Positive Treadmill Test Research Articles

English

BACKGROUND: Ischemic heart disease (IHD) is the leading cause of death and disability in industrialized countries. In India also there is increasing trends of death and disability due to IHD. The prevalence of IHD in India is 96.7/1000 in urban and 27.1/1000 in rural areas. Main risk factors for IHD are diabetes mellitus, hypertension, obesity, smoking and hyperlipidemia. AIM: The present study aims at early detection of IHD which can prevent death and disability in persons with risk factors. DESIGN: The present study is cross sectional observational study carried out in the govt. medical college of rural Indian set-up. MATERIALS AND METHODS: The present study was carried out on 70 asymptomatic patients of age group 30-70 years with any of the above mentioned risk factors for IHD. The treadmill test was performed in these patients. STATISTICAL ANALYSIS: The analysis was done using MS office excel 2007 software. RESULTS: 24.22% patients showed positive treadmill test. This means 24.22% of patients were having underlying IHD though they were asymptomatic. CONCLUSION: Thus treadmill test is a valuable, non-invasive tool for early detection of myocardial ischemia among the asymptomatic patients with risk factors for coronary artery disease.

A Retrospective Demographic Analysis of Patients with Coronary Slow Flow Phenomenon Presented with Severe Myocardial Ischemia

Background: The related literature has shown a higher prevalence of definitively positive exercise testing in patients with coronary slow flow phenomenon (CSFP). But there was no similar study to analyze the conventional risk factors of coronary artery disease with the patients of CSFP in our review. We retrospective analyzed patients presented with severe myocardial ischemia which documented by strongly positive Treadmill test, also accepted coronary angiography, and tried to delineate differences in the cardiac risk profile among the patients of significant coronary heart disease (SCHD), CSFP and normal coronary artery groups. Methods: We retrospectively recruited 139 patients presented with severe myocardial ischemia which documented by strongly positive Treadmill test. All patients received coronary angiography at Changhua Christian Hospital Taiwan, from November, 2008 to August, 2010. There were classified into three groups; SCHD (97 patients); CSFP (32 patients); and normal coronary angiography results (10 patients). All cardiac risk factors were recorded and analyzed. Results: The average age in CSFP group is younger than the SCHD group's (56.53 years: 62.57 years, p＜0.025) and normal group's (56.53 years: 64.80 years, p＜0.05). Although the difference of sex between these three groups was not statistically significant, but the percentage of women in the CSFP group is higher than the SCHD group's (37.50%: 28.87%, p=0.19). The most difference of the CAD risk factors between the CSFP and SCHD group is in DM (9.38%: 37.11%, p＜0.025) and hypertension (43.75%: 69.07%, p＜0.025). Conclusion: In our retrospective analysis, the data suggest that the younger females without definite type 2 DM and hypertension, whose Treadmill test showed strong positive, had higher opportunity to suffer from CSFP than SCHD.

Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascular disease

Aims/hypothesisCyclophilin A, an immunophilin is secreted from human monocytes activated by high glucose. Given its role as an inflammatory mediator of vascular tissue damage associated with inflammation and oxidative stress, we examined plasma levels of cyclophilin A in normal healthy volunteers and patients with type 2 diabetes (DM), with or without coronary artery disease (CAD).MethodsStudy subjects comprised of 212 patients with DM and CAD,101 patients with diabetes, 122 patients with CAD and 121 normal healthy volunteers. Diabetes was assessed by HbA1c levels while coronary artery disease was established by a positive treadmill test and/or coronary angiography. Plasma cyclophilin A was measured using a cyclophilin A ELISA Kit. Relationship of plasma cyclophilin A levels with blood markers of type 2 diabetes, blood lipid levels and medication for diabetes and coronary artery disease were also explored.ResultsPlasma Cyclophilin levels were higher in diabetes patients with or without CAD compared to normal subjects (P < 0.001). Age, fasting blood sugar levels and HbA1C levels were positively associated with increased plasma cyclophilin. Patients using metformin had reduced levels of plasma cyclophilin (p < 0.001).Serum levels of total cholesterol, LDL cholesterol and triglycerides had no significant association with plasma cyclophilin levels. In patients with increased serum CRP levels, plasma cyclophilin A was also elevated (p = 0.016). Prevalence odds for DM, DM + CAD and CAD are higher in those with high cyclophilin values, compared to those with lower values, after adjusting for age and sex, indicating strong association of high cyclophilin values with diabetes and vascular disease.Conclusions/interpretationsOur study demonstrates that patients with type 2 diabetes have higher circulating levels of cyclophilin A than the normal population. Plasma cyclophilin levels were increased in patients with diabetes and coronary artery disease suggesting a role of this protein in accelerating vascular disease in type 2 diabetes. Considering the evidence that Cyclophilin A is an inflammatory mediator in atherogenesis, the mechanistic role of cyclophilin A in diabetic vascular disease progression deserves detailed investigation.

New Strategy for Detection of Subclinical Coronary Atherosclerosis in Asymptomatic Patients With Type 2 Diabetes Based on Cardiac Multi-Detector Computed Tomography and Treadmill Test

The current screening strategy for subclinical coronary atherosclerosis in asymptomatic diabetic patients is not sufficient in real clinical practice. A new strategy was investigated that uses cardiac multi-detector computed tomography (MDCT) and a treadmill test (TMT). A total of 445 self-referred asymptomatic diabetic patients underwent cardiac MDCT. The treatment plan was determined according to the new strategy that uses MDCT and TMT. All patients underwent clinical follow-up and cardiac events were investigated. The incidence of subclinical atherosclerosis was 49.4%. The group without plaque underwent clinical follow-up without treatment and did not experience any cardiac events in 675.1 person-years of follow-up. Among patients with subclinical atherosclerosis without significant stenosis (n=136) who received medical treatment only, 11 patients experienced cardiac events over 326.4 person-years. The patients with significant stenosis (n=84) underwent TMT. Patients with positive TMT (n=14) underwent coronary angiograms and revascularization therapy was performed in all of them over 39.2 person-years. Patients with negative TMT (n=70) underwent medical treatment, and 27 of them experienced cardiac events. The incidence of cardiac death was 0% during 3 years of follow-up. The new strategy for detecting subclinical atherosclerosis on MDCT combined with TMT may be a useful method for minimizing the mortality rate from cardiovascular disease in asymptomatic diabetic patients.

Coregistered Intravascular Ultrasound and Optical Coherence Tomography Imaging During Implantation of a Bioresorbable Vascular Scaffold

A 50-year-old man presented with exertional angina and a positive treadmill test. Coronary angiography demonstrated a significant lesion in the mid-right coronary artery, and he proceeded to percutaneous coronary intervention. Because implantation of a bioresorbable vascular scaffold (BVS) (Abbott

The serum pentraxin-3 is elevated in patients with cardiac syndrome X

Cardiac syndrome X (CSX) is a clinical entity that is defined as normal coronary arteries with angina pectoris and objective sins of ischemia. The correlation between CSX and inflammatory markers such as high-sensitivity C-reactive protein (hs-CRP) is well established, however an association with pentraxin-3 (PTX-3) has not been examined. The aim of this study was to investigate the association between PTX-3 and CSX. A total of 122 patients (58 female, 64 male, mean age 49.6±5.8 years) with suspected of coronary artery disease (CAD) were included in the study. Those with evidence of ischemia (50 patients with positive treadmill tests, 32 patients with positive myocardial perfusion scintography) underwent coronary angiography (82 patients). Patients with a normal angiogram were considered the CSX group (n=41) and patients with coronary lesions were referred to as the CAD group (n=41). Patients without signs of ischemia served as the control group. Serum PTX-3 and hs-CRP levels were measured in all patients. The CSX group had significantly increased PTX-3 levels relative to the control group (0.46±0.16 vs. 0.23±0.09 ng/ml, p<0.001). However there were no differences in levels of PTX-3 and hs-CRP between the CSX and the CAD groups (PTX-3: 0.46±0.16 vs. 0.51±0.13 ng/ml, p=0.21; hs-CRP: 1.04±0.45 vs. 1.16±0.64 mg/dl, p=0.62). The control group had significantly lower hs-CRP levels (0.73±0.51 mg/dl) when compared to the both CSX and CAD groups (p=0.03 and p=0.002, respectively). Serum PTX-3 levels were weakly correlated with hs-CRP levels (r=0.30, p=0.001). PTX-3, a novel inflammatory marker, is elevated in patients with CSX, similar to the well known inflammatory marker hs-CRP, and may be a promising biomarker reflecting inflammatory status in these patients.

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.

Aortocoronary Dissection With Extension to the Suprarenal Abdominal Aorta: A Rare Complication After Percutaneous Coronary Intervention

A 53-year-old man presented with chest tightness and a positive treadmill test. A percutaneous coronary intervention (PCI) was performed on the distal total occlusion of the right coronary artery (RCA) with a 6-F Amplatz Left 1 guiding catheter and a Runthrough floppy wire (Terumo, Leuven, Belgium

Role of selected parameters and integral indices of treadmill test in the assessment of complication risk among patients with chronic coronary heart disease

Aim. To identify the value of selected parameters and integral indices of treadmill test (TT), such as Duke Treadmill Score (DTS), Centre for Preventive Medicine index (CPMI), and modified CPMI, in the assessment of cardiovascular complication (CVC) risk among patients with chronic coronary heart disease (CCHD). Material and methods. The study included all consecutive patients with the admission diagnosis of CCHD (n=260), who underwent coronary angiography (CAG) and TT in the period from January 1st 2004 to December 31st 2007, and were permanent residents of Moscow City or Moscow Region. Primary end-point was death from all causes; non-fatal CVC included acute myocardial infarction, acute cerebrovascular accident, and revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery). Results. The mean time to the development of primary end-point was 3,2 years; it total, it was registered in 71 patients (32,0 %). The incidence of primary end-point was higher in patients with ST segment depression ≥1 mm at TT, positive TT result, or chest pain development during the test. Achievement of target heart rate and TT time ≥12 minutes was associated with a better prognosis. In patients with high and intermediate risk by DTS and CPMI, the incidence of primary end-point was higher than in patients with low risk. Modified CPMI demonstrated high correlation with the primary end-point. Conclusion. The highest prognostic value in the assessment of the risk of CCHD complications was demonstrated by TT result, ST segment depression ≥1 mm, TT time, and chronotropic TT response. The role of CPMI and modified CPMI as predictors of CVC risk in CCHD patients was assessed.

Assessment of heart rate variability in patients with chronic stable angina

Background and objectives: A prospective study performed in Ibn-Albitar hospital a tertiary center to assess the effect of ischemic heart disease on heart rate variability. Methods: Thirty nine consecutive patients all with history of chronic stable angina &amp;with positive treadmill test underwent 24 hours holter test to assess heart rate variability. Compared it with 25 age &amp; sex matched control volunteer group. Results: Thirty one (79.48%) male of patients group&amp; 20 (80%) male of control group . heart rate variability expressed as (SDNN) standard deviation of normal to normal interval, (RMSSD) square root of the mean squared differences of successive normal to normal intervals&amp; (pNN50) the proportion derived by dividing (NN50) the number of interval differences of successive normal to normal intervals greater than 50 milliseconds (ms.) by the total number of normal to normal intervals all were significantly lower in patients group. Conclusion: This study showed that heart rate variability significantly lower in patients with chronic stable angina.

Symptoms of Anxiety and Depression Are Correlates of Angina Pectoris by Recent History and an Ischemia-Positive Treadmill Test in Patients with Documented Coronary Artery Disease in the Pimi Study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Computed Tomography Coronary Angiography for Ostial Left Main Stem Stenosis

A 54-year-old man underwent invasive coronary angiography, following presentation with exertional angina and a positive treadmill test. Left system injection demonstrated a tight narrowing in the left main stem commencing at the ostium (Fig. 1). There was no catheter tip pressure damping, chest pain, or ST-segment shift on engagement. The rest of the epicardial coronary tree, including the right system, was free of significant disease (Supplemental Fig. S1). Therefore, the possibility of catheter tip spasm was considered.

A randomised controlled trial of the effect of high concentration oxygen on myocardial ischaemia during exercise

BackgroundInternational guidelines recommend the use of oxygen for angina, based on Level C evidence. We aimed to determine whether high concentration oxygen influences the time to exercise-induced ischaemia or angina in patients with stable ischaemic heart disease (IHD). Methods22 subjects with IHD and a positive exercise treadmill test (ETT) awaiting coronary angiography were randomised to two further ETTs according to a double-blind, crossover study design, during which they breathed oxygen or air at 15L/min via a non-rebreather mask. Subjects in whom significant coronary artery disease was not subsequently confirmed by coronary angiography were excluded from analysis. The primary outcome was time to exercise-induced myocardial ischaemia, defined as ≥1mm ST depression on contiguous electrocardiographic (ECG) leads. The secondary outcome was time to onset of angina. ResultsExercise-induced myocardial ischaemia occurred in 17 of the 19 subjects with coronary artery disease, with the remaining two stopping due to shortness of breath. The mean (SD) time to inducible ischaemia was 35 (47) s longer (95% CI 11 to 59, P=0.007) with oxygen compared to air. Exercise-induced angina occurred in 9 subjects and started a mean 19 (32) s later (95% CI −6 to 43, P=0.12) with oxygen compared to air. All subjects who developed myocardial ischaemia or angina did so during both of the study ETTs. ConclusionHigh concentration oxygen increases the time to onset of exercise-induced myocardial ischaemia in patients with stable IHD.

Flow-mediated dilatation has an additive value to stress ECG for the diagnosis of angiographically significant coronary atherosclerosis

The objective of this study is to determine if flow-mediated endothelial-dependent vasodilatation (FMD) performed after stress electrocardiogram (ECG) test has an additive value for the diagnosis of significant coronary artery disease (CAD). We studied 322 patients who underwent stress ECG test, coronary arteriography (CAG), and FMD evaluation. The pretest probability (preTP) for the presence of significant CAD (≥50% stenosis) was 73%. The probability for the disease after positive or negative ECG test (postTP) was 75% and 62%, respectively. A positive FMD response after a positive stress test resulted in 86% postTP with prevalence of advanced CAD in this subgroup −70.4%. A negative FMD response after a positive treadmill test decreased the postTP to 50% (prevalence of significant CAD 25.5%) and could change clinical behavior – additional tests before proceeding to CAG. After negative stress test the postTP increased to 78% when FMD was positive (prevalence of the disease 50%), necessitating the performance of CAG. It decreased to 36% after a negative FMD (prevalence of the disease 11.5%), directing to conservative behavior. In a group with a high pretest probability for the presence of advanced coronary atherosclerosis, FMD has an additive value to stress ECG for the diagnosis of significant CAD and could guide clinical behavior.

10-Year Follow-Up of the First Cypher Stent Implanted in Human: An Invasive Evaluation With Angiography, Intravascular Ultrasound, and Optical Coherence Tomography

A 75-year-old woman presented to our service with stable angina (Canadian Cardiovascular Society III) and a positive treadmill test in December 1999. She had a previous history of systemic hypertension, hyperlipidemia, and hypothyroidism. Her coronary angiography showed significant single de novo

False-Positive Stress Tests… or False-Negative Rest Angiograms?

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 43-year-old man was sent to coronary angiography for suspect angina with a positive electrocardiographic treadmill test. The angiogram was negative for coronary artery disease, and the coronaries were defined as “normal” (

Regional functions of the left ventricle in patients with coronary slow flow and the effects of nebivolol

Microvascular and endothelial dysfunction have been implicated for coronary slow flow (CSF). Nebivolol, besides its beta-receptor blocking activity, causes an endothelium-dependent vasodilatation through increased nitric oxide release. This study included 27 patients with CSF and 27 subjects with normal coronary arteries. Segmental functions of the left ventricle (LV) were assessed using myocardial tissue Doppler velocities before and 3 months after treatment with nebivolol 5 mg/day. Compared with the control group, mitral deceleration time (DT) was significantly longer, and E/A ratio, systolic velocity of lateral mitral annulus (S(m)) and regional myocardial peak systolic and early diastolic velocities (V( s), V(d)) were significantly lower in patients with CSF. The reason for coronary angiography was typical angina in 21 (77.8%) and positive treadmill test in six (22.2%) CSF patients. There were significant correlations between presence of CSF in left anterior descending artery (LAD) with S( m) (r =-0.404, p =0.002) and V(s) in anterior (r =-0.531, p < 0.001 ) and lateral (r =-0.495, p < 0.001 ) segments and between presence of CSF in RCA and V(s) in posterior segments (r =-0.501, p < 0.001). Treatment with nebivolol significantly decreased blood pressures (128.5+/-12.5/82.5+/-8.8 to 119.8+/- 12.6/76.4+/- 7.4 mmHg, p < 0.001), DT (252.3+/-53.6 to 222.0+/-41.0 ms, p < 0.001 ) and IVRT (115.7+/-19.9 to 103.3+/-17.0 ms, p <0.001), and increased exercise capacity (8.7+/-1.3 to 10.4+/-0.9 METs, p < 0.001), E/A ratio (0.87+/-0.26 to 1.08+/-0.23, p <0.001) and myocardial velocities (p < 0.001). All the patients were free of angina after treatment. Patients with CSF had impaired diastolic and regional LV functions. Nebivolol may therefore be useful in improving angina, exercise capacity and LV functions in patients with CSF.

Faced with an abnormal stress electrocardiogram, the next test should be a …?

This is an editorial on the original research article “Cost-Effectiveness of Multidetector Computed Tomography Compared With Myocardial Perfusion Imaging as Gatekeeper to Invasive Coronary Angiography in Asymptomatic Firefighters With Positive Treadmill Tests.”

Cost-effectiveness of multidetector computed tomography compared with myocardial perfusion imaging as gatekeeper to invasive coronary angiography in asymptomatic firefighters with positive treadmill tests

In a prospective evaluation of 3950 Los Angeles County firefighters who underwent wellness/fitness examinations, 495 firefighters had abnormal treadmill tests and were referred for cardiology evaluation. Cost of the traditional myocardial perfusion imaging (MPI) followed by invasive coronary angiography (ICA) was compared with a method incorporating 64-slice multidetector computed tomography (MDCT) with coronary calcium score (CCS) followed by computed tomographic angiography (CTA) and ICA as indicated. We compared the costs of 2 methods of predicting coronary artery disease (CAD) by ICA among asymptomatic patients with positive treadmill tests. A decision-analytic framework was used to compare the net direct costs of CAD diagnosis associated with MDCT versus MPI. In the MDCT arm, all received CCS followed by CTA for those with calcium scores>10 and ICA for those with > or =50% stenosis on CTA. For the MPI arm, results were estimated from prior years' experience, in which firefighters with abnormal treadmill results were referred to ICA. Of 495 firefighters, 131 (26.9%) had abnormal CCS and went to CTA; 40 (8.1%) had > or =50% stenosis on CTA and went to ICA. According to prior years' experience with MPI, 146 (29.5%) would have shown abnormalities requiring ICA. Average cost was $1376/person for MPI versus $503/person for CCS with or without CTA as gatekeeper. All sensitivity analyses showed lower costs for the MDCT pathway compared with MPI. In this firefighter population, the cost of ICA-confirmed diagnosis of CAD is substantially lower with MDCT as gatekeeper than with MPI.