Hospital (CMH), Multan, Pakistan, from 2002 to 2004. There were 291 male soldiers between ages 30 and 45 years who presented with chest pain and had normal resting ECG. All patients were subjected to ETT. Positive ETT cases had Coronary Angiogram (CA) as the gold standard. Negative cases were subjected to TST. Normal CA cases also had TST to rule out microvascular disease. Those with normal ETT and positive CAD risk factors also had TST. Those with negative TST had CA as service requirement. All 291 cases had ETT, 130 cases were found positive, 161 had negative ETT. When CA was done on 130 positive cases, 95 had CAD (true positive, TP) and 35 had normal coronaries (false positive, FP). Out of the 161 negative ETT cases, 128 had normal coronaries (true negative, TN) and 33 had CAD (false negative, FN). TST was conducted on 196 cases, out of which 78 cases were found positive and 118 had negative TST. When subjected to CA, out of 78 positive cases, 30 had CAD (TP) and 48 had normal coronaries (FP). Out of 118 negative TST cases, 115 had normal coronaries (TN) and 3 had CAD (FN). ETT was found to have sensitivity of 74.2%, specificity of 78.5%, Positive Predictive Value (PPV) of 73.1%, Negative Predictive Value (NPV) of 79.5% and test accuracy of 76.6%. TST had sensitivity of 90.9%, specificity of 70.6%, PPV of 38.5%, NPV of 97.5% and accuracy of 74.0%. TST was found to be more sensitive and less specific than ETT in the diagnosis of CAD.