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1.1 Document Development Process #### 1.1.1 Writing Committee Organization The writing committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director, an early-career cardiologist, highly experienced members representing

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

This position paper provide guidelines on the minimum requirements of both personnel and equipment for the safe performance of clinical exercise electrocardiography, and for the adequate interpretation and assessment of results. This document was originally developed by Professor Ben Freedman and members of the Rehabilitation, Exercise and Prevention Working Group in 1996. It has been recently reviewed by a Working Group chaired by Associate Professor David Colquhoun. The resulting, revised Statement was considered by the Continuing Education and Recertification Committee and ratified at the CSANZ Board meeting held on 1st August 2014.

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

Over the last 6 or 7 years Dr. Richard Ross and I in the department of medicine at Johns Hopkins Medical School have had a continuing interest in objective methods which might be used in assessing the individual who comes to the physician complaining of chest pain. Angina pectoris is many things; it is a metabolic defect with lactate excess, it is a certain pathological picture, it is a group of individuals who are disposed to have certain things happen to them, but most of all angina pectoris is pain in the chest. It is pain in the chest as far as the patient is concerned, and this is the symptom on which the physician has to base important decisions concerning diagnosis, prognosis and treatment. The problem with chest pain is that it is a very subjective complaint, and a discussion with the patient is certainly the most satisfactory way to establish its cause.

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.

Aims Evaluation of angiographical and intracoronary Doppler-derived parameters of coronary stenosis severity. Methods and Results A total of 225 patients with one-vessel disease were studied before PTCA and at 6 months follow-up. Exercise electrocardiography was performed to document presence (n=157) or absence (n=138) of an ST segment shift (greater than or equal to 0.1 mV). Intracoronary blood flow velocity analysis was performed to determine the proximal/distal flow velocity ratio, the distal diastolic/systolic flow velocity ratio and coronary flow velocity reserve. Receiver operator characteristic curves were calculated to assess the predictive value of these variables compared with the exercise test. The distal coronary flow velocity reserve demonstrated the best linear correlation for both percentage diameter stenosis and minimum lumen diameter (r=0.67 and r=0.66; P Conclusions The distal coronary flow velocity reserve is the best intracoronary Doppler parameter for evaluation of coronary narrowings. Angiographical estimates of coronary lesion severity and distal coronary flow velocity reserve are good and independent predictors for the assessment of functional severity of coronary stenosis, emphasizing the complementary role of these parameters for clinical decision making. (C) 2000 The European Society of Cardiology.

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

Although exercise electrocardiography (ECG) is a useful noninvasive screening test for coronary artery disease (CAD), one prerequisite for ECG screening is that patient be able to exercise enough to evoke myocardial ischemia. Thus, exercise ECG may not be suitable for, some elderly people with CAD who cannot exercise enough. We compared electron beam Computed Tomography (EBCT) with exercise ECG for detecting CAD in 196 patients (mean age, 58.4 +/- 12.5 [standard deviation]) who had undergone coronary angiography. Using the angiographic findings as the "gold standard", we found that the sensitivity, specificity, positive predictive value, and negative predictive value were 88%, 77%, 89%, and 77%, respectively, for EBCT, and 66%, 72%, 83%, and 52%, respectively, for exercise ECG. Although the results were similar when the subjects were divided into different age groups, the negative predictive value for exercise ECG, among older patients was very low. These findings suggest that EBCT is superior to exercise ECG in detecting CAD in the elderly.

We compared the specificity of exercise electrocardiography in 1880 men and 1818 women with women grouped by menopausal and estrogen replacement status. Specificity for > or = 1 mm horizontal or downsloping ST-segment depression was determined using angiography in 781 patients and using two other nonangiography-based methods (a pretest probability-based method and a predictive accuracy-based method) in all patients. Using angiography, the specificities+/-SE were 84 +/- 2 for men, 79 +/- 3 for women, 81 +/- 5 for premenopausal women, 81 +/- 4 for postmenopausal women without estrogen replacement, and 77 +/- 5 for women on estrogen replacement. None of these were significantly different. For all patients, the respective specificities using the probability and predictive accuracy-based methods were 97 +/- 1 and 94 +/- 1 for men, 90 +/- 1 and 88 +/- 1 for women, 97 +/- 1 and 92 +/- 2 for premenopausal women, 92 +/- 4 and 88 +/- 3 for postmenopausal women without estrogen replacement, and 85 +/- 4 and 81 +/- 3 for women on estrogen replacement. (Men vs. all women groups except premenopausal women-P < 0.05). Therefore, the premenopausal women had significantly greater specificity than women on estrogen replacement (P < 0.001) and no difference in specificity with men. Women on estrogen replacement had a significantly lower specificity than postmenopausal women not on estrogen replacement (P < 0.05). These results suggest that estrogen replacement therapy and not naturally occurring estrogen has a role in producing false positive exercise electrocardiograms in women.

Many studies have examined the information content that can be garnered from noninvasive stress testing to inform patient management. For exercise electrocardiography (ECG), optimal interpretation does not involve simply whether ST segment depression is present. Recent literature has examined

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.

To assess for sex-related differences in posttest referral bias, we compared the accuracy of exercise electrocardiography in biased (coronary angiography only) and unbiased (all unselected) populations with possible coronary disease. A retrospective analysis of clinical and exercise test data from 4467 patients (788 who underwent angiography) was performed (2824 men and 1643 women). The accuracy of a positive exercise test result was assessed in the entire unbiased group with a method that used disease probability (derived with a logistic algorithm) rather than angiography results. We found that the sensitivity and specificity were significantly greater in men than in women with use of the biased or unbiased groups. When the results for the unbiased and biased groups were compared, the sensitivities for the unbiased group were significantly lower and the specificities were significantly higher than those of the biased group. These differences reflect the effects of posttest referral bias. The amounts that sensitivity decreased and specificity increased, however, was not different for men and women. Therefore, we conclude that the accuracy of exercise electrocardiography is lower in women than men irrespective of whether a biased or an unbiased group is used. However, these differences cannot be explained on the basis of sex-related differences in posttest referral bias.

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.

To the Editor: I read with great interest the article by Shaw et al1 reporting results of the very well designed What Is the Optimal Method for Ischemia Evaluation in Women (WOMEN) trial. The WOMEN trial addressed an important clinical issue, whether evaluation with myocardial perfusion imaging results in better outcomes in women in comparison with …

Koroner arter hastalığı (KAH) tüm dünyada erişkin nüfusta en sık karşılaşılan mortalite ve morbidite nedenleri arasındadır. Eforlu ve istirahat elektrokardiyografi (EKG), miyokard perfüzyon sintigrafisi (MPS), ekokardiyografi (EKO) ve manyetik rezonans görüntüleme (MRG) KAH’ın tanı ve takibinde günümüzde yaygın olarak kullanılan invaziv olmayan tekniklerdir. MPS, verdiği fizyolojik bilgiler nedeniyle günümüzde KAH’nın değerlendirilmesinde vazgeçilmez bir yere sahiptir. Bu çalışmada; KAH veya şüphesi bulunan hastalarda istirahat EKG, eforlu EKG, EKO bulguları ve KAH için risk faktörlerinin miyokard iskemisiyle olan ilişkisinin EKG- gated miyokard perfüzyon SPECT ile değerlendirilmesi amaçlandı. Bu çalışma, Ocak 2008-Mayıs 2010 tarihleri arasında Elazığ Eğitim ve Araştırma Hastanesi Nükleer Tıp Ünitesi ve Dicle Üniversitesi Tıp Fakültesi Nükleer Tıp Anabilim Dalına MPS için gönderilen 558 hastanın geriye dönük olarak dosyalarının incelenmesi ile yapıldı. Tüm hastalara Tc-99m MIBI ile EKG-gated MPS yapılmıştı. Hastaların detaylı anamnez bilgileri, istirahat ve eforlu EKG ve ekokardiyografi sonuçları not edildi. Çalışmaya alınan toplam 558 hastanın 283’ü kadın (%49,3), 275’i erkek (%50,7) olup yaş ortalaması 52,4±11,2 yıl idi. Erkek cinsiyette kadınlara göre iskemi sıklığı daha fazlaydı. 55 yaş üstü erkek cinsiyette iskemi sıklığı aynı yaş grubundaki kadınlara göre yine daha fazlaydı (p0,05). Günlük yaşamda efor kapasitesi kötü olan, HT, DM, hiperlipidemisi olan, efor testinde sonlandırma sebebi göğüs ağrısı şikayeti olan, efor testinde sınırlayıcı tarzda göğüs ağrısı olan, efor testinde ST depresyonu görülen, eforda T negatifliği olan, efor test sonucu pozitif olan, ekokardiyografide segmenter duvar hareket bozukluğu olan, EKO’da sol ventrikül dilatasyonu olan, EKO’da sol ventrikül EF0.05). The rate of myocardial ischemia observed in patients who had poor effort capacity during their daily life; who had HT, DM or hyperlipidemia; whose exercise stress testing had been terminated due to a chest pain; who had a limiting chest pain during the exercise stress testing; in whom ST segment depression and a negative T wave were observed during the exercise stress testing; who had a positive exercise stress testing result; who had a segmenter impaired left ventricular wall motion, left ventricle dilation and left ventricle EF

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

Background: Electrocardiographic methods still provide the bulk of cardiovascular diagnostics. Cardiac ischemia is associated with typical alterations in cardiac biosignals that have to be measured, analyzed by mathematical algorithms and allegorized for further clinical diagnostics. The fast growing fields of biomedical engineering and applied sciences are intensely focused on generating new approaches to cardiac biosignal analysis for diagnosis and risk stratification in myocardial ischemia. Objectives: To present and review the state of the art in and new approaches to electrocardiologic methods for non-invasive detection and risk stratification in coronary artery disease (CAD) and myocardial ischemia; secondarily, to explore the future perspectives of these methods. Methods: In follow-up to the Expert Discussion at the 2008 Workshop on "Biosignal Analysis" of the German Society of Biomedical Engineering in Potsdam, Germany, we comprehensively searched the pertinent literature and databases and compiled the results into this review. Then, we categorized the state-of-the-art methods and selected new approaches based on their applications in detection and risk stratification of myocardial ischemia. Finally, we compared the pros and cons of the methods and explored their future potentials for cardiology. Results: Resting ECG, particularly suited for detecting ST-elevation myocardial infarctions, and exercise ECG, for the diagnosis of stable CAD, are state-of-the-art methods. New exercise-free methods for detecting stable CAD include cardiogoniometry (CGM); methods for detecting acute coronary syndrome without ST elevation are Body Surface Potential Mapping, functional imaging and CGM. Heart rate variability and blood pressure variability analyses, microvolt T-wave alternans and signal-averaged ECG mainly serve in detecting and stratifying the risk for lethal arrythmias in patients with myocardial ischemia or previous myocardial infarctions. Telemedicine and ambient-assisted living support the electrocardiological monitoring of at-risk patients. Conclusions: There are many promising methods for the exercise-free, non-invasive detection of CAD and myocardial ischemia in the stable and acute phases. In the coming years, these new methods will help enhance state-of-the-art procedures in routine diagnostics. The future can expect that equally novel methods for risk stratification and telemedicine will transition into clinical routine., GMS German Medical Science; 8:Doc27; ISSN 1612-3174

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

運動負荷体表面電位図がマスター二階段負荷心電図偽陽性例を鑑別する上で有用か否かを検討した.対象はマスター二階段負荷試験で陽性所見を示した64例である.このうち46例で201T1負荷心筋シンチ (SPECT) 陽性の22例をI群, 陰性の24例をII群とし, さらにI群とII群をSTT変化がV3-V6誘導に出現するa群 (Ia, IIa群) とII, III, aVF誘導に出現するb群 (Ib, IIb群) に分類し, IaとIIa, IbとIIbを鑑別するために判別式を導いた.残りの18例は判別式の妥当性を検討するためtest caseとして用いた.AQRSTの (負荷後-負荷前) として求めたDAQRSTを用いるとIa, IIa群は式Z=-1.75× (K1) -1.24× (H1) -0.31を用いると正診率74%, Ib, IIb群ではZ=-3.28× (I3) +0.01で正診率70%判別可能であった.さらにその判別式をtest caseに適用した場合にもほぼ同様の正診率が得られた.以上より運動負荷体表面電位図はマスター二階段試験の偽陽性例を鑑別する上で有用と考えられた.

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.

運動を始める前のメディカルチェックとして, Bruceの第2段階から始めるトレッドミル負荷試験を心疾患の既往のない外見上健康な成人505人 (男性209人, 平均42歳, 女性296人, 平均43歳) に行ない, 運動負荷時の心電図異常出現頻度について検討した.本法にて比較的短時間に (平均男性7.2分, 女性5.7分) , 安全に自覚的亜最大負荷を行なえた.負荷時のST下降は高年齢ほど多くみられ, 男女ともに10.5%の頻度にみられたが, 負荷後のST下降の回復は早かった.負荷時の心室期外収縮のみられる頻度は加齢とともに増加し, 男性の26.2%, 女性の22.5%にみられ, その約1/10が多形性, 連発性であった.上室期外収縮は男性の9.7%, 女性の12.6%にみられた.従来検討の少ない外見上健康な日本人におけるトレッドミル運動負荷心電図異常の発現頻度について報告した.

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.

Aims To prospectively compare multislice computed tomography (MSCT) and exercise electrocardiography (ex-ECG) for diagnosis of coronary artery disease (CAD) with conventional coronary angiography as the reference standard. Methods and results A consecutive cohort of 80 patients with suspected CAD was examined with MSCT using 16 × 0.5 mm detector collimation, ex-ECG, and conventional coronary angiography according to standard protocols. Results were compared using the paired McNemar's test, the χ 2 test, and 95%CIs. Both the sensitivity and specificity of MSCT [91% (40 of 44 patients, 95%CI 78–97%) and 83% (30 of 36 patients, 95%CI 67–94%)] were significantly higher ( P = 0.039 and P < 0.001) than those for ex-ECG [73% (32 of 44 patients, 95%CI 57–85%) and 31% (11 of 36 patients, 95%CI 16–48%)]. The pairwise McNemar's test showed significant differences between MSCT and ex-ECG in the overall diagnosis in patients with suspected CAD ( P = 0.036). The rate of non-diagnostic examinations was not significantly ( P = 0.078) different between MSCT and ex-ECG [8% (6 of 80 patients, 95%CI 3–16%) vs. 19% (15 of 80 patients, 95%CI 11–29%)]. Conclusion In this consecutive cohort of patients scheduled to undergo conventional coronary angiography, the performance of MSCT for diagnosis of CAD was superior to that of ex-ECG.

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.