Positive Treadmill Exercise Test Research Articles

Utility of Pretest Probability and Exercise Treadmill Test in Korean Women with Suspected Coronary Artery Disease.

Pretest probability (PTP) and an exercise treadmill test (ETT) are recommended for the initial evaluation of possible coronary artery disease (CAD), but the applicability of these tests in Korean women has not been evaluated. Korean women with PTP, ETT, and invasive coronary angiography results were enrolled. Across all PTP levels, PTP and ETT statistics were evaluated and independent CAD predictors obtained. Of the 335 patients (mean age 58.0 ± 10.2 years), 99 and 236 were in the low (LPTP) and intermediate PTP (IPTP) groups, respectively. The observed prevalence of CAD was significantly lower than the PTP. (7.1% vs. 9.1 ± 4.9% in LPTP, p < 0.001; 23.3% vs. 33.0 ± 15.1% in IPTP, p < 0.001) The ETT's sensitivity and positive predictive values (PPVs) appeared lower than previously reported (LPTP: 42.9% and 16.7%; IPTP: 61.8% and 37.0%), whereas the negative predictive values (NPVs) were higher (LPTP: 95.1%; IPTP: 85.4%). After multivariate adjustments, positive ETT (odds ratio 3.276, 95% confidence interval 1.643-6.532, p = 0.001) independently predicted the presence of CAD, but the PTP showed only marginal predictability (odds ratio 1.019, 95% confidence interval 0.998-1.041, p = 0.069). In Korean women, the observed prevalence of CAD was lower than the PTP, and PTP showed only marginal CAD predictability. Although a positive ETT independently predicted CAD, the ETT showed lower sensitivity and PPVs than previously reported. Despite the limited value of PTP and ETT, the high NPVs of ETT appear useful for saving patients from unnecessary further examinations.

Fragmented QRS Is Associated with Improved Predictive Value of Exercise Treadmill Testing in Patients with Intermediate Pretest Likelihood of Significant Coronary Artery Disease.

The predictive value of exercise treadmill testing (ETT) remains inadequate in diagnosing patients with suspected coronary artery disease (CAD) and needs to be improved. The aim of this study was to investigate whether the presence of FQRS on 12-lead ECG would increase the PPV of ETT in patients with an intermediate likelihood of CAD. fQRS, defined as the presence of notched R or S waves without accompanying typical bundle branch block or the existence of an additional wave-like RSR' pattern in the original QRS complex (with a duration of <120 ms), was assessed in 95 patients with positive ETT. Coronary angiogram (CA) was performed in all patients, divided into two groups as the significant CAD group and nonsignificant CAD group according to coronary artery lesions. The differences between the groups in terms of the presence of fQRS and clinical characteristics were investigated. The mean age of patients was 51.3 ± 11.3 years, and 74 of them were males (77.9%). FQRS was present in 47 (49.5%) patients, and significant CAD was demonstrated in 51 subjects (53.7%) among the enrolled subjects. fQRS was more prevalent in the significant CAD group compared to nonsignificant CAD group (P < 0.001). The presence of FQRS increased the PPV of positive ETT from 53.7% to 85.1%. In addition, FQRS was associated with the increased risk of significant CAD in multivariate analysis (OR = 2.839, P < 0.001). In clinical practice, the presence of fQRS in patients with positive ETT may support clinicians during the decision-making process with regard to the referral for a coronary angiography.

The significance of early post-exercise ST segment normalization

BackgroundThe persistence of ST segment depression in recovery signifies a strongly positive exercise treadmill test (ETT). However, it is unclear if early recovery of ST segments portends a similar prognosis. We sought to determine if persistence of ST depression into recovery correlates with ischemic burden based on myocardial perfusion imaging (MPI). MethodsThis was a retrospective analysis of 853 consecutive patients referred for exercise MPI at a tertiary academic center over a 24-month period. Patients were stratified into three groups based on the results of the ETT: normal (negative ETT), persistence (positive ETT with >1mm ST segment depression at 1minute in recovery) and early normalization (positive ETT with <1mm ST segment depression at 1minute in recovery). Summed stress scores (SSSs) were calculated then for each patient, while the coronary anatomy was reported for the subset of patients who received coronary angiograms. ResultsA total of 513 patients had a negative ETT, 235 patients met criteria for early normalization, while 105 patients met criteria for persistence. The persistence group had a significantly greater SSS (8.48±7.77) than both the early normalization (4.34±4.98, p<0.001) and normal (4.47±5.31, p<0.001) groups. The SSSs of the early normalization and normal groups were not statistically different and met the prespecified non-inferiority margin (mean difference 0.12, −0.66=lower 95% CI, p<0.001). Among the 87 patients who underwent an angiogram, significant three-vessel or left main disease was seen in 39.3% of the persistence group compared with 5.9% of normal and 7.4% of early normalization groups. ConclusionAmong patients with an electrically positive ETT, recovery of ST segment depression within 1minute was associated with a lower SSS than patients with persistence of ST depression beyond 1minute. Furthermore, early ST segment recovery conferred a similar SSS to patients with a negative ETT. These results suggest that among patients evaluated for chest pain with a positive ETT, early recovery of the ST segment during recovery is associated with a significantly less ischemic burden on subsequent MPI and thus may represent a false positive finding in exercise treadmill testing.

Thermodilutional Confirmation of Coronary Microvascular Dysfunction in Patients With Recurrent Angina After Successful Percutaneous Coronary Intervention

BackgroundRecurrent angina (RA) after percutaneous coronary intervention (PCI) remains a challenging problem that confronts cardiologists in routine clinical practice. In patients without epicardial coronary causes, RA is commonly speculated as resulting from coronary microvascular dysfunction. The aim of this study was to investigate the coronary microvascular function in patients with RA late after successful PCI and without epicardial stenosis at the time of repeat angiography. MethodsWe studied 39 consecutive patients with RA in whom PCI was successfully performed 6 to 12 months previously because of angina and single-vessel disease and without restenosis and disease progression at the time of repeat angiography. Twelve subjects without RA were recruited as the control group. Thermodilution-derived coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured using a pressure-temperature sensor-tipped coronary wire. The exercise treadmill test was performed according to the Bruce protocol. ResultsPatients with RA showed significantly higher IMR and lower CFR than control subjects, in the target arteries and in the reference vessels (P < 0.05). The hyperemic IMR was more remarkably increased in the target arteries than in the reference vessels (29.3 ± 11.7 vs 24.4 ± 9.7; P = 0.008). The hyperemic IMR was increased and the CFR was impaired more significantly in patients with a positive exercise treadmill test (P < 0.05). ConclusionsUsing an intracoronary thermodilution method, to our knowledge, we have for the first time confirmed that, in patients who underwent successful coronary stenting and without epicardial stenosis at repeat angiography late after PCI, coronary microvascular dysfunction was responsible for the RA.

Advanced electrocardiography identifies patients with false positive exercise treadmill test results

Advanced electrocardiography identifies patients with false positive exercise treadmill test results

Abstract 17791: Yield of Different Approaches for Screening for Cardiovascular Disease in Asymptomatic Diabetics

Introduction: While diabetes has long been considered a coronary heart disease equivalent, there is increasing evidence to suggest that not all individuals with diabetes have cardiovascular disease, and it is unclear how best to risk stratify this population. We sought to compare the yield of testing for pre-clinical atherosclerosis with various approaches. Methods: A group of 98 asymptomatic subjects with type 2 diabetes mellitus (T2DM) without known coronary artery disease (CAD) were enrolled in a prospective study and underwent carotid ultrasound, exercise treadmill testing (ETT), coronary artery calcium (CAC) scoring, and coronary computed tomography angiography (CTA). CTA was used as the reference standard for CAD. Results: Of 98 subjects (average age 55±6, 64% female, 22 on insulin, mean A1c 7.3%), 43 (44%) had coronary plaque detectable on CTA, and 38 (39%) had CAC score &gt; 0. By CTA, 16 (16%) had coronary stenosis ≥ 50%, including 3 subjects with CAC=0. Subjects with coronary plaque had greater prevalence of carotid plaque (58% vs. 38%, p=0.01) and greater carotid intima media thickness (0.80±0.20 mm vs. 0.70±0.11mm, p=0.02). However, 18 of the 55 subjects (33%) with normal CTA had carotid plaque. Eight subjects had a positive ETT, of whom 5 had ≥ 50% coronary stenosis and 2 had &lt;50% stenosis, but there was no difference in METS achieved between subjects with and without plaque (8.2 vs. 8.7, p=0.19). Test characteristics of different imaging modalities for prediction of coronary plaque are shown in Figure 1. Conclusion: Among asymptomatic subjects with T2DM, a majority (56%) had no CAD by CTA. CAC was the most accurate screening modality for detection of CAD while ETT and carotid ultrasound had a limited sensitivity. Interestingly, 33% of subjects with normal CTA had carotid plaque. Further studies are needed to better characterize stroke risk in such patients and whether there is a role for screening for carotid plaque in diabetics without CAC or with normal CTA.

Comparison of the Use of Downstream Tests After Exercise Treadmill Testing by Cardiologists Versus Noncardiologists

Although exercise treadmill testing (ETT) is a useful initial test for patients with suspected cardiovascular (CV) disease, there is concern regarding the use of downstream imaging tests especially in the setting of equivocal or positive ETTs. Patients with no history of coronary artery disease who underwent ETT between 2009 and 2010 were prospectively included. Referring physicians were categorized as cardiologists and noncardiologists. Downstream tests included nuclear perfusion imaging, coronary computed tomography angiography, stress echocardiography, stress magnetic resonance, and invasive coronary angiography performed up to 6 months after the ETT. Patients were followed for CV death, myocardial infarction, and coronary revascularization for a median of 2.7 years. Among 3,656 patients, the ETT were negative in 2,876 (79%), positive in 132 (3.6%), and inconclusive in 643 (18%). Cardiologists ordered less downstream tests than noncardiologists (9.5% vs 12.2%, p=0.02), with less noninvasive tests (5.9% vs 10.4%, p<0.0001) and more invasive angiography (3.6% vs 1.8%, p<0.0001). After adjustment for confounding, patients evaluated by cardiologists were less likely to undergo additional testing after equivocal (odds ratio: 0.65, p=0.02) or positive ETT results (odds ratio: 0.39, p=0.02), whereas after negative ETT, the odds ratio was 1.7 (p=0.06). There was no difference in the rate of adverse CV events between patients referred by cardiologists versus noncardiologists. In conclusion, patients referred for ETT by cardiologists are less likely to undergo additional testing, particularly noninvasive tests, than those referred by noncardiologists. The lower rate of tests is driven by a lower rate of tests after positive or inconclusive ETT.

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Cost-effectiveness of cardiovascular magnetic resonance in the diagnosis of coronary heart disease: an economic evaluation using data from the CE-MARC study

ObjectiveTo evaluate the cost-effectiveness of diagnostic strategies for coronary heart disease (CHD) derived from the CE-MARC study.DesignCost-effectiveness analysis using a decision analytic model to compare eight strategies for the diagnosis...

Coronary heart disease diagnosis bases on the change of different parts in treadmill exercise test ECG

Summarize the value of the change of different parts in treadmill exercise test (TET) ECG to coronary heart disease (CHD) diagnosis. Four hundred and forty-five cases have been included in this investigation, which stayed in our hospital from January of 2006 to March of 2011 and underwent TET and coronary arteriography (CAG). The change of different parts in TET ECG in these patients had been retrospective summarized to determine its diagnosis value to CHD. (1) In the 445 cases of TET testers, 200 cases showed positive in TET with 150 cases of positive CAG, and 50 cases of negative CAG; 245 cases showed negative in TET with 206 cases of negative CAG, and 39 cases of positive CAG. The diagnosis sensitivity of CHD was 79.36% (150/189), the specificity was 80.47% (206/256), positive prediction value was 75.00% (150/200), negative prediction value was 84.08% (206/245), and false-positive rate was 25.00% (50/200) with prediction accuracy of 80.00% (356/445). (2) In the 200 cases with positive TET: 51 cases were in the limb lead group; 73 cases were in the chest lead group; and 76 cases were in the limb lead + chest lead group. There were 150 cases showing positive in CAG: 22 cases were in the limb lead group; 58 cases were in the chest lead group; and 70 cases were in the limb lead + chest lead group. The positive diagnosis rate of ST change in the chest lead was obviously higher than that of simple limb lead group (P < 0.05). (3) People with healthy coronary artery will have decreased amplitude of R wave while patients with coronary stenosis have elevated amplitude of R wave. (4) As for the T wave, the positive CAG had no statistical significance between normal T wave group and TET positive group (P > 0.05); CAG results had statistical significance between normal T wave group and TET negative group (P < 0.05). (5) Positive CAG results had no statistical significance between U-wave inversion group and TET positive group (P > 0.05); positive CAG results has statistical significance when TET negative group compared with U-wave inversion group or TET positive group (P < 0.05). TET is a relatively idea invasive diagnosis method for coronary disease, which can be utilized to evaluate the stage of CHD when integrating with the change of TET ECG.

Elderly Patients and Coronary Heart Disease on Response to Treadmill Exercise Test

To study the response of the cardiovascular system, to exercise tolerance in-patients over 75 years old with coronary heart disease (CHD), and to evaluate the significance of the parameters of the treadmill exercise test (TET). 110 patients received TET and coronary artery angiography. They were divided into two groups: the elderly patients group included 50 patients over 75 years old, and the control group included 60 patients under 60 years old. (1) With aging, there were much more CHD patients in the positive TET (P < 0.05) than in the negative TET (P > 0.05). (2) The parameters of TET for the elderly CHD patients group, included exercise time, peak heart rate, and the onset of ST depression, were lower than the control group (P < 0.05). There was no statistical significance between the two groups in the extent and duration of ST depression (P < 0.05). (1) In TET, the elderly patients had the higher diagnostic value on CHD. (2) The elderly patients with CHD had the lower endurance to exercise test.

Correlation of red cell distribution width with the severity of coronary artery disease: a large Chinese cohort study from a single center

Background It has been reported that increased red blood cell width (RDW) is a marker associated with the presence and adverse outcomes of various cardiovascular diseases. The aim of the present study was prospectively evaluate the severity of coronary artery disease (CAD) and RDW in a large Chinese cohort. Methods A total of 677 consecutive individuals who underwent coronary angiography due to the presence of angina-like chest pain and/or positive treadmill exercise test were enrolled in this study. All patients received coronary angiography and were then divided into two groups based on the results of coronary angiography (CAD group (n=499) and control group (n=178)). The clinical information including classical CAD risk factors and RDW were analyzed to identify their relationship to CAD. The severity of CAD was evaluated by Gensini score and its relationship with RDW was also analyzed. Results Patients with angiographic CAD had significantly elevated RDW levels compared with controls ((12.95±0.77)% vs. (12.73±0.83)%, P=0.001). There was a significant positive correlation between RDW and the Gensini score (r=0.37, P &lt;0.0010. In multivariate Logistic regression analysis, RDW was demonstrated to be an independent predictor for both angiographic CAD (OR=1.34, 95% CI: 1.02-1.77, P &lt;0.05) and for a higher Gensini score (&gt;13, OR=2.23, 95% CI: 1.62-3.08, P &lt;0.0010. In a receiver operating characteristic (ROC) curve analysis, an RDW value of 12.85% was identified as an effective cut-point in predicting the presence or absence of CAD with a sensitivity of 50.0% and a specificity of 65.2%. Conclusion RDW is associated with both presence of CAD and the severity of coronary stenosis, suggesting that it might be a readily available marker for the prediction of CAD and its severity.

Clinical value and severity of myocardial perfusion defects in asymptomatic diabetic patients with negative or weakly positive exercise treadmill test.

Objective:Although coronary artery disease (CAD) is the leading cause of death in type 2 diabetic patients, it is frequently asymptomatic. Myocardial perfusion imaging (MPI) is reported to show ischemia in a significant number of asymptomatic diabetic patients. We studied the prevalence and severity of myocardial perfusion defects in asymptomatic diabetic patients and its clinical impact.Methods and patients:One hundred thirty consecutive asymptomatic patients, aged 35-65 years with type 2 diabetes mellitus and with no history of CAD and no cardiac symptoms were recruited in the study. Echocardiography, electrocardiography (ECG), routine laboratory tests and exercise treadmill test (ETT) were performed and patients with weakly positive or negative ETT underwent Dipyridamole MPI. Patients with positive ETT were referred to coronary angiography. Patients were followed for at least 17 months (mean 21.7 months) and any cardiac event was recorded.Results:We studied 81 female and 49 male patients with mean age of 51.8 years. Negative, weakly positive and positive ETT result was noted in 74.3%, 15% and 10.7% respectively. 75% of patients with positive ETT had coronary artery disease in angiography. Gated myocardial perfusion SPECT was done in 106 patients. MPI showed reversible defect in 26.9% of the patients with a mean summed stress score of 3.3±1.8. Follow up completed in 112 patients and only one patient with abnormal MPI underwent coronary angiography followed by PTCA. No cardiac death, MI, UA or hospital admission occurred among our patients during follow up (17-26 months). Mean stress end diastolic volume (EDV) was significantly higher in patients with reversible defect compared to patients without reversible defect based on MPI findings (62.0±31.6 Vs 48.5±18.4 ml, P=0.04). Blood glucose and HbA1c were significantly higher in patients with ischemia compared to patients without ischemia (P<0.05). Meanwhile the ratio of TG to HDL was 6.06±3.2 in ischemic patients compared to 4.8±2.3 in normal subjects (P=0.03).Conclusion:Reversible defects are commonly seen in myocardial perfusion SPECT in asymptomatic diabetic patients and are mild in severity and not associated with adverse cardiac events. Routine approach for detection of CAD beginning with ETT seems to be appropriate in these patients.

Myocardial bridge: The cause of angina in a young man

Myocardial bridging is basically the systolic narrowing of epicardial coronary arteries, secondary to their tunneled course in myocardium. Though it is a benign condition it can have the symptoms like acute coronary syndrome, arrhythmias and sudden cardiac death. We report a 32-year-old male, who presented with typical exertional angina, had positive exercise treadmill and thallium-201 test. Coronary angiography revealed myocardial bridge of distal left anterior descending coronary artery. He was put on β-blockers and was doing well at 8 years of follow-up.

Improving the Positive Predictive Value of Exercise Testing in Women for Coronary Artery Disease

The exercise treadmill test (ETT) in women has been limited by a low positive predictive value (PPV) for coronary artery disease (CAD). However, the reliability of previous studies was unsatisfactory because of the inclusion of younger women with a low prevalence of CAD. To further evaluate the diagnostic properties of the ETT in women, we evaluated a group of women with chest pain who had a positive ETT result and subsequent coronary angiography. Of the 111 women, 56 had significant CAD on angiogram, yielding a PPV of 51% for the group. However, inclusion in the analysis of several pretest attributes and specific exercise test responses improved the PPV of the ETT. Age had a major effect, with the youngest group (35 to 50 years old) having a PPV of 36% compared to 68% in the oldest group (>65 years old). Several specific exercise responses (ST-segment depression >2 mm and delayed ST-segment recovery >3.0 minutes) further separated true from false positives across all age groups, increasing the PPV to approximately 80%. Onset of ischemia at a relatively low cardiac workload of <80% maximum predicted heart rate was not a significant predictor. In conclusion, the standard ETT should remain the test of choice in ambulatory women with chest pain and no significant abnormalities on baseline electrocardiogram especially in those >65 years of age.

Are intraventricular gradients a cause of false positive treadmill exercise tests?

BackgroundTreadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations. ObjectivesTo determine:1.the prevalence of IVG in a selected population of false positives on treadmill stress testing;2.whether this prevalence is different from that described for non-selected populations;3.whether patient characteristics are related to the presence of IVG;4.the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure. Methods and ResultsWe evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05). Conclusions1.The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients.2.This prevalence is significantly higher than that described for non-selected populations.3.Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disease/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG.4.The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.

Are intraventricular gradients a cause of false positive treadmill exercise tests?

BackgroundTreadmill exercise testing has low specificity for the detection of significant epicardial coronary artery disease (CAD). A possible mechanism to explain some of the false positives is transient subendocardial ischemia induced by intraventricular gradients (IVG) during stress. The development of IVG during dobutamine stress echocardiography (DSE) occurs in 8-38% of non-selected populations. ObjectivesTo determine:1.the prevalence of IVG in a selected population of false positives on treadmill stress testing;2.whether this prevalence is different from that described for non-selected populations;3.whether patient characteristics are related to the presence of IVG;4.the relation between the presence of IVG and the occurrence of ECG abnormalities, symptoms and blood pressure. Methods and ResultsWe evaluated 50 consecutive patients with false positive treadmill stress tests (normal CT coronary angiography, nuclear perfusion tests or angiography) with DSE (2D and Doppler evaluation). All DSE exams were negative for ischemia. Stress-induced IVG was seen in 34 of the 50 patients (68%) and 16 patients (32%) did not develop IVG (p<0.05). The prevalence of IVG in our selected population (68%) was significantly higher than that described for non-selected populations (8-38%) (p<0.001). Most patient characteristics (gender, age, risk factors for CAD, treatment with beta-blockers/calcium antagonists, significant valvular disease/left ventricular hypertrophy [LVH], symptoms, and blood pressure during stress) were not statistically associated with the prevalence of IVG (p>0.05). However, the presence of IVG was associated with the occurrence of ischemic ST depression during dobutamine stress echo (p<0.05). Conclusions1.The prevalence of IVG during dobutamine stress echocardiography in a selected population of false positives on treadmill stress testing is very high, occurring in more than two-thirds of patients.2.This prevalence is significantly higher than that described for non-selected populations.3.Age, gender, risk factors for CAD, treatment with beta-blockers/calcium channel antagonists, significant valvular disease/LVH, symptoms and blood pressure during stress were not associated with the presence or absence of IVG.4.The presence of IVG is associated with the occurrence of ischemic ST changes during dobutamine stress echocardiography.

Chewing areca nut increases the risk of coronary artery disease in taiwanese men: a case-control study

BackgroundAreca nut chewing has been reported to be associated with obesity, metabolic syndrome, hypertension, and cardiovascular mortality in previous studies. The aim of this study was to examine whether chewing areca nut increases the risk of coronary artery disease (CAD) in Taiwanese men.MethodsThis study is a hospital-based case-control study. The case patients were male patients diagnosed in Taiwan between 1996 and 2009 as having a positive Treadmill exercise test or a positive finding on the Thallium-201 single-photon emission computed tomography myocardial perfusion imaging. The case patients were further evaluated by coronary angiography to confirm their CAD. Obstructive CAD was defined as a ≥ 50% decrease in the luminal diameter of one major coronary artery. The patients who did not fulfill the above criteria of obstructive CAD were excluded.The potential controls were males who visited the same hospital for health check-ups and had a normal electrocardiogram but no history of ischemic heart disease or CAD during the time period that the case patients were diagnosed. The eligible controls were randomly selected and frequency-matched with the case patients based on age. Multiple logistic regression analyses were used to estimate the odds ratio of areca nut chewing and the risk of obstructive CAD.ResultsA total of 293 obstructive CAD patients and 720 healthy controls, all men, were analyzed. Subjects who chewed areca nut had a 3.5-fold increased risk (95% CI = 2.0-6.2) of having obstructive CAD than those without, after adjusting for other significant covariates. The dose-response relationship of chewing areca nut and the risk of obstructive CAD was also noted. After adjusting for other covariates, the 2-way additive interactions for obstructive CAD risk were also significant between areca nut use and cigarette smoking, hypertension and dyslipidemia.ConclusionsLong-term areca nut chewing was an independent risk factor of obstructive CAD in Taiwanese men. Interactive effects between chewing areca nut and cigarette smoking, hypertension, and dyslipidemia were also observed for CAD risk. Further exploration of their underlying mechanisms is necessary.

Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain

Background— The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA. Methods and Results— The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect &gt;50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a &gt;70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis &gt;50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men &lt;40 years old or women &lt;50 years old or individuals who achieved at least 13 metabolic equivalents on ETT. Conclusions— Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of &gt;50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.

The diagnostic and prognostic value of first hour glycogen phosphorylase isoenzyme BB level in acute coronary syndrome

Evaluating patients with symptoms suggestive of acute coronary syndrome (ACS) is a time consuming, expensive and problematic process in the emergency department. This study aimed to evaluate the diagnostic and prognostic value of glycogen phosphorylase isoenzyme-BB (GP-BB) in ACS. A total of 72 patients (mean age 61.8 ± 11.6 years) with ACS were enrolled. The ELISA method for determining GP-BB level was performed and considered positive at 〉 10 ng/mL. Duration of angina, type of ACS, demographic features, myoglobin, creatinine kinase and troponin T (cTnT) were also assessed. The cTnT levels eight hours after pain onset was considered the gold standard test for the diagnosis of myocardial infarction. The most sensitive biomarker at first hour of admission was GP-BB (95.8%). However, the specificity of GP-BB was low (43.7%). Receiver operating characteristics curve analysis of the GP-BB level for predicting myocardial infarction revealed the area under the curve value as 0.82 (SE 0.04; 95% CI 0.78-0.85). Positive treadmill exercise test (60% vs 17%, p = 0.047), coronary artery disease (CAD; 59% vs 19%, p = 0.007), percutaneous coronary intervention (44% vs 27%, p = 0.031) and 30-day mortality and/or readmission (33% vs 5%, p = 0.028) were found to be higher in unstable angina (UA) patients having GP-BB (+). GP-BB is considerably cardiosensitive at the first hour of admission in patients with ACS, but the specificity of GP-BB is lower and it is elevated in nearly half of the patients with UA. However, in this group, GP-BB predicts significant CAD and the combined end-point of mortality and re-hospitalization.