Standard Exercise Treadmill Test Research Articles

Stroke Incidence in Patients With Hypertension According to Cardiorespiratory Fitness.

Hypertension and physical inactivity are risk factors for stroke. The effect of cardiorespiratory fitness (CRF) on stroke risk in patients with hypertension has not been assessed. We evaluated stroke incidence in patients with hypertension according to CRF and changes in CRF. We included 483 379 patients with hypertension (mean age±SD; 59.4±9.0 years) and no evidence of unstable cardiovascular disease as indicated by a standardized exercise treadmill test. Patients were assigned to 5 age- and sex-specific CRF categories based on peak metabolic equivalents achieved at the initial exercise treadmill test and in 4 categories based on metabolic equivalent changes over time (n=110 576). Multivariable Cox models, adjusted for age, and comorbidities were used to estimate hazard ratios and 95% CIs for stroke risk. During a median follow-up of 10.6 (interquartile range, 6.6-14.6) years, 15 925 patients developed stroke with an average yearly rate of 3.1 events/1000 person-years. Stroke risk declined progressively with higher CRF and was 55% lower for the High-fit individuals (hazard ratio, 0.45 [95% CI, 0.42-0.48]) compared with the Least-fit. Similar associations were observed across the race, sex, and age spectra. Poor CRF was the strongest predictor of stroke risk of all comorbidities studied (hazard ratio, 2.24 [95% CI, 2.10-2.40]). Changes in CRF reflected inverse and proportional changes in stroke risk. Poor CRF carried a greater risk than any of the cardiac risk factors in patients with hypertension, regardless of age, race, or sex. The lower stroke risk associated with improved CRF suggests that increasing physical activity, even later in life, may reduce stroke risk.

CHRONIC KIDNEY DISEASE INCIDENCE AND CARDIORESPIRATORY FITNESS ASSOCIATION IN HYPERTENSIVE PATIENTS

Objective: Chronic hypertension (HTN) is considered a strong risk factor for developing chronic kidney disease (CKD). Increased cardiorespiratory fitness (CRF) is associated with lower CKD risk. However, the CRF-CKD association in patients with HTN has not been assessed. Thus, we examined the the association between CRF and the risk of developing CKD in hypertensive patients. Design and method: Hypertensive individuals (n=471,579; age 63.0+8.8 years) with normal kidney function prior to HTN and no evidence of ischemia indicated by a maximal standardized exercise treadmill test (ETT). The cohort was part of the ETHOS study (n=750,302). We established five CRF categories based on age-and-gender-adjusted peak metabolic equivalents (METs) achieved: Least-Fit (4.5±1.2 METs; n=106,955); Low-Fit Fit (6.9±1.1 METs; n=122,612); Moderate-Fit (8.3±1.2 METs; n=91,995); Fit (10.3±1.2 METs; n=111,472); and High-Fit (13.2±1.6 METs; n=38,545). CKD risk across CRF categories was assessed by multivariable Cox Regression analysis, adjusted for age, blood pressure, body mass index (BMI), alcohol abuse, traditional risk factors, and medications. Results: During 6,146,773.0 person-years of follow-up (median 12.9 years), 58,701 individuals developed CKD (9.6 events/1,000 person-years of observation). The CRF-CKD association was inverse, independent of comorbidities and graded. The risk of developing CKD was 9% lower for each 1-MET increase (Hazard Ratio [HR] 0.91; 95% confidence interval [CI] 0.90-0.93). When CKD risk was assessed across CRF categories using the Least-fit category as the referent, the risk was 20% lower (HR 0.80; CI 0.78-0.81, p<0.001) for those in the Low-fit category (6.9±1.1 METs). The risk declined progressively with increased CRF and was 49% lower for those in the highest CRF category (HR 0.49; CI 0.47-0.51, p<0.001). Similar findings were observed in the subgroup of hypertensive patients with diabetes mellitus (n=192,966). Conclusions: We noted an inverse and dose-response association between CRF and CKD incidence. The risk was attenuated significantly beyond a MET level of 6.9±1.1 METs, suggesting that moderate increases in exercise capacity lowers the risk of developing CKD in hypertensive patients.

RESTING HEART RATE AND MORTALITY RISK IN HYPERTENSIVE PATIENTS WITH NO ATRIAL FIBRILLATION

Objective: The recent ESH Guidelines include elevated resting heart rate (RHR) as an independent risk factor among the established and suggested novel risk factors that influence cardiovascular risk in patients with hypertension, indicating sympathetic overdrive. Increased fitness affects both mortality and RHR. However, the association between RHR and mortality risk, adjusted for cardiorespiratory fitness, age, comorbidities and medication has not been fully explored. Design and method: We evaluated the association between RHR and mortality in 422,702 hypertensive patients (mean age 62.5 ± 8.6 years) with no evidence of atrial fibrillation during the entire follow-up. All completed a standardized exercise treadmill test (ETT), with no evidence of overt heart disease prior to and at the time of the ETT. To assess the risk in a wide and clinically relevant spectrum, we established 6 RHR categories per 10 heartbeat intervals ranging from <=60 to >100 beats. We used multivariable Cox regression to assess the RHR-mortality association. We adjusted the models for age, body mass index, cardiac risk factors, exercise capacity, and medications (including b-blockers). Results: During the median follow-up of 10.6 years, providing 4,551,327 person-years, there were 107,863 deaths with an average annual rate of 23.7 events per 1,000 person-years. We noted approximately 7% increase in risk for each 10 heart beats. Mortality risk was significantly elevated at a RHR of >80 beats/min (HR; 1.15, CI; 1.12 - 1.17; p <0.006) and increased progressively to 41% (HR; 1.41, CI; 1.36 - 1.45; p <0.001) for those with a RHR of >100 beats/min. Similar trends were noted for subjects aged <60; 60-69; and >=70 years and those treated with b blockers. In all assessments, mortality risk was consistently overestimated when fitness was not considered. Conclusions: We noted a progressive increase in mortality risk with increased RHR at >80 bpm in hypertensive patients with no AF. The association was independent of comorbidities, and medications.

Cardiorespiratory fitness and risk of heart failure with preserved ejection fraction.

Preventive strategies for heart failure with preserved ejection fraction (HFpEF) include pharmacotherapies and lifestyle modifications. However, the association between cardiorespiratory fitness (CRF) assessed objectively by a standardized exercise treadmill test (ETT) and the risk of HFpEF has not been evaluated. Thus, we evaluated the association between CRF and HFpEF incidence. We assessed CRF in US Veterans (624 551 men; mean age 61.2 ± 9.7 years and 43 179 women; mean age 55.0 ± 8.9 years) by a standardized ETT performed between 1999 and 2020 across US Veterans Affairs Medical Centers. All had no evidence of heart failure or myocardial infarction prior to completion of the ETT. We assigned participants to one of five age- and gender-specific CRF categories (quintiles) based on peak metabolic equivalents (METs) achieved during the ETT and four categories based on CRF changes in those with two ETT evaluations (n = 139 434) ≥1.0 year apart. During a median follow-up of 10.1 years (interquartile range 6.0-14.3 years), providing 6 879 229 person-years, there were 16 493 HFpEF events with an average annual rate of 2.4 events per 1000 person-years. The adjusted risk of HFpEF decreased across CRF categories as CRF increased, independent of comorbidities. For fit individuals (≥10.5 METs) the hazard ratio (HR) was 0.48 (95% confidence interval [CI] 0.46-0.51) compared with least fit (≤4.9 METs; referent). Being unfit carried the highest risk (HR 2.88, 95% CI 2.67-3.11) of any other comorbidity. The risk of unfit individuals who became fit was 37% lower (HR 0.63, 95% CI 0.57-0.71), compared to those who remained unfit. Higher CRF levels are independently associated with lower HFpEF in a dose-response manner. Changes in CRF reflected proportional changes in HFpEF risk, suggesting that the HFpEF risk was modulated by CRF.

Abstract 14518: Interactive Effects of Statins, Obesity, and Cardiorespiratory Fitness in Type 2 Diabetes Mellitus Incidence

Introduction: Statin therapy and obesity are associated with increased risk of developing type 2 diabetes mellitus (T2DM). Conversely, cardiorespiratory fitness (CRF) is inversely related to T2DM incidence. The interaction between statin therapy, obesity, and CRF has not been addressed. Hypothesis: Obesity and statins will be associated with increased risk of T2DM, while CRF will mitigate this increased risk. Methods: From the ETHOS cohort, we identified 570, 054 patients (age 60.7±10.1 years) with no T2DM. All completed a standardized exercise treadmill test (ETT) with no evidence of ischemia. Subsequently, 322,805 (56.6%) were treated with statins for at least 8 months (mean 9.5±5.9 years) and 247,249 were not. Participants were classified based on body mass index (BMI) as normal weight (BMI<25.0 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), Obese-I (BMI 30.0-34.9 kg/m2), and Obese-II (BMI ≥35.0 kg/m 2 ). We established five CRF categories based on age-specific quintiles of peak metabolic equivalents achieved: Least-Fit (n=95,071); Low-Fit (n=133,404); Moderate-Fit (n=110,973); Fit (n=158,004) and High-Fit (n=72,602). Adjusted Cox proportional hazards models were constructed to evaluate the association between BMI, statin therapy and T2DM risk, and the interaction with CRF status. Results: During the follow-up period (median 10.3 years), 44,662 developed T2DM (7.4 events/1,000 person-years of observation). The risk of developing T2DM was 44% higher in those treated with statins [Hazard Ratio (HR) 1.44; 95% confidence interval (CI) 1.41-1.48)] compared to those not on statin therapy. The risk increased progressively with higher BMI levels and was nearly 3 times higher for those in the Obese-II category (HR 2.96, CI 2.85-3.06). When T2DM risk was assessed across CRF categories within BMI groups, we noted a progressive decline in T2DM risk with increased CRF regardless of statin therapy or BMI status. The adjusted risk was approximately 25% to 40% lower for those in the two highest CRF categories. Conclusions: Statin therapy and obesity were associated with increased risk of developing T2DM. This risk was mitigated significantly with increased CRF regardless of BMI status.

COVID-19 AND MORTALITY IN HYPERTENSIVE PATIENTS ACCORDING TO CARDIORESPIRATORY FITNESS

Objective: COVID-19 mortality risk increases with the presence of underlying comorbidities, including hypertension. Epidemiologic evidence also suggests an inverse association between self-reported physical activity and COVID-19 cases and deaths. However, no information exists regarding the association between cardiorespiratory fitness (CRF) assessed objectively by a standardized exercise treadmill test (ETT) and mortality in hypertensive patients. We assessed the hypothesis that CRF is inversely and independently associated with COVID-19 mortality risk in non-vaccinated hypertensive patients Design and method: From 2020 to 2021, we identified 17,358 hypertensive patients (mean age: 60.3 ± 8.2 years) with a normal response to an exercise tolerance test (ETT), prior to COVID-19. We established five CRF categories based on age-stratified quintiles of peak metabolic equivalents (MET) achieved: Least-Fit (4.7 ± 1.2 METs; n = 3,486); Low-Fit (7.1 ± 1.3; n = 4,616); Moderate-Fit (8.4 ± 1.3 METs; n = 3,320); Fit (10.3 ± 0.9 METs; n = 4,084); and High-Fit (12.8 ± 1.6 METs; n = 1,852). Multivariable Cox proportional hazard models were constructed to estimate hazard ratios (HR) and 95% confidence intervals [CI] for mortality across CRF categories. The models were adjusted for age, gender, race, comorbidities, medications, hospitalization, intubation, and time elapsed between ETT and COVID-19. The Least-Fit category was used as the reference group. Results: Results: During the follow-up of 100 days, 1,853 individuals died (10.7%). The risk for death was 7% lower for each 1-MET increase in exercise capacity (HR = 0.93, CI: 0.92-0.95; p < 0.001). The risk across fitness categories declined progressively with increased CRF and was 26% lower for the Least-Fit individuals (HR = 0.74; CI: 0.66 - 0.84), approximately 30% to 40% lower for Moderate-Fit and Fit, and 50% lower (HR = 0.50; CI: 0.41 - 0.62; p < 0.001) for High-Fit patients. Conclusions: Increased CRF was inversely related to COVID-19 mortality risk in hypertensive patients. The association was graded and independent of comorbidities.

Cardiorespiratory Fitness and Mortality Risk Across the Spectra of Age, Race, and Sex

BackgroundCardiorespiratory fitness (CRF) is inversely associated with all-cause mortality. However, the association of CRF and mortality risk for different races, women, and elderly individuals has not been fully assessed. ObjectivesThe aim of this study was to evaluate the association of CRF and mortality risk across the spectra of age, race, and sex. MethodsA total of 750,302 U.S. veterans aged 30 to 95 years (mean age 61.3 ± 9.8 years) were studied, including septuagenarians (n = 110,637), octogenarians (n = 26,989), African Americans (n = 142,798), Hispanics (n = 35,197), Native Americans (n = 16,050), and women (n = 45,232). Age- and sex-specific CRF categories (quintiles and 98th percentile) were established objectively on the basis of peak METs achieved during a standardized exercise treadmill test. Multivariable Cox models were used to estimate HRs and 95% CIs for mortality across the CRF categories. ResultsDuring follow-up (median 10.2 years, 7,803,861 person-years of observation), 174,807 subjects died, averaging 22.4 events per 1,000 person-years. The adjusted association of CRF and mortality risk was inverse and graded across the age spectrum, sex, and race. The lowest mortality risk was observed at approximately 14.0 METs for men (HR: 0.24; 95% CI: 0.23-0.25) and women (HR: 0.23; 95% CI: 0.17-0.29), with no evidence of an increase in risk with extremely high CRF. The risk for least fit individuals (20th percentile) was 4-fold higher (HR: 4.09; 95% CI: 3.90-4.20) compared with extremely fit individuals. ConclusionsThe association of CRF and mortality risk across the age spectrum (including septuagenarians and octogenarians), men, women, and all races was inverse, independent, and graded. No increased risk was observed with extreme fitness. Being unfit carried a greater risk than any of the cardiac risk factors examined.

RENIN-ANGIOTENSIN SYSTEM INHIBITION, CARDIORESPIRATORY FITNESS AND MORTALITY RISK IN DIABETIC PATIENTS

Objective: Patients with type 2 diabetes mellitus (T2DM) have significantly higher risk of cardiovascular events and mortality. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) decrease mortality risk in T2DM patients. Cardiorespiratory fitness (CRF) is associated with lower mortality risk in T2DM patients. However, the combined effects of CRF and ACEI/ARBs on mortality risk in T2DM patients has not been assessed. Design and method: We identified 6,888 T2DM patients (age 58.3 + 10.1 years) with no evidence of ischemia as indicated by a maximal standardized exercise treadmill test. We established two CRF categories based on age-adjusted median peak metabolic equivalents (METs) achieved: Unfit (5.4 ± 1.3 METs; n = 3,474) and Fit (9.0 ± 2.3 METs; n = 3414). We then formed 2 groups within each CRF category (treated and not treated with ACEI/ARBs) for a total of four CRF-ACEI/ARBs groups. Cox proportional hazards models, adjusted for known risk factors were constructed to assess the CRF-ACEI/ARBs interaction and mortality risk association. Results: During a follow-up of 14.2 + 6.9 years, 2,495 patients died, accounting for 25.5 events/ 1,000 person-years of observation. Patients treated with ACE/ARBs had 25% lower mortality risk compared to those not treated with ACE/ARBs (HR 0.75; 95% CI: 0.69-0.82). When CRF-ACEI/ARBs categories were considered, Unfit individuals not treated with ACEI/ARBs had 24% higher mortality risk compared to those treated with ACEI/ARBs (HR 1.24; 95% CI 1.11–1.38). For Fit individuals, the risk was 26% lower (HR: 0.74; CI: 0.66–0.83) for those not treated with ACEI/ARBs and 45% lower in those treated with ACEI/ARBs (HR 0.55; 95% CI 0.48–0.62). Conclusions: ACEI/ARBs therapy and increased CRF are effective in lowering mortality risk in in T2DM patients. The combination of ACEI/ARBs and higher CRF was synergistic, resulting in substantially lower mortality risk than either therapy alone.

SAT-LB96 Chronic Kidney Disease Incidence and Cardiorespiratory Fitness Association in Patients With Diabetes And/Or Hypertension

Introduction: Type 2 diabetes mellitus (T2DM) and hypertension (HTN) are considered strong risk factors for developing chronic kidney disease (CKD). Increased cardiorespiratory fitness (CRF) is associated with lower CKD risk. However, the CRF-CKD association in patients with T2DM and/or HTN has not been assessed.Methods: We identified 9,751 patients (age 58.6 + 10.1 years) with T2DM (N=1,444) or HTN (n=5,031) or both (n=3,276) prior to a maximal standardized exercise treadmill test (ETT) and no evidence of ischemia as indicated by the ETT. We established four CRF categories based on age-adjusted peak metabolic equivalents (METs) achieved: Least-Fit (4.6±1.2 METs; n=2,231); Low-Fit Fit (6.4±1.1 METs; n=2,693); Moderate-Fit (8.0±1.0 METs; n=2,432); and High-Fit (10.8±2.1 METs; n=2,395). We performed multivariable Cox Regression analyses to access the risk of CKD according to fitness. The models were adjusted for age, body mass index (BMI), traditional risk factors and medications. Results: During the median follow-up of 12.4 years, 1,118 patients developed CKD, accounting for 9.1 events/ 1,000 person-years of observation. The association between CRF and CKD was inverse and graded. The risk of CKD was 21% lower (Hazard Ratio [HR] 0.79; 95% confidence interval [CI] 0.77-0.81). When CRF categories were considered, the CKD risk was 44% lower for Moderate-Fit patients (HR 0.56; 95% CI 0.48-0.67) and 80% lower for High-Fit (HR 0.20; 95% CI 0.15-0.25). Similar findings were noted in patients with both T2DM and HTN. Conclusions: We noted an inverse and dose-response association between CRF and CKD incidence. The risk was attenuated significantly beyond a mean peak MET level of 8.0±1.0, suggesting that moderate increases in exercise capacity confers favorable health benefits in patients at high risk of developing CKD.

2086-P: The Interaction of Fitness, Body Mass Index, and Mortality Risk in Type 2 Diabetes

Introduction: Obesity and poor cardiorespiratory fitness (CRF) commonly coexists in type 2 diabetes (T2DM). Moreover, CRF has been associated with lower mortality risk in T2DM patients. In this study, we assessed the modulatory impact of fitness on mortality risk in T2DM patients across the obesity spectrum. Methods: We identified 6,888 T2DM patients (age 58.3+10.1 years) with no evidence of ischemia as indicated by a maximal standardized exercise treadmill test. We established two CRF categories based on age-adjusted median peak metabolic equivalents (METs) achieved: Unfit (5.4±1.3 METs; n=3,474) and Fit (9.0±2.3 METs; n=3414). We also defined the cohort based on body mass index (BMI) normal-weight (BMI 18.5-24.9 kg/m2); over-weight (BMI 25.0-29.9 kg/m2); and obese (BMI ≥30 kg/m2). We then combined the BMI and CRF categories to form a total of six groups CRF-BMI categories. Cox proportional hazards models, adjusted for known risk factors were constructed to assess the association between CRF-BMI interaction and mortality risk. Results: During a follow-up of 14.2+6.9 years, 2,495 patients died, accounting for 25.5 events/1,000 person-years of observation. When CRF-BMI groups were considered, the normal-weight-Fit category was used as the referent. Mortality risk in the normal-weight but Unfit patients was 64% higher compared to their Fit counterparts (HR 1.64; 95% CI: 1.35-2.00). In the overweight category, mortality risk was 20% lower in the Fit (HR 0.80; 95% CI: 0.67-0.94) and 28% higher (HR 1.28; 95% CI: 1.09-1.51) in Unfit patients. In obese category the risk was 29% lower for the Fit (HR 0.71; 95% CI: 0.60-0.86) and 23% higher for the Unfit patients (HR 1.23; 95% CI: 1.05-1.45). Conclusion: Increased CRF favorably modulates mortality risk across the obesity spectrum in T2DM patients. Poor fitness had a substantially greater and negative impact on Normal than over-weight and obese individuals. Disclosure E. Nylen: None. P. Kokkinos: None. C. Faselis: None. P. Narayan: Research Support; Self; AstraZeneca, Eli Lilly and Company. P. Karasik: None. J.N. Myers: None.

292-OR: Renin-Angiotensin System Inhibition, Cardiorespiratory Fitness, and Mortality Risk in Diabetic Patients

Introduction: Patients with type 2 diabetes mellitus (T2DM) have significantly higher risk of cardiovascular events and mortality. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) decrease mortality risk in T2DM patients. Cardiorespiratory fitness (CRF) is associated with lower mortality risk in T2DM patients. However, the combined effects of CRF and ACEI/ARBs on mortality risk in T2DM patients has not been assessed. Methods: We identified 6,888 T2DM patients (age 58.3±10.1 years) with no evidence of ischemia as indicated by a maximal standardized exercise treadmill test. We established two CRF categories based on age-adjusted median peak metabolic equivalents (METs) achieved: Unfit (5.4±1.3 METs; n=3,474) and Fit (9.0±2.3 METs; n=3414). We then formed 2 groups within each CRF category (treated and not treated with ACEI/ARBs) for a total of four CRF-ACEI/ARBs groups. Cox proportional hazards models, adjusted for known risk factors were constructed to assess the CRF-ACEI/ARBs interaction and mortality risk association. Results: During a follow-up of 14.2±6.9 years, 2,495 patients died, accounting for 25.5 events/1,000 person-years of observation. Patients treated with ACE/ARBs had 25% lower mortality risk compared to those not treated with ACE/ARBs (HR 0.75; 95% CI: 0.69-0.82). When CRF-ACEI/ARBs categories were considered, Unfit individuals not treated with ACEI/ARBs had 24% higher mortality risk compared to those treated with ACEI/ARBs (HR 1.24; 95% CI 1.11-1.38). For Fit individuals, the risk was 26% lower (HR: 0.74; CI: 0.66-0.83) for those not treated with ACEI/ARBs and 45% lower in those treated with ACEI/ARBs (HR 0.55; 95% CI 0.48-0.62). Conclusions: ACEI/ARBs therapy and increased CRF are effective in lowering mortality risk in in T2DM patients. The combination of ACEI/ARBs and higher CRF was synergistic, resulting in substantially lower mortality risk than either therapy alone. Disclosure P. Kokkinos: None. J.N. Myers: None. L. Sidossis: None. C. Faselis: None. P. Narayan: Research Support; Self; AstraZeneca, Eli Lilly and Company. E. Nylen: None. X. Sui: None. H. Moore: None. P. Karasik: None.

Noninvasive Stress Testing for Coronary Artery Disease.

Stress testing remains the cornerstone for noninvasive assessment of patients with possible or known coronary artery disease (CAD). The most important application of stress testing is risk stratification. Most patients who present for evaluation of stable CAD are categorized as low risk by stress testing. These low-risk patients have favorable clinical outcomes and generally do not require coronary angiography. Standard exercise treadmill testing is the initial procedure of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise.

Evaluation of the Zurich Guidelines and Exercise Testing for Return to Play in Adolescents Following Concussion

To evaluate return to play (RTP) and return to classroom outcomes when the Zurich guidelines are combined with a standardized exercise treadmill test [Buffalo Concussion Treadmill Test (BCTT)] and computerized neuropsychological (cNP) testing in adolescent athletes after concussion. Retrospective chart review and follow-up. University Sports Medicine Concussion Clinic. One hundred seventeen athletes (75% male) with sport concussion ages 13 to 19 years and telephone follow-up of 91 (77.8%) athletes and their parents. Concussed athletes who were asymptomatic at rest completed Automated Neuropsychological Assessment Metrics or Immediate Post-concussion Assessment and Cognitive Test cNP testing followed by the BCTT on the same day. Athletes then followed the Zurich consensus guidelines for RTP. The primary outcome measure was the degree of success in RTP, that is, RTP with or without return of concussive symptoms. Secondary outcome measure was return to school with or without symptoms. All athletes returned to sport without exacerbation of symptoms. Telephone follow-up revealed that 38.5% experienced new issues upon return to the classroom. Forty-eight percent of athletes had 1 or more cNP subtests below average (<ninth percentile) when asymptomatic. Ultimately, performance on cNP was not predictive of return to school issues. The BCTT in combination with the Zurich consensus guidelines seems to be safe and successful for RTP. There is evidence to suggest that cNP testing performed in athletes who do not have a preinjury baseline test was not related to RTP or problems upon return to school.

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.

387 EFFECT OF RAMIPRIL THERAPY ON WALKING ABILITY AND QUALITY OF LIFE IN PATIENTS WITH INTERMITTENT CLAUDICATION

Background: One third of patients with peripheral artery disease (PAD) experience intermittent claudication, with the major consequence being loss of quality of life. This study was conducted to determine the efficacy of ramipril in improving walking ability and quality of life in patients with PAD. Design and Methods: 200 PAD patients (66 ± 6 years (mean ± SD) were randomised to receive ramipril, 10 mg once daily (n = 99) or placebo (n = 101) for 24 weeks in a double blind study. Pain free walking time (PFWT) and maximum walking time (MWT) were determined using a standard exercise treadmill test. The standard Walking Impairment Questionnaire (WIQ) and Short Form-36 (SF-36) questionnaire were administered to quantify walking ability and quality of life respectively. Results: Ramipril increased PFWT by 92% (Placebo 8.9 ± 2 secs; Ramipril 87.2 ± 65.8; p < 0.0001) and MWT by 139% (Placebo 14.4 ± 32.9 secs; Ramipril 192.7 ± 125.9; p < 0.0001). The treatment group reported significantly higher scores on the distance (Placebo −3.4 ± 7.0; Ramipril 12.4 ± 9.5; p < 0.0001), speed (Placebo −3.2 ± 4.5; Ramipril 11.1 ± 7.8; p < 0.0001) and stair climbing (Placebo −7.1 ± 10.5; Ramipril 23.8 ± 18.7; p < 0.0001) subscales of the WIQ. The treatment group also reported higher scores on the physical functioning subscale of the SF-36 (Placebo −0.1 ± 0.9, Ramipril 2.1 ± 2.8; p < 0.0001). Conclusions: This is thefirst adequately powered randomized trial demonstrating that ACE inhibition improves walking ability and quality of life in patients with PAD; an improvement substantially beyond that reported with conventional medical therapies.

ST-segment elevation in the recovery phase of nuclear exercise stress test with 99mTc-sestamibi in a patient with critical RCA stenosis and subtle systolic dysfunction in speckle tracking imaging

An asymptomatic Caucasian male patient underwent coronary artery disease diagnostics. Standard exercise treadmill test was inconclusive, and Holter ECG study didn't show any significant abnormalities. Considering the high risk of ischemic heart disease nuclear exercise stress test was performed,which revealed ST-segment elevation in the recovery phase of the treadmill exercise test. Single photon emission computed tomography (SPECT/CT) showed myocardial perfusion abnormalities in the inferior and lateral walls of the left ventricle. Furthermore,speckle tracking imaging showed subtle left ventricle dysfunction. Finally critical stenosis in the second segment of right coronary artery was diagnosed in coronary angiography.

Simple prediction formula for peak oxygen consumption in patients with chronic heart failure

Peak oxygen consumption (VO2) is one of the strongest predictors of survival in patients with chronic congestive heart failure (CHF), but it is unavailable in most practices. Peak VO2 < 14 mL/kg/min identifies patients who might benefit from referral to a specialized CHF center. Accordingly, the current study was undertaken to derive a prediction formula based on routine stress data obtained from patients referred for cardiopulmonary exercise tolerance testing (CPETT). Subsequently, the prediction formula was validated in a separate cohort of similar patients referred for CPETT at another institution. The derivation cohort consisted of 208 patients with a diagnosis of CHF with reduced systolic function (left ventricular ejection fraction < 40%) who underwent elective CPETT. A multiple linear regression analysis was performed on available treadmill testing variables. A simple prediction formula was derived: Predicted peak VO2 = 16.7 – 1.3 (sex) – 3.8 × (New York Heart Association functional class) + 0.04 × (peak heart rate) + 0.92 × (estimated metabolic equivalents). The validation cohort consisted of 112 patients referred for CPETT at a different institution for the evaluation of advanced CHF. The predicted peak VO2 as obtained by the prediction formula was compared to the actual peak VO2 using a Pearson coefficient of correlation. The predicted peak VO2 was well correlated with the actual peak VO2 demonstrating a correlation coefficient of r = 0.77 with a 95% confidence interval of (0.68–0.83). A simple prediction formula using four variables that are routinely obtained in standard exercise treadmill testing can identify patients in whom formal CPETT is advisable and facilitate early referral to specialized heart failure centers.

ST-segment elevation in the recovery phase of nuclear exercise stress test with 99mTc-sestamibi in a patient with critical RCA stenosis and subtle systolic dysfunction in speckle tracking imaging

Although lymphomas are generally considered as tumors of lymph nodes about 25-40% arise at extranodal sites. We report a case of a 60 years old female who developed a right breast B-diffuse large cell non-Hodgkin lymphoma in 2005 treated by chemo/radio-therapy which relapsed at the same breast in 2007 and at the other breast in 2010. The patient underwent both radiologic and nuclear medicine studies.

Traditional Cardiovascular Disease Risk Factors Related to Heart Rate Responses at the Onset of Exercise

The standard exercise treadmill test (ETT) is known to be one of the most powerful, noninvasive tools for risk stratifying patients with or suspected of having cardiovascular disease (CVD). However, controversy exists regarding the heart rate (HR) profile in early exercise and its association with mortality in asymptomatic adults. Peak and post exercise HR responses are well known, but to determine clinical utility, HR responses at the onset of exercise in apparently healthy men and women must be better understood. PURPOSE: To identify the HR increase profile and determine the association of traditional CVD risk factors with an absolute change in HR at one minute and one-third (1/3) total exercise time in apparently healthy adults. METHODS: Retrospective examination of a symptom-limited maximal ETT was performed for asymptomatic, self-referred adult participants of a university-based fitness program between 1990-2006. Records were analyzed for HR responses from individuals (N=947) of both sexes representing a broad range of age and fitness levels (11-78 yrs; VO2peak: 16.5 to 49.4 ml·kg-1·min-1). The HR response of the BSU/Bruce ramp protocol was identified. The association of traditional CVD risk factors with absolute changes in HR at minute one and 1/3 of total exercise time from pre-test standing HR were identified. RESULTS: The mean HR increase at minute one was 18.4±9.1 and 22.9±10.9 beats (25th to 75th percentile range 13 to 26 beats) for men and women respectively (p<0.05). The mean HR increase at 1/3 total exercise time was 32.8±10.4 and 34.8±10.1 beats for men and women respectively (p<0.05). A significantly better CVD risk factor profile (lower systolic and diastolic BP, BMI, total cholesterol, triglycerides, higher VO2peak, and regular exercise) was associated with less of an increase in HR at minute one than a greater increase in HR, despite consisting of a greater percentage of current smokers. However, no significant difference in CVD risk factor profiles existed at 1/3 total exercise time. CONCLUSIONS: A lower HR increase at minute one of exercise was significantly associated with a better CVD risk factor profile but the same differences were not seen at 1/3 total exercise time. These data suggest a greater parasympathetic influence at the onset of exercise may be protective in an asymptomatic population.

Exercise-induced renal tubular injury in intermittent claudication

While, exercise in intermittent claudication (IC) may improve symptoms and exercise tolerance, it has been shown to produce an ischemia-reperfusion injury. This study aimed to assess the impact of this on renal function, by measuring the changes in activity of the urinary enzyme N-acetyl-β-D-glucosaminidase (NAG), a sensitive marker of renal tubular damage. 15 patients with IC and 15 controls underwent a standardized exercise treadmill test. Changes in Ankle/Brachial Pressure Index (ABPI) were measured as was the urinary activity of NAG at rest, and following exercise. While a marked change was seen in ABPI's of the IC group, no change was apparent in the controls. Urinary NAG activity rose significantly in the IC group following exercise (mean 51.25 µmol/h/mmol creatinine) compared with both resting levels (30.4) and with the post-exercise NAG of controls (26.4),P<0.05. There was no significant difference in NAG levels within the control group (23.5 vs 26.4). Exercise in intermittent claudication is associated with a renal tubular cell injury, which may be related to an ischemia-reperfusion injury.