Search

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., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Inc.)

Importance: Recent European guidance supports a diminished role for exercise electrocardiography (ECG) in the assessment of suspected stable angina., Objective: To evaluate the utility of exercise ECG in contemporary practice and assess the value of combined functional and anatomical testing., Design, Setting, and Participants: This is a post hoc analysis of the Scottish Computed Tomography of the Heart (SCOT-HEART) open-label randomized clinical trial, conducted in 12 cardiology chest pain clinics across Scotland for patients with suspected angina secondary to coronary heart disease. Between November 18, 2010, and September 24, 2014, 4146 patients aged 18 to 75 years with stable angina underwent clinical evaluation and 1417 of 1651 (86%) underwent exercise ECG prior to randomization. Statistical analysis was conducted from October 10 to November 5, 2019., Interventions: Patients were randomized in a 1:1 ratio to receive standard care plus coronary computed tomography (CT) angiography or to receive standard care alone. The present analysis was limited to the 3283 patients who underwent exercise ECG alone or in combination with coronary CT angiography., Main Outcomes and Measures: The primary clinical end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years., Results: Among the 3283 patients (1889 men; median age, 57.0 years [interquartile range, 50.0-64.0 years]), exercise ECG had a sensitivity of 39% and a specificity of 91% for detecting any obstructive coronary artery disease in those who underwent subsequent invasive angiography. Abnormal results of exercise ECG were associated with a 14.47-fold (95% CI, 10.00-20.41; P < .001) increase in coronary revascularization at 1 year and a 2.57-fold (95% CI, 1.38-4.63; P < .001) increase in mortality from coronary heart disease death at 5 years or in cases of nonfatal myocardial infarction at 5 years. Compared with exercise ECG alone, results of coronary CT angiography had a stronger association with 5-year coronary heart disease death or nonfatal myocardial infarction (hazard ratio, 10.63; 95% CI, 2.32-48.70; P = .002). The greatest numerical difference in outcome with CT angiography compared with exercise ECG alone was observed for those with inconclusive results of exercise ECG (5 of 285 [2%] vs 13 of 283 [5%]), although this was not statistically significant (log-rank P = .05)., Conclusions and Relevance: This study suggests that abnormal results of exercise ECG are associated with coronary revascularization and the future risk of adverse coronary events. However, coronary CT angiography more accurately detects coronary artery disease and is more strongly associated with future risk compared with exercise ECG., Trial Registration: ClinicalTrials.gov Identifier: NCT01149590.

Background: In the United Kingdom (UK), exercise intensity is prescribed from a fixed percentage range (% heart rate reserve (%HRR)) in cardiac rehabilitation programmes. We aimed to determine the accuracy of this approach by comparing it with an objective, threshold-based approach incorporating the accurate determination of ventilatory anaerobic threshold (VAT). We also aimed to investigate the role of baseline cardiorespiratory fitness status and exercise testing mode dependency (cycle vs . treadmill ergometer) on these relationships., Design and Methods: A maximal cardiopulmonary exercise test was conducted on a cycle ergometer or a treadmill before and following usual-care circuit training from two separate cardiac rehabilitation programmes from a single region in the UK. The heart rate corresponding to VAT was compared with current heart rate-based exercise prescription guidelines., Results: We included 112 referred patients (61 years (59-63); body mass index 29 kg·m -2 (29-30); 88% male). There was a significant but relatively weak correlation ( r  = 0.32; p  = 0.001) between measured and predicted %HRR, and values were significantly different from each other ( p  = 0.005). Within this cohort, we found that 55% of patients had their VAT identified outside of the 40-70% predicted HRR exercise training zone. In the majority of participants (45%), the VAT occurred at an exercise intensity <40% HRR. Moreover, 57% of patients with low levels of cardiorespiratory fitness achieved VAT at <40% HRR, whereas 30% of patients with higher fitness achieved their VAT at >70% HRR. VAT was significantly higher on the treadmill than the cycle ergometer ( p <  0.001)., Conclusion: In the UK, current guidelines for prescribing exercise intensity are based on a fixed percentage range. Our findings indicate that this approach may be inaccurate in a large proportion of patients undertaking cardiac rehabilitation.

Objective: To evaluate the use of stress testing in a community population with de novo stable chest pain, a normal resting electrocardiogram (ECG), and the ability to exercise., Patients and Methods: We identified eligible patients by searching the electronic medical record of all outpatients seen at Mayo Clinic Rochester from January 1, 2010, through December 31, 2013. We determined the frequency of initial exercise stress testing, computed tomography coronary angiography, and invasive coronary angiography, as well as the use of subsequent second procedures (including percutaneous coronary intervention [PCI] and coronary artery bypass grafting) within 90 days. Patients were followed for 5 years for death, nonfatal myocardial infarction, and hospitalization for unstable angina., Results: The data search identified 1175 patients with chest pain and normal resting ECGs. Only 331 patients underwent cardiac testing. A slight majority (185; 55.9%) underwent an exercise ECG alone. The remainder underwent exercise echocardiography (112; 33.8%), exercise single-photon-emission computed tomography (32; 9.7%), or computed tomography coronary angiography (2; 0.9%). Few patients (30; 9.1%) required additional testing within 90 days. Of the 14 patients (4.2%) who underwent invasive coronary angiography, 12 (85.7%) had significant coronary artery disease, and were referred for percutaneous coronary intervention or coronary artery bypass grafting. At 5 years, the mortality rate was 1.2%, and the combined event rate was 3.8%., Conclusion: Most community patients with chest pain and a normal resting ECG do not require further cardiac evaluation. In patients who require testing, and are able to exercise, noninvasive stress testing is preferred. Invasive coronary angiography is applied selectively and associated with a high rate of significant coronary artery disease and referral to coronary revascularization. Long-term outcomes are excellent., (Copyright © 2019 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

The latest aminophylline shortage has prompted a need for alternative reversal agents for pharmacological stress testing. Cardiac stress testing is common for diagnosis and prognosis in patients with coronary heart disease. Options for pharmacological stress test agents include adenosine, regadenoson, dipyridamole, and dobutamine, whereas aminophylline is the recommended reversal agent. Adenosine and dobutamine can be used as alternatives to regadenoson and dipyridamole to decrease or eliminate the use of aminophylline. Alternatives to aminophylline include theophylline and caffeine. It is important to efficiently identify alternatives during a drug shortage to maintain optimal patient outcomes.

Objective: To develop a mobile app called "TMT Predict" to predict the results of Treadmill Test (TMT), using data mining techniques applied to a clinical dataset using minimal clinical attributes. To prospectively test the results of the app in realtime to TMT and correlate with coronary angiogram results., Methods: In this study, instead of statistics, data mining approach has been utilized for the prediction of the results of TMT by analyzing the clinical records of 1000 cardiac patients. This research employed the Decision Tree algorithm, a new modified version of K-Nearest Neighbor (KNN) algorithm, K-Sorting and Searching (KSS). Furthermore, curve fitting mathematical technique was used to improve the Accuracy. The system used six clinical attributes such as age, gender, body mass index (BMI), dyslipidemia, diabetes mellitus and systemic hypertension. An Android app called "TMT Predict" was developed, wherein all three inputs were combined and analyzed. The final result is based on the dominating values of the three results. The app was further tested prospectively in 300 patients to predict the results of TMT and correlate with Coronary angiography., Results: The accuracy of predicting the result of a TMT using data mining algorithms, Decision Tree and K-Sorting & Searching (KSS) were 73% and 78%, respectively. The mathematical method curve fitting predicted with 82% accuracy. The accuracy of the mobile app "TMT Predict", improved to 84%. Age-wise analysis of the results show that the accuracy of the app dips when the age is more than 60years indicating that there may be other factors like retirement stress that may have to be included. This gives scope for future research also. In the prospective study, the positive and negative predictive values of the app for the results of TMT and coronary angiogram were found to be 40% and 83% for TMT and 52% and 80% for coronary angiogram. The negative predictive value of the app was high, indicating that it is a good screening tool to rule out coronary artery heart disease (CAHD)., Conclusion: "TMT Predict" is a simple user-friendly android app, which uses six simple clinical attributes to predict the results of TMT. The app has a high negative predictive value indicating that it is a useful tool to rule out CAHD. The "TMT Predict" could be a future digital replacement for the manual TMT as an initial screening tool to rule out CAHD., (Copyright © 2018. Published by Elsevier B.V.)

Objective: Cardiopulmonary exercise testing (CPET) is the 'gold standard' method of determining VO 2peak . When CPET is unavailable, VO 2peak may be estimated from treadmill or cycle ergometer workloads and expressed as estimated metabolic equivalents (METs). Cardiac rehabilitation (CR) programmes use estimated VO 2peak (METs) to report changes in cardiorespiratory fitness (CRF). However, the accuracy of determining changes in VO 2peak based on estimated functional capacity is not known., Methods: A total of 27 patients with coronary heart disease (88·9% male; age 59·5 ± 10·0 years, body mass index 29·6 ± 3·8 kg m -2 ) performed maximal CPET before and after an exercise-based CR intervention. VO 2peak was directly determined using ventilatory gas exchange data and was also estimated using the American College of Sports Medicine (ACSM) leg cycling equation. Agreement between changes in directly determined VO 2peak and estimated VO 2peak was evaluated using Bland-Altman limits of agreement (LoA) and intraclass correlation coefficients., Results: Directly determined VO 2peak did not increase following CR (0·5 ml kg -1 min -1 (2·7%); P = 0·332). Estimated VO 2peak increased significantly (0·4 METs; 1·4 ml kg -1  min -1 ; 6·7%; P = 0·006). The mean bias for estimated VO 2peak versus directly determined VO 2peak was 0·7 ml kg -1  min -1 (LoA -4·7 to 5·9 ml   kg -1  min -1 ). Aerobic efficiency (ΔVO 2 /ΔWR slope) was significantly associated with estimated VO 2peak measurement error., Conclusion: Change in estimated VO 2peak derived from the ACSM leg cycling equation is not an accurate surrogate for directly determined changes in VO 2peak . Our findings show poor agreement between estimates of VO 2peak and directly determined VO 2peak . Applying estimates of VO 2peak to determine CRF change may over-estimate the efficacy of CR and lead to a different interpretation of study findings., (© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Cardiovascular diseases are common; therefore, adequate and guideline-based diagnostics and treatment are essential. In addition to an electrocardiogram (ECG) and (treadmill) exercise tests, echocardiography plays the pivotal role in functional cardiac testing. It is permanently available at the bedside and has a high diagnostic accuracy; however, examinations such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) as well as nuclear medical imaging, e.g. single proton emission CT (SPECT) and positron emission tomography (PET) are becoming more and more common in clinical practice. This is due to the wide range of additional information and the high diagnostic accuracy. In the following article, the individual possibilities of non-invasive cardiac functional testing are presented and their meaningful application will be discussed; however, studies on the meaningful application of non-invasive diagnostics are scarce.

Myocardial ischemia can be assessed by ECG at rest or doing the stress test, which also serves to evaluate the results of cardiac rehabilitation., Aim: The aim of this study was to determine the usefulness of the scale before exercise and exercise to assess the risk of coronary heart disease and recognition by physiotherapists., Materials and Methods: The study included three groups of people: 1. 65 patients with stable coronary heart disease (IHD), including 45 men and 20 women, ranging in age from 33 to 79 years, an average of 60.18 ± 9.43 years who exercise test was positive; 2. 24 patients after myocardial infarction undergoing subsequent rehabilitation, including 20 men and 4 women, aged from 42 to 78 years, an average of 58.75 ± 8.45 years; 3. 70 healthy subjects without ischemic heart disease, including 34 men and 36 women, ranging in age from 24 to 70 years, an average of 56.24 ± 12.33 years. All healthy people and patients were hospitalized in the Department of Internal Medicine and Cardiac Rehabilitation, University Hospital im. WAM in Lodz. The study groups were assessed risk of coronary heart disease based on the result obtained in the scale before exercise and exercise. The results were statistically analyzed using Statistica version 12 (StatSoft, Poland). For the statistically significant level of p<0.05., Results: Compared to healthy individuals in both the ischemic heart disease (p=0.04) and in the group treated with rehabilitation (p=0.03) results in a scale before stress was significant higher. Compared to healthy individuals, both in the group of ischemic heart disease (p <0.001) and in the group treated with rehabilitation (p<0.001) The results on a scale of exercise were significantly higher., Conclusions: The use of scale before exercise to assess the risk of coronary heart disease is useful for physical therapists in their professional practice. There legitimacy of the use of scale exercise for the initial diagnosis of coronary artery disease without knowing the interpretation of the ECG stress test.

Background: Stress cardiac magnetic resonance (CMR) has typically involved pharmacologic agents. Treadmill CMR has shown utility in single-center studies but has not undergone multicenter evaluation., Methods and Results: Patients referred for treadmill stress nuclear imaging (SPECT) were prospectively enrolled across 4 centers. After rest (99m)Tc SPECT, patients underwent resting cine CMR. In-room stress was then performed using an MR-compatible treadmill with continuous 12-lead electrocardiogram monitoring. At peak stress, (99m)Tc was injected, and patients rapidly returned to the MR scanner isocenter for real-time, free-breathing stress cine and perfusion imaging. After recovery, cine and rest perfusion followed by late gadolinium enhancement acquisitions concluded CMR imaging. Stress SPECT was then acquired in adjacent nuclear laboratories. A subset of patients not referred for invasive coronary angiography within 2 weeks of stress underwent coronary computed tomography angiography. Angiographic data available in 94 patients showed sensitivity of 79%, specificity of 99% for exercise CMR with positive predictive value of 92% and negative predictive value of 96%. Agreement between treadmill stress CMR and angiography was strong (κ=0.82), and moderate between SPECT and angiography (κ=0.46) and CMR versus SPECT (κ=0.48)., Conclusions: The multicenter EXACT trial indicates excellent diagnostic value of treadmill stress CMR in typical patients referred for exercise SPECT., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Appropriate use criteria (AUC) for cardiac stress tests address concerns about utilization growth and patient safety. We systematically reviewed studies of appropriateness, including within physician specialties; evaluated trends over time and in response to AUC updates; and characterized leading indications for inappropriate/rarely appropriate testing., Methods: We searched PubMed (2005-2015) for English-language articles reporting stress echocardiography or myocardial perfusion imaging (MPI) appropriateness. Data were pooled using random-effects meta-analysis and meta-regression., Results: Thirty-four publications of 41,578 patients were included, primarily from academic centers. Stress echocardiography appropriate testing rates were 53.0% (95% CI, 45.3%-60.7%) and 50.9% (42.6%-59.2%) and inappropriate/rarely appropriate rates were 19.1% (11.4%-26.8%) and 28.4% (23.9%-32.8%) using 2008 and 2011 AUC, respectively. Stress MPI appropriate testing rates were 71.1% (64.5%-77.7%) and 72.0% (67.6%-76.3%) and inappropriate/rarely appropriate rates were 10.7% (7.2%-14.2%) and 15.7% (12.4%-19.1%) using 2005 and 2009 AUC, respectively. There was no significant temporal trend toward rising rates of appropriateness for stress echocardiography or MPI. Unclassified stress echocardiograms fell by 79% (p = 0.04) with updated AUC. There were no differences between cardiac specialists and internists., Conclusions: Rates of appropriate use tend to be lower for stress echocardiography compared to MPI, and updated AUC reduced unclassified stress echocardiograms. There is no conclusive evidence that AUC improved appropriate use over time. Further research is needed to determine if integration of appropriateness guidelines in academic and community settings is an effective approach to optimizing inappropriate/rarely appropriate use of stress testing and its associated costs and patient harms.

Background: Exercise electrocardiography in asymptomatic adults has been criticized because of relatively poor accuracy predicting future heart disease risk, but studies may have been too short. We investigated if integrated analysis of graded exercise tolerance tests (GXT) predicted long-term coronary heart disease (CHD) and all-cause mortalities among community-dwelling older adults., Methods and Results: From 1972 to 1974, 1789 adult residents of a predominantly Caucasian, middle- to upper-middle-class southern California community participated in a clinical evaluation that included a GXT; 52.4% (N=939) of those who had baseline GXT were followed up to 2010-up to 36years-for vital status, CHD and all-cause mortality. Multiply adjusted hazard ratios of an abnormal graded GXT were 1.65 (95% CI 0.78-3.49) and 1.56 (95% CI 1.15-2.11) for CHD and all-cause mortality, respectively. An integrated analysis hazard ratio was calculated based on the following GXT findings: significant ST change, inability to achieve target heart rate [THR], abnormal heart rate recovery [HRR], and chronotropic incompetency [ChI]. Compared to those with 0 or 1 abnormality, participants with 2 or more positive findings had significantly higher CHD (HR 2.18) and all-cause (HR 1.92) mortalities. Participants with 3 or more positive findings showed even higher hazard ratios-CHD (HR 6.16) and all-cause (HR 2.49) mortalities. When adjusted for any of 3 Framingham risk models, the integrated electrocardiographic model correlated well with CHD and all-cause mortalities., Conclusions: An integrated analysis of electrocardiographic and non-electrocardiographic measures of GXT is useful in predicting long-term CHD and all-cause mortalities in an asymptomatic middle-aged population., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Unlabelled: Measurement of oxygen uptake at the maximal exercise (VO2max) in the cardio-pulmonary exercise test provides the most reliable information about exertion tolerance., Aim of the Study: Establishment of VO2peak, VE/CO2 and AT value in the early diagnosis of asymptomatic heart dysfunction in patients with coronary disease (CAD) and prognosis during 2-years observation. The study population: 57 patients (35 M) with CAD, without any signs or symptoms of heart dysfunction, without any features of myocardial infarction, in the age 51.08 +/- 4.01., Methods: The analysis was performed twice: in the beginning and after 2-years observation. Physical examinations, echocardiographic parameters [(assessment of systolic and diastolic dysfunction of the left ventricle (LV)] and spiroergometric parameters (VO2peak, VE/CO2 at AT). On the basis of echocardiographic examination, there were created groups of patients: Group A--the patients with normal LV function (n=32; 56.2%; 23 M); Group B--the patients with diastolic heart dysfunction (n=22; 38.6%; 10 M);, Results: Group A--32 patients in the age of 50.9 +/- 4, 23 men. Values of VO2pe ak :28.8 +/- 6 ml/kg/min, VE/CO2 28.8 +/- 4.9 and AT 18 +/- 2.5. Group B--the patients with diastolic heart dysfunction: 22 (39%) patients; 10 men, in the age of 51.2 +/- 4.3. Values of VO2peak: 26 +/- 3.4 mi/ kg/min, VE/CO2 31.2 +/- 5.1 and AT 16 +/- 2.5. In the beginning of the study was established significantly differences between anaerobic threshold and degree of heart dysfunction (p=0.039)., Conclusions: (1) There was observed that VO2 A and VE/CO2 depended on filling LV profile LV and also of systolic LV function. Anaerobic threshold significantly depended on LV filling pattern. (2) In asymptomatic patients with LV diastolic dysfunction and VO2peak < or = 18.4 ml/kg/min was observed progression of LV diastolic dysfunction during two years.

Exercise-induced ischemic preconditioning (IPC) can be assessed with the second exercise stress test during sequential testing. Exercise-induced IPC is defined as the time to 1 mm ST segment depression (STD), the rate-pressure product (RPP) at 1 mm STD, the maximal ST depression and the rate-pressure product at peak exercise. The purpose of this meta-analysis is to validate the parameters used to assess exercise-induced IPC in the scientific community. A literature search was performed using electronic database. The main key words were limited to human studies, which were (a) ischemic preconditioning, (b) warm-up phenomenon, and (c) exercise. Meta-analyses were performed on the study-specific mean difference between the clinical measures obtained in the two consecutive stress tests (second minus first test score). Random effect models were fitted with inverse variance weighting to provide greater weight to studies with larger sample size and more precise estimates. The search resulted in 309 articles of which 34 were included after revision (1053 patients). Results are: (a) time to 1 mm ST segment depression increased by 91 s (95% confidence interval (CI): 75-108), p < 0.001; (b) peak ST depression decreased by -0.38 mm (95% CI: -0.66 to -0.10), p < 0.01; and (c) rate-pressure product at 1 mm STD increased by 1.80 × 10(3)mmHg (95% CI: 1.0-2.0), p < 0.001. This is the first meta-analysis to set clinical parameters to assess the benefit of exercise-induced ischemic preconditioning in sequential stress testing. The results of this first meta-analysis on the sequential stress test confirm what is presented in the literature by independent studies on exercise-induced ischemic preconditioning. From now on, the results could be used in further research to set standardized parameters to assess the phenomenon., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: The utility of clinical exercise tests depends on their support of treatment decisions. We sought to assess the utility of exercise tests for the selection of primary-care patients for referral to cardiologic care, and to determine whether referral decisions were biased by gender or socioeconomic status. We also evaluated referral rates and cardiovascular events in patients with positive exercise tests., Methods: We designed a prospective observational study of 438 men and 427 women from 28 Swedish primary-care clinics who were examined with exercise testing for suspected coronary disease. All participants were followed-up with respect to cardiologist referrals and cardiovascular events (hospitalisation for unstable angina, myocardial infarction, and cardiovascular death) within six months and revascularisation within 250 days. Variables associated with referral were identified by multivariable logistic regression. Socioeconomic status was determined by educational level and employment., Results: Positive/inconclusive exercise tests and exertional chest pain predicted referral in men and women. Of 865 participants, patients with positive, inconclusive, or negative exercise tests were referred to cardiologists in 67.3%, 26.1%, and 3.5% of cases, respectively. Overall, there was no significant difference in referral rates related to gender or socioeconomic level. Self-employed women were referred more frequently compared to other women (odds ratio (OR) 3.62, 95% confidence interval (CI) 1.19-10.99). Among non-manual employees, women were referred to cardiologic examination less frequently than men (OR 0.40, 95% CI 0.16-1.00; p = 0.049; ORs adjusted for age, exertional chest pain, and exercise test result). In patients with positive exercise tests, the referral rate decreased continuously with age (OR 0.48, 95% CI 0.23-0.97; adjusted for cardiovascular co-morbidity). Cardiovascular events occurred in 22.2% (4/18) of non-referred patients with positive exercise tests; 56% (10/18) of these patients were not considered for cardiologic care, with continuity problems in primary care as one possible contributing cause., Conclusions: Exercise tests are important for selecting patients for referral to cardiologic care. Interactions related to gender and socioeconomic status affected referral rates. In patients with positive exercise tests, referral rates decreased with age. An increased awareness of possible bias regarding age, gender, and socioeconomic status, which may influence medical decisions, is therefore necessary.

Background: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure., Objective: To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making., Design: Analyses of repeated cross-sectional data., Setting: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010)., Patients: Adults without coronary heart disease., Measurements: Cardiac stress test referrals and inappropriate use., Results: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02])., Limitation: Cross-sectional design with limited clinical data., Conclusion: National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease., Primary Funding Source: National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.

Purpose: To provide advanced practice nurses (APNs) with practice recommendations for noninvasive cardiac stress testing (NCST) to enhance diagnostic test selection and to improve the interpretation of the test results., Data Sources: A review and synthesis of current scientific literature on noninvasive cardiac stress tests was conducted including a review of pertinent guidelines, indications, contraindications, procedures and findings of exercise, pharmacological, echocardiographic, and myocardial perfusion imaging studies., Conclusions: Noninvasive cardiac stress testing is an integral component in the care of men and women for the diagnosis, prognosis, and management of individuals at risk for cardiovascular conditions or with known histories of cardiovascular disorders., Implications for Nps: Cardiovascular disorders are common in our society. APNs care for a variety of individuals in the inpatient and outpatient settings that may require noninvasive cardiac stress tests for the evaluation of significant health histories and clinical presentations. An enhanced understanding of NCST improves test selection, preparation and education of patients, interpretation of test results, and implications for future patient care., (©2014 The Author(s) ©2014 American Association of Nurse Practitioners.)

Dipyridamole/technetium sestamibi scans (more commonly known as MIBI scans, an acronym for methoxyisobutyl isonitrile) are used commonly for the diagnosis and risk stratification of coronary artery disease. Adverse events from MIBI scans are extremely rare. We present the case of a 64-year-old man who was successfully resuscitated after two asystolic episodes following dipyridamole infusion for a MIBI scan. The second asystolic episode occurred in the emergency department 40 minutes after the patient had been transferred from the Cardiac Stress Test Laboratory. To our knowledge, there are no previous reports of patients having two discrete asystolic episodes or an asystolic episode as delayed as we report after a MIBI scan. Our case illustrates why emergency physicians should be aware of the potential for asystole following MIBI scanning and why aminophylline, the antidote for dipyridamole, should be readily available in emergency departments that could see patients after pharmacologic stress testing. Patients who become asystolic following dipyridamole infusion likely require prolonged cardiac monitoring, given the potential for further episodes after periods of hemodynamic stability.

Background: Exercise has been shown to beneficially alter arterial stiffness in selected clinical settings. However, the effects of a standardized exercise protocol--"cardiac rehabilitation (CR)"--on measures of arterial stiffness in patients with established coronary heart disease (CHD) has not been well studied., Methods: Using applanation tonometry, we studied arterial vascular properties in 26 men and 22 women (mean age 60.5 ± 10.8 years) with established CHD over a 20 week CR program. All patients continued to receive their anti-anginal and vasoactive medications. In addition to standard hemodynamics we estimated central aortic pressure, central arterial pulsatility, augmentation index and arterial pulse wave velocity (PWV)., Results: After 20 weeks of CR, there were no significant changes in resting heart rate or peripheral blood pressure. In 33 patients with at least two follow-up visits, central aortic systolic pressure was consistently lower than peripheral arterial blood pressure and decreased over the CR program time (baseline, 109 ± 16 mmHg; final, 105 ± 14 mmHg. p=0.01). Both carotid-radial (n=12) and carotid-femoral (n=21) - derived PWV decreased over the CR program (carotid-radial: baseline, 7.3 ± 1.2m/s; final, 6.6 ± 1.2m/s, p=0.028. carotid-femoral: baseline, 7.2 ± 1.4m/s; final, 6.5 ± 1.3m/s, p=0.02)., Conclusions: In this group of patients with established CHD, arterial PWV was noted to significantly decrease over a 20 week CR program. This change occurred in the absence of detectable changes in peripheral blood pressure or heart rate. Decreases in PWV may serve as a sensitive indicator of improved arterial stiffness in patients with atherosclerotic arterial disease notwithstanding ongoing medical therapy., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The prognostic value of an isolated J-point depression, or rapidly upsloping ST-segment, on an exercise ECG has long been assumed to be a benign variant. However, little or no data supporting this assumption may be found in the literature. Our task was to examine if a rapidly upsloping ST-segment on an exercise ECG is associated with changes in risk of dying from CHD in 2014 healthy middle-aged men followed for 35 years., Methods: A group of healthy middle-aged men (n = 2014) participated in a cardiovascular survey. They underwent an examination programme including a symptom-limited ECG bicycle exercise test. Exercise induced ST-segments were categorised in three groups: normal ST-segment (n = 1383), rapidly upsloping (n = 401), and ST-depression (n = 230). Survival analyses were adjusted for smoking status, total cholesterol, systolic blood pressure, maximal heart rate, and physical fitness. The mean follow-up time was 35 years., Results: The rapidly upsloping group had a 30% decreased risk of CHD death (hazard ratio, HR, 0.70, 95% CI 0.51-0.95) compared to the normal ST-segment group. The risk of CVD-death was numerically lower in the rapidly upsloping group (HR 0.82, 95% CI 0.65-1.04) compared to the normal ST-segment group. The ST-depression group had a 1.45-fold (HR 1.45, 95% CI 1.09-1.90) increased risk of CHD death compared to the normal ST-segment group., Conclusions: The rapidly upsloping ST-segment was a common finding (20%) on exercise ECG among healthy middle-aged men and was associated with a 30% reduced risk of dying from CHD compared to individuals with normal ST-segment. A rapidly upsloping ST-segment on exercise ECG may represent the true healthy state.

Exercise hypertension independently predicts cardiovascular mortality, although little is known about exercise central hemodynamics. This study aimed to determine the contribution of arterial wave travel and aortic reservoir characteristics to central blood pressure (BP) during exercise. We hypothesized that exercise central BP would be principally related to forward wave travel and aortic reservoir function. After routine diagnostic coronary angiography, invasive pressure and flow velocity were recorded in the ascending aorta via sensor-tipped intra-arterial wires in 10 participants (age, 55±10 years; 70% men) free of coronary artery disease with normal left ventricular function. Measures were recorded at baseline and during supine cycle ergometry. Using wave intensity analysis, dominant wave types throughout the cardiac cycle were identified (forward and backward, compression, and decompression), and aortic reservoir and excess pressure were calculated. Central systolic BP increased significantly with exercise (Δ=19±12 mm Hg; P<0.001). This was associated with increases in systolic forward compression waves (Δ=12×10(6)±17×10(6) W·m(-2)·s(-1); P=0.045) and forward decompression waves in late systole (Δ=9×10(6)±6×10(6) W·m(-2)·s(-1); P<0.001). Despite significant augmentation in BP (Δ=9±6 mm Hg; P=0.002), reflected waves did not increase in magnitude (Δ=-1×10(6)±3×10(6) W·m(-2)·s(-1); P=0.2). Excess pressure rose significantly with exercise (Δ=16±9 mm Hg; P<0.001), and reservoir pressure integral fell (Δ=-5×10(5)±5×10(5) Pa·s; P=0.010). Change in reflection coefficient negatively correlated with change in central systolic BP (r=-0.68; P=0.03). We conclude that elevation of exercise central BP is principally because of increases in aortic forward traveling waves generated by left ventricular ejection. These findings have relevance to understanding central BP waveform morphology and pathophysiology of exercise hypertension.

Background: The incremental prognostic value of myocardial perfusion-gated single photon emission computed tomography (MPGS) compared with exercise test has not yet been properly evaluated., Methods and Results: Five thousand six hundred seventy-two consecutive patients with known or suspected coronary disease undergoing exercise MPGS between 1997 and 2007 were included. Three-year predictive models for total death and death from cardiovascular causes or acute myocardial infarction (ie, major cardiovascular events [MCE]) were built using Cox-regression modeling, including only the clinical information. Then the exercise and MPGS information was sequentially added. The added discriminative ability of exercise test information and MPGS was assessed by net reclassification improvement and integrated discrimination improvement. The increase in predictive ability of exercise information for death and MCE was high as assessed by net reclassification improvement (0.199 and 0.263) and integrated discrimination improvement (0.042 and 0.021). The only variable of MPGS associated with total death was ejection fraction (hazard ratio, 0.84; 95% confidence interval, 0.79-0.89; P<0.001). Global stress ischemic score emerged as an additional variable associated with MCE (hazard ratio, 1.07; 95% confidence interval, 1.02-1.12; P=0.007). Adding MPGS information barely improved the prognostic value for total death (net reclassification improvement, 0.017; integrated discrimination improvement, 0.013), but it increased for MCE (net reclassification improvement, 0.122; integrated discrimination improvement, 0.033)., Conclusions: Adding MPGS information to exercise information does not improve prediction of total death, although it allows a more accurate prediction of MCE.

Background: For exercise prescription, rating of perceived exertion is the subjective tool most frequently used in addition to methods based on percentage of peak exercise variables. The aim of this study was the validation of a subjective method widely called the Talk Test (TT) for optimization of training intensity in patients with recent myocardial revascularization., Design and Methods: Fifty patients with recent myocardial revascularization (17 by coronary artery bypass grafting and 33 by percutaneous coronary intervention) were enrolled in a cardiac rehabilitation programme. Each patient underwent three repetitions of the TT during three different exercise sessions to evaluate the within-patient and between-operators reliability in assessing the workload (WL) at TT thresholds. These parameters were then compared with the data of a final cardiopulmonary exercise testing, and the WL range between the individual aerobic threshold (AeT) and anaerobic threshold (AnT) was considered as the optimal training zone., Results: The within-patient and between-operators reliability in assessing TT thresholds were satisfactory. No significant differences were found between patients' and physiotherapists' evaluations of WL at different TT thresholds. WL at Last TT+ was between AeT and AnT in 88% of patients and slightly

Background: Despite the association between HIV and coronary artery disease (CAD), there are no specific recommendations for the cardiovascular evaluation of the HIV-infected population. Besides being a tool for the evaluation of CAD, the exercise treadmill test (ETT) provides insights into functional capacity and autonomic function, which have been frequently affected in HIV infection, and thus may be useful in this setting., Methods: Forty-nine HIV-infected individuals without known CAD underwent ETT. Peak oxygen consumption during exercise (VO2 peak), functional capacity (in metabolic equivalents [METs]), exercise-induced ischemia, chronotropic incompetence (CI) and abnormal heart rate recovery (HRR) after exercise were studied., Results: VO2 peak was 31.4±4.8 mL/kg/min and functional capacity was 9.2±1.6 MET. CI was observed in 30.6%, and 10.2% had abnormal HRR. VO2 peak was lower in women and inversely correlated with age and body mass index. None of the patients displayed ischemic changes., Conclusion: Although functional capacity was good, risk markers such as CI and abnormal HRR were not infrequent. This study identifies a subgroup of HIV-infected patients-the older, overweight, or obese-who may have higher risk and deserve cardiovascular screening with the ETT.

Objectives: The goal of this study was to evaluate the prevalence and clinical characteristics of mental stress-induced myocardial ischemia., Background: Mental stress-induced myocardial ischemia is prevalent and a risk factor for poor prognosis in patients with coronary heart disease, but past studies mainly studied patients with exercise-induced myocardial ischemia., Methods: Eligible patients with clinically stable coronary heart disease, regardless of exercise stress testing status, underwent a battery of 3 mental stress tests followed by a treadmill test. Stress-induced ischemia, assessed by echocardiography and electrocardiography, was defined as: 1) development or worsening of regional wall motion abnormality; 2) left ventricular ejection fraction reduction ≥ 8%; and/or 3) horizontal or downsloping ST-segment depression ≥ 1 mm in 2 or more leads lasting for ≥ 3 consecutive beats during at least 1 mental test or during the exercise test., Results: Mental stress-induced ischemia occurred in 43.45%, whereas exercise-induced ischemia occurred in 33.79% (p = 0.002) of the study population (N = 310). Women (odds ratio [OR]: 1.88), patients who were not married (OR: 1.99), and patients who lived alone (OR: 2.24) were more likely to have mental stress-induced ischemia (all p < 0.05). Multivariate analysis showed that compared with married men or men living with someone, unmarried men (OR: 2.57) and married women (OR: 3.18), or living alone (male OR: 2.25 and female OR: 2.72, respectively) had higher risk for mental stress-induced ischemia (all p < 0.05)., Conclusions: Mental stress-induced ischemia is more common than exercise-induced ischemia in patients with clinically stable coronary heart disease. Women, unmarried men, and individuals living alone are at higher risk for mental stress-induced ischemia. (Responses of Myocardial Ischemia to Escitalopram Treatment [REMIT]; NCT00574847)., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Summarize the value of the change of different parts in treadmill exercise test (TET) ECG to coronary heart disease (CHD) diagnosis. Four hundred and forty-five cases have been included in this investigation, which stayed in our hospital from January of 2006 to March of 2011 and underwent TET and coronary arteriography (CAG). The change of different parts in TET ECG in these patients had been retrospective summarized to determine its diagnosis value to CHD. (1) In the 445 cases of TET testers, 200 cases showed positive in TET with 150 cases of positive CAG, and 50 cases of negative CAG; 245 cases showed negative in TET with 206 cases of negative CAG, and 39 cases of positive CAG. The diagnosis sensitivity of CHD was 79.36% (150/189), the specificity was 80.47% (206/256), positive prediction value was 75.00% (150/200), negative prediction value was 84.08% (206/245), and false-positive rate was 25.00% (50/200) with prediction accuracy of 80.00% (356/445). (2) In the 200 cases with positive TET: 51 cases were in the limb lead group; 73 cases were in the chest lead group; and 76 cases were in the limb lead + chest lead group. There were 150 cases showing positive in CAG: 22 cases were in the limb lead group; 58 cases were in the chest lead group; and 70 cases were in the limb lead + chest lead group. The positive diagnosis rate of ST change in the chest lead was obviously higher than that of simple limb lead group (P < 0.05). (3) People with healthy coronary artery will have decreased amplitude of R wave while patients with coronary stenosis have elevated amplitude of R wave. (4) As for the T wave, the positive CAG had no statistical significance between normal T wave group and TET positive group (P > 0.05); CAG results had statistical significance between normal T wave group and TET negative group (P < 0.05). (5) Positive CAG results had no statistical significance between U-wave inversion group and TET positive group (P > 0.05); positive CAG results has statistical significance when TET negative group compared with U-wave inversion group or TET positive group (P < 0.05). TET is a relatively idea invasive diagnosis method for coronary disease, which can be utilized to evaluate the stage of CHD when integrating with the change of TET ECG.

Purpose: The purpose of this study was to investigate the relationship between the Duke Treadmil Score (DTS) and coronary artery disease (CAD) complexity in patients with suspected coronary artery disease (CAD)., Methods: Sixty five patients who had positive exercise testing for CAD were enrolled. Coronary angiography was performed and Syntax score (SxScore), a marker of CAD complexity, was determined. The relationship between DTC and SxScore then evaluated., Results: There was a strong negative correlation between DTS and SxScore (r = - 0.91, p < 0.001). In addition, patients with higher and intermediate risk as evaluated by DTS had increased SxScore compare to those that were low risk (23 ± 6, 6 ± 5 and 0 ± 0 respectively)., Conclusions: A strong negative correlation was seen between DTS and coronary lesion complexity. By assessing DTS important information about coronary artery lesion complexity can be obtained before invasive coronary angiography.

Current clinical practice for patients presenting to the emergency department with a resolved episode of chest pain and no electrographic or biomarker abnormalities is to conduct routine noninvasive testing, in accordance with American College of Cardiology and American Heart Association guidelines. The rationale is to further reduce the risk of missing a myocardial infarction, a major source of suits filed against emergency department physicians. Patients with negative stress test results may be reassured, with low event rates in the subsequent 30 days. Patients with positive stress test results have higher 30-day event rates, and a small fraction undergo revascularization procedures. Despite this endorsement, open questions remain. Does our current practice lead to the stenting of asymptomatic patients in the inevitable cases where the inciting pain was noncardiac? And, most importantly, does our practice improve outcomes? Randomized trials evaluating routine stress testing in other contexts have yielded negative results, despite diagnosing significant coronary artery disease. Population data suggest that our current practice may be increasing the diagnosis of coronary artery disease and the rate of intervention while failing to decrease rates of myocardial infarction. We propose that randomized trials be conducted to evaluate whether any testing is better than no further intervention. Data from such an evidence-based approach has the potential to reverse our current practice.

Background: In myocardial perfusion scintigraphy (MPS), typically a stress and a rest study is performed. If the stress study is considered normal, there is no need for a subsequent rest study. The aim of the study was to determine whether nuclear medicine technologists are able to assess the necessity of a rest study., Methods: Gated MPS using a 2-day 99mTc protocol for 121 consecutive patients were studied. Visual interpretation by 3 physicians was used as gold standard for determining the need for a rest study based on the stress images. All nuclear medicine technologists performing MPS had to review 82 training cases of stress MPS images with comments regarding the need for rest studies, and thereafter a test consisting of 20 stress MPS images. After passing this test, the nuclear medicine technologists in charge of a stress MPS study assessed whether a rest study was needed or not or if he/she was uncertain and wanted to consult a physician. After that, the physician in charge interpreted the images and decided whether a rest study was required or not., Results: The nuclear medicine technologists and the physicians in clinical routine agreed in 103 of the 107 cases (96%) for which the technologists felt certain regarding the need for a rest study. In the remaining 14 cases the technologists were uncertain, i.e. wanted to consult a physician. The agreement between the technologists and the physicians in clinical routine was very good, resulting in a kappa value of 0.92. There was no statistically significant difference in the evaluations made by technicians and physicians (P = 0.617)., Conclusions: The nuclear medicine technologists were able to accurately determine whether a rest study was necessary. There was very good agreement between nuclear medicine technologists and physicians in the assessment of the need for a rest study. If the technologists can make this decision, the effectiveness of the nuclear medicine department will improve.

Background: The prognostic value of the 6-minute walk test (6MWT) in patients with stable coronary heart disease is unknown. We sought to determine whether the 6MWT predicted cardiovascular events in ambulatory patients with coronary heart disease., Methods: We measured 6MWT distance and treadmill exercise capacity in 556 outpatients with stable coronary heart disease from September 11, 2000, through December 20, 2002. Participants were followed up for a median of 8.0 years for cardiovascular events (heart failure, myocardial infarction, and death)., Results: Cardiovascular events occurred in 218 of 556 participants (39.2%). Patients in the lowest quartile of 6MWT distance (87-419 m) had 4 times the rate of events as those in the highest quartile (544-837 m) (unadjusted hazard ratio, 4.29; 95% CI, 2.83-6.53; P < .001). Each SD decrease in 6MWT distance (104 m) was associated with a 55% higher rate of cardiovascular events (age-adjusted hazard ratio, 1.55; 95% CI, 1.35-1.78). After adjustment for traditional risk factors and cardiac disease severity measures (ejection fraction, inducible ischemia, diastolic dysfunction, amino-terminal portion of the prohormone of brain-type natriuretic peptide, and C-reactive protein), each SD decrease in 6MWT was associated with a 30% higher rate of cardiovascular events (hazard ratio, 1.30; 95% CI, 1.10-1.53). When added to traditional risk factors, the 6MWT resulted in category-free net reclassification improvement of 39% (95% CI, 19%-60%). The discriminative ability of the 6MWT was similar to that of treadmill exercise capacity for predicting cardiovascular events (C statistics both 0.72; P = .29)., Conclusions: Distance walked on the 6MWT predicted cardiovascular events in patients with stable coronary heart disease. The addition of a simple 6MWT to traditional risk factors improved risk prediction and was comparable with treadmill exercise capacity.

Objective: To investigate the value of QT hysteresis index during treadmill exercise test (TET) in diagnosing coronary heart disease (CHD)., Methods: One hundred consecutive patients suspected for CHD were referred for TET and selective coronary angiography (CAG). Patients were divided into positive [n = 55, age (56.0 ± 7.9) years] and negative [n = 45, age (53.2 ± 6.7) years] group based on their CAG results. For each TET recording, 50 points were selected for the RR, QTp, and QTe interval measurements. QTp and QTe interval was plotted against corresponding RR interval. QT/RR curve was constructed by connect all point, QT hysteresis index was calculated for each patient., Results: The QTp [(22.4 ± 10.3) ms vs. (6.7 ± 4.6) ms, P < 0.001] and QTe [(27.1 ± 11.1) ms vs. (7.6 ± 4.6) ms, P < 0.001] hysteresis index of patients in positive group were significantly higher than those in negative group. The sensitivity of QTp and QTe hysteresis index for diagnosing CHD was 89.1% (49/55) and 94.5% (52/55), respectively, and the specificity was 82.2% (37/45) and 80.0% (36/45), respectively. If the patient fulfilled both the classical TET and QT hysteresis criteria, the sensitivity for diagnosing CHD increased to 94.3% (33/35, QTp) and 94.6% (35/37, QTe), and the specificity were both 100% (26/26, 26/26). Moreover, QTp (r = -0.399, P < 0.001) and QTe (r = -0.547, P < 0.001) hysteresis index highly correlated to Duke treadmill score., Conclusion: QT hysteresis index is useful parameter for CHD diagnosis and which could improve the diagnostic value of TET for CHD in combination with the classical TET criteria for diagnosis of CHD.

Borderline personality disorder (BPD) is characterized by inherent difficulties with self-regulation. While a number of studies have examined the relationship between BPD and body mass index (BMI)/overweight/obesity, findings have been mixed. In this cross-sectional study of a consecutive sample of 238 participants presenting for cardiac stress testing, we investigated the relationship between borderline personality symptoms, according to two self-report measures, and BMI. Compared to participants who were negative on both measures of borderline personality symptoms, participants who were positive on either measure of borderline personality symptoms demonstrated no differences in current BMI or highest BMI in adulthood. These results in a unique study population mirror the findings of other studies in medical and community populations.

Significant advances in medical treatment, medical technology, and the focus on sex-specific research have contributed to a reduction in cardiovascular mortality in women. Despite these advances, coronary artery disease (CAD) is the leading cause of cardiovascular death of women in the Western world. In the past 2 decades, the focused research on women at risk for CAD has helped to clarify our understanding of some of the sex-specific factors that are important in the detection of CAD. In women, the detection and evaluation of physiologically significant CAD can be challenging. Many of the traditional tests that are designed to detect focal areas of coronary artery stenosis are less sensitive and specific in female patients, who have a greater burden of symptoms, higher atherosclerotic burden, and lower prevalence of obstructive coronary disease. In this article, we review the available evidence on the role of contemporary noninvasive diagnostic techniques in the evaluation of women with symptoms of CAD. The authors have no funding, financial relationships, or conflicts of interest to disclose., (© 2012 Wiley Periodicals, Inc.)

Background: Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective., Methods and Results: We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from <22% to >75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%., Conclusions: When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence., (© 2011 American Heart Association, Inc.)

The review is devoted to exercise tests (ET) potential in patients with different forms of coronary heart disease (CHD) exacerbation and suspected unstable angina. It is well known that unstable angina untreated pharmacologically is a contraindication for ET. Of interest in clinical practice is diagnosis, risk assessment and treatment policy in patients with chest pain. The main focus is on ET conduction in unstable angina suspects with low and intermediate risk, on safety and validity of ET conduction in these patients.

Objective: We prospectively investigated the efficacy of the screening methods for asymptomatic coronary heart disease (CHD) in Japanese patients with type 2 diabetes using the treadmill tolerance test (TTT) as a first-line test or the American Diabetes Association (ADA) guidelines., Methods: The subjects included consecutive inpatients with type 2 diabetes (n=331) assessed with both electrocardiogram (ECG) at rest and TTT. Subjects with abnormal TTT findings were evaluated using stress myocardial perfusion scintigraphy (MPS)., Results: A total of 60 out of 69 subjects with positive TTT findings underwent MPS, among whom a total of 22 subjects (6.6% of the total number of subjects) had positive MPS results. Among those with positive MPS results, a total of 14 subjects underwent coronary angiography, eight of whom were determined to have significant coronary artery stenosis. The prevalence rates of hypertension and micro/macroalbuminuria were significantly higher in the MPS-positive group (77.3% and 54.5%, respectively) than in the TTT-negative group (44.7% and 27.1%, respectively). Among the subjects with positive MPS results, 68.2% met the 1998 ADA criteria., Conclusion: Neither the TTT as a first-line test nor the ADA guidelines are sufficiently adequate screening methods to detect asymptomatic CHD in Japanese subjects with type 2 diabetes. Conducting routine screening for asymptomatic CHD in Japanese patients with type 2 diabetes may therefore not be very useful.

Background: Coronary heart disease is the leading cause of death in adults. Screening for abnormalities by using resting or exercise electrocardiography (ECG) might help identify persons who would benefit from interventions to reduce cardiovascular risk., Purpose: To update the 2004 U.S. Preventive Services Task Force evidence review on screening for resting or exercise ECG abnormalities in asymptomatic adults., Data Sources: MEDLINE (2002 through January 2011), the Cochrane Library database (through the fourth quarter of 2010), and reference lists., Study Selection: Randomized, controlled trials and prospective cohort studies., Data Extraction: Investigators abstracted details about the study population, study design, data analysis, follow-up, and results and assessed quality by using predefined criteria., Data Synthesis: No study evaluated clinical outcomes or use of risk-reducing therapies after screening versus no screening. No study estimated how accurately resting or exercise electrocardiography classified participants into high-, intermediate-, or low-risk groups, compared with traditional risk factor assessment alone. Sixty-three prospective cohort studies evaluated abnormalities on resting or exercise ECG as predictors of cardiovascular events after adjustment for traditional risk factors. Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST-segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1). Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG). No study estimated harms from subsequent testing or interventions, although rates of angiography after exercise ECG ranged from 0.6% to 2.9%., Limitations: Only English-language studies were included. Statistical heterogeneity was present in several of the pooled analyses., Conclusion: Abnormalities on resting or exercise ECG are associated with an increased risk for subsequent cardiovascular events after adjustment for traditional risk factors, but the clinical implications of these findings are unclear.