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Introduction Exercise electrocardiography (EET) is a safe and cost-effective method to predict the presence, prognosis, and severity of coronary artery disease (CAD). Various score models have been developed to increase predictive power of EET. In this study, we aimed to evaluate whether adding ST depression duration could have an effect on increasing the value of Duke treadmill score (DTS) in predicting obstructive CAD. Methods In this single centred, cross-sectional study, we evaluated a total of 258 patients who presented with a complaint of chest pain and undergone coronary angiogram in result of a positive EET. DTS was calculated for all the patients. The new score-revised DTS- was calculated by adding total ST depression time to classical DS parameters. We compared area under the curve (AUC) of DTS and revised DTS by Delongi method. Results Mean age of the group was 58.43 +/- 9.37, and 37.2% (n = 96) were female. Mean total ST-depression duration was 171.72 +/- 91.43 msec in normal artery group,241.54 +/- 118.11 msec in non-obstructive CAD group, and 281.26 +/- 113.64 in obstructive CAD group.ST-depression duration in both exercise and recovery, and total ST depression duration were significantly higher in obstructive CAD group than non-obstructive and normal artery groups (p = 0.024, p = 0.01, p < 0.01, and p < 0.01, respectively). Revised DTS had significantly higher predictive value of obstructive CAD compared to classical DS (AUC (95%CI): 0.744 vs. 0.626, p < 0.001). The AUC of DS was significantly lower than the new score (z-score:3.274, p = 0.011). Conclusion In conclusion, adding ST depression duration to DTS calculation is increasing the discriminative value of DTS to predict obstructive CAD. Benefits of EET within the context of the management of CAD is well-known, hence, it is clear that physicians may use revised DTS.

Myocardial ischemia (MI) has the highest mortality rate in the world. Traditional noninvasive MI examinations include exercise electrocardiography tests (EETs) and stress echocardiography (SE). Treadmill and dobutamine tests are commonly used as stress protocols. In the present study, 278 patients with suspected MI were examined, 66 of whom were diagnosed with MI and 212 did not show evidence of MI by coronary angiography (CAG)/coronary CT angiography (CCTA). All patients underwent clinical EET and SE evaluations prior to CAG/CCTA. All groups were compared based on specific clinical parameters including age, sex, blood pressure, heart rate, blood oxygen saturation, underlying conditions and ejection fraction/fraction shortening. The data indicated superior diagnostic efficiency of the combined EET+SE method for the diagnosis of suspected MI compared with either EET or SE alone. The sensitivity/specificity/positive predictive value and negative predictive value for detecting MI were excellent compared with those of traditional examinations. The diagnostic efficiency of the combination analysis may reduce the prevalence of MI and medical costs. The present study provided novel insight for the development of methods that may be used for MI detection and prediction.

The role of exercise electrocardiography (ECG) and stress echocardiography (SE) in the management of patients with valvular heart diseases (VHD) has been reviewed in this article relying on the recent evidence and the recommendations of the European Society of Cardiology/European Association of Cardio-Thoracic Surgery (ESC/EACTS) and the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the management of VHD. Both guidelines emphasise the role of exercise ECG to unmask objectively the occurrence of symptoms in patients, who deny symptoms or have doubtful symptoms; however, the role of SE to assess the haemodynamic component of VHD and unmask subclinical myocardial dysfunction is questioned. The above-mentioned guidelines strongly recommend deciding regarding valve surgery according to the presence of symptoms and the left ventricular (LV) morphological and functional parameters assessed at rest. SE can be useful in selected VHD patients for the determination of prognosis, clarification of symptoms and deciding on the timing of surgery. Despite existing evidence, there is still a need for randomised clinical outcome trials evaluating the role of stress imaging in the daily practise decision-making.

Coronary artery disease (CAD) is the most common cause of death globally. Patients with suspected CAD are usually assessed by exercise electrocardiography (ECG). Subsequent tests, such as coronary angiography and coronary computed tomography angiography (CCTA) are performed to localize the stenosis and to estimate the degree of blockage. The present study describes a non-invasive methodology to identify patients with CAD based on the analysis of both rest and exercise seismocardiography (SCG). SCG is a non-invasive technology for capturing the acceleration of the chest induced by myocardial motion and vibrations. SCG signals were recorded from 185 individuals at rest and immediately after exercise. Two models were developed using the characterization of the rest and exercise SCG signals to identify individuals with CAD. The models were validated against related results from angiography. For the rest model, accuracy was 74\%, and sensitivity and specificity were estimated as 75\% and 72\%, respectively. For the exercise model accuracy, sensitivity, and specificity were 81\%, 82\%, and 84\%, respectively. The rest and exercise models presented a bootstrap-corrected area under the curve of 0.77 and 0.91, respectively. The discrimination slope was estimated 0.32 for rest model and 0.47 for the exercise model. The difference between the discrimination slopes of these two models was 0.15 (95\% CI: 0.10 to 0.23, p < 0.0001). Both rest and exercise models are able to detect CAD with high accuracy, sensitivity, and specificity. Performance of SCG is better compared to stress-ECG and it is identical to stress-echocardiography and CCTA. SCG examination is fast, inexpensive, and may even be carried out by laypersons.

Background/Aims: This study is a head-to-head comparison of predictive values for long-term cardiovascular outcomes between exercise electrocardiography (ex-ECG) and computed tomography coronary angiography (CTCA) in patients with chest pain. Methods: Four hundred and forty-two patients (mean age, 56.1 years; men, 61.3%) who underwent both ex-ECG and CTCA for evaluation of chest pain were included. For ex-ECG parameters, the patients were classified according to negative or positive results, and Duke treadmill score (DTS). Coronary artery calcium score (CACS), presence of plaque, and coronary artery stenosis were evaluated as CTCA parameters. Cardiovascular events for prognostic evaluation were defined as unstable angina, acute myocardial infarction, revascularization, heart failure, and cardiac death. Results: The mean follow-up duration was 2.8 ± 1.1 years. Fifteen patients experienced cardiovascular events. Based on pretest probability, the low- and intermediate-risks of coronary artery disease were 94.6%. Odds ratio of CACS > 40, presence of plaque, coronary stenosis ≥ 50% and DTS ≤ 4 were significant (3.79, p = 0.012; 9.54, p = 0.030; 6.99, p < 0.001; and 4.58, p = 0.008, respectively). In the Cox regression model, coronary stenosis ≥ 50% (hazard ratio, 7.426; 95% confidence interval, 2.685 to 20.525) was only significant. After adding DTS ≤ 4 to coronary stenosis ≥ 50%, the integrated discrimination improvement and net reclassification improvement analyses did not show significant. Conclusions: CTCA was better than ex-ECG in terms of predicting long-term outcomes in low- to intermediate-risk populations. The predictive value of the combination of CTCA and ex-ECG was not superior to that of CTCA alone.

The paper presents a case of 67-year-old man in whom coronarography was performed after positive exercise electrocardiography. During the angiography, extremely rare contrast reaction occured. Within the next few hours patient’s clinical condition deteriorated significantly, so that he required special and atypical treatment. Finally, the patient recovered completely without any neurological or other deficits.

IntroductionExercise electrocardiography (EET) is frequently used in coronary artery disease, but the specificity of this test is very low. In the literature, parameters such as QT prolongation and QT dispersion which show coronary artery disease and arrhythmia were not sufficiently investigated using EET. The aim of this study was to investigate whether QT interval prolongation or dispersion (QT disp) in a positive EET test could predict critical coronary artery disease (CAD).Material and methodsPatients with a positive exercise test were included in the study. Data regarding QT, QTc (corrected QT interval) and QT disp values before, during and after EET were noted. Critical coronary artery occlusions (≥ 70%) was recorded from coronary angiographic images. Patients were divided into two groups (critical CAD and non-critical CAD).ResultsA total of 192 patients were found to be eligible for the study. There were 126 patients in the non-critical CAD group (group 1) and 66 patients in the critical CAD group (group 2). Recovery QTc, peak QT disp, and recovery QT disp were significantly increased in group 2 (p < 0.001 for each). Also, target heart rate (p = 0.012), basal systolic blood pressure (p = 0.005) and diastolic blood pressure (p < 0.001) were significantly higher in group 1. Recovery QTc (OR = 1.051) and recovery QT disp (OR = 1.117) were determined as the independent predictors for critical CAD. The ROC analysis results indicated that critical CAD could be diagnosed with 90% sensitivity when the recovery QTc cut-off value was set as 404 ms.ConclusionsIn patients with positive EET, prolonged QTc and QT disp values measured during the recovery period would predict critical CAD. Thus, the clinical accuracy of EET may be enhanced.

BACKGROUND: The utility of exercise‐induced ST‐segment depression for diagnosing ischemic heart disease (IHD) in women is unclear. HYPOTHESIS: Based on evidence that IHD pathophysiology in women involves coronary vascular dysfunction, we hypothesized that coronary vascular dysfunction contributes to exercise electrocardiography (Ex‐ECG) ST‐depression in the absence of obstructive coronary artery disease, so‐called false positive results. We tested our hypothesis in a pilot study evaluating the relationship between peripheral vascular endothelial function and Ex‐ECG. METHODS: Twenty‐nine asymptomatic women without cardiac risk factors underwent maximal Bruce protocol exercise treadmill testing and peripheral endothelial function assessment using peripheral arterial tonometry (Itamar EndoPAT 2000) to measure reactive hyperemia index (RHI). The relationship between RHI and Ex‐ECG ST‐segment depression was evaluated using logistic regression and differences in subgroups using 2‐tailed t tests. RESULTS: Mean age was 54 ± 7 years, body mass index 25 ± 4 kg/m(2), and RHI 2.51 ± 0.66. Three women (10%) had RHI 0.05). RHI did not predict ST‐segment depression. CONCLUSIONS: Our pilot study demonstrates high prevalence of exercise‐induced ST‐segment depression in asymptomatic, middle‐aged, overweight women. Peripheral vascular endothelial dysfunction did not predict Ex‐ECG ST‐segment depression. Further work is needed to investigate the utility of vascular endothelial testing and Ex‐ECG for IHD diagnostic and management purposes in women.

Objectives We hypothesised that stress echocardiography (SE), may be superior to exercise ECG (ExECG), for predicting CAD and outcome, and cost-beneficial, when performed as initial investigation in newly suspected angina. Methods All patients seen in 2011, with suspected angina, no history of CAD, pre-test likelihood of CAD of > 10% and who underwent SE or ExECG as first line were identified retrospectively. Cost to diagnosis was calculated by adding the cost of all tests, up to and including coronary angiography (CA), on an intention-to-treat basis. Follow-up data on cardiac death and myocardial infarction (MI) were collected, 26 months after the presentation of the last study patient. Results A total of 456 patients underwent ExECG (224 (49%) negative, 93 (20%) positive, 139 (31%) inconclusive) and 241 underwent SE (200 (83%) negative, 35 (15%) positive, 6 (2%) inconclusive) as first line. In patients subsequently undergoing CA, CAD was present in 46% (37/80) of patients with positive ExECG vs. 72% (23/32) patients with positive SE (p = 0.01). Mean cost to diagnosis was £456 for the ExECG vs. £360 for the SE group (p = 0.002). Over a mean follow-up period of 31 ± 5 months, cardiac events were 2% each in negative SE vs. negative ExECG (p = 0.9). Conclusions SE is superior to ExECG for prediction of CAD and is cost-beneficial when used as initial test in patients with no history of CAD presenting with suspected angina.

La prueba de esfuerzo electrocardiográfica evalúa los ajustes fisiológicos en respuesta a un aumento en el metabolismo; además, permite establecer el diagnóstico y pronóstico de diferentes enfermedades cardiovasculares. Esta prueba continúa siendo el método diagnóstico de más fácil acceso y menos costoso para la evaluación inicial de pacientes con síntomas estables, que tienen un riesgo bajo o intermedio de enfermedad coronaria, y en aquellas personas con dolor torácico que consultan al servicio de urgencias. Sin embargo, posee limitaciones en la exactitud diagnóstica, con falsos negativos alrededor del 40% (sensibilidad del 60%) y falsos positivos alrededor del 10% (especificidad del 90%). En este artículo se discute información sobre la prueba de esfuerzo electrocardiográfica, su aplicación tanto para el diagnóstico como el pronóstico y su utilidad en la toma de decisiones en los pacientes en quienes se sospecha o tienen una enfermedad coronaria. Igualmente, se presentan aspectos prácticos para la realización del procedimiento, una propuesta de informe con los principales hallazgos y algunos ejemplos clínicos.

Since the first recording of electrocardiograms (ECGs) of a horse in Japan was carried out in 1944, studies on ECGs have been performed intensively. During the early stages of research from the 1950s to 1960s, leads to use for ECG recording were evaluated using several different approaches including unipolar leads, bipolar limb leads, and bipolar chest leads. Based on these studies, the AB lead, which is oriented along the long axis of the heart, became the standard reference method in Japan. Electrodes of the AB lead are placed on the upper 1/4th point along a straight line between the withers and the left shoulder blade (base: B), and 10 cm posterior to the left olecranon (apex: A). The incidence of equine arrhythmias among racehorses has been surveyed, and details of the electrocardiographic characteristics of several arrhythmias have been investigated. In particular, atrial fibrillation (AF) has been extensively studied, and papers have reported findings such as that paroxysmal AF occurs during racing and described electrocardiographic changes that occur at the onset of AF during exercise. Development of a radiotelemetry system for ECG recording enabled the first recording of equine ECGs during galloping in 1964, the detection of arrhythmias, and calculation of heart rate during exercise. Studies on comparative and developmental changes of ECGs have described characteristics of the equine ECGs. Future research on changes in cardiac function, including autonomic function, that occur with aging may lead to new developments in equine electrocardiography and contribute to improving the health and welfare of the horse.

Exercise electrocardiography (exercise ECG) is the least expensive and most readily available functional test for obstructive coronary artery disease (CAD). Its major weakness is limited accuracy, with a false negative rate of around 50% (sensitivity 50%), and a false positive rate of around 10% (specificity 90%). We discuss the information yielded by exercise ECG and its use in decision-making for patients with suspected or known CAD. The role of exercise ECG in the management of other cardiac disorders is also reviewed. We summarize the practical aspects of performing exercise ECG.

Objectives: To compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain. Background: Noninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED). Methods: Low risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥50%) underwent catheterization, while those with no or intermediate stenosis (

ObjectivesThis study was designed to determine the prognostic value of multidetector coronary computed tomography angiography (CTA) in relation to exercise electrocardiography (XECG) findings.BackgroundThe prognostic usefulness of coronary CTA findings of coronary artery disease in relation to XECG findings has not been explored systematically.MethodsPatients with suspected coronary artery disease who had undergone both coronary CTA and XECG (

Background: Both coronary computed tomography angiography (CCTA) and exercise electrocardiography (ExECG) are non-invasive testing methods for the evaluation of coronary artery disease (CAD). However, there was controversy on the diagnostic performance of these methods due to the limited data in each single study. Therefore, we performed a meta-analysis to address these issues. Methods: We searched PubMed and Embase databases up to May 22, 2015. Two authors identified eligible studies, extracted data and accessed quality. Pooled estimation of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), summary receiver-operating characteristic curve (SROC) and the area under curve (AUC) of CCTA and ExECG for the diagnosis of CAD were calculated using Stata, Meta-Disc and Review Manager statistical software. Results: Seven articles were included. Pooled sensitivity of CCTA and ExECG were 0.98 [95% confidence intervals (CIs): 0.95–0.99] and 0.66 (95% CIs: 0.59–0.72); pooled specificity of CCTA and ExECG were 0.84 (95% CIs: 0.81–0.87) and 0.75 (95% CIs: 0.71–0.79); pooled DOR of CCTA and ExECG were 110.24 (95% CIs: 35.07–346.55) and 6.28 (95% CIs: 2.06–19.13); and AUC of CCTA and ExECG were 0.9950±0.0046 and 0.7727±0.0638, respectively. There is no heterogeneity caused by threshold effect in CCTA or ExECG analysis. The Deeks’ test showed no potential publication bias (P=0.17). Conclusions: CCTA has better diagnostic performance than ExECG in the evaluation of CAD, which can provide a better solution for the clinical problem of the diagnosis for CAD.

Outlining the severity of the myocardial bridge (MB) is a critical step for selecting the appropriate option among medical, surgical, or angioplasty-based treatments. Invasive treatments are usually preferred if treatment-resistant symptoms are observed or ischemia is proven by tests such as fractional flow reserve or myocardial perfusion scintigraphy (MPS). In this report, we present a patient who developed severe hypotension during treadmill exercise test, even though there were no perfusion defects during adenosine-induced MPS. This case suggests MPS with adenosine is not a good choice for evaluating ischemia in MB patients, as it may cause false negative results. - Tıbbi, cerrahi ve anjiyoplastiye dayalı tedavi seçe- neklerinden uygun olana karar verebilmek için kritik adım miyokart köprüleşmesinin (MK) ciddiyetini belirlemektir. Ge- nellikle tedavide invaziv yöntemler; fraksiyonel akım rezervi ya da miyokart perfüzyon sintigrafisi (MPS) gibi yöntemler- le iskemi kanıtlanırsa veya tedaviye dirençli semptomların varlığında tercih edilir. Bu yazıda, adenozin ile yapılmış MPS'de perfüzyon defekti saptanmamasına rağmen koşu bandı egzersiz testinde ciddi hipotansiyon gelişen bir hasta- yı sunuyoruz. Bu olgu adenozinli MPS'nin, MK'si olan has- talarda iskemi değerlendirmesi için iyi bir seçenek olmaya- cağını düşündürmektedir.

Aims Exercise electrocardiography (ExECG) is widely used in suspected stable angina (SA) as the initial test for the evaluation of coronary artery disease (CAD). We hypothesized that exercise stress echo (ESE) would be efficacious with cost advantage over ExECG when utilized as the initial test. Methods and results Consecutive patients with suspected SA, without known CAD were randomized into ExECG or ESE. Patients with positive tests were offered coronary angiography (CA) and with inconclusive tests were referred for further investigations. All patients were followed-up for cardiac events (death, myocardial infarction, and unplanned revascularization). Cost to diagnosis of CAD was calculated by adding the cost of all investigations, up to and including CA. In the 194 and 191 patients in the ExECG vs. ESE groups, respectively, pre-test probability of CAD was similar (34 ± 23 vs. 35 ± 25%, P = 0.6). Results of ExECG were: 108 (55.7%) negative, 14 (7.2%) positive, 72 (37.1%) inconclusive and of ESE were 181 (94.8%) negative, 9 (4.7%) positive, 1 (0.5%) inconclusive, respectively. Patients with obstructive CAD following positive ESE vs. Ex ECG were 9/9 vs. 9/14, respectively ( P = 0.04). Cost to diagnosis of CAD was £266 for ESE vs. £327 for ExECG ( P = 0.005). Over a mean follow-up period of 21 ± 5 months, event rates were similar between the two groups. Conclusion In this first randomized study, ESE was more efficacious and demonstrated superior cost-saving, compared with ExECG when used as the initial investigation for the evaluation of CAD in patients with new-onset suspected SA without known CAD.

BACKGROUND: Most exercise-related cardiac arrests in men aged ≥45 years are due to coronary artery disease (CAD). The current sports medical evaluation (SME) of middle-aged sportsmen includes medical history, physical examination and resting and exercise electrocardiography (ECG). We investigated the added value of low-dose cardiac computed tomography (CCT) - both non-contrast CT for coronary artery calcium scoring (CACS) and contrast-enhanced coronary CT angiography (CCTA) - in order to detect occult CAD in asymptomatic recreational sportsmen aged ≥45 years without known cardiovascular disease. METHODS: Following a normal SME (with resting and bicycle exercise ECG), 318 asymptomatic sportsmen underwent CCT and 300 (94%) had a low European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE) risk. Occult CAD was defined as a CACS ≥100 Agatston units (AU) or obstructive (≥50%) luminal stenosis on CCTA. The number needed to screen (NNS) in order to prevent one cardiovascular event within 5 years with statin treatment was estimated. RESULTS: Fifty-two (16.4%, 95% confidence interval (CI): 12.7-20.8%) of 318 participants had a CACS ≥100 AU. The CCTA identified an additional eight participants with luminal narrowing ≥50% (and a CACS

The relatively low performance obtained with the ECG and VCG at rest for the diagnosis of coronary insufficiency explains why ECG and VCG recorded during and after exercise are used. Indeed, it is logical to expect accentuation of electrocardiographic disturbances during effort. But even using these records, there are marked discrepancies between electrocardiographic findings and the established reference criteria such as anginal complaints and/or coronarography. This explains why the published results taking coronarography into account vary from 74 to 100% in specificity, 44 to 86% in sensitivity and from 67 to 81% in performance (=[specificity+sensitivity]/2).

Guidelines recommend exercise electrocardiography (ECG) for patients with a normal baseline ECG referred for diagnostic stress testing. The additive value of myocardial perfusion Single-Photon Emission Computed Tomography (MPS) for ischemia detection, and its prognostic impact in this population

In Fabry cardiomyopathy, little is known about the interaction between its key feature of myocardial replacement fibrosis and changes in resting, Holter, and exercise electrocardiography (-ECG).Resting ECG, 24-h Holter ECG, and exercise ECG were performed in 95 patients (50 women) with Fabry disease, staged using cardiac magnetic resonance imaging to measure left ventricular fibrosis. With resting ECG, T alterations were seen in patients with cardiac fibrosis, while time intervals and rhythm were unchanged (except for a longer QRS duration in patients with severe fibrosis). All patients with severe fibrosis showed T inversion, ST alteration, or both. With Holter ECG, maximum and minimum heart rate did not differ with fibrosis severity. Patients without fibrotic tissue showed less ventricular premature beats (VPB) (median 5/24 h) compared to those with mild (median 11/24 h) or severe fibrosis (median 115/24 h; P 0.05, respectively). Fibrosis was a strong predictor of VPB burden (rOur data suggest that cardiac replacement fibrosis is responsible for repolarization abnormalities on resting ECG and increased VPB with Holter ECG. During exercise ECG, advanced cardiomyopathy is characterized by chronotropic incompetence with limitations on blood pressure and heart rate increase.

We evaluated clinical and economic outcomes of diagnostic strategies on the basis of pharmacologic stress echocardiography (PhSE) versus exercise electrocardiography test (EET) in 527 patients with chest pain (274 women; age 59 +/- 10 years) who underwent both EET and PhSE. We investigated 3 strategies, ie, coronary angiography: after positive EET (strategy 1); after positive PhSE (strategy 2); or after a positive PhSE performed after a positive EET (strategy 3). A patient was correctly identified if he or she had negative test results and no events, or had positive test results and abnormal coronaries. The cost per patient correctly identified was calculated as the ratio between the cost of each strategy and the number of patients correctly identified. The accuracy in correctly identifying the patients was 78%, 92%, and 91% with strategies 1, 2, and 3, respectively. The cost of each patient correctly identified was 1572 US dollars, 1097 US dollars, and 1081 US dollars with strategies 1, 2, and 3, respectively. In conclusion, PhSE-based strategies are cost-effective versus EET.

Welcome Historical Session Opening Address Lauder Brunton History of Angina Pathophysiological Session The Pathology of Angina Experimental Studies on the Myocardial Collateral Circulation First Discussion Coronary Blood Flow and Myocardial Metabolism in Angina Pectoris Cardiac Function in Patients with Angina Second Discussion Therapeutic Session The Modern Epidemic Is Angina Preventable? Third Discussion Chest Pain, Exercise Electrocardiography and Coronary Arteriography (Correlative Studies in Angina Pectoris Prognosis of Angina Pectoris Panel Discussion Summing Up

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

Coronary computed tomographic angiography (CCTA) is emerging as a powerful non-invasive tool in the diagnosis of coronary artery disease (CAD). However, there is concern that CCTA is being used indiscriminately without sufficient examination of its added value vis-a-vis more established forms of non-invasive testing.1 With an ever-growing armament of non-invasive tests for the diagnosis and evaluation of CAD, cardiologists must consider the following questions in weighing up the implementation of a new diagnostic modality in the routine clinical setting. Is testing necessary for the diagnosis of CAD in a particular patient group? Will testing guide management decisions and identify patients who may benefit from coronary revascularization? Will the benefits of testing outweigh its potential risks? The study by Mollet et al. 2 provides important insights into the relationship between the findings of CCTA and conventional treadmill exercise electrocardiography (ECG), but also raises important issues regarding the role of both tests in the diagnosis of CAD. The authors examined, in 62 patients with typical angina pectoris, the diagnostic value of exercise ECG and 16-slice multidetector CCTA, alone and in combination, to predict ≥50% diameter stenoses detected on invasive, selective coronary angiography (SCA) in any coronary artery branch with a calibre of ≥2 mm. Exercise ECG data from 53 patients and CCTA data from 61 patients were included in the analyses. The sensitivity of exercise ECG was 78%, specificity was 67%, and positive and negative predictive values were 89 and 47%, respectively. The sensitivity of CCTA was 100%, specificity was 87%, and positive and negative predictive values were 96 and 100%, respectively. In an analysis based on Bayesian principles, an abnormal CCTA increased the post-test probability of significant CAD after a positive exercise ECG from 89 to 99% and after a negative exercise ECG from 58 to 91%. A normal CCTA … *Corresponding author. E-mail address : gerber.thomas{at}mayo.edu

Patient initials or identifier number FS ### Relevant clinical history and physical exam A 65-year old man was admitted our hospital with CCS class 2 effort angina. Exercise electrocardiography showed ischemic response and coronary angiography was performed. His coronary risk factor was

我々が開発した新しい運動負荷心電図自動診断システム (ML1100) の有用性を検討した.2病院における274人の診断的運動負荷試験の心電図結果について, 異なる病院の3人の医師判定を基準として, 自動診断の感度, 特異度を検討した.その際, あらかじめ5段階で行った評価を, 陰性 (陰性, 陽性であるが可能性なし, 判定不能 (心拍数上昇不良) ) と, 陽性 (境界域, 可能性あり) に2分して取り扱った.自動診断の陽性判定閾値を0.1mvから0.09mvにすることにより, 自動診断の感度は63.6%から77.3%に増加した.0.09mvの陽性判定閾値にて自動診断の診断能を検討すると, 負荷方法による自動診断能には差がなかった.負荷前心電図正常例 (感度88.9%) , 医師判定全員一致例 (感度95.5%) における自動診断の感度が高かった.本システムは, スクリーニング検査としての運動負荷心電図検査に有用と思われた.

We reviewed the exercise thallium-201 ( 201 Tl) myocardial single photon emission tomography (SPET) results and clinical data of 28 patients, adhering to a strict definition of syndrome X. All of the patients had a normal resting left ventricular ejection fraction (LVEF) and no cardiac abnormalities. The results of the exercise electrocardiography (ECG) studies were evaluated and compared with the results of 201 Tl SPET. Of the 28 patients, only 3 (11%) had a normal 201 Tl SPET scan and 25 (89%) had an abnormal 201 Tl SPET scan. We found that a normal 201 Tl SPET scan was rare when adhering to a strict definition of syndrome X, and the results of exercise ECG did not correlate well with the perfusion defects observed on the 201 Tl SPET scan.

We studied by means of probability analysis the role of exercise ECG in identifying coronary restenosis. A total of 213 patients were independently evaluated by clinical history, conventional assessment of the exercise ECG ('yes or no' statement), D score (a discriminant function derived from exercise ECG), and coronariography, 5.4 +/- 2.8 months after successful coronary angioplasty. The initial probability of restenosis (30%), that is, the prevalence of the condition, was radically changed by the result of clinical history (77% for patients with angina vs. 17% for those without angina). By contrast, ECG binary assessment, due to its low accuracy (70% vs 82% of clinical history, P0.005), was unable to significantly change the established probabilities after symptomatic evaluation. Finally, D score, which greatly enhanced specificity (92% vs. 76% of bivariate assessment, P0.0001), proved to be useful in changing the probability (from 32% to 76% or to 25%) of patients (n = 34) with a discordant result (no angina/positive exercise ECG). When this stepwise approach was tested in 46 new patients, predicted and observed probabilities were actually very similar. We conclude that exercise ECG has a very limited role in identifying coronary restenosis if positive responses are not adjusted with a weighted score which takes into account other exercise derived factors.

Twenty healthy male subjects (age range, 15-25 years; median, 21 years) underwent magnetocardiography during physical exercise. Significant ST-segment displacements of the magnetic signal were found during exercise at a heart rate of 120 beats/min compared to the magnetic signal at rest (P.001). Since no significant ST-segment changes were found in the electrocardiogram recorded simultaneously with the magnetocardiogram, it is concluded that the magnetocardiogram shows junctional ST-T segment changes earlier than the electrocardiogram.

Summary Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare malignant arrhythmia, usually diagnosed in the adolescent years. The diagnosis can typically be made by one or more of the following: a positive family history, exercise electrocardiography, ambulatory ECG monitoring and/ or an intra-cardiac, electrophysiological examination. This is a case report of a patient with CPVT that was refractory to treatment with beta-blockade and an implanted automatic cardioverter defibrillator. However, after a selective serotonin re-uptake inhibitor (SSRI) was added to the therapeutic regimen, no further episodes of ventricular tachycardia occurred during the following two years.

To assess the performance of currently used stress tests for the detection of coronary artery disease (CAD) in a series of female hypertensive patients. We performed exercise electrocardiography (ECG), technetium-99m sestamibi (MIBI) single photon emission computed tomography, dobutamine and dipyridamole echocardiography, and coronary angiography in 76 hypertensive women. Of the 76 study patients, 31 (41%) had significant CAD. The sensitivity of exercise ECG (81%), MIBI scanning (90%), and dobutamine echocardiography (87%) was greater than that of dipyridamole echocardiography (61%). This finding resulted from the lower sensitivity of dipyridamole echocardiography in the detection of single-vessel CAD (47% vs 76%, 88%, and 82% for the other 3 methods). In contrast, the sensitivity of the 4 tests was similar in the detection of multivessel CAD. The specificity of exercise ECG (56%) and MIBI scanning (53%) was less than that of dobutamine (82%, both p

Objectives: When autopsy is performed after sudden death of a young person, cause of death remains undetermined in 6-65%, which is termed sudden unexplained death (SUD). In these cases molecular autopsy and cardiological and genetic examination in surviving first degree relatives is known to unmask its cause, especially primary arrhythmia syndromes. We explored the yield of family screening in a large series of young SUD victims. Methods: We studied all consecutive families who presented to the cardiogenetics department of our university hospital between 1996-2008 for family screening because of ≥1 first degree related SUD victim aged 1-50 years. In the Netherlands autopsy is not mandatory in these cases, and was not performed in 53.8%. It the remainder, autopsy did not reveal a cause of death. First, relatives were questioned on their personal and family medical history and a resting ECG was made. If possible, autopsy of the heart was revised. In most cases, relatives were referred to a cardiologist, who generally performed an exercise test and echocardiography. Other examinations, such as ajmaline drug challenge, Holter monitoring and cardiac MRI, were performed on indication. Genetic analysis of the associated candidate gene(s) was performed in material obtained from the deceased person or in those relatives with clinical abnormalities. Results: Relatives of 115 SUD victims (mean age at death 29.1 years, 67.8% male) were examined. In 52.6% events occurred at rest and in 29.8% upon exertion. Approximately 16% of the victims had experienced an unexplained syncope before the event, mainly at exertion, and one victim had survived a previous out-of-hospital cardiac arrest. A mean of 2.5 (1-8) first-degree relatives were examined per family (N=242). In 28 families another first degree family member aged

Objectives: When autopsy is performed after sudden death of a young person, cause of death remains undetermined in 6-65%, which is termed sudden unexplained death (SUD). In these cases molecular autopsy and cardiological and genetic examination in surviving first degree relatives is known to unmask its cause, especially primary arrhythmia syndromes. We explored the yield of family screening in a large series of young SUD victims. Methods: We studied all consecutive families who presented to the cardiogenetics department of our university hospital between 1996-2008 for family screening because of ≥1 first degree related SUD victim aged 1-50 years. In the Netherlands autopsy is not mandatory in these cases, and was not performed in 53.8%. It the remainder, autopsy did not reveal a cause of death. First, relatives were questioned on their personal and family medical history and a resting ECG was made. If possible, autopsy of the heart was revised. In most cases, relatives were referred to a cardiologist, who generally performed an exercise test and echocardiography. Other examinations, such as ajmaline drug challenge, Holter monitoring and cardiac MRI, were performed on indication. Genetic analysis of the associated candidate gene(s) was performed in material obtained from the deceased person or in those relatives with clinical abnormalities. Results: Relatives of 115 SUD victims (mean age at death 29.1 years, 67.8% male) were examined. In 52.6% events occurred at rest and in 29.8% upon exertion. Approximately 16% of the victims had experienced an unexplained syncope before the event, mainly at exertion, and one victim had survived a previous out-of-hospital cardiac arrest. A mean of 2.5 (1-8) first-degree relatives were examined per family (N=242). In 28 families another first degree family member aged

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 68 consecutive patients. Our data show that stress echocardiography and exercise electrocardiography offer similar prognostic information after uncomplicated non-Q-wave AMI.

Coronary revascularization procedures (coronary artery bypass graft - CABG surgery, percutaneous coronary intervention - PCI) are widely used in patients with coronary artery disease (CAD). By assessing myocardial perfusion, single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) aids the diagnosis of CAD and patient risk stratification, providing useful information regarding the decision about revascularization and is well suited to assess patients after intervention. Saphenous vein graft occlusion rates range between 8% (early) and 45% (11.5 years after CABG surgery), while the 10-year occlusion rate for arterial conduits such as the internal mammary artery is about 20%. PCI restenosis rates without stenting range between 20%-65% during the first 6 months of follow-up, while coronary stenting has been shown to reduce restenosis rates of about 20%. Chest pain and exercise electrocardiography are largely unhelpful in identifying patients at risk after revascularization procedures. MPI is of proven value to assess patients post intervention. Information gained from post-intervention myocardial SPECT is crucial to differentiate patients with angina from those with exo-cardiac chest pain syndromes, to assess peri-intervention myocardial damage/acute vessel closure, to predict-detect restenosis after PCI and graft occlusion/stenosis after CABG surgery, to detect CAD progression in non-revascularized vessels, to assess left ventricular function (gated-SPECT), to evaluate the effects of intervention if required for occupational reasons and to predict long-term prognosis. With respect to detecting graft patency, MPI has an 80-96% sensitivity and 61-88% specificity, while regarding restenosis after PCI, sensitivity and specificity range between 74-94% and 67-88%, respectively. Despite the large amount of published data demonstrating the value of myocardial perfusion SPECT imaging in patients after CABG surgery or PCI, there is still debate on whether or not these tests should be performed routinely. © 2008 Bentham Science Publishers Ltd. 5 1 9 16

Ninety-one patients with Kawasaki disease were examined by cross sectional echocardiography between 1980 and 1988. In the 75 patients evaluated during the acute phase of the illness (the first month), the first echocardiographic examination was carried out at a mean time of 16 days (range 5-30) and coronary arterial lesions were seen in 21 (28%). Two patients with medium sized aneurysms had myocardial infarctions, and one died. Coronary arterial lesions persisted in 17 (23%) patients, most often in younger children. The remaining 16 patients were examined from one month to four years after their acute illnesses, and this group did not have coronary arterial abnormalities. Seven patients with coronary artery lesions have reached school age and require regular echocardiographic examination and exercise electrocardiography. Selective coronary arteriography may be indicated in some patients to identify coronary artery stenosis, which the Japanese experience has shown may progress for several years after the acute illness.

心室性期外収縮 (PVC) 症例における自律神経活動を検討するために, 器質的心疾患を有さないPVC症例16例に自律神経反射試験, 運動負荷試験およびホルター心電図 (Holter ECG) を同時に施行し, 自律神経反射試験によりPVCの誘発が認められるgroup A 8症例と, 誘発が認められないgroup B 8症例に分けて検討した.その結果, 運動負荷試験によりPVCの誘発される症例は, group Aで8例中5例 (62%) に対してgroup Bでは8例中1例 (13%) であり, その頻度はgroup Aで有意に高かった.運動負荷中のpressure ratep roductもgroup Aに有意の高値が認められた.またHolter ECGにおけるPVCの重症度や, その発現様式には両群間で差は認められなかったが, 日常生活における心拍数の変動はgroup Aに大である傾向が認められた.Group Aの症例は, 主に交感神経活動が亢進した状態にあることが考えられ, 同じ器質的心疾患を有さないPVC症例においても, 自律神経反射試験によりPVCの誘発される症例は, そうでない症例に比べ臨床的に異なった意義を有することが示唆された.

Background To explore the prognostic performance of coronary computed tomography angiography (CCTA) and exercise electrocardiography (XECG) in asymptomatic subjects. Methods We retrospectively enrolled 812 (59 ± 9 years, 60.8% male) asymptomatic subjects who underwent CCTA and XECG concurrently from 2003 through 2009. Subjects were followed-up for major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, unstable angina, and revascularization after 90 days from index CCTA. Results The prevalence of occult coronary artery disease (CAD) detected by CCTA was 17.5% and 120 subjects (14.8%) had positive XECG. During a mean follow-up of 37 ± 16 months, nine subjects experienced MACE. In multivariable Cox-regression analysis, only the presence of CAD by CCTA independently predicted future MACE (p = 0.002). Moreover, CAD by CCTA improved the predictive value when added to a clinical risk factor model using the likelihood ratio test (p < 0.001). Notably, the prognostic value of CCTA persisted in the moderate-to-high-risk group as classified by the Duke treadmill score (p = 0.040), but not in the low-risk group (p = 0.991). Conclusion CCTA provides incremental prognostic benefit over and above XECG in an asymptomatic population, especially for those in a moderate-to-high-risk group as classified by the Duke treadmill score. Risk stratification using XECG may prove valuable for identifying asymptomatic subjects who can benefit from CCTA.

Background: A recent study on exercise testing (ET) suggested that ST-segment changes in the right precordial leads (RPL) may increase its sensitivity substantially. However, this study looked at a highly selected population of patients who all underwent thallium-201 scintigraphy and coronary angiography. The present study evaluated the clinical utility of ST-segment changes in the RPL and lead aVR in an unselected population of patients undergoing ET. Methods: A total of 906 consecutive patients who received ET were included in the study. ET was done using the Bruce Protocol with a 12-lead electrocardiogram (ECG) substituting V 4 R and V 6 R for V 1 and V 6 . Leads V 1 and V 6 were selected for omission as these two leads hardly ever manifest changes in isolation. Substituting two leads would obviate the need for a more complex recording system, thus improving clinical utility. Results: On the basis of horizontal/downsloping ST-segment depression (STD) of 1.0 mm or more (the usually accepted criterion for a positive ET), 159 (17.5%) patients had a positive ET. In those patients with a negative ET (545 patients), 4 patients (0.7%) manifested STD and 5 patients (0.9%) manifested ST-segment elevation (STE) in leads V 4 R and/or V 6 R, respectively. Of note, 44.7% of the positive ET group had STE in lead aVR. Conclusion: The use of ST-segment changes in RPL during exercise stress testing does not appreciably change the test results of a standard ET. If one was to consider an additional marker, STE in aVR may be more useful, as it shows a stronger correlation with positive tests and does not require the recording of additional leads.