Treadmill Stress Research Articles

Evaluation of left ventricular flow field changes after stress in patients with nonobstructive coronary artery disease using ultrasonic flow vector imaging.

Vector flow mapping and treadmill exercise stress echocardiography were used to evaluate and explore changes in the left ventricular (LV) flow field of patients with nonobstructive coronary artery disease. Overall, 34 patients with nonobstructive (<50%) left anterior descending coronary artery stenosis (case group) and 36 patients with no coronary artery stenosis (control group) were included. Apical four-, three-, and two-chamber echocardiographic images were collected at rest and during early recovery from treadmill exercise. LV flow field, vortex area, and circulation (cir) changes were recorded in different phases: isovolumetric systole (S1), rapid ejection (S2), slow ejection (S3), isovolumetric diastole (D1), rapid filling (D2), slow filling (D3), and atrial systole (D4). Intra- and inter-group differences were compared before and after exercise loading. The control and case groups demonstrated regular trends of eddy current formation and dissipation at rest and under stress. Compared with the control group, the case group had irregular streamline distributions. Abnormal vortices formed in the S1 and D3 apical segments and D1 left ventricular middle segment in the resting group. Compared with the control group, the resting group had decreased left ventricular S1 vortex areas and increased S3 vortex areas. The post-stress D1 and D3 vortex areas and D1 and D2 cir increased. Compared with at rest, after stress, the control group had decreased S1, S3, D2, and D3 vortex areas; increased S2, D1, D3, and D4 cir; and decreased D2 cir. After stress, the case group had decreased S3 and D2 vortex areas, increased D1 vortex areas, and increased S2, D1, D3, and D4 cir (P all < 0.001). Logistic regression and ROC curve analyses show that increased D1 vortex area after stress is an independent risk factor for stenosis in nonobstructive stenosis of coronary arteries (OR: 1.007, 95% CI: 1.005-1.010, P < 0.05). A D1 vortex area cutoff value of 82.26 had an AUC, sensitivity, and specificity of 0.67, 0.655, and 0.726, respectively. The resting left ventricular flow field changed in patients with nonobstructive left anterior descending coronary artery stenosis. Both groups had more disordered left ventricular blood flow after stress. The increased D1 vortex area after stress is an independent risk factor for mild coronary stenosis and may contribute to the assessment of nonobstructive coronary stenosis. VFM combined with treadmill stress is useful in evaluating left ventricular flow field changes in patients with nonobstructive coronary artery disease, which is valuable in the early evaluation of coronary heart disease.

Comparative study among the patients with different coronary risk factors for detection of asymptomatic coronary artery disease by treadmill test confirmed by coronary angiography

Background: Cardiovascular diseases (CVD) such as ischemic heart disease (IHD) and cerebrovascular accidents such as stroke lead to 17.7 million deaths and are the leading cause of death worldwide. Global Burden of Disease study found that age-standardized CVD death rate in India (272/100,000 population) is much higher than the global average (235/100,000 population). Aims and Objectives: This study aimed to compare among different coronary risk factors like dyslipidemia, diabetes mellitus hypertension (HTN), and obesity which may lead to coronary artery disease (CAD) and early detection of ischemic heart disease by the stress treadmill test (TMT) among the patients having coronary risk factors. Materials and Methods: This is a prospective and observational study among 170 patients of age group 18–60 years having one or more coronary risk factors such as dyslipidemia, HTN, diabetes mellitus, and obesity. Patients with diagnosed IHD and other chronic debilitating diseases were excluded from the study. Results: Out of 170 patients, 153 patients were males and 17 patients were females. Among all these patients, 42 patients were suffering from dyslipidemia, 44 patients were suffering from Type 2 diabetes, 45 patients were suffering from HTN, and 39 patients were having more than one risk factor. All 170 patients with coronary risk factors performed TMT. Out of those patients, 53 were found to be TMT-positive. Binary regression analysis showed among all the selected risk factors, dyslipidemia (P&lt;0.05; odds ratio [OR]-2.104) and HTN (P&lt;0.05; OR-2.159) were found to be significantly associated with the positive outcome of TMT. All 53 TMT-positive patients were selected for CAG. Out of those patients, 37 were found to be suffering from CAD. Binary regression analysis showed among all the selected risk factors, dyslipidemia (P&lt;0.05; OR-1.964) and HTN (P&lt;0.05; OR-2.125) were found to be significantly associated with the positive outcome of CAG. Conclusion: Dyslipidemia and HTN were found to be significantly associated with the TMT-positivity as well as CAD. Diabetes mellitus and obesity were not statistically significant, though OR was more than 1 for both these risk factors.

The Prognostic Value of Duke Treadmill Score in Prediction of MPI Result

Abstract Objective This study was designed to reinforce the duke treadmill score of anginas during the treadmill stress test through a comparative study between the result of SPECT MPI study and the duke treadmill score of the suspected CAD since many centers and cardiology units have no capability of MPI study and eventually, that improve the early detection and the management of the high-risk cases in the limited units. Background Coronary artery disease is the leading cause of death worldwide and in our country Egypt. The diagnosis of CAD can be difficult to make. Frequently, the disease is diagnosed only after the patient has had a heart attack as symptoms of CAD range from unstable angina to no symptoms at all. Duke treadmill score (DTS) is well recognized as a simple prognostic score in patients with suspected coronary artery disease (CAD). Patients and Methods A retrospective review of the studies patients underwent stress treadmill test MPI between January to October 2020 were consecutively included in our study. The study was conducted in ALFA Scan Radiology Center, Cairo, Egypt. Results There was a highly statistically significant difference between the high risk and the other 2 groups (low &amp; moderate) regarding the inability to continue the test. Where High-risk group showed an increased incidence of early inability to continue and there was a significant relation between the duke treadmill score and Aston summed stress score among the studied patients (P= 0.018). Conclusion Duke's score is valid in predicting coronary arterial disease. High-risk Duke's score patients need to be referred directly to coronary angiography for they usually have significant coronary disease. DTS can provide pre-processing guidance about revascularization for physicians before the procedure. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Features of the course of arterial hypertension in military servicemen in the conditions of the Аrctic region

Purpose.To study the frequency of occurrence of cardiovascular risk factors and the course of arterial hypertension in military personnel in the Arctic region.Materials and methods.251 male servicemen aged 23–44 years (mean age 33.7±4.9 years) were examined and studied medical records. Depending on the place of service, all the examined were divided into two groups: I — 159 military personnel serving in the Arctic, II — 92 military personnel from the Western Military District. The studied cardiovascular risk factors included dyslipidemia, tobacco smoking, high blood pressure, abdominal obesity, psychosocial factors, dietary disorders, regular alcohol consumption, physical inactivity. We also analyzed the frequency of occurrence of a confirmed diagnosis of neurocirculatory asthenia and stage I–II hypertension.Results and its discussion.The survey showed a significant increase in the incidence of most of the studied predictors of cardiovascular risk (dyslipidemia, smoking, negative psychosocial factors, dietary disorders, and regular alcohol consumption) in the Arctic region group compared to the temperate climate group. This is realized in the form of a higher incidence of arterial hypertension and a trend towards an increase in the number of cases of generalized atherosclerosis among military personnel in the Arctic. The data obtained may indicate the need for a more thorough selection for service in the Arctic region with a mandatory in-depth examination of the circulatory and metabolic systems, including electrocardiography, echocardiography, stress treadmill test, ultrasound examination of the brachiocephalic arteries with the determination of the thickness of the intima-media complex, sphygmomanometry with the determination of the stiffness and biological age of the vessels, the study of the lipid profile and fasting glycemia. It is advisable to conduct an annual examination of the military personnel of the Arctic group at the place of service with the involvement of visiting military medical commissions, which should include a cardiologist and a specialist in functional diagnostics.

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A 67-year-old man with several cardiovascular risk factors was referred to cardiology consultation, due to effort angina – Canadian Cardiology Society (CCS) class II/IV, for the last 6 months, under optimal medical treatment. Resting electrocardiogram and transthoracic echocardiogram (TTE) were normal. Stress treadmill test was positive. The coronary angiogram revealed a long proximal chronic total occlusion (CTO) of the left anterior descending artery (LAD; J-CTO=1, Rentrop3), a distal CTO of the left circumflex artery (J-CTO=0, Rentrop3) and a 50% stenosis [...]

The Effect of Echocardiography Based on Lipid Nano Contrast Agent on Cardiology Patients with Heart Failure and Atrial Fibrillation.

This paper discusses the effect and evaluation of echocardiography based on lipid nano contrast agent on patients with heart failure and atrial fibrillation in cardiology department, providing reference for clinical diagnosis and treatment. Fifty two patients with diastolic heart failure diagnosed by echocardiography were selected for routine echocardiographic examination after optimizing the drug treatment scheme, and then the patients underwent treadmill exercise test and stress echocardiography evaluation. The results of conventional echocardiography and stress echocardiography after treatment were compared with those before treatment, and the clinical parameters and biochemical indexes before and after treatment were compared. Results after treatment, the clinical symptoms of the patients improved, the level of NT proBNP in the N-terminal forebrain decreased significantly, and the exercise tolerance increased significantly. Compared with the conventional echocardiography before and after treatment, the left ratio and e' value of stress echocardiography after treatment increased significantly, while E/e' decreased significantly. There was no significant difference in the indexes of general echocardiography before and after treatment. After treatment, positively correlated with the ratio of peak a to peak E. The results show that the sensitivity of stress echocardiography to evaluate ischemic diastolic heart failure has been improved, and some indexes have clinical significance. Compared with conventional echocardiography, it can effectively evaluate the therapeutic effect of drugs.

The Diagnostic Accuracy of Exercise Treadmill Testing and Stress Echocardiography for the Detection of Obstructive Coronary Artery Disease in Patients Aged ≥ 70 Years

to compare diagnostic accuracy of exercise treadmill testing and stress echocardiography in the diagnosis of stable coronary artery disease (CAD) in patients aged &gt;70 years. The study included 390 patients aged &gt;70 years with suspected stable ischemic heart disease, who underwent elective coronary artery angiography (CAG). Exercise treadmill testing (ETT) according to the modified Bruce protocol was carried out in 189 patients (48 %), bicycle stress echocardiography - in 179 patients (46 %). Initially we determined the prevalence of angiographically significant CAD according to the gender and chest pain character, and identified persons in whom stress testing was appropriate. After that diagnostic accuracy of both tests was evaluated in patients with atypical angina and non-anginal chest pain. Among 72 patients with atypical angina and non-anginal pain who underwent ETT and had unequivocal results, 38 (53 %) had obstructive CAD. ETT for detection of obstructive CAD had sensitivity 79 %, specificity 82 %, positive likelihood ratio (LR+) 4.4, and negative likelihood ratio (LR-) 0.3. Positive result increased probability of obstructive CAD from 53 % to 83 %, negative result reduced probability of obstructive CAD to 25 %. Among 111 patients with atypical angina and non-anginal pain who underwent stress echocardiography and had unequivocal results, 69 (62 %) had obstructive CAD. Sensitivity, specificity, LR+, and LR- of stress echocardiography were equal to 89 %, 95 %, 17.8, and 0.1, respectively. Positive result increased probability of obstructive CAD from 62 % to 95 %, negative result reduced probability of obstructive CAD to 16 %. bicycle stress echocardiography was found to be more accurate than ETT to rule in or rule out obstructive CAD in patients aged ≥ 70 years with atypical angina and non-anginal pain.

P2644Coronary atherosclerotic burden and risk of major adverse cardiac events in hypertensive patients with erectile dysfunction

Abstract Purpose Aim of the study is to assess the prevalence of angiographically coronary artery disease (CAD) and the incidence of future cardiovascular (CV) events among hypertensive males with erectile dysfunction (ED) on the basis of calculated total CV risk at first presentation. Methods A total of 392 hypertensive ED patients without diabetes or known cardiovascular disease underwent a comprehensive evaluation for presence of target organ damage (TOD) and stratified into three total CV risk categories based on blood pressure (BP) category, CV risk factors, TOD and presence of chronic kidney disease. Total testosterone (TT) and peak systolic velocity (PSV) at penile arteries were measured as markers of ED severity and predictors of CV risk. All patients underwent exercise treadmill test and stress echocardiography to reveal myocardial ischemia. Men with positive one or both of the two tests were referred for coronary angiography in order to document CAD. Our primary outcome was a composite measure which included acute myocardial infarction (AMI), stroke, congestive heart failure, revascularization with either percutaneous coronary intervention or coronary artery bypass graft surgery. All patients were followed from cohort entry until major CV event, or end of study period (December 2018), whichever occurred first. Results The whole population was divided into high (n=176), intermediate (n=120) and low (n=96) total CV risk groups. The three groups had similar mean age (57 yrs). The prevalence of angiographically documented CAD was significantly higher among patients in the high risk group (n=32, 18%), compared to intermediate (n=15, 12.5%) and low risk (n=4, 4.1%) (overall P&lt;0.05). Furthermore, there was a progressive decrease in penile PSV and TT levels from low to moderate and high total CV risk (35 vs 31 vs 28 cm/s and 5.1 vs 4.3 vs 3.8 ng/ml, respectively, overall P&lt;0.001), indicating significant microvascular damage and androgen deficiency in men with a higher CV risk category. Interestingly, Kaplan-Meier analysis revealed a comparable incidence of major CV events in patients who were at high and intermediate total CV risk at entry (12.5% vs. 11%, respectively, log-rank =0.57) and a greater incidence of major CV events compared to that of low CV risk patients (3.2%), (log-rank P=0.004, for all comparisons) during a 9-year follow-up period (figure). CV events during a 9-year follow-up Conclusion The incidence of future CV events is considerably high among hypertensive ED patients with a intermediate total CV risk at first evaluation. Such patients may require a comprehensive evaluation to reveal occult CAD and they need an aggressive management of BP and concomitant risk factors to reduce their CV risk and improve their sexual life.

Abstract 163: Economy of Handheld Ultrasound in an Outreach Clinic Setting

Introduction: The usefulness of Handheld Ultrasound (HHU) is increasingly recognized in a variety of settings. This study demonstrates the ability of HHU to dramatically reduce costs in the clinic setting. Objectives: An HHU was implemented in 2018 to perform bedside echocardiograms at the USF outreach clinic (BRIDGE) with the expectation of cost savings. Methods: The implementation of the HHU at the BRIDGE clinic began in early 2018. Prior to 2018, all BRIDGE patients requiring any cardiac tests were referred to the separate USF Cardiology clinic. Following the implementation of the HHU at the BRIDGE clinic, all necessary echocardiograms were performed initially with the HHU in-clinic with additional testing referred to USF Cardiology, if needed. Data on all BRIDGE clinic patients who received cardiac care in 2017 was compiled and compared to all clinic patients who received cardiac care in 2018, after the implementation of the HHU. Primary variables compared by patient were number of follow-up visits, and number and type of tests ordered (complete and stress echocardiograms, treadmill and nuclear stress tests, and ambulatory monitors). An analysis was then conducted to determine differences in visits and overall costs by BRIDGE clinic patients before and after HHU implementation. Cost data for tests was obtained from the USF financial department. Results: In 2017, 17 patients were seen in BRIDGE clinic that were subsequently referred to cardiology for further care/testing. In 2018, 20 cardiac patients were evaluated in BRIDGE clinic and 25% required further testing. Across 2017 patients, there was an average of 1.53 cardiology follow-up visits and 1.47 cardiac tests conducted per patient, while overall tests costs averaged $383.77 per patient. In comparison, across 2018 patients there was an average of 0.4 cardiology follow-up visits and 0.3 cardiac tests conducted per patient, while overall test costs averaged $284.40 across patients who received further testing. This represents an 25.9% decrease in cost after implementation of HHU. Conclusions: These results demonstrate that BRIDGE clinic patients after HHU implementation had both less cardiology follow-up visits and tests conducted, which led to lower overall costs. This was largely due to the significant reduction in the number of complete echocardiogram tests ordered as these were performed in-clinic with the lower-cost HHU.

Increased monocyte-to-HDL cholesterol ratio is related to cardiac syndrome X

Objective: Cardiac syndrome X (CSX) is typically identified with ischaemia in treadmill exercise test or stress myocardial perfusion scintigraphy as well as angina-like chest pain without stenosis in coronary angiography. The purpose of the present study is to investigate the association between cardiac syndrome X and monocyte-to-HDL cholesterol ratio (MHR) which is a new marker associated with inflammation.Patients and methods: A total of 230 patients (105 patients with cardiac syndrome X and 125 normal controls) were included in the study. Peripheral venous blood samples were drawn from all study population before coronary angiography for measuring MHR and other haematological parameters.Results: The patients with cardiac syndrome X were more likely to have higher platelet counts, plateletcrit (PCT), monocyte count and MHR values. Monocyte count and MHR of the CSX group were significantly higher than the control group [0.53 (0.35–1) vs. 0.49 (0.23–0.96); p = .002, .011 (0.006–0.038) vs. 0.010 (0.004–0.034); p < .001, respectively]. HDL-cholesterol levels of the CSX group were significantly lower than the control groups (46.3 ± 10.1 vs. 49.6 ± 11.6; p = .021). Higher MHR and PCT values were found to be associated with the presence of CSX by multivariate logistic regression analysis.Conclusions: Elevated MHR level independently was found in association with the presence of CSX. The value of MHR appears additive to conventional expensive methods commonly used in CSX prediction.

Contractile reserve and cardiopulmonary exercise parameters in patients with dilated cardiomyopathy, the two dimensions of exercise testing.

Left ventricular (LV) contractile reserve assessed using imaging and cardiopulmonary exercise testing (CPX) has been shown to predict outcome in patients with dilated cardiomyopathy (DCM). Few clinical studies have, however, analyzed the relationship between them. A cohort of 75 ambulatory patients with DCM underwent stress treadmill echocardiography with CPX. LV contractile reserve was calculated as absolute change (ΔLVEF=LVEFpeak -LVEFrest ) and percent change (%LVEF=[(LVEFpeak -LVEFrest )/LVEFpeak) ]×100) in LVEF, circumferential and longitudinal strain (LS). Exercise capacity was measured as peak oxygen uptake (peak VO2 ) and ventilatory efficiency as the slope of minute ventilation to CO2 production (VE/VCO2 slope). Values of contractile reserve were compared to matched controls. We also explored which metric of ventricular response (absolute or percent change) was less dependent on baseline LV function. Patients with DCM had a mean age, rest and peak LVEF of 44±10years, 42±10% and 50±12%, respectively. Among parameters of contractile reserve, peak cardiac output was the strongest parameter associated with peak VO2 (r=.63, P<.001). Along with age, sex, and BMI, it explained more than 70% of the variance in peak VO2 . In contrast, LVEF and LS were only weakly related to peak VO2 . With regard to ventilatory efficiency, the strongest parameter that emerged was right atrial volume index (r=.36, P<.001). Percent change in LVEF was more independent of baseline function than absolute change. Echocardiographic contractile reserve and CPX provide complementary information. Percent change in contractile reserve was most independent of baseline function, therefore may be preferred when analyzing the ventricular response to exercise.

Coronary angiography finding of exercise tread mill test positive patients in a tertiary care center

Background and Aims: The use of coronary angiography in diagnosing coronary artery disease is limited by its invasive property. In the other hand correct interpretation of tread mill test data and its use as a key diagnostic modality also has been a problem. The study was thus aimed to see the diagnostic accuracy of treadmill test to rule out coronary artery disease.Methods: We included all the patients who had positive tread mill stress test and underwent coronary angiography and were subsequently analyzed for presence of coronary artery disease.Results: A total of 303 patients were included with 119 males and 184 females with mean age of 53.6±10.5 yrs and 51.7±8.6 yrs respectively. Normal coronaries was seen in 114(54.0%), borderline lesion in 29 (13.7%) and significant lesion in 68 (32.2%) with 48(22.7%) having single vessel disease, 29(13.7%) double vessel disease and 14(6.6%) triple vessel disease. Coronary artery diseases was highest among diabetics (57.7%, OR 1.72 (95 % CI: 0.92 to 3.20), p value-0.08).Similarly the risk of coronary artery disease was significantly highest among patient with ≥2 risk factor (OR: 8.10,95 % CI: 4.96 to 13.24, P &lt; 0.0001). Gender distribution showed that coronary artery disease was significantly higher in males than females (53% vs 35% respectively, OR: 2.08, 95 % CI: 1.30 to 3.32, p value-0.002).Conclusion: The value of tread mill test to predict coronary artery disease is highest in patients with two or more risk factor especially in those with diabetes with significance increased among males.

Costs of Anatomic vs. Functional Testing for Coronary Artery Disease

In the PROMISE trial, researchers randomized 10,000 symptomatic outpatients without known coronary artery disease (CAD) to anatomic testing (computed tomography angiography [CTA]) or functional testing (exercise treadmill testing, stress echocardiography, or nuclear stress testing) to evaluate for obstructive CAD. At a median follow-up of 25 months, the primary and secondary outcomes, which included all-cause mortality and myocardial infarction, …

A Red Herring in a College Track and Field Thrower

HISTORY: 18 year old male track and field thrower, who was previously healthy, presented to the training room clinic 2 months after being diagnosed with mono by his PCP. The symptoms at the time of presentation to his PCP were fatigue and palpitations, and his labs showed elevated liver enzymes. The patient continued to have the same symptoms at the time of presentation to us. He had been on long term (>1 yr) Bactrim for acne, denied taking Tylenol regularly, but did occasionally drink ETOH. At the time of presentation to the training room, he had been scheduled for a stress treadmill and cardiac evaluation for work up of the palpitations. PHYSICAL EXAMINATION: Constitutional: Well developed. Eyes: B/L No injection. Neck: Inspection reveals symmetry. Respiratory: Lungs clear to auscultation. Normal effort Cardiovascular: No murmurs RRR No edema is present. Vascular: Pulses Capillary refill less than 2 sec. Abd: Symmetric - no distention. BS +, no bruits. NT, no RRG. No hepatic enlargement. Integumentary: No impressive skin lesions present. Ext: No edema. Neurological: Memory: Intact . Psychiatric: OA x 3 demonstrates the appropriate mood and affect. DIFFERENTIAL DIAGNOSIS: - Drug-induced hepatitis from multiple years of Bactrim use -ETOH abuse - Viral hepatitis - Gallbladder polyp/stones - Hemochromatosis - Mono TEST AND RESULTS: Hepatitis panel negative, CMP- Normal except for ALT 211 AST 87 Negative treadmill stress test FU lab 9 m later showed- Negative mono test, but ferritin was 5172, Total iron binding capacity 317, % of iron sat 91 %, iron 289, genetic testing for hemochromatosis was negative. FINAL WORKING DIAGNOSIS: Hemochromatosis TREATMENT AND OUTCOMES: Patient is doing much better at this time. Patient started out getting phlebotomies every 2 weeks and then was increased to twice weekly. His last ferritin was 750 and he continues now with once weekly phlebotomies. He is currently participating without restrictions in track and field at the NCAA level.

A Thermal Stress Treadmill Walk for Clinic Evaluation of Candidates for Hazardous Materials (HazMat) Duty

U.S. guidance for examining hazmat workers recommends stress testing be considered when heat stress is expected. However, the most common stress test—Bruce protocol treadmill electrocardiography (BPTE) wearing gym clothes—creates little thermal stress. Objective. Evaluate a novel thermal stress treadmill walk (TSTW). Methods. Body temperatures and heart rates during BPTE in 93 current and potential hazmat workers wearing gym clothes were compared with later values in 35 of these subjects while they were wearing thermally-restrictive “sauna suits “ during a 45-min TSTW. Physiological strain index (PSI) was calculated from temperature and heart rate changes and compared with PSI values from hazmat simulations and climatic chamber exercises. Results. Tympanic temperature (TT) rose 0.5 °C (SD 0.5) during BPTE lasting 12.4 min (SD 2.9). PSI reached 6.0 (SD 1.3). TT rose 1.0°C (SD 0.5) during TSTW, p < .01. PSI averaged 6.6 (SD 1.9) in 29 subjects who completed TSTW, versus 5.7 (SD 5.7) in the 6 subjects who did not. Ingested thermistor temperatures increased more than did TT during TSTW, yielding PSI of 7.0 (SD 1.5), equal to PSI values from climatic chamber exercises, i.e., 7.0 (SD 1.0). Conclusion. TSTW increased body temperature and PSI in 29 of the 35 subjects who completed it to levels matching those of operational simulations in climatic chambers and during hazmat exercises. This TSTW may be useful for evaluating candidates for hazmat duty.

Abstract 89: Utility of Stress Echocardiography in Cocaine Associated Chest Pain

Background: Patients presenting with Cocaine associated chest pain are typically younger than patients with traditional risk factors but are at risk for accelerated Coronary artery disease. Radiation exposure associated with modes of stress testing such as Coronary CT or SPECT, makes it concerning especially in young females of childbearing age group presenting with cocaine associated chest pain. Stress echocardiography avoids radiation exposure, is more cost effective, saves time and adds to diagnostic information especially in patients with chest pain. However, safety of stress echocardiography has not been well studied in cocaine positive patients. Pharmacological testing with dobutamine raises concerns regarding provoking vasospasm or an exaggerated hypertensive response in these patients due to excessive sympathetic stimulation. Hypertensive response with stress testing can cause wall motion abnormalities without coronary disease and affect specificity of stress echocardiography. Methods: We conducted a retrospective analysis of patients who presented with chest pain and underwent stress echocardiography and had toxicology screen for cocaine positive during that visit. Cocaine positive patients were compared with age matched cocaine negative patients and assessed for hypertensive response, ischemic changes and complications during stress echocardiography. Results: No sustained arrhythmias, cardiac arrests or major complications occurred in both groups and overall safety in cocaine positive patients was similar to the control group both with treadmill and dobutamine stress echocardiography. Incidence of hypertensive response was not increased compared to controls with both exercise and dobutamine stress testing. Conclusion: Stress echocardiography appears to be a safe and useful procedure for risk stratification for cocaine associated chest pain patients once acute coronary syndrome is ruled out.

1:46 PM Abstract No. 94 - ■ Dr. Constantin Cope Medical Student Research AwardThermographic view of below the knee arteries: based on angiosome concept

Purpose To propose thermographic views of foot and ankle based on angiosome concept and to evaluate the infra-red thermographic findings of foot and ankle using pre- and post-stress treadmill tests. Materials and Methods Twenty four healthy volunteers were enrolled in this study. In all study population, various thermophotographic views of foot and ankle were obtained using infra-red thermophotography (IRIS-5000, Medicore™) before and after stress treadmill tests (AP3126, Apsun Inc.;12% incline, 5 min, 2 mph). For temperature measurement, region of interest (ROI) was placed in territories of three major arteries below the knee, based on angiosome concept. We compared the foot and ankle temperatures before and after stress treadmill tests and analyzed by Mann-Whitney test. Results The temperature range was 26.06 to 30.19 on pre-stress tests and 26.03 to 29.72 on post-stress tests. The average temperature was 27.66 ± 1.30 on pre-stress tests and 27.24 ± 1.14 on post-stress tests. There was statistically significant difference of the average temperature between pre- and post- stress tests (P Conclusion Infra-red thermophotography combined with treadmill stress test and its quantitative measurement might be a one of screening modality for evaluation of BTK arterial insufficiency. Further improvements of the technique and the diagnostic criteria are expected for more useful in the clinical application.

Prognostic Value of Late Heart Rate Recovery After Treadmill Exercise

Recovery from exercise can be divided into an early, rapid period and a late, slower period. Although early heart rate (HR) recovery 1 minute after treadmill exercise independently predicts survival, the prognostic value of late HR recovery has not been well studied. The aim of this study was to evaluate the independent prognostic value of late HR recovery for all-cause mortality. A total of 2,082 patients referred to the nuclear cardiology laboratory of an urban academic medical center for treadmill exercise with imaging from August 1998 to December 2003 were followed for all-cause mortality. During 9.9 ± 1.5 years of follow-up, 196 deaths (9%) occurred. To avoid overlap with early HR recovery or the baseline HR, late HR recovery was defined as the percentage of the cycle length change between rest and peak exercise that had been recovered after 5 minutes. Lower values represent impaired recovery, by analogy with 1-minute HR recovery. Impaired late HR recovery was a significant univariate predictor of all-cause mortality (hazard ratio 0.28 per percentage, 95% confidence interval 0.17 to 0.46, p <0.001). It significantly improved a nested, multivariate model (change in chi-square 8.66, p = 0.003), including 1-minute HR recovery, with independent prognostic value (adjusted hazard ratio 0.58, 95% confidence interval 0.41 to 0.84, p = 0.004). In conclusion, late HR recovery after treadmill exercise stress adds prognostic value for all-cause mortality to a multivariate model including early, 1-minute HR recovery.

Exercise Stress Treadmill Testing

Exercise Stress Treadmill Testing

Survival by Stress Modality in Patients With a Normal Myocardial Perfusion Study

We sought to determine the differential prognosis of patients with a normal single-photon emission computed tomographic (SPECT) perfusion study by type of stress modality. Even with a normal SPECT perfusion study, patients selected for adenosine stress have a worse survival than those selected for exercise stress. In patients who are able, low-level treadmill exercise is commonly performed during adenosine infusion ("walking" adenosine). The adjusted differential prognosis of patients performing walking adenosine is unknown. Our historical cohort underwent adenosine or treadmill stress with SPECT imaging during 2003 and 2004. Adenosine studies were classified as walking or adenosine only (no low-level exercise). Patients with an abnormal single-photon emission computed tomogram or missing demographic information were excluded. All-cause mortality was determined through July 2008. In total 3,479 patients were included, of which 1,451 (41.7%) were stressed with adenosine only, 201 (5.8%) with walking adenosine, and 1,827 (52.5%) with treadmill exercise. Over an average of 4.3 ± 1.0 years of follow-up, 307 (8.8%) died. Mortality was greatest for adenosine only, intermediate for walking adenosine, and least for exercise (p <0.001 by log-rank test), even after accounting for covariates (adjusted hazard ratio for walking adenosine 0.57, p = 0.044). In conclusion, patients with a normal SPECT perfusion scan who are able to undergo an adenosine protocol in conjunction with exercise have an intermediate prognosis between those who cannot perform low-level exercise and patients able to undergo full treadmill exercise. This differential survival remains significant after adjustment, perhaps because of differences in baseline functional capacity.