Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies

Enhancing the diagnostic specificity of exercise ECG testing in obstructive coronary artery disease: the role of the Selvester QRS score

BACKGROUND

Exercise ECG testing is a widely used, noninvasive tool for detecting obstructive coronary artery disease (OCAD). However, its diagnostic performance is often limited by low specificity, leading to false-positive results and unnecessary invasive procedures.

OBJECTIVE

This study aims to assess the potential of combining the Selvester QRS score with exercise ECG to enhance diagnostic specificity for OCAD in patients with suspected stable angina.

METHODS

This retrospective study included 203 patients who presented with chest pain, underwent exercise ECG and were assessed for OCAD by coronary angiography or computed tomography angiography. Receiver operating characteristic analysis identified the optimal Selvester QRS score cutoff and assessed the diagnostic performance of exercise ECG and the combined model. Multivariable logistic regression was performed in the exercise ECG positive and negative groups.

RESULTS

Of the 203 patients, 116 were diagnosed with OCAD. The optimal Selvester QRS score cutoff was ≥3, with a sensitivity of 83.6% and a specificity of 93.1%. The combination of a positive exercise ECG and a Selvester QRS score ≥3 achieved the highest specificity (98.9%). Regression analyses showed that Selvester QRS score ≥3 was an independent predictor of OCAD, even in patients with negative exercise ECG results (adjusted odds ratio: 7.018; P < 0.001).

CONCLUSION

The Selvester QRS score can improve the specificity of the exercise ECG in detecting OCAD in patients with suspected stable angina. This approach has the potential to reduce false positives and unnecessary invasive procedures by improving risk stratification.

Evaluating patients with chest pain in the emergency department

Identifying patients with chest pain that is of cardiac origin is crucial owing to the high mortality and morbidity of cardiovascular diseases. History, electrocardiogram, and cardiac biomarkers are the core elements of the assessment. High sensitivity cardiac troponins (hs-cTn) are the preferred biomarkers for diagnosing acute myocardial infarction, allowing for more accurate detection and exclusion of myocardial injury. However, elevations in hs-cTn can occur in patients who are not experiencing acute myocardial infarction. Therefore, it is important for clinicians to recognize how to integrate hs-cTn levels into their clinical decision making process. Structured risk assessments, using evidence based diagnostic protocols, should be employed to estimate the risk of acute coronary syndrome and adverse events in patients with chest pain. Clinical decision pathways should be used routinely in emergency departments. Patients at intermediate or high risk of obstructive coronary artery disease might benefit from cardiac imaging and further testing. Patients should be involved in decision making, with information provided about risks, radiation exposure, costs, and alternative options to facilitate informed decision making.

Use of ST/HR hysteresis decreases false positive rate in exercise electrocardiography test of middle-aged asymptomatic women

BACKGROUND

Exercise electrocardiography (ECG) is a common diagnostic and prognostic method for the detection of coronary artery disease (CAD). However, its accuracy in asymptomatic women has not been comprehensively investigated and the diagnostic criteria may require refinements. This study evaluated the performance of ECG-derived ST/HR-index, ST/HR hysteresis and ST-segment depression parameters among asymptomatic middle-aged women.

METHODS

108 women (mean age 56 ± 4 years) performed exercise ECG test on treadmill until exhaustion three times within a nine-month period. False-positive rates of maximum ST/HR-index, ST/HR hysteresis, and ST-segment depression values measured from 12 leads at peak exercise and after one-minute recovery were evaluated with recommended diagnostic partition values. Repeatability was assessed with intraclass correlation (ICC) and Bland-Altman plot analysis.

RESULTS

False-positive rate was lower for all variables when a two‑lead configuration was used instead of a single‑lead configuration. Using a two‑lead configuration, ST/HR hysteresis (0-1.9 %) and ST-segment depression after one-minute recovery (0-2.8 %) had lower false-positive rates compared to ST/HR index (3.7-20.4 %) and ST-segment depression at peak exercise (9.3-27.8 %). ICC values indicated moderate repeatability for ST/HR hysteresis while ST/HR index, ST-segment at peak exercise, and ST-segment after one-minute recovery had moderate-to-good repeatability. Bland-Altman analysis indicated poor repeatability for all evaluated ECG variables.

CONCLUSION

In asymptomatic middle-aged women, practitioners should prefer the use of ST/HR hysteresis and ST-segment after one-minute recovery over the conventional ST-segment depression at peak exercise or ST/HR index, and evaluate the ECG data from a two‑lead configuration instead of single‑lead.

Brazilian Guideline for Exercise Testing in Children and Adolescents - 2024

CLASSES OF RECOMMENDATION

LEVELS OF EVIDENCE

Cardiomegaly: Navigating the uncharted territories of heart failure - A multimodal radiological journey through advanced imaging, pathophysiological landscapes, and innovative therapeutic frontiers

Cardiomegaly is among the disorders categorized by a structural enlargement of the heart by any of the situations including pregnancy, resulting in damage to heart muscles and causing trouble in normal heart functioning. Cardiomegaly can be defined in terms of dilatation with an enlarged heart and decreased left or biventricular contraction. The genetic origin of cardiomegaly is becoming more evident due to extensive genomic research opening up new avenues to ensure the use of precision medicine. Cardiomegaly is usually assessed by using an array of radiological modalities, including computed tomography (CT) scans, chest X-rays, and MRIs. These imaging techniques have provided an important opportunity for the physiology and anatomy of the heart. This review aims to highlight the complexity of cardiomegaly, highlighting the contribution of both ecological and genetic variables to its progression. Moreover, we further highlight the worth of precise clinical diagnosis, which comprises blood biomarkers and electrocardiograms (EKG ECG), demonstrating the significance of distinguishing between numerous basic causes. Finally, the analysis highlights the extensive variation of treatment lines, such as lifestyle modifications, prescription drugs, surgery, and implantable devices, although highlighting the critical need for individualized and personalized care.

Machine learning in cardiac stress test interpretation: a systematic review

Coronary artery disease (CAD) is a leading health challenge worldwide. Exercise stress testing is a foundational non-invasive diagnostic tool. Nonetheless, its variable accuracy prompts the exploration of more reliable methods. Recent advancements in machine learning (ML), including deep learning and natural language processing, have shown potential in refining the interpretation of stress testing data. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of ML applications in stress electrocardiogram (ECG) and stress echocardiography for CAD prognosis. Medical Literature Analysis and Retrieval System Online, Web of Science, and the Cochrane Library were used as databases. We analysed the ML models, outcomes, and performance metrics. Overall, seven relevant studies were identified. Machine-learning applications in stress ECGs resulted in sensitivity and specificity improvements. Some models achieved rates of above 96% in both metrics and reduced false positives by up to 21%. In stress echocardiography, ML models demonstrated an increase in diagnostic precision. Some models achieved specificity and sensitivity rates of up to 92.7 and 84.4%, respectively. Natural language processing applications enabled the categorization of stress echocardiography reports, with accuracy rates nearing 98%. Limitations include a small, retrospective study pool and the exclusion of nuclear stress testing, due to its well-documented status. This review indicates the potential of artificial intelligence applications in refining CAD stress testing assessment. Further development for real-world use is warranted.

The roles of exercise stress echocardiography for the evaluation of heart failure with preserved ejection fraction in the heart failure pandemic era

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly 70% of all HF and has become the dominant form of HF. The increased prevalence of HFpEF has contributed to a rise in the number of HF patients, known as the "heart failure pandemic". In addition to the fact that HF is a progressive disease and a delayed diagnosis may worsen clinical outcomes, the emergence of disease-modifying treatments such as sodium-glucose transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists has made appropriate and timely identification of HFpEF even more important. However, diagnosis of HFpEF remains challenging in patients with a lower degree of congestion. In addition to normal EF, this is related to the fact that left ventricular (LV) filling pressures are often normal at rest but become abnormal during exercise. Exercise stress echocardiography can identify such exercise-induced elevations in LV filling pressures and facilitate the diagnosis of HFpEF. Exercise stress echocardiography may also be useful for risk stratification and assessment of exercise tolerance as well as cardiovascular responses to exercise. Recent attention has focused on dedicated dyspnea clinics to identify early HFpEF among patients with unexplained dyspnea and to investigate the causes of dyspnea. This review discusses the role of exercise stress echocardiography in the diagnosis and evaluation of HFpEF.

Temporal Relationship-Aware Treadmill Exercise Test Analysis Network for Coronary Artery Disease Diagnosis

The treadmill exercise test (TET) serves as a non-invasive method for the diagnosis of coronary artery disease (CAD). Despite its widespread use, TET reports are susceptible to external influences, heightening the risk of misdiagnosis and underdiagnosis. In this paper, we propose a novel automatic CAD diagnosis approach. The proposed approach introduces a customized preprocessing method to obtain clear electrocardiograms (ECGs) from individual TET reports. Additionally, it presents TETDiaNet, a novel neural network designed to explore the temporal relationships within TET ECGs. Central to TETDiaNet is the TETDia block, which mimics clinicians' diagnostic processes to extract essential diagnostic information. This block encompasses an intra-state contextual learning module and an inter-state contextual learning module, modeling the temporal relationships within a single state and between states, respectively. These two modules help the TETDia block to capture effective diagnosis information by exploring the temporal relationships within TET ECGs. Furthermore, we establish a new TET dataset named TET4CAD for CAD diagnosis. It contains simplified TET reports for 192 CAD patients and 224 non-CAD patients, and each patient undergoes coronary angiography for labeling. Experimental results on TET4CAD underscore the superior performance of the proposed approach, highlighting the discriminative value of the temporal relationships within TET ECGs for CAD diagnosis.

Practice guidance for stress echocardiography

Stress echocardiography has been one of the most promising methods for the diagnosis of ischemic heart disease, hypertrophic cardiomyopathy, and pulmonary hypertension. The Japanese Society of Echocardiography produced practical guidance for the implementation of stress echocardiography in 2018. At that time, stress echocardiography was not yet widely disseminated in Japan; therefore, the 2018 practical guidance for the implementation of stress echocardiography included a report on stress echocardiography and a specific protocol to promote its use at many institutions in Japan in the future. And now, an era of renewed interest and enthusiasm surrounding the diagnosis and treatment of valvular heart disease and heart failure with preserved ejection fraction (HFpEF) has come, which are driven by emerging trans-catheter procedures and new recommended guideline-directed medical therapy. Based on the continued evidence of stress echocardiography, the new practical guideline that describes the safe and effective methodology of stress echocardiography is now created by the Guideline Development Committee of the Japanese Society of Echocardiography and is designed to expand the use of stress echocardiography for valvular heart disease and HFpEF, as well as ischemic heart disease, hypertrophic cardiomyopathy, and pulmonary hypertension. The readers are encouraged to perform stress echocardiography which will enhance the diagnosis and management of these patients.

Development and Validation of a Nomogram for Predicting the Severity of Coronary Artery Disease Based on Cardiopulmonary Exercise Testing

As a major global health concern, coronary artery disease (CAD) demands precise, noninvasive diagnostic methods like cardiopulmonary exercise testing (CPET) for effective assessment and management, balancing the need for accurate disease severity evaluation with improved treatment decision-making. Our objective was to develop and validate a nomogram based on CPET parameters for noninvasively predicting the severity of CAD, thereby assisting clinicians in more effectively assessing patient conditions. This study analyzed 525 patients divided into training (367) and validation (183) cohorts, identifying key CAD severity indicators using least absolute shrinkage and selection operator (LASSO) regression. A predictive nomogram was developed, evaluated by average consistency index (C-index), the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA), confirming its reliability and clinical applicability. In our study, out of 25 variables, 6 were identified as significant predictors for CAD severity. These included age (OR = 1.053, P < .001), high-density lipoprotein (HDL, OR = 0.440, P = .002), hypertension (OR = 2.050, P = .007), diabetes mellitus (OR = 3.435, P < .001), anaerobic threshold (AT, OR = 0.837, P < .001), and peak kilogram body weight oxygen uptake (VO2/kg, OR = 0.872, P < .001). The nomogram, based on these predictors, demonstrated strong diagnostic accuracy for assessing CAD severity, with AUC values of 0.939 in the training cohort and 0.840 in the validation cohort, and also exhibited significant clinical utility. The nomogram, which is based on CPET parameters, was useful for predicting the severity of CAD and assisted in risk stratification by offering a personalized, noninvasive diagnostic approach for clinicians.

Combined low-dose dobutamine and exercise stress echocardiography: a new hybrid protocol to detect inducible ischaemia

Aims

Myocardial response to stress echocardiography may be elicited physiologically, through exercise, or pharmacologically, often with dobutamine. Both have advantages but also limitations due to reduced exercise capacity or side-effects to stressor agent/lack of closeness to true pathophysiology of ischaemic cascade. We have combined low-dose dobutamine and exercise, creating a 'hybrid' protocol to utilize the advantages of both techniques and limit the drawbacks. The aim of the study was to evaluate its safety and feasibility.

Methods and results

In the hybrid protocol, low-dose dobutamine infusion (up to 10 µg/kg/min) is enhanced by supine bicycle exercise at 3-min increments of workload of 25 W to achieve target heart rate (THR). We analysed safety and outcome data for all the patients who underwent this protocol from 2017 to 2022. Out of 835, 727 (87.1%) patients referred for evaluation of ischaemia underwent the hybrid protocol. The median age was 61 years old and 61% (442/727) were men. The median exercise time was 11 (9-13.5) min with a median maximum workload of 100 W (75-125). Out of 727, 670 (92.2%) achieved THR. Atropine was not used. Out of 727, 192 (26.4%) of studies were positive for ischaemia. Out of 122, 102 (83.6%) with positive stress who underwent invasive angiography had significant coronary disease. The incidence of complications was low: 1/727-severe arrhythmia, 5/727 (0.7%) developed a vasovagal episode, and 14/727 (1.9%) had a hypertensive response to exercise.

Conclusion

Our findings suggest that this protocol is safe, feasible, and has a high success rate in achieving THR.

The Value of Exercise Electrocardiography in Outpatients with Stable Chest Pain and Low Pre-Test Probability of Significant Coronary Artery Disease

The role of exercise electrocardiography (ECG) in the investigation of stable chest pain has been questioned. The American Heart Association guidelines suggest the use of exercise ECG in patients with stable chest pain and low pre-test probability (PTP) of significant coronary artery disease, while the European Society of Cardiology Guidelines does not. This retrospective observational study aimed to assess the usefulness of exercise ECG in the low-PTP population with stable chest pain. We reviewed the medical records for all outpatient exercise ECGs conducted because of stable chest pain at the Department of Medicine and Emergency, Sahlgrenska University Hospital, Mölndal, Sweden, during 2016-2018. The identified patients were categorized in low-, intermediate-, or high-risk pre-test probability of significant coronary artery disease. All low-PTP patients were followed for one year post investigation for the incidence of acute coronary syndrome and all-cause mortality. Thus, 505 patients (mean age 60 years, 56% women) with low PTP were included in the study. Only four patients (0.6%) experienced incident myocardial infarction (three patients) or all-cause mortality (one patient). The negative predictive value of exercise ECG was 99.7%, and the positive predictive value was 28.6%. In this low-PTP population, exercise ECG yields a good negative predictive value and a poor positive predictive value.

Clinical case report of a professional triathlete with positive exercise stress test but negative coronary angiography

This article describes the clinical case of a master athlete, practising triathlon, who came to our Sports Medicine Center to be eligible for competitive sport. The subject, who had a family history of ischemic heart disease, presented a significant lowering of the ST segment in the inferolateral leads on the maximal cycle ergometer exercise test. Inducible myocardial ischemia emerged from the second level investigations. However, it was not confirmed by two coronary angiographies, the second performed after 9 years. The subject remained asymptomatic for the entire duration of the follow-up and in excellent clinical conditions, having never shown adverse events of cardiovascular nature.

Machine Learning Approach on High Risk Treadmill Exercise Test to Predict Obstructive Coronary Artery Disease by using P, QRS, and T waves' Features

Treadmill Exercise Test (TET) results and patients' clinical symptoms influence cardiologists' decision to perform Coronary Angiography (CAG) which is an invasive procedure. Since TET has high false positive rates, it can cause an unnecessary invasive CAG. Our primary objective was to develop a machine learning model capable of optimizing TET performance based on electrocardiography (ECG) waves characteristics and signals. TET reports from 294 patients who underwent CAG following high risk TET were collected and categorized into those with critical CAD and others. The signal was converted to time series format. A dataset containing the P, QRS, and T wave times and amplitudes was created. Using this dataset, 5 machine learning algorithms were trained with 5-fold cross validation. All these models were then compared to the performance of cardiologists on V5 signal. The results from 5 machine learning models were clearly superior to the cardiologists' V5 signal performance (P < 0.0001). In addition, the XGBoost model, with an accuracy of 80.92±6.42% and an area under the curve (AUC) of 0.78±0.06, was the most successful model. Machine learning models can produce high-performance diagnoses using the V5 signal markers only as it does not require any clinical markers obtained from TET reports. This can lead to significant contributions to improving clinical prediction in non-invasive methods.

Epidemiological analysis of coronary heart disease and its main risk factors: are their associations multiplicative, additive, or interactive?

OBJECTIVE

The purpose of this study was to discover how considering multiplicative, additive, and interactive effects modifies results of a prospective cohort study on coronary heart disease (CHD) incidence and its main risk factors.

MATERIAL AND METHODS

The Kuopio Ischaemic Heart Disease Risk Factor (KIHD) Study provided the study material, 2682 Eastern Finnish middle-aged men, followed since the 1980s. We applied multiplicative and additive survival models together with different statistical metrics and confidence intervals for risk ratios and risk differences to estimate the nature of associations.

RESULTS

The mean (SD) follow-up time among men who were free of CHD at baseline (n = 1958) was 21.4 (10.4) years, and 717 (37%) of them had the disease and 301 (15%) died for CHD before the end of follow-up. All tested non-modifiable and modifiable risk factors statistically significantly predicted CHD incidence. We detected three interactions: circulating low-density lipoprotein cholesterol (LDL-C) × age, obesity × age, and obesity × smoking of which LDL-C × age was the most evident one. High LDL-C increased the risk of CHD more among men younger than 50 [risk ratio (RR) 2.10] than those older than 50 (RR 1.22). LDL-C status was the only additive covariate. The additive effect of high LDL-C increased almost linearly up to 18 years and then reached a plateau. The simple multiplicative survival model stressed glycemic status as the strongest modifiable risk factor for developing CHD [hazard ratio (HR) for diabetes vs. normoglycemia was 2.69], whereas the model considering interactions and time dependence emphasised the role of LDL-C status (HR for high LDL-C vs. lower than borderline was 4.43). Age was the strongest non-modifiable predictor.

CONCLUSIONS

Including covariate interactions and time dependence in survival models potentially refine results of epidemiological analyses and ease to define the order of importance across CHD risk factors. KEY MESSAGESIncluding covariate interactions and time dependence in survival models potentially refine results of epidemiological analyses on coronary heart disease.Including covariate interactions and time dependence in survival models potentially ease to define the order of importance across coronary heart disease risk factors.

The Autonomic Imbalance of Myocardial Ischemia during Exercise Stress Testing: Insight from Short-Term Heart Rate Variability Analysis

Exercise stress testing (EST) has limited power in diagnosing obstructive coronary artery disease (CAD). The heart rate variability (HRV) analysis might increase the sensitivity of CAD detection. This study aimed to evaluate the correlation between short-term HRV and myocardial ischemia during EST, including the acceleration, maximum, and recovery stages of heart rate (HR). The HRV during EST from 19 healthy (RHC) subjects and 35 patients with CAD (25 patients with insignificant CAD (iCAD), and 10 patients with significant CAD (sCAD)) were compared. As a result, all HRV indices decreased at the maximum stage and no significant differences between iCAD and sCAD were found. The low-frequency power of heart rate signal (LF) of the RHC group recovered relatively quickly from the third to the sixth minutes after maximum HR, compared with that of the sCAD group. The relative changes of most HRV indices between maximum HR and recovery stage were lower in the sCAD group than in the RHC group, especially in LF, the standard deviation of all normal to normal intervals (SDNN), and the standard deviation in the long axis direction of the Poincaré plot analysis (SD2) indices (p < 0.05). The recovery slope of LF was significantly smaller in the sCAD group than in the RHC group (p = 0.02). The result suggests that monitoring short-term HRV during EST provides helpful insight into the cardiovascular autonomic imbalance in patients with significant CAD. The relative change of autonomic tone, especially the delayed sympathetic recovery, could be an additional marker for diagnosing myocardial ischemia.

The feasibility and safety of stepwise protocol in cardiopulmonary exercise testing-exercise stress echocardiography for subjects with heart failure

BACKGROUND

Exercise stress testing using a ramp protocol has been favored for cardiopulmonary exercise testing (CPX) in patients with heart failure (HF). However, the stepwise protocol for CPX was preferred for its possible combination with exercise stress echocardiography (ESE). We, therefore, investigated the feasibility and safety of using a stepwise protocol for CPX-ESE in patients with HF.

METHODS

Ambulatory outpatients with chronic HF were enrolled for a symptom-limited stepwise bicycle exercise test in the semi-supine position on a cycle ergometer. The test was started at a workload of 30 W and increased by 15 W every 3 minutes until maximal exertion. The echocardiographic and respiratory variables and any complications during the exercise were recorded.

RESULTS

Among a total of 36 participants (age 61.2 ± 12.4 years; 69.4% men), all subjects achieved anerobic threshold during CPX-ESE and reached 72.3% of the age-predicted peak heart rate. The peak oxygen consumption was 14.7 mL/kg/min, and the peak RER was 1.25. There were no severe adverse complications, and only two minor rhythmic events were reported: nonsustained supraventricular tachycardia and isolated ventricular premature beats. The echocardiographic images acquired at each stage were of good quality in 92.6% of all acquisitions, and the intra-observer and interobserver repeatability was >80%.

CONCLUSION

The stepwise protocol, with an initial workload of 30 W, followed by 15 W increments every 3 minutes, was feasible and provided an adequate stress load for patients with HF. This exercise stress modality was safe and well-tolerated.

Chronic Coronary Syndrome in Frail Old Population

The demographic trend of aging is associated with an increased prevalence of comorbidities among the elderly. Physical, immunological, emotional and cognitive impairment, in the context of the advanced biological age segment, leads to the maintenance and precipitation of cardiovascular diseases. Thus, more and more data are focused on understanding the pathophysiological mechanisms underlying each fragility phenotype and how they potentiate each other. The implications of inflammation, sarcopenia, vitamin D deficiency and albumin, as dimensions inherent in fragility, in the development and setting of chronic coronary syndromes (CCSs) have proven their patent significance but are still open to research. At the same time, the literature speculates on the interdependent relationship between frailty and CCSs, revealing the role of the first one in the development of the second. In this sense, depression, disabilities, polypharmacy and even cognitive disorders in the elderly with ischemic cardiovascular disease mean a gradual and complex progression of frailty. The battery of tests necessary for the evaluation of the elderly with CCSs requires a permanent update, according to the latest guidelines, but also an individualized approach related to the degree of frailty and the conditions imposed by it. By summation, the knowledge of frailty screening methods, through the use of sensitive and individualized tools, is the foundation of secondary prevention and prognosis in the elderly with CCSs. Moreover, a comprehensive geriatric assessment remains the gold standard of the medical approach of these patients. The management of the frail elderly, with CCSs, brings new challenges, also from the perspective of the treatment particularities. Sometimes the risk–benefit balance is difficult to achieve. Therefore, the holistic, individualized and updated approach of these patients remains a desired objective, by understanding and permanently acquiring knowledge on the complexity of the frailty syndrome.

The Value of Cardiopulmonary Exercise Testing in Predicting the Severity of Coronary Artery Disease

Background: There have been a limited number of quantitative studies on the relationship between coronary artery disease (CAD) and cardiorespiratory fitness (CRF), as measured by cardiopulmonary exercise testing (CPET). Thus, we aimed to investigate the association between CRF and the severity of coronary artery disease from the most comprehensive perspective possible, and to affirm the predictive value of CPET in the severity assessment of CAD. Methods: Our study included 280 patients with coronary angiography, who had undergone CPET in Tongji Hospital. The patients’ CRF was measured through their peak oxygen uptake (VO2@peak), their oxygen uptake at the anaerobic threshold (VO2@AT) and through other parameters of CPET on a bicycle ergometer. The severity of the coronary artery disease was assessed in the following three layers: functionally significant lesions (quantitative flow ratio [QFR] ≤ 0.8), the number of stenotic coronary arteries (SCA, stenosis ≥ 50%) and the Gensini score. The correlation analyses were carried out between the CRF and the severity of the coronary artery disease. A ROC curve was plotted, and the AUC was calculated to distinguish the severe CAD and the non-severe CAD patients, as measured by the QFR, the number of SCA, and the Gensini score. Results: The VO2@AT and VO2@peak were inversely associated with the QFR. The VO2@AT, VO2@peak and VO2/kg@peak were associated with the number of SCA. Meanwhile, the VO2@AT, VO2/kg@AT, VO2@peak and VO2/kg@peak were associated with the Gensini score. An ROC analysis proved that a combination of traditional clinical risk factors and the VO2@peak/VO2prediction is valuable in predicting CAD severity. Conclusions: Our study demonstrated a strong and inverse association between CRF and the severity of CAD. A combination of traditional clinical risk factors and CRF is valuable in predicting CAD severity.

Characteristics of Second-Line Investigations of Middle-Aged Athletes Who Failed Preparticipation Examinations

OBJECTIVE

The role of exercise testing during preparticipation examinations (PPEs) of middle-aged athletes is uncertain. This study examined the characteristics of disqualifications after an initial PPE that includes an exercise test in competitive athletes older than 30 years. We investigated disqualification rates and reasons, second-line investigations performed, and final decisions regarding competitive sports participation.

DESIGN

Chart review.

SETTING

Sports medicine clinic.

PARTICIPANTS

Athletes aged >30 years that performed an exercise test as part of their annual PPE at our sports medicine clinic (n = 866).

INDEPENDENT VARIABLES

Age, sex, height, weight, sport type, cardiovascular risk factors, and abnormal PPE findings.

MAIN OUTCOME MEASURES

Additional investigations performed, approval/disqualification regarding competitive sports participation.

RESULTS

The initial disqualification rate of athletes was 9.8%. Three (3.6%) athletes were disqualified following questionnaire and physical examination, 19 (22.4%) because of resting electrocardiogram findings, and 65 (76.5%) following the exercise test. After additional work-up, only 5 athletes (0.4%) were ultimately found ineligible for competitive sports. From those, only 2 athletes (0.2%) were disqualified because of exercise test findings, which were episodes of supraventricular tachycardia and not ischemia-related.

CONCLUSIONS

The addition of an exercise test to the PPE of middle-aged athletes is of limited value. If exercise testing of older athletes is performed, arrhythmias are probably of higher significance than ST-T changes.

Continuous hands-free monitoring of echocardiographic exercise test using probe fixation device

BACKGROUND

Stress echocardiography has been widely used in clinical practice for decades and has recently gained even more importance in diagnostic approaches to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise tests. The aim herein, is to assess the feasibility of probe fixation for use during exercise echocardiography.

METHODS

Forty-eight subjects (47 men, mean age 42 ± 17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). The semi-quantitative quality of acquired apical views were assessed at each stage using a four-point grading system.

RESULTS

The mean time required for probe fixation was 9 ± 2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. Twenty-five patients required probe repositioning during exercise (more often on a treadmill). During peak exercise quality of images in all views declined, but for diagnostic purposes it remained sufficient in 29 patients. Thus, 76% of performed tests (60% study population) had sufficient image quality.

CONCLUSIONS

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. The device is suitable almost exclusively for male patients and in some patients requires repositioning.

Changing Paradigms in the Diagnosis of Ischemic Heart Disease by Multimodality Imaging

Coronary artery disease (CAD) represents the most common cardiovascular disease, with high morbidity and mortality. Historically patients with chest pain of suspected coronary origin have been assessed with functional tests, capable to detect haemodynamic consequences of coronary obstructions through depiction of electrocardiographic changes, myocardial perfusion defects or regional wall motion abnormalities under stress condition. Stress echocardiography (SE), single-photon emission computed tomography (SPECT), positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) represent the functional techniques currently available, and technical developments contributed to increased diagnostic performance of these techniques. More recently, cardiac computed tomography angiography (cCTA) has been developed as a non-invasive anatomical test for a direct visualisation of coronary vessels and detailed description of atherosclerotic burden. Cardiovascular imaging techniques have dramatically enhanced our knowledge regarding physiological aspects and myocardial implications of CAD. Recently, after the publication of important trials, international guidelines recognised these changes, updating indications and level of recommendations. This review aims to summarise current standards with main novelties and specific limitations, and a diagnostic algorithm for up-to-date clinical management is also proposed.

Análise da Custo-Efetividade da Angiotomografia Coronariana no SUS, em Comparação com Outros Métodos Não Invasivos na Suspeita de DAC Estável

Fundamento

Objetivos

Métodos

Resultados

Conclusão

QT variability unrelated to RR variability during stress testing for identification of coronary artery disease

Stress test electrocardiogram (ECG) analysis is widely used for coronary artery disease (CAD) diagnosis despite its limited accuracy. Alterations in autonomic modulation of cardiac electrical activity have been reported in CAD patients during acute ischemia. We hypothesized that those alterations could be reflected in changes in ventricular repolarization dynamics during stress testing that could be measured through QT interval variability (QTV). However, QTV is largely dependent on RR interval variability (RRV), which might hinder intrinsic ventricular repolarization dynamics. In this study, we investigated whether different markers accounting for low-frequency (LF) oscillations of QTV unrelated to RRV during stress testing could be used to separate patients with and without CAD. Power spectral density of QTV unrelated to RRV was obtained based on time-frequency coherence estimation. Instantaneous LF power of QTV and QTV unrelated to RRV were obtained. LF power of QTV unrelated to RRV normalized by LF power of QTV was also studied. Stress test ECG of 100 patients were analysed. Patients referred to coronary angiography were classified into non-CAD or CAD group. LF oscillations in QTV did not show significant differences between CAD and non-CAD groups. However, LF oscillations in QTV unrelated to RRV were significantly higher in the CAD group as compared with the non-CAD group when measured during the first phases of exercise and last phases of recovery. ROC analysis of these indices revealed area under the curve values ranging from 61 to 73%. Binomial logistic regression analysis revealed LF power of QTV unrelated to RRV, both during the first phase of exercise and last phase of recovery, as independent predictors of CAD. In conclusion, this study highlights the importance of removing the influence of RRV when measuring QTV during stress testing for CAD identification and supports the added value of LF oscillations of QTV unrelated to RRV to diagnose CAD from the first minutes of exercise. This article is part of the theme issue 'Advanced computation in cardiovascular physiology: new challenges and opportunities'.

Diagnostic value of scoring model of treadmill exercise test combined with dynamic electrocardiogram for latent coronary heart disease

OBJECTIVE

To investigate the diagnostic value of scoring model of treadmill exercise test (TET) combined with dynamic electrocardiogram (DECG) for latent coronary heart disease (LCHD).

MATERIALS AND METHODS

Using coronary angiography, the diagnostic values of TET and DECG alone or combination for LCHD of 200 eligible patients were compared. The effects of different clinical features and DECG indices on the positive detection rate of TET combined with DECG were compared. Multivariate logistic regression analysis was performed for factors influencing diagnostic accuracy, and nomogram prediction model was established using screened independent risk factors.

RESULTS

Serial and parallel combinations of TET and DECG had superior sensitivity, specificity, positive and negative predictive values and accuracy than those of single detection. Patients with an age > 65 years, smoking, hypertension, diabetes mellitus, hyperlipidemia, family history of CHD and positive DECG indicators had higher positive detection rate, as independent risk factors for accuracy. The diagnostic accuracy of TET combined with DECG predicted by the nomogram model was 82.9%. The actual concordance index (C-index) for model evaluation was 0.817, the C-index after internal validation was 0.811, and the C-index after external validation was 0.802, indicating a good concordance of the model.

CONCLUSIONS

TET combined with DECG has high diagnostic accuracy for LCHD, and the scoring model constructed by DECG indicators can prominently improve the accuracy of combined diagnosis. Therefore, TET combined with DECG is significantly better than TET or DECG alone, which is of great diagnostic value for LCHD.

Low risk patients with acute atrial fibrillation and elevated high-sensitivity troponin do not have increased incidence of pathological stress tests

OBJECTIVES

Many patients with atrial fibrillation (AF) or atrial flutter (AFL) and rapid ventricular response (RVR) have elevated high-sensitivity troponin T (hsTnT) values. Elevated hsTnT is an independent risk marker for cardiovascular events and mortality. The aim was to examine if AF/AFL patients with RVR and elevated hsTnT have an increased incidence of pathological cardiac stress tests, indicating need of further evaluation for coronary artery disease (CAD). Design: We prospectively included 90 AF/AFL patients without known heart failure and CAD presenting with AF/AFL and RVR. Half of the patients had elevated hsTnT (cases) and half had levels below the 99th percentile (controls). All patients were discharged in sinus rhythm. After approximately one week in sinus rhythm a new hsTnT was analysed and the patients performed a bicycle exercise stress test within the 30 day follow-up. The primary endpoint was a pathological stress test confirmed by a pathological SPECT myocardial perfusion imaging or a coronary angiography. Results: None of the controls reached the primary endpoint. Two patients (4%) out of the 45 cases reached the primary endpoint (p = .49 vs controls), but only one was found to have significant CAD at subsequent coronary angiography. Conclusion: Patients with paroxysmal AF/AFL, without a history of CAD and heart failure, who present with a RVR and minor hsTnT elevations were not found to have an increased incidence of pathological stress tests compared to patients with hsTnT values below the 99th percentile.

Simple heart rate and QT parameters during stress exercise testing to assess presence and severity of stable coronary artery disease

Aim: The relationship between QT prolongation and myocardial ischemia is well known, however not many studies have correlated corrected QT interval and heart rate recovery with the severity of coronary artery disease (CAD). Methods: This was a single-center, prospective, observational study which included 127 patients with CAD and 124 patients without CAD. Results: Corrected QT variability from peak to recovery correlated well with CAD with a p value of 0.03. Receiver operative characteristic analysis did not show any significant diagnostic accuracy with any heart rate or QT parameters for predicting the presence or severity of CAD. Conclusion: Coronary artery disease is predicted by reduced ability of the heart rate to rise from rest to peak exercise and reduced recovery of heart rate and corrected QT from peak exercise to recovery at 1 min.

Stress echocardiography vs coronary oomputed tomography angiography for the detection of obstructive coronary artery disease in patients aged >70 years with suspected stable coronary artery disease

Aim. To compare stress echocardiography and coronary computed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged >70 years.

Materials and methods. The study included 390 patients aged >70 years with suspected stable CAD, which underwent elective coronary artery angiography (CAG). Initially, patients for whom stress echocardiography and CCTA is appropriate was determined. After that diagnostic accuracy of both methods in the detection of obstructive CAD was evaluated in patients with atypical angina and non-anginal chest pain.

Results. Among 111 patients with atypical angina and non-anginal pain which underwent stress echocardiography and had unequivocal results, 69 (62 %) patients had obstructive CAD. Stress echocardiography has sensitivity of 89%, specificity of 95%, positive likelihood ratio (LR+) of 17,8, and negative likelihood ratio (LR-) of 0,1. Positive result increased probability of obstructive CAD from 62% to 95%, while negative result reduced probability to 16%. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA, 48 (59 %) patients had obstructive CAD. CCTA has sensitivity of 100 %, specificity of 88%, LR+ of 8,3, and LR- of 0,3. Positive result increased post-test probability of obstructive CAD from 59% to 86%, while negative result reduced post-test probability to 0%.

Conclusion. Stress echocardiography and CCTA has comparable diagnostic accuracy in the detection of obstructive CAD in patients aged >70 years with atypical angina and non-anginal pain. Stress echocardiography has a greater diagnostic value of positive result; CCTA has a greater diagnostic value of negative result.

The Role of Aortic Stiffness Parameters in Evaluating Myocardial Ischemia

BACKGROUND

Arterial stiffness is a process resulting in deterioration of hemodynamic function of the aorta, a decrease in its compliance and elasticity, caused by the proportional change of components of the extracellular matrix. Although many researches have been done to determine the etiologies of myocardial ischemia in the absence of obstructive coronary artery disease, none of them has investigated the relation between the parameters of aortic stiffness and the myocardial ischemia documented by the exercise stress test. The present cross-sectional study aimed to investigate the difference of aortic stiffness parameters between the groups separated by exercise stress test result as positive and negative ischemic findings in the absence of obstructive coronary artery disease.

METHODS

The present study included 79 patients who were admitted to Istanbul Faculty of Medicine, Department of Cardiology with complaint of chest pain. Forty patients (21 women and 19 men) have ischemic findings on the exercise electrocardiography (ECG) test and 39 patients (20 women and 19 men) have normal exercise ECG results. The patients who have positive exercise ECG findings underwent coronary angiography and all the patients had non-obstructive coronary artery disease. Demographic features (age, sex and comorbidities) were statistically similar between the groups. Aortic stiffness measurements (pulse wave velocity, pulse pressure, aortic augmented pressure, augmentation index, systolic pressure-time index, diastolic pressure-time index and subendocardial viability ratio) were done with tonometric methods.

RESULTS

There was no significant difference between the two groups in terms of the aortic stiffness parameters. Systolic blood pressure (P = 0.33), diastolic blood pressure (P = 0.24), pulse pressure (P = 0.60), systolic pressure-time index (P = 0.10), diastolic pressure-time index (P = 0.91), subendocardial viability ratio (P = 0.19), aortic augmented pressure (P = 0.87), augmentation index (P = 0.58) and pulse wave velocity (P = 0.56) were detected between the two groups. Biochemical parameters were found similar between the two groups. Only low-density lipoprotein levels were slightly higher in patients with negative exercise stress test result (139 vs. 123 mg/dL, P = 0.02).

CONCLUSION

There is no finding supporting that the aortic stiffness identifies the patients with non-obstructive coronary artery disease but with signs of myocardial ischemia and further investigation of other causes of myocardial ischemia is required.

Cardiovascular Biomarkers and Imaging in Older Adults: JACC Council Perspectives

Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.

Exercise cardiovascular magnetic resonance: development, current utility and future applications

Stress cardiac imaging is the current first line investigation for coronary artery disease diagnosis and decision making and an adjunctive tool in a range of non-ischaemic cardiovascular diseases. Exercise cardiovascular magnetic resonance (Ex-CMR) has developed over the past 25 years to combine the superior image qualities of CMR with the preferred method of exercise stress. Presently, numerous exercise methods exist, from performing stress on an adjacent CMR compatible treadmill to in-scanner exercise, most commonly on a supine cycle ergometer. Cardiac conditions studied by Ex-CMR are broad, commonly investigating ischaemic heart disease and congenital heart disease but extending to pulmonary hypertension and diabetic heart disease. This review presents an in-depth assessment of the various Ex-CMR stress methods and the varied pulse sequence approaches, including those specially designed for Ex-CMR. Current and future developments in image acquisition are highlighted, and will likely lead to a much greater clinical use of Ex-CMR across a range of cardiovascular conditions.

Noninvasive Testing for Diagnosis of Stable Coronary Artery Disease in the Elderly

Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient's situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists' associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.

Ultrasound Measurement of Carotid Intima-Media Thickness and Plaques in Predicting Coronary Artery Disease

Ultrasound measurement of carotid intima-media thickness (CIMT) and plaque thickness (PT) may be an additional tool for risk stratification of patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). The aim of this study was to evaluate the correlation of CIMT and PT with coronary artery disease (CAD) in risk stratification tests.This prospective observational study was conducted in an academic tertiary care ED. Carotid ultrasound measurements were obtained for emergency patients with suspected ACS. Carotid measurements included PT, mean CIMT and maximum CIMT. The correlations between carotid ultrasound and the results of coronary catheter angiography (CA), coronary computed tomography angiography (CCTA) and stress tests were identified. The convenience sample included 58 patients comprising 39 men and 19 women with a mean age of 60 ± 12 y. Twenty-two percent (13/58) of patients were positive for CAD, as indicated by results of the cardiac risk stratification tests. Presence of plaque correlated with CCTA findings, with a high specificity (92.8%) for a positive test. Max CIMT predicted abnormal CCTA (area under the curve [AUC] = 0.93, 95% confidence interval: 0.80-1). The correlations with stress test (0.78, 0.46-1) and CA (0.55, 0.28-0.82) were weaker. Presence of carotid plaque correlated significantly with findings of CAD on all risk stratification tests, but especially with CCTA. Carotid ultrasound could have a role in risk stratification in the ED, though more research is needed.

Homocysteine concentration and adenosine A2A receptor production by peripheral blood mononuclear cells in coronary artery disease patients

Hyperhomocysteinemia is associated with coronary artery disease (CAD). The mechanistic aspects of this relationship are unclear. In CAD patients, homocysteine (HCy) concentration correlates with plasma level of adenosine that controls the coronary circulation via the activation of adenosine A_2A receptors (A_2AR). We addressed in CAD patients the relationship between HCy and A_2AR production, and in cellulo the effect of HCy on A_2AR function. 46 patients with CAD and 20 control healthy subjects were included. We evaluated A_2AR production by peripheral blood mononuclear cells using Western blotting. We studied in cellulo (CEM human T cells) the effect of HCy on A_2A R production as well as on basal and stimulated cAMP production following A_2A R activation by an agonist‐like monoclonal antibody. HCy concentration was higher in CAD patients vs controls (median, range: 16.6 [7‐45] vs 8 [5‐12] µM, P < 0.001). A_2A R production was lower in patients vs controls (1.1[0.62‐1.6] vs 1.53[0.7‐1.9] arbitrary units, P < 0.001). We observed a negative correlation between HCy concentration and A_2A R production (r = −0.43; P < 0.0001), with decreased A_2A R production above 25 µM HCy. In cellulo, HCy inhibited A_2AR production, as well as basal and stimulated cAMP production. In conclusion, HCy is negatively associated with A_2A R production in CAD patients, as well as with A_2A R and cAMP production in cellulo. The decrease in A_2A R production and function, which is known to hamper coronary blood flow and promote inflammation, may support CAD pathogenesis.

Preoperative nuclear stress testing in the very old patient population

BACKGROUND

Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population.

AIM

To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery.

METHODS

Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed.

RESULTS

A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P < 0.01) more likely to develop peri-operative MACE.

CONCLUSION

Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery.

Psychological Well-Being as an Independent Predictor of Exercise Capacity in Cardiac Rehabilitation Patients With Obesity

Objective: Exercise capacity (EC) is a well-established predictor of cardiovascular health. It is notoriously influenced by several factors, but the independent effect of psychological well-being (PWB) on EC has not yet been explored. The present study aims to investigate (1) whether PWB is an independent predictor of EC over and above selected demographic, behavioral, and biomedical parameters in a sample of CR patients with obesity and (2) whether PWB is a stronger predictor of EC than the other variables.

Methods: Data from 1968 patients were collected at the time of their inclusion in a cardiac rehabilitation (CR) program and retrospectively analyzed in a cross-sectional study. Since cardiorespiratory parameters defined in normal weight populations differ from those of their obese counterparts, an ad hoc validated formula taking body mass index (BMI) into consideration was used to predict EC.

Results: A multiple regression analysis revealed left ventricular eject fraction (LVEF) to be the strongest predictor of EC, followed by PWB, type 2 diabetes (DM), smoking status, atrial fibrillation (AF), and education. Bayesian evaluation of informative hypotheses corroborated LVEF as the best predictor of EC, and confirmed the superiority of PWB over and above DM and smoking status in influencing EC.

Conclusion: These findings strengthen the link between psychological and physical health, suggesting a better PWB is associated with greater EC. Prompt screening of a patient’s mood and readiness to perform an active lifestyle would therefore enhance the long-term health benefits of CR.

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

AIM

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.

MATERIALS AND METHODS

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.

RESULTS

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 %.

CONCLUSION

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.

Stress echocardiography in coronary artery disease: a practical guideline from the British Society of Echocardiography

Stress echocardiography is an established technique for assessing coronary artery disease. It has primarily been used for the diagnosis and assessment of patients presenting with chest pain in whom there is an intermediate probability of coronary artery disease. In addition, it is used for risk stratification and to guide revascularisation in patients with known ischaemic heart disease. Although cardiac computed tomography has recently been recommended in the United Kingdom as the first-line investigation in patients presenting for the first time with atypical or typical angina, stress echocardiography continues to have an important role in the assessment of patients with lesions of uncertain functional significance and patients with known ischaemic heart disease who represent with chest pain. In this guideline from the British Society of Echocardiography, the indications and recommended protocols are outlined for the assessment of ischaemic heart disease by stress echocardiography.

The Utilization of Stress Tests Prior to Percutaneous Coronary Intervention for Stable Coronary Artery Disease in Taiwan

Background

Ischemia shown in non-invasive tests is considered to be a fundamental requirement for treating patients with stable coronary artery disease (CAD) with a percutaneous coronary intervention (PCI). In a nationwide cohort, we investigated the utilization of stress tests, including myocardial perfusion imaging (MPI), treadmill exercise test (TET) and stress echocardiography (SE) prior to elective PCI.

Methods

This retrospective study used the Longitudinal Health Insurance Database 2000 (LHID2000) of the National Health Insurance program in Taiwan. The LHID2000 is comprised of one million randomly sampled beneficiaries. We enrolled patients receiving elective PCI for stable CAD from 2000 to 2013. Stress tests performed within 90 days prior to PCI and patient characteristics correlated with the utilization of stress tests were investigated.

Results

During the investigation period, 3,163 patients received elective PCI for stable CAD and 1,847 (58.4%) patients had at least one stress test within 90 days prior to PCI. Among them, 1,461 (79.1%) had MPI, 1,228 had TET (66.4%) and only 1 had SE (0.05%). Age < 80 years, regional hospital and hyperlipidemia were independently associated with an increased likelihood of receiving stress tests. On the other hand, Charlson-comorbidity index score ≥ 1, prior catheterization and heart failure were independently associated with a decreased likelihood of receiving stress tests.

Conclusions

In the setting of stable CAD, almost 60% of our patients received stress tests within 90 days prior to elective PCI, and MPI was the most commonly used test.

Ivabradine for coronary artery disease and/or heart failure-a protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis

BACKGROUND

Coronary artery disease and heart failure are both highly prevalent diseases with a global prevalence of 93 million and 40 million. These patients are at increased risk of morbidity and mortality. The management of these patients involves medical therapy, and both diseases can be treated using the heart rate-lowering drug ivabradine. However, the evidence regarding the use of ivabradine in the treatment of coronary artery disease and/or heart failure is unclear. Our objective is to assess the beneficial and harmful effects of ivabradine in the treatment of coronary artery disease and/or heart failure.

METHODS

This protocol for a systematic review was undertaken using the recommendations of The Cochrane Collaboration, the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P), and the eight-step assessment procedure suggested by Jakobsen and colleagues. We plan to include all relevant randomised clinical trials assessing the use of ivabradine in the treatment of coronary artery disease and/or heart failure. We will search the Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Latin American and Caribbean Health Sciences Literature (LILACS), Science Citation Index Expanded on Web of Science, Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Science Journal Database (VIP), and BIOSIS in order to identify relevant trials. We will begin the searches in February 2019. All included trials will be assessed and classified at low risk of bias or at high risk of bias. Our primary conclusions will be based on the results from the primary outcomes at low risk of bias. Extracted data will be analysed using Review Manager 5.3 and Trial Sequential Analysis 0.9.5.10. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes, and we will assess the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

The systematic review will have the potential to aid clinicians in decision-making regarding ivabradine and to benefit patients with coronary artery disease and/or heart failure.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018112082.

Ischaemic heart disease and pregnancy

Although ischaemic heart disease is currently rarely encountered in pregnancy, occurring between 2.8 and 6.2 per 100 000 deliveries, it is becoming more common as women delay becoming pregnant until later life, when medical comorbidities are more common, and because of the higher prevalence of obesity in the pregnant population. In addition, chronic inflammatory diseases, which are more common in women, may contribute to greater rates of acute myocardial infarction (AMI). Pregnancy itself seems to be a risk factor for AMI, although the exact mechanisms are not clear. AMI in pregnancy should be investigated in the same manner as in the non-pregnant population, not allowing for delays, with investigations being conducted as they would outside of pregnancy. Maternal morbidity following AMI is high as a result of increased rates of heart failure, arrhythmia and cardiogenic shock. Delivery in women with history of AMI should be typically guided by obstetric indications not cardiac ones.

Layer-specific strain in dipyridamole stress echo: A new tool for the diagnosis of microvascular angina

BACKGROUND

Dipyridamole stress echocardiography (DSE) represents a fundamental test in patients with suspected coronary artery disease (CAD). The diagnosis of microvascular disease is still challenging. We aimed to determine the diagnostic value of left ventricular (LV) layer-specific longitudinal (LS) and circumferential strain (CS) by Speckle Tracking in detecting CAD during DSE and to study if they can help in discriminate between a negative echo and a suspected microvascular angina.

METHODS AND RESULTS

We enrolled 66 patients with known or suspected CAD. All underwent standard DSE. We identified 3 groups according to the result of DSE (36 negative DSE, 19 positive DSE, 11 indicatives for microvascular disease). Wall motion score index, global LV LS and CS (global longitudinal strain [GLS] and global circumferential strain [GCS]), and layer-specific LV LS and CS were measured at rest and peak stress. The Delta between rest and peak stress values was calculated. GLS increased after injection in negative DSE and microvascular disease while reducing in positive DSE. Endocardial GCS and transmural GCS values were stable in microvascular disease while increasing significantly in negative DSE, helping in the diagnosis. The specific analysis of endocardial LS showed the most powerful difference between healthy and macrovascular CAD patients, both for LS and CS.

CONCLUSIONS

Global circumferential strain can be a new valuable added tool in the echocardiographic diagnosis of microvascular disease. Endocardial GLS is the best indicator of an altered wall deformation in the presence of macrovascular ischemia.

Exercise cardiac magnetic resonance imaging: a feasibility study and meta-analysis

Cardiac stress testing improves detection and risk assessment of heart disease. Magnetic resonance imaging (MRI) is the clinical gold-standard for assessing cardiac morphology and function at rest; however, exercise MRI has not been widely adapted for cardiac assessment because of imaging and device limitations. Commercially available magnetic resonance ergometers, together with improved imaging sequences, have overcome many previous limitations, making cardiac stress MRI more feasible. Here, we aimed to demonstrate clinical feasibility and establish the normative, healthy response to supine exercise MRI. Eight young, healthy subjects underwent rest and exercise cinematic imaging to measure left ventricular volumes and ejection fraction. To establish the normative, healthy response to exercise MRI we performed a comprehensive literature review and meta-analysis of existing exercise cardiac MRI studies. Results were pooled using a random effects model to define the left ventricular ejection fraction, end-diastolic, end-systolic, and stroke volume responses. Our proof-of-concept data showed a marked increase in cardiac index with exercise, secondary to an increase in both heart rate and stroke volume. The change in stroke volume was driven by a reduction in end-systolic volume, with no change in end-diastolic volume. These findings were entirely consistent with 17 previous exercise MRI studies (226 individual records), despite differences in imaging approach, ergometer, or exercise type. Taken together, the data herein demonstrate that exercise cardiac MRI is clinically feasible, using commercially available exercise equipment and vendor-provided product sequences and establish the normative, healthy response to exercise MRI.

Prognostic value of electrocardiogram exercise testing for risk stratification in asymptomatic coronary artery disease

BACKGROUND

Several variables of electrocardiogram exercise testing (EET) predict cardiovascular events in the general population and in patients with coronary artery disease (CAD). However, most of the studies have not included patients with asymptomatic CAD. The aim of this study was to evaluate the prognostic value of EET in asymptomatic CAD patients.

PATIENTS AND METHODS

We carried out a retrospective single-center analysis including all patients with asymptomatic CAD documented by angiography who underwent EET from January 2010 to December 2013. A number of EET variables and three exercise scores [Duke Treadmill Score (DTS), Morise score, and FIT score] were analyzed. The primary endpoint was the combined incidence of myocardial infarction (MI), myocardial revascularization, and death from any cause during follow-up.

RESULTS

A total of 306 patients were included (mean age was 65±10 years, 61% had previous MI, and the median exercise capacity was 9.4±2.7 metabolic equivalent of task). The primary endpoint occurred in 15.7% of patients during 3.3 years of follow-up. The DTS and FIT were independent predictors of the primary endpoint unlike the Morise score (DTS: hazard ratio=0.91, 95% confidence interval: 0.85-0.99, P=0.018; FIT score: 0.99, 0.98-0.996, P=0.001; Morise score: 0.97, 0.93-1.02, P=0.20). The DTS was independent predictor of MI or revascularization, whereas FIT predicted death from any cause. Excluding patients with early revascularization, DTS had no predictive power at the composite endpoint.

CONCLUSION

In our population with asymptomatic CAD, FIT and DTS had significant value for risk prediction and consequently the EET can be a valid tool in the clinical follow-up of this population.