Stress Testing In Patients Research Articles

Simple exercise test score versus cardiac stress test for the prediction of coronary artery disease in patients with type 2 diabetes

Type 2 diabetes markedly increases the risk of coronary heart disease (CHD), and screening for CHD is suggested by the guidelines. The aim of the study was to compare the diagnostic usefulness of the simple exercise test score, incorporating the clinical data and cardiac stress test results, with the standard stress test in patients with type 2 diabetes. A total of 62 consecutive patients (aged 65.4 ±8.5 years; 32 men) with type 2 diabetes and clinical symptoms suggesting CHD underwent a stress test followed by coronary angiography. The simple score was calculated for all patients. Significant coronary stenosis was observed in 41 patients (66.1%). Stress test results were positive in 36 patients (58.1%). The mean simple score was high (65.5 ±14.3 points). A positive linear relationship was observed between the score and the prevalence of CHD (R2 = 0.19; P <0.001) as well as its severity (R² = 0.23; P <0.001). The area under the receiver-operating characteristic curve for the simple score was 0.74 (95% confidence interval [CI], 0.62-0.86). At the original cut-off value of 60 points, the score had a similar prognostic value to that of the standard stress test. However, in a multivariate analysis, only the simple score (odds ratio [OR], 1.46; 95% CI, 1.11-1.94; P <0.01 for an increase in the score by 1 point) and male sex (OR, 1.57; 95% CI, 1.24-1.98; P <0.001) remained independent predictors of CHD. In patients with type 2 diabetes, the simple score correlated with the prevalence and severity of CHD. However, the cut-off value of 60 points was inadequate in the population of diabetic patients with high risk of CHD. The simple score used instead of or together with the stress test was a better predictor of CHD than the stress test alone.

PW316 Feasibility and safety of nuclear stress testing in patients referred for dobutamine stress echocardiography

PW316 Feasibility and safety of nuclear stress testing in patients referred for dobutamine stress echocardiography

Refining a brief decision aid in stable CAD: cognitive interviews

BackgroundWe describe the results of cognitive interviews to refine the “Making Choices©” Decision Aid (DA) for shared decision-making (SDM) about stress testing in patients with stable coronary artery disease (CAD).MethodsWe conducted a systematic development process to design a DA consistent with International Patient Decision Aid Standards (IPDAS) focused on Alpha testing criteria. Cognitive interviews were conducted with ten stable CAD patients using the “think aloud” interview technique to assess the clarity, usefulness, and design of each page of the DA.ResultsParticipants identified three main messages: 1) patients have multiple options based on stress tests and they should be discussed with a physician, 2) take care of yourself, 3) the stress test is the gold standard for determining the severity of your heart disease. Revisions corrected the inaccurate assumption of item number three.ConclusionsCognitive interviews proved critical for engaging patients in the development process and highlighted the necessity of clear message development and use of design principles that make decision materials easy to read and easy to use. Cognitive interviews appear to contribute critical information from the patient perspective to the overall systematic development process for designing decision aids.

The Response of Circulating Leptin Levels to Exercise Stress Testing in Subjects Diagnosed with Metabolic Syndrome

Aim. To assess the plasma leptin responses after exercise stress testing in patients with metabolic syndrome (MS). Material and Methods. We investigated 67 patients with MS, with mean age of 55 ± 7 years. They underwent exercise stress testing on cycloergometer. The lot was divided into three groups: group 1—10 patients with a true positive test, group 2—18 patients with a true negative test, and group 3—39 patients with a false negative test. Leptin levels were measured using the ELISA method. Results. Leptin levels decreased after effort in patients with MS (9.42 ± 11.08 ng/mL before and 8.18 ± 11.5 ng/mL after the exercise stress test, P = 0.0005, r = 0.874). In groups 1 (8.98 ± 9.09 at rest versus 5.98 ± 8.73 ng/mL after the exercise test, P = 0.002) and 3 (8.6 ± 10.53 at rest versus 6.91 ± 9.07 ng/mL, P = 0.0005), lower leptin levels were recorded immediately after exercise testing. Leptin levels were not significantly lower in group 2 before effort (9.49 ± 11.36 ng/ml) and after (9.46 ± 13.81 ng/mL). We found no correlation between leptinemia and exercise stress testing parameters, regardless of group. Conclusion. Our research showed that short-term exercise lowers leptin levels in coronary patients, without a relationship between its parameters and leptin values.

2D and 3D Analysis of Magnetocardiographic Data in the Evaluation of the Ventricular Repolarization Changes under Exercise Stress Test in Patients with CAD

Objective: Non-invasive methods of evaluation of electrical activity of the heart are still the most important functional diagnostics methods in coronary artery disease (CAD) detection. It has been shown that magnetocardiography (MCG) appears to be rather sensitive in diagnostics of chronic CAD even in the patients at rest with unchanged ECG. The objective of present paper is to investigate the influence of non-invasive tests with a physical exerciseon MCG parameters in the patients with chronic CAD. Materials and Methods: In total, 10 patients were examined (mean age 41 ± 5 years) suffering from chronic stable angina (CAD). CAD was diagnosed by clinical evidences, bicycle ergometria positive data and coronary angiography (stenosis > 70% in at least onr main coronary angiography). The control group consisted of 14 healthy volunteers. MCG mapping was performed by means of a 7-channel SQUID-magnetometer installed in an unshielded room. The MCG examination was conducted twice, whilst patients were at rest and after exercise on the bicycle (in healthy persons it was conducted immediately after exercise and in the patients, after the ST depression and/or chest pain had disappeared). The homogeneity and electric motive force (EMF) direction disturbances on magnetic field distribution maps on an extent of ST-T interval have been evaluated. Results: Statistically significant differences between groups examined based both on 2D and 3D quantitative criteria were demonstrated. Conclusion: The application of a set of MCG criteria based on the analysis both of ventricular depolarization and repolarization will enable a greater degree of accuracy for the results of the exercise stress test, especially in doubtful cases.

To Stent or Not to Stent: The President Bush Stent Controversy

Politicians, especially US presidents, are involved in the harsh, palatable realities of politics, activities that lead not only to headaches but to heartache as well. Once someone in power presents with cardiovascular disease, its management becomes the subject of debate among the medical community and the media; it boosts heart disease awareness and opens our eyes to the variety of treatment modalities. Although he did not present with symptoms of coronary artery disease, this past summer former US President George W. Bush received a stent after a blockage was discovered during a routine physical examination that included a stress test. An abnormal finding on electrocardiogram led to a computed tomography angiogram where the coronary lesion was detected. That lesion was treated with a stent as first-line therapy. Immediately after implantation, a ferocious debate arose. So what provoked this debate? Throughout the years, there has been amovement to minimize the use of stents as first-line therapy for the treatment of patients with significant coronary disease evenwhen symptomatic;medical therapy was historically advised as a first-line therapy in this population, especially within asymptomatic subjects. Howwill stent implantation improve symptoms for symptomatic and asymptomatic patients? The American Heart Association states that in asymptomatic individuals, a stress test should not be part of routine screening. Dr. Steven Nissen (Cleveland Clinic, OH) recently stated in an interview that routine stress testing in patients without symptoms can lead to non-indicated procedures. He added that Bush likely, “...got the classical thing that happens to VIP patients, when they get so-called executive physicals and they get a lot of tests that aren't indicated. This is American medicine at its worst.” In contrast, in a video statement from the president of the Society for Cardiovascular Angiography and Interventions (SCAI), Dr. Ted Bass recognized that heart disease treatment is complicated and admitted that medications are the first line of therapy while stents are secondary, both to failure of the drugs to relieve symptoms or when the drug is not well tolerated. In his recorded video message Dr. Bass recommend that patients consult with their physicians for optimal, individualized therapy. When a recent poll on www.crtonline.org asked whether asymptomatic patients with positive stress tests and significant lesions should undergo coronary stenting, physicians answered: yes, 70%; no 24%; and unknown, 6%. So why the controversy? Is it because medical therapy has historically been considered adequate for these patients and that stents do not prolong life or reduce heart attacks in stable angina patients? Is it cost driven? Or is it due to fear of complications, such as stent thrombosis and restenosis? With recent improvements in stent technology that mitigate complications and

Ventricular response to dobutamine stress relates to the change in peak oxygen uptake during the 5-year follow-up in young patients with repaired tetralogy of Fallot

To evaluate the additional value of dobutamine stress testing in patients with repaired tetralogy of Fallot (TOF) by relating stress imaging parameters at baseline to relevant parameters of clinical condition and right ventricular (RV) size during a serial follow-up. We prospectively included 27 patients (14 ± 4 years at baseline), who were studied twice with a 5-year interval. Patients underwent cardiovascular magnetic resonance imaging to assess RV systolic and diastolic function at rest and during dobutamine stress. Normal response to dobutamine was defined as a decrease in RV end-systolic volume, and a increase in RV ejection fraction (EF) during stress. Exercise testing and electrocardiography were performed to determine peak oxygen uptake (peak VO₂), QRS duration, and QT interval corrected for heart rate (QTc) interval. RV volumes, QRS duration, and QTc interval increased significantly from baseline to follow-up; peak VO₂ tended to decrease (95 ± 20-89 ± 14%, P = 0.086). Response to dobutamine was normal in 26 of 27 patients and remained stable during the follow-up [relative increase in RVEF during stress: +25 ± 9% (baseline) vs. +27 ± 10% (follow-up)]. A smaller relative increase in RVEF during stress at baseline related to a larger relative decrease in peak VO₂ during the follow-up (r = 0.59, P = 0.004). No significant associations were found with the relative increase in QRS duration, QTc interval, or RV end-diastolic volume during a 5-year follow-up. In a young TOF population, response to dobutamine stress was normal and remained stable during the 5-year follow-up. A smaller increase in RVEF during stress at baseline was predictive for a larger decrease in peak VO₂ during the 5-year follow-up.

ECG DISPERSION MAPPING PARAMETERS DURING THE TREADMILL TEST IN PATIENTS WITH CORONARY HEART DISEASE

Aim.The aim of the study was the complex analysis of the ECG-12 and ECG dispersion mapping (DM) parameters during the physical stress test in patients with coronary heart disease (CHD).Material and methods.The main group included 143 CHD patients with Functional Class I–III angina (99 men and 44 women; mean age 50,6±4,6 years). The control group included 37 healthy individuals (mean age 44,3±4,8 years). Patients with heart failure signs and symptoms were excluded. All participants underwent the graduated physical stress test.Results.Two variants of the ECG changes were observed, with normal and abnormal reaction of ECG DM parameters. The latter group was characterised by the following: ratio of heart rate and myocardial micro-alternation index (HRmax/MMImax) 30% at the peak HR.Conclusion.Using the ECG DM method during the treadmill test is a feasible and useful approach to gain additional diagnostic information on the myocardial electro-physiological status and, therefore, to select the patients who need further examination and treatment.

ECG DISPERSION MAPPING PARAMETERS DURING THE TREADMILL TEST IN PATIENTS WITH CORONARY HEART DISEASE

Aim. The aim of the study was the complex analysis of the ECG-12 and ECG dispersion mapping (DM) parameters during the physical stress test in patients with coronary heart disease (CHD).Material and methods. The main group included 143 CHD patients with Functional Class I–III angina (99 men and 44 women; mean age 50,6±4,6 years). The control group included 37 healthy individuals (mean age 44,3±4,8 years). Patients with heart failure signs and symptoms were excluded. All participants underwent the graduated physical stress test.Results. Two variants of the ECG changes were observed, with normal and abnormal reaction of ECG DM parameters. The latter group was characterised by the following: ratio of heart rate and myocardial micro-alternation index (HRmax/MMImax) 30% at the peak HR.Conclusion. Using the ECG DM method during the treadmill test is a feasible and useful approach to gain additional diagnostic information on the myocardial electro-physiological status and, therefore, to select the patients who need further examination and treatment.

Reduction in Observation Unit Length of Stay With Coronary Computed Tomography Angiography Depends on Time of Emergency Department Presentation

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

Coronary sinus filling time: A novel method to assess microcirculatory function in patients with angina and normal coronaries

Dysfunction of the coronary microcirculation is considered as one of the factors responsible for symptoms and abnormal stress tests in patients with angina and normal coronaries (syndrome X). We sought to evaluate the usefulness of coronary sinus filling time (CSFT) to assess coronary microcirculation in this group of patients. We compared the CSFT of patients having definite angina or atypical angina with positive treadmill electrocardiography test (angina group), with that of patients undergoing coronary angiogram (CAG) prior to balloon mitral valvuloplasty (control group). During CAG, coronary sinus was visualized in appropriate views and CSFT in seconds was derived from frame count. Thrombolysis In Myocardial Infarction (TIMI) flow grade, corrected TIMI (cTIMI) frame count, TIMI Myocardial Perfusion grade (TMP) were assessed. There were 41 patients in angina group and 16 in control group. Among the angina group 68.8% were females as against 81.8% in the control group. 87.8% (n=36) had typical angina. Mean CSFT was 4.25±0.72s and 3.46±0.99sin the angina group and control group respectively (p=0.001). No significant differences were found between the groups with respect to TMP (p=0.68) & cTIMI frame count (p=0.22). CSFT is a simple method to assess the transit time through coronary microcirculation. CSFT was significantly delayed in patients with angina and normal coronaries. TMP and cTIMI frame count were not significantly different between groups.

Probability Distributions

Probabilities provide a measure of the uncertainty in our world, just as a ruler can describe its geometry. We live in at least 4 dimensions and require more complex measuring devices than a ruler to understand it. Similarly, a single probability that something is present now or will happen in the future can sometimes be an inadequate representation of uncertainty. Increasingly, we turn to describing the likelihood of events as probability distributions that have shape and moments, especially when we perform sensitivity analyses. Costeffectiveness acceptability curves have become standard fare. But what about intuition and System I reasoning? When we teach the principles of decision making and logic to students and when we explore them ourselves, we soon discover that it is difficult to provide an intuitive understanding of probabilities. The difficulty increases by orders of magnitude when we focus on probability distributions. In this issue of Medical Decision Making (MDM), Van den Ende and colleagues demonstrate these misperceptions in a small study in which clinicians and students were presented with a scenario of suspected tuberculosis and asked to visualize the post-workup probability distribution. Although the participants proposed a variety of distributions, the vast majority proposed unimodal distributions, whether uniform, symmetric, or skewed; only 2 of 41 participants proposed a bimodal ‘‘U-shaped’’ distribution, which the authors suggest is the correct answer, based on their prior study of suspected tuberculosis in Rwanda. The authors go on to suggest that the lack of intuition about the shape of the posttest distributions can lead clinicians to overestimate the effect of small or modest changes in the therapeutic threshold and therefore to believe that thresholds are unstable in that small changes might recruit many more unaffected patients into the empiric treatment arm of the decision tree or may move many more affected patients into the no-treatment arm. Van den Ende and colleagues provide a second example of a U-shaped bimodal posterior distribution from the classic study by Diamond and others of exercise stress testing in patients who may have coronary disease. Although they posit that such bimodal posterior distributions are common, 2 examples may not establish a general principle. Of course, if such U-shaped posterior distributions were common, then indeed small or even moderate changes in the threshold for empiric treatment in a population might shift relatively few individuals from one strategy to the other (depending on where the threshold was located), making therapeutic thresholds far more stable and perhaps more trustworthy. Although Van den Ende’s work has been in populations, the same principles might apply to our belief in posttesting distributions in individual patients.

Prediction of Coronary Artery Stenosis at Rest in Patients With Normal Left Ventricular Wall Motion

Noninvasive detection of coronary artery stenosis usually requires a stress test in patients without left ventricular (LV) regional wall motion abnormalities (RWMA). In contrast, abnormal regional LV relaxation caused by ischemia may persist beyond recovery from transient ischemia. The aim of the present study was to determine whether segmental analysis of abnormal regional LV relaxation using the strain imaging diastolic index (SI-DI) at rest could predict coronary artery stenosis in the three major vessels in patients without LV dysfunction or RWMA. We performed 2D speckle tracking echocardiography and coronary angiography in 85 patients without RWMA with suspected coronary artery disease. Patients with LV dysfunction or acute coronary syndrome were excluded. Echocardiographic images of the LV were obtained in the apical 2-, 3-, and 4-chamber views and divided into 6 segments. In each segment, SI-DI derived from transverse strain imaging was determined. Forty-eight patients had significant coronary artery stenosis (≥ 70%). The optimal cutoff values of SI-DI were 60.5% in the mid anteroseptal segment for detecting left anterior descending artery stenosis (sensitivity, 83.3%; specificity, 81.1%), 60.5% in the basal anterolateral segment for detecting left circumflex artery stenosis (sensitivity, 80.9%; specificity, 90.3%), and 61.5% in the basal inferior segment for detecting right coronary artery stenosis (sensitivity, 74.1%; specificity, 77.8%). A segmental analysis of SI-DI at rest predicted coronary artery stenosis in the three major vessels in patients without RWMA. This noninvasive method may be useful for detecting coronary artery stenosis without a stress test.

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease

A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jacc.2012.07.013

Comparative Prediction of Cardiac Events by Wall Motion, Wall Motion Plus Coronary Flow Reserve, or Myocardial Perfusion Analysis: A Multicenter Study of Contrast Stress Echocardiography

This study sought to determine whether the increasing difficulty of assessing wall motion (WM), Doppler coronary flow reserve on the left anterior descending coronary artery (CFR-LAD), and myocardial perfusion (MP) during stress echocardiography (SE) was justified by increasing prognostic information in patients with known or suspected coronary artery disease. The use of echocardiographic contrast agents during SE permits the assessment of both CFR-LAD and MP, but their relative incremental prognostic value is undefined. This study followed a multicenter cohort of 718 patients for 16 months after high-dose dipyridamole contrast SE for evaluation of known or suspected coronary artery disease. The ability of WM, CFR-LAD, and MP to predict cardiac events was studied by multivariable models and risk reclassification. Abnormal SE was detected as a reversible WM abnormality in 18%, reversible MP defect in 27%, and CFR-LAD <2 in 38% of subjects. Fifty cardiac events occurred (annualized event rate 6.0%). A normal MP stress test had a 1-year hard event rate of 1.2%. The C-index of outcomes prediction based on clinical data was improved with MP (p < 0.001) and WM/CFR-LAD (p = 0.037), and MP (p = 0.003) added to clinical and WM data. Net risk reclassification was improved by adding MP (p < 0.001) or CFR-LAD (net reclassification improvement p = 0.001) in addition to clinical and WM data. The model including clinical data, WM/CFR-LAD, and MP performed better than that without MP did (p = 0.012). The multiparametric assessment of WM, CFR-LAD and MP during stress testing in patients with known or suspected coronary artery disease is feasible. Contrast SE allowed better prognostication, irrespective of the use of CFR-LAD or MP. The addition of either CFR-LAD or MP assessment to standard WM analysis and clinical parameters yielded progressively higher values for the prediction of cardiac events and may be required in today's intensively treated patients undergoing SE, because their average low risk of future cardiac events requires methods with higher predictive sensitivity than that available with standalone WM assessment.

Shared Decision Making

A primary challenge to the American healthcare system is to improve quality by being more evidence based, cost-effective, and patient centered.1,2 The first 2 markers of quality are familiar to physicians and policy makers, wherein disease-specific performance measures and cost data are commonly used to gauge outcomes. The third quality parameter, patient-centered care, has gained increased awareness among the healthcare community but remains elusive to many. Patient-centered outcomes focus on patients’ experiences (eg, symptoms, quality of life) and preferences for these and other outcomes. Thus, the best outcome may be different for different individuals, depending on their priorities, values, and goals. For example, in assessing the outcome of implanting a defibrillator in an 80-year-old patient, we may need to look beyond 1-year mortality and ask whether the decision is consistent with the patient’s values concerning dying and acceptance of potential inappropriate shocks.3 In a patient-centered model, the focus is on high-quality decision making, stemming from the exchange of (1) balanced, evidence-based, disease-specific information; (2) presentation of treatment options and their inherent benefits and tradeoffs; (3) assessment of patient values, priorities, and goals; and (4) alignment of patient values with treatment decisions.4 This process of shared decision making (SDM) has the potential to advance patients’ desired wishes and to achieve better patient-centered outcomes while lowering the costs of care should patients choose less expensive treatment options.5,6 Decision aids are commonly used to facilitate SDM, conveying information about a particular disease and the risks and benefits associated with different treatment strategies, including no treatment at all.7 Decision aids may take the form of a Web-based tool, video, or pamphlet and may be administered in the hospital or office or even independently by patients before their visit. To date, >86 randomized trials have been …

Lack of the QTc physiologic decrease during cardiac stress test in patients with type 2 diabetes treated with secretagogues

Patients with type 2 diabetes are at increased susceptibility to a prolonged QT interval. Furthermore, insulin secretagogues, drugs used to treat diabetes, may prolong QT interval and provoke arrhythmias. We evaluated whether secretagogues can affect QTc interval during cardiac stress test in 20 patients with type 2 diabetes treated with secretagogues. ECG stress test was performed in all patients. QTc interval was calculated both before cardiac stress test (BCST) and at acme of cardiac stress test (ACST). Diabetic patients treated with secretagogues showed longer QTc-ACST values than those treated with metformin only. QTc-ACST values resulted shorter than QTc-BCST values in control group. Diabetic patients treated with secretagogues showed QTc-ACST values significantly longer than QTc-BCST values. In our study, diabetic patients treated with secretagogues did not show the QTc physiologic decrease that is a protective against arrhythmias. These results suggest to evaluate, in these patients, QT length, even during routine cardiac stress test.

2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consensus documents society of thoracic surgeons society for vascular medicine

2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consensus documents society of thoracic surgeons society for vascular medicine

Stress Testing in Patients With Hypertrophic Cardiomyopathy

Exercise echocardiography is an important and useful tool for the evaluation of symptoms and monitoring the response to therapy in patients with hypertrophic cardiomyopathy (HCM). A significant number of patients without resting left ventricular outflow tract gradients develop dynamic obstruction with exercise. Detection of an exercise-induced gradient provides a therapeutic target for the relief of symptoms. Abnormal blood pressure response to exercise is an important, although nonspecific, risk factor for cardiovascular death in patients with HCM. Stress testing such as myocardial perfusion imaging lacks specificity in diagnosing coronary artery disease in patients with HCM but has a good negative predictive value. Exercise stress test in controlled environment seems to be safe in properly selected patients with HCM, and benefits of the diagnostic and prognostic information obtained outweigh the small risks.

The Chest Pain Choice Decision Aid

Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24-72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34-1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6-21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.