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The first step towards approaching a patient with an inconclusive stress test is to identify the initial reason why a stress test was ordered and examine what factors led to inconclusive test results. Next, it is important to ask whether the patient will benefit from further testing, as not all patients with inconclusive test results require additional testing. In patients who are at low-to-intermediate risk, it may be useful to perform coronary CT angiography (CTA) to exclude the presence of obstructive coronary atherosclerosis. Among individuals with no prior history of coronary artery disease, a possible advantage of CTA is that if subclinical atherosclerosis is identified, intensification of lifestyle interventions, and often pharmacotherapy, should be advocated. On the other hand, in high-risk patients or individuals that already have coronary artery disease, the primary objective is to quantify the presence and magnitude of ischemia in order to define the potential role of coronary revascularization procedures. This can be achieved by myocardial perfusion imaging using nuclear imaging or cardiac MRI. Alternatively, a functional evaluation to identify stress-induced wall motion abnormalities using stress echocardiography or MRI can be obtained. In selecting which test to obtain, it is important to understand the strengths and limitations of different imaging tests and to consider patient factors (e.g., body habitus) that may influence the accuracy of various tests. In addition, physicians should consider whether there are any other clinical questions that require imaging. For instance, cardiac MRI may be used to evaluate for infiltrative myocardial disease or pericardial disease whereas cardiac CT can evaluate for lung pathology or diseases of the aorta. Finally, any decision regarding what type of additional testing to obtain should also be based on knowing the local expertise and availability of various testing options. [ABSTRACT FROM AUTHOR]

The peripheral arterial disease (PAD), caused by localized atherosclerosis in the legs, is an important marker for generalized atherosclerosis and is closely related with CV events. The carotid arteries are among the vessels that are prone to develop atherosclerotic lesions in the presence of risk factors such as cigarette smoking and hypertension. Our aim was to evaluate the incidence and the risk factors mostly associated with the occurrence of carotid artery stenosis (CAS) and myocardial ischemia in individuals with PAD. The study enrolled 648 patients, between 2007-2011, aged >50 years, mean age 63±5 years, 53% men and 47% women, from family medicine offices of Timiş County. The median follow-up time was 34±6 months. The study inclusion criteria were defined as age between 50-79 years and the presence or history of PAD and at least one major risk factor for CV diseases. The ABI was performed using a continuous wave Doppler probe and a sphygmomanometer. The PAD was defined as a resting ABI < 0.90 or when post exercise the ABI decreased at least in one leg with >20%. Only 151 patients matched with the study inclusion criteria and were considered for carotid ultrasound and exercise stress test (EST), together with a similar control group. The carotid color Doppler scanning was performed to detect and to quantify the hemodynamic severity of the CAS. An artery lumen stenosis >50% was considered significant. The values obtained from the ABI measurement ranged from 0.42 to 1.53, with a mean of 0.98. ABI <0.9 was found in 174 patients (27%). CAS > 50% was found in 26 patients (17%) of the study group and in 8 subjects (5.3%) of the control group (OR: 3.71; 95% CI: 1.07-11.13, P = 0.031). The prevalence of CAS increased to 34% and 50% in patients who had three or four risk factors for CV disease. EST was positive in 31 patients (20.5%) from the study group and in 17 (11.3%) control cases (OR: 2.03; 95% CI: 0.56-5.32, P=0.036). The incidence of CAS and positive EST was higher in elderly patients, smokers and in those with hypertension, diabetes or dyslipidemia The ABI and the carotid ultrasound proved to be easy-to-perform, cheap and non-invasive investigations, with great importance in the early diagnosis of the atherosclerosis elsewhere in the vascular system and with a significant contribution in predicting future CV events in patients at high risk. [ABSTRACT FROM AUTHOR]

Background: Sex comparisons between girls and boys in response to exercise in trained adolescents are missing and we investigated similarities and differences as a basis for clinical interpretation and guidance. Methods: A total of 24 adolescent females and 27 adolescent males aged 13–19 years underwent a maximal bicycle exercise stress test with measurement of cardiovascular variables, cardiac output, lung volumes, metabolic factors/lactate concentrations and breath-by-breath monitoring of ventilation, and determination of peak VO2. Results: Maximum heart rate was similar in females (191 ± 9 bpm) and males (194 ± 7 bpm), cardiac index at maximum exercise was lower in females (7.0 ± 1.0 l/min/m2) than in males (8.3 ± 1.4 l/min/m2, P < 0.05). Metabolic responses and RQ at maximum exercise were similar (females: 1.04 ± 0.06 vs. males: 1.05 ± 0.05). Peak VO2 was lower in females (2.37 ± 0.34 l/min) than in males (3.38 ± 0.49 l/min, P < 0.05). When peak VO2 was normalized to leg muscle mass sex differences disappeared (females: 161 ± 21 ml/min/kg vs. males: 170 ± 23 ml/min/kg). The increase in cardiac index during exercise is the key factor responsible for the greater peak VO2 in adolescent boys compared to girls. Conclusions: Differences in peak VO2 in adolescent boys and girls disappear when peak VO2 is normalized to estimated leg muscle mass and therefore provide a tool to conduct individual and intersex comparisons of fitness when evaluating adolescent athletes in aerobic sports. [ABSTRACT FROM AUTHOR]

The article presents a study of the quick time (QT) interval adoption in response to exercise in pediatric patients with congenital long-QT syndrome (LQTS). A total of 158 patients were divided into three groups wherein each patient underwent a uniform exercise protocol with a cycle ergometer. The study concluded that genotype-specific changes in repolarization response to exercise and recovery exist in the pediatric population and are of diagnostic utility in LQTS.

Objective. Hypertensive response at peak exercise and blunted blood pressure (BP) recovery, altered BP responses obtained from exercise stress testing, have been suggested as risk factors for future onset of hypertension in previous studies. Epicardial fat, a new cardiometabolic risk factor, has been linked to hypertension in some recent studies. In this study, we tested the primary hypothesis suggesting that the epicardial fat thickness (EFT) is related to altered BP responses to treadmill exercise testing. We also evaluated the sensitivity and specificity of the EFT as a predictor of hypertensive response to peak exercise. Methods. Normotensive subjects underwent to treadmill stress testing and transthoracic echocardiography. Hypertensive response to peak treadmill exercise testing was defined as ≥ 210/105 mmHg and ≥190/105 mmHg at peak exercise in males and females, respectively. BP recovery index (BPRI) was defined as the ratio of the BP at the 3rd minute of the recovery phase to BP at peak exercise. EFT was measured by echocardiography. Thirty-two subjects with hypertensive response to peak exercise constituted Group 1 and 48 subjects with normal response constituted Group 2. Results. The mean EFT of subjects in Group 1 was significantly higher (8.2 ± 1.1 mm vs 5.1 ± 1.5 mm; p == 0.0001) than subjects in Group 2. In correlation analysis performed in Group 1, EFT was found to be significantly correlated with BPRI ( r == 0.51, p < 0.003). An EFT of ≥6.5 mm predicted the hypertensive response to peak exercise test with 68.8% sensitivity and 87.5% specificity (receiving operator characteristic area under curve: 0.879, 95% CI 0.793-0.965, p < 0.001). Patients with EFT ≥6.5 mm showed a significantly increased BPRI (0.89 ± 0.07 vs 0.74 ± 0.09, p < 0.0001) and peak systolic BP (198.4 ± 15.3 mmHg vs 169.4 ± 19.8 mmHg, p < 0.0001). There were significant differences in metabolic equivalents, maximum heart rate, homeostatic model assessment of insulin resistance, high-density lipoprotein-cholesterol, waist circumference and age values between two patients groups dichotomized according to the cut-off value of EFT. BPRI was the only independent variable related to EFT in the multivariate analysis (odds ratio == 1.4, 95% CI 2.75-7.16, p == 0.001). Conclusions. EFT was found to be related to altered BP responses to exercise stress testing. The echocardiographic measurement of EFT may serve as a useful non-invasive indicator of heightened risk of future hypertension. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous studies have reported ambiguous results regarding the effect of acute exercise on platelet reactivity in healthy and cardiac patients. Objectives: We aimed to assess platelet reactivity among diabetic patients before and immediately after an acute exercise stress test. Methods: Patients (controls: mean age 53.1±12.1 years; four males; body mass index 27.0±5.7 kg/m2; HbA1c 6.0±1.1%, n=8) and diabetic patients (52.9±11.3; six males; body mass index 30.7±2.2 kg/m2; HbA1c 7.8±1.7%, n=8) referred for diagnostic nuclear exercise stress test were recruited. Blood samples obtained at rest and immediately post-exercise were stimulated with adenosine diphosphate (ADP), collagen and arachidonic acid. Expression of CD41 (pan-platelet marker) and CD62p (platelet stimulation marker) were measured by flow cytometry. Aspirin responsiveness was measured using VerifyNow. Results: Although peak systolic blood pressure was significantly higher in the diabetics compared with nondiabetics (186.3±25.4 vs. 157.1±19.1, respectively, P=.028), peak exercise heart rate was similar (156.5±8.3 vs. 155.5±12.1 for diabetics and nondiabetics, respectively). No differences were observed between groups for aspirin resistance. Platelet stimulation with ADP exhibited significantly lower CD62p-positive cell population (%) in the diabetic patients both prior to and following the exercise stress test (P=.03). In addition, although not significant, platelet stimulation was higher post-exercise in the diabetic patients (6.3±4.7% vs. 12.0±5.6%, for pre- and post-exercise, respectively, P=.2) with no difference in controls (9.2±5.5% vs. 8.9±5.9%). Conclusion: Platelet stimulation in diabetic patients is blunted and might be explained by the prolonged exposure of platelets to multiple diabetic risk factors. [ABSTRACT FROM AUTHOR]

Objective: High sensitivity C-reactive protein (hsCRP) and neopterin are associated with atherosclerosis. We aimed to evaluate the association between hsCRP and neopterin, and myocardial ischemia during exercise stress test (EST) in patients with stable angina pectoris (SAP) and to assess the predictive value of these mediators in obstructive coronary artery disease. Methods: Forty-five patients with SAP were included in this prospective observational study. EST- positive group included 23 patients (15 males, mean age 54±10 years) and EST-negative group-22 patients (14 males, mean age 52±9 years). In each patient, blood samples were obtained 1 hour before and 30 minutes after EST. In EST-positive group, coronary angiography was performed to determine the presence and severity of coronary artery lesions as assessed by Gensini score. Statistical analysis was performed using Chi-square, unpaired t, Mann-Whitney U and Wilcoxon rank tests. Logistic regression analysis was used to establish the predictive value of tests. Results: Before EST, hsCRP and neopterin levels were similar between the two groups, however, hsCRP levels were higher in EST-positive group after EST (p=0.03). There was no significant difference between the two groups with respect to neopterin levels after EST (p=0.4). In ESTpositive group, EST resulted in significant increases in both hsCRP and neopterin levels (from 3.8±2.8 mg/L to 4.3±3.1 mg/L, p=0.001; from 8.7±4.0 nmol/L to 13.1±10.0 nmol/L, p=0.001, respectively). In EST-negative group only neopterin levels significantly increased after EST (from 6.9±1.8 nmol/L to 9.0±3.9 nmol/L, p=0.001). No relation was observed between the obstructive coronary lesions and the levels of hsCRP or neopterin at any point. Conclusion: In SAP patients, independent with the existence of obstructive coronary lesion, elevated levels of hsCRP after EST might be an indicator of immune activation caused by myocardial ischemia. [ABSTRACT FROM AUTHOR]

Background: The most common cause of death in patients with chronic kidney disease is cardiovascular. Coexistence of reduced estimated glomerular filtration rate (eGFR) and erectile dysfunction (ED) may predate severe underlying coronary artery disease (CAD). The aim of this study was to evaluate the predictive value of presence and severity of ED and reduced estimated eGFR in the risk stratification of CAD in patients with chest pain. Methods: Two hundred and sixty-five consecutive male patients with chest pain were included. All patients underwent exercise stress test (EST), of whom those with positive EST underwent coronary angiography. eGFR was calculated and sexual health inventory for men (SHIM) form was applied to evaluate ED. The relation between SHIM scores, eGFR and the number of arteries with significant lesions was evaluated. Results: Of the 265 male patients, 105 had positive EST while the remaining 160 patients had negative EST. ED was present in 62 patients (38.8%) in the EST (−) group and in 64 patients (61%) in the EST (+) group ( P = 0.000). In the EST (+) group, coronary angiography (CAG) revealed normal coronary anatomy or insignificant coronary lesions in 19 (18%), one-vessel disease in 45 (43%), two-vessel disease in 22 (21%) and three-vessel disease in 19 (18%) patients, respectively. The lowest ED prevalence (36.8%) was seen in patients who had normal coronary anatomy or insignificant coronary lesions while the highest prevalence was in those with three-vessel disease (89.5%). When eGFR were taken into account, there was a significant difference between the groups as well (107.2 ± 19.2 ml/min in the EST (−) group versus 94.1 ± 20.0 ml/min in the EST (+) group; P = 0.001). Conclusion: The presence and severity of ED and reduced eGFR are associated with the severity of underlying CAD in patients presenting with chest pain, and they could be implemented in the risk stratification of these patients. [ABSTRACT FROM AUTHOR]

Background: Exercise and QT dynamics during ambulatory monitoring impact mortality in a variety of populations. Heart rate recovery (HRR) after exercise is a known strong predictor of mortality. Objective: This study assessed the independent prognostic significance of the QT response to changing heart rate (QT dynamics) during recovery from exercise. Methods: The cohort included patients referred for treadmill exercise stress testing over a 5-year period. Patients had to have at least 4 electrocardiographic tracings within 5 minutes of peak exercise. One had to be recorded 60 seconds into recovery to calculate the HRR. Linear regression of the QT–RR relation during recovery was used to predict the QT interval at cycle lengths of 500 and 600 ms (QT-500 and QT-600). Only studies with an R2 ≥ 0.9 (72%) were retained. Optimal binary cut points were chosen. All-cause mortality was determined from either the Social Security Death Index or hospital records. Results: A total of 2,994 patients met inclusion criteria; 228 (7.6%) died during an average follow-up of 7.6 ± 1.9 years. Abnormal QT-500 (>316 ms) was the strongest univariate QT dynamics predictor in a Cox proportional hazards model (hazard ratio = 2.13, P <.001). It remained an independent predictor of mortality after adjustment for age, exercise capacity, medications, single photon emission computed tomography defects, and abnormal (<12 beats/min) HRR (hazard ratio = 1.46, P = .014). Conclusion: An abnormal predicted QT interval at 500 ms (120 beats/min) during recovery from exercise independently predicts all-cause mortality. Because QT dynamics in recovery incorporate information on both repolarization and autonomic responsiveness, its role in risk prediction for sudden cardiac death should be further explored. [Copyright &y& Elsevier]

Background: Exercise testing has shown modest utility in the ability to diagnose and genotype long QT syndrome (LQTS). Although numerous small studies have shown a genotype-specific repolarization response to exercise, the repolarization responses during recovery from exercise have received less focus. Objective: The purpose of this study was to characterize genotype-specific QT responses during recovery from exercise and to determine its potential as a diagnostic and genotyping tool. Methods: Seventy-five patients were age and sex matched into three groups (n = 25): LQT1, LQT2, and unaffected controls based on Schwartz score and genetic testing results. Each group underwent upright burst and gradual bicycle exercise testing while being monitored by 12-lead electrocardiogram. Results: LQT1 patients had significantly longer corrected QT (QTc) than LQT2 intervals during early recovery (P <.01). Control subjects showed little variation in QTc throughout the recovery period, maintaining a QTc within normal limits. Each group showed a distinct pattern of QTc adaptation during recovery. LQT1 patients began the recovery period at a QTc of 492 ± 11 ms, after which the QTc decreased by 33 ± 11 ms during recovery. Conversely, the LQT2 patients began recovery at its lowest mean QTc of 420 ± 10 ms, which increased by 40 ± 16 ms. At the end of recovery, a QTc cut-off value of 445 ms distinguished 92% of LQTS patients from unaffected controls, while a start-of-recovery QTc cut-off of 460 ms correctly identified genotype in 80% of LQT1 and 92% of LQT2 patients. Conclusions: Genotype-specific differences exist in QT recovery after exercise. These differences can help to identify LQTS patients and distinguish LQT1 from LQT2 genotypes. [Copyright &y& Elsevier]

Objectives The results of the studies in which the effect of hormone replacement therapy (HRT) on cardiac function have been evaluated are rather disputable. In these studies, cardiac function was evaluated with conventional echocardiographic methods. This study was planned in order to investigate the effects of HRT on myocardial velocities and myocardial performance index (MPI) in healthy early postmenopausal women. Method In a prospective, controlled study, 60 healthy postmenopausal women were assigned to two groups (32 in the HRT group and 28 in the control group). After conventional echocardiographic parameters were measured, tissue Doppler echocardiography recordings were obtained from the mitral and tricuspid annulus. Systolic myocardial velocity (Sm), early and late diastolic myocardial velocities (Em and Am) and time intervals were measured and MPI was calculated. Then the symptom-limited exercise stress test using the Bruce protocol was performed. After 3 and 6 months of HRT (oral 0.625 mg conjugated estrogen + 2.5 mg medroxyprogesterone acetate/day), the same examinations were repeated. The effects of HRT on myocardial velocities, MPI and exercise time were evaluated at the 3rd and 6th months. Results The parameters of the control group remained statistically unchanged during the study. HRT did not have any effect on segmental and mean left ventricular (LV) Sm or right ventricular (RV) Sm. However, LV Em/Am and RV Em/Am ratios significantly increased at the 6th month of HRT, and LV and RV MPI values were observed to decrease significantly as compared to basal values. Additionally, a significant increase was observed in exercise duration and metabolic equivalent values after 3 months of HRT, and this increase continued at the 6th month as well. The favorable changes in all parameters in the HRT group were significantly different from those of the control group. Conclusion Data obtained in this study suggest that HRT is not only effective for treating menopausal complaints but also increases cardiovascular performance by improving especially diastolic functions in early postmenopausal women. [ABSTRACT FROM AUTHOR]

Aim: To investigate the correlation between 6-min walk test (SMWT) and incremental treadmill exercise stress test (EST) as indicators for the functional capacity in children. Methods: Healthy children aged 9–12 years were included. The anthropometric data, SMWT and EST were prospectively measured using the standard protocols. Various parameters were analysed to define the correlation between SMWT and EST. Results: A total of 100 subjects (53 boys) aged 10.3 ± 1.0 years participated in the study. The SMWT distance was 586.1 ± 44.0 m. Height (r = 0.59, R2 = 35%), length of the leg (r = 0.64, R2 = 41%), heart rate at the end of SMWT (r = 0.59, R2 = 35%) and heart rate difference at the end of SMWT (r = 0.71, R2 = 50%) were found to have significant correlation with SMWT distance. The estimated maximal oxygen consumption (eVO2) obtained during the EST tended to be greater in boys than in girls. Among the parameters obtained during EST, maximal heart rate (r = 0.33, R2 = 11%) and the eVO2 (r = 0.54, R2 = 53%) were found to have significant correlation with SMWT. Conclusions: SMWT distance is significantly correlated with the eVO2 obtained during the EST. This indicates that SMWT is also one of the predictive markers for EST performance. [ABSTRACT FROM AUTHOR]

Objective In patients with acute myocardial infarction, pre-infarction angina is associated with smaller infarct size, probably mainly through myocardial protection induced by ischaemic preconditioning. However, in models of recurrent thrombosis myocardial ischaemia also improves arterial patency. This study investigated whether myocardial ischaemia has any effect on platelet function in patients with coronary artery disease. Patients and design Twenty patients with low-workload myocardial ischaemia underwent, in a randomised crossover study, two treadmill exercise stress tests (EST) on two separate days: a single maximal EST (EST-1) and a maximal EST (EST-2) performed 45 minutes after a low-workload EST stopped at 1-mm ST depression (p-EST). Platelet reactivity was evaluated by measuring the closure time in response to ADP/collagen by the PFA-100 method, and monocyte—platelet aggregate (MPA) formation and CD41 platelet expression, with and without ADP stimulation, by flow cytometry. Results Compared to resting values, closure time decreased at peak EST-1 (p<0.001) but not at peak EST-2. MPA after ADP stimulation increased more significantly at peak EST-1 compared with peak EST-2 (p<0.001). Repetition in seven patients of the pEST/EST-2 protocol after intravenous administration of the adenosine antagonist theophylline showed prevention of the effects of p-EST on exercise-induced platelet reactivity. Conclusions A short episode of myocardial ischaemia induces protection against an exercise-induced increase of platelet reactivity. These data also suggest a role for adenosine in this phenomenon. [ABSTRACT FROM AUTHOR]

Reproducibility of corrected QT interval ( QTc), especially QTc after exercise, has not been thoroughly investigated. We reviewed charts of pediatric patients who underwent treadmill-exercise stress testing without medication multiple times within 1 year. In patients with long- QT syndrome ( LQTS; n = 22), the discrepancy in QTc between two treadmill exercise stress tests using Fridericia's formula was 14 ± 12 ms at rest, 13 ± 12 ms 4 min after exercise, with a maximum of 14 ± 12 ms after exercise. There was no statistically significant difference in QTc between the two tests. Intraclass correlation coefficients ( ICC) were 0.84, 0.85, and 0.85, respectively. In controls (n = 13), the discrepancy in QTc was 18 ± 12 ms at rest, 14 ± 7 ms 4 min after exercise, with a maximum of 14 ± 9 ms after exercise. There was no significant difference in QTc between the two tests. ICC were 0.78, 0.80, and 0.80, respectively. QTc calculated using Bazett's formula also showed high reproducibility. Reproducibility of QTc in children is high at rest and after exercise. [ABSTRACT FROM AUTHOR]

The principle of exercise stress test and myocardial perfusions scintigraphy (MPS) is based on the detection of exercise-induced myocardial ischaemia by ECG and non-invasive assessment of myocardial perfusion respectively, MPS being the more sensitive method. The exercise stress test is the method of choice in patients with a normal resting ECG and good exercise tolerance, whereas MPS is a suitable test for patients with abnormal resting ECG and/or exercise intolerance. Stressors for MPS included exercise, pharmacological stress, or a combination. Both exercise stress test and MPS are suitable for the evaluation of patients with chest pain and intermediate pre-test probability of significant coronary artery disease. For patients with high pre-test probability, both tests are helpful for risk stratification. Neither test makes sense for the evaluation of patients with chest pain and low pre-test probability of significant coronary artery disease or unselected asymptomatic patients. [ABSTRACT FROM AUTHOR]

Objective: Exercise stress testing has not been recommended by the American Heart Association or the American College of Cardiology as a screening tool in the asymptomatic population because such testing has limited value in this population. It was the goal of this study to investigate family physician adherence to clinical guidelines regarding exercise stress testing of the asymptomatic adult. Methods: This trial surveyed osteopathic family physicians attending a continuing education conference. Physician identifiers were not requested or recorded. Both descriptive and inferential statistics were produced. Frequencies and percentages as well as chi-square analysis were performed with significance set at an α ≤ 0.05. Results: A total of 181 osteopathic family physicians completed surveys. Participating physicians were more likely to order a stress test as the patient aged and as their Framingham risk increased. Universally more physicians ordered stress tests for men than women in all categories. Non-diabetic men (83% vs. 86%) and women (83% vs. 84.5%) greater than 59 years of age who planned to start an exercise program were stress tested with greater frequency than their age matched diabetic counterparts (p < 0.001, p < 0.001). Conclusions: This study demonstrates that physician use of exercise stress testing as a screening tool for coronary heart disease is not well correlated with American Heart Association/American College of Cardiology evidence-based guidelines. The study also identified a lack of recognition of diabetes as a cardiovascular risk equivalent. Further studies are needed to delineate potential barriers to physician adherence of these guidelines. [Copyright &y& Elsevier]

Background Reduced systolic reserve on effort may be present in subjects with hypertension but no evidence of hypertensive cardiomyopathy. We assessed the determinants of abnormal cardiac performance during exercise in hypertensive patients without left ventricular hypertrophy. Materials and methods Thirty-five newly diagnosed, never-treated-earlier hypertensive patients without definite indication for left ventricular hypertrophy at echocardiography underwent radionuclide ambulatory monitoring of left ventricular function at rest and during upright bicycle exercise testing. Results The patients were classified into two groups according to their ejection fraction response to exercise. In 21 patients (group 1), the ejection fraction increased ≥ 5% with exercise and in 14 patients (group 2), the ejection fraction either increased < 5% or decreased with exercise. Patients of group 1 had lower peak filling rate at rest and less augmentation in end-diastolic volume during exercise (both P < 0·01) when compared with patients of group 2. A significant relationship between the magnitude of change in ejection fraction with exercise and both peak filling rate at rest ( r = 0·58, P < 0·01) and exercise-induced change in end-diastolic volume ( r = 0·45, P < 0·01) was found. Conclusions In newly diagnosed, never-treated-earlier hypertensive subjects with no evidence of hypertensive cardiomyopathy, the cardiac response to exercise is dependent on adequate diastolic filling volume to maintain systolic performance. [ABSTRACT FROM AUTHOR]

Abstract: Background and aims: Heart rate (HR) response to exercise has not been fully described in the obese. We wanted to study the differences between obese and non-obese patients in HR behavior during an exercise stress test and to determine whether these differences influence exercise capacity. Methods and results: We studied 554 patients (318 females) who underwent a treadmill exercise test. All subjects were in sinus rhythm. Patients with ischemic heart disease, with reduced ejection fraction and patients taking drugs that interfere with HR were excluded. The population included 231 patients with BMI<30kg/m2 (group 1), 212 patients who were unfit and obese (group 2) and 111 patients who were trained obese (group 3). Resting HR was similar in the various groups. Peak HR, HR recovery and chronotropic index were lower in obese subjects, regardless of their fitness level. Multivariate analysis showed that HR related variables were associated with age, BMI, height, hypertension and various pharmacologic treatments, while exercise capacity was strongly dependent on HR behavior, as well as on sex, age, BMI and diabetes. Conclusion: Obese subjects have a marked impairment of HR behavior during exercise and in the recovery period, and the blunted increase in HR is the most important factor that influences exercise capacity. [Copyright &y& Elsevier]

Objectives: The aim of this study was to determine whether post-ischemic left ventricular (LV) delayed relaxation could be detected by using strain imaging (SI) derived from 2-dimensional speckle-tracking echocardiography in patients with stable effort angina. Background: Regional LV delayed relaxation during early diastole is a sensitive sign of acute myocardial ischemia and may persist beyond recovery of exercise-induced ischemia. Methods: Regional LV transverse strain changes during the first one-third of diastole duration (strain imaging diastolic index [SI-DI]) were determined at baseline and 5 and 10 min after the exercise test in 162 patients with stable effort angina. The ratio of SI-DI before and after exercise (SI-DI ratio) was used to identify regional LV delayed relaxation. Results: A total of 117 patients had significant (≥50% of luminal diameter) coronary stenoses. The mean SI-DI decreased from 78.0 ± 9.7% to 27.6 ± 16.0% (p < 0.0001) in 191 territories perfused by coronary arteries with significant stenoses 5 min after the treadmill exercise, whereas it remained unchanged in 280 territories perfused by arteries with nonsignificant stenoses. Ten minutes after exercise, regional delayed relaxation was still observed in 85% of territories perfused by stenotic coronary arteries. An SI-DI ratio with a cutoff value of 0.74 had a sensitivity of 97% and a specificity of 93% to detect significant coronary stenosis in the receiver-operator characteristic curve. Conclusions: Detection of post-ischemic regional LV delayed relaxation or diastolic stunning after treadmill exercise using SI is a sensitive and reliable method for the detection of coronary artery disease. [Copyright &y& Elsevier]

Background: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). Methods: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged ≥75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). Results: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 ± 1.6 METs in G1 vs. 5 ± 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351–0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559–16.833, P = 0.007), viability (HR 3.354, CI 1.162–9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114–0.945, P = 0.039) predicted hard cardiac events. Conclusion: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE. [ABSTRACT FROM AUTHOR]

The article evaluates various tests for exercise-induced bronchospasm (EIB) to assist the physician in reporting the services accurately and appropriately. Consideration of the medical indication, test type and testing location is often overlooked during the billing process, resulting in claim denial. Identifying necessary information can assist physicians in reporting and receiving payment for services rendered.

Background Fatigability and dyspnoea on effort are present in many patients with Fabry's disease. We assessed the determinants of cardiac performance during exercise in patients with Fabry's disease and preserved left ventricular ejection fraction at rest. Materials and methods Sixteen patients with Fabry's disease and 16 control subjects underwent radionuclide angiography at rest and during exercise, tissue Doppler echocardiography and magnetic resonance imaging at rest. Results The exercise-induced change in stroke volume was +25 ± 14% in controls and +5·8 ± 19% in patients with Fabry's disease ( P < 0·001). In 10 patients (group 1), the stroke volume increased (+19 ± 10%), and in 6 patients (group 2) it decreased (–16 ± 9%) with exercise. Patients of group 2 were older, had worse renal function, higher left ventricular mass and impaired diastolic function compared to group 1. The abnormal stroke volume response to exercise in group 2 was associated with a decrease in end-diastolic volume ( P < 0·001) and a lack of reduction of end-systolic volume ( P < 0·01) compared with both controls and group 1. The ratio of peak early-diastolic velocity from mitral filling to peak early-diastolic mitral annulus velocity was the only independent predictor of exercise-induced change in stroke volume (B –0·44; SE 0·119; β–0·70; P < 0·005). Conclusions The majority of patients with Fabry's disease were able to augment stroke volume during exercise by increasing end-diastolic volume, whereas patients with more advanced cardiac involvement may experience the inability to increase cardiac output by the Frank Starling mechanism. [ABSTRACT FROM AUTHOR]

We compared treadmill exercise stress testing (EST) in 28 medically screened, chronic cocaine users with the cardiovascular effects of an IV cocaine challenge (25 mg or 50 mg). All subjects had a clinically normal EST and echocardiography (except 2 subjects had septal wall hypokinesis). The EST produced significantly greater increases in heart rate and rate-pressure product than did the cocaine challenges. These findings suggest that EST may not provide additional diagnostic information in medically screened cocaine users. EST may cause more cardiac work (indicated by heart rate and blood pressure) than intravenous cocaine (at the doses in this study). [ABSTRACT FROM AUTHOR]

Recently, though there is increasing interest in health promotion, reports of the accident during exercise also have been increasing. In this review, a safe exercise prescription for patients with lifestyle-related disease from the medical check before exercise to a method of exercise stress test is given. Firstly, basic clinical information before exercise such as inquiry into rational symptoms, anamnesis, family history, and daily lifestyle, and resting blood pressure and electrocardiography should be taken. Secondly, the exercise stress test should be carefully performed while monitoring blood pressure and electrocardiography during the exercise stress test in patients with high risk of cardiovascular accident during exercise. Thirdly, exercise intensity is considered to be a key factor in the prescription of exercise therapy. An exercise prescription is better determined according to the indices of anaerobic threshold (AT) such as lactate threshold, ventilatory threshold, and double-product break point, because the sympathetic nervous system, renin-angiotensin system activities, and incidence of myocardial ischemia increases exponentially above the AT during the exercise stress test. And finally, the heart rate at AT was demonstrated to be significantly lower than when using a generally estimated method for optimum exercise intensity. Therefore, if an exercise stress test can not be performed, exercise intensity must be prescribed to be less than a general estimate method for optimum exercise intensity (i.e., percent heart rate max and percent heart rate reserve) in patients with lifestyle-related disease, though we should basically carry out the exercise stress test. In summary, exercise for safe and effective exercise therapy must be carefully prescribed according to the physical condition and physiological response during exercise in patients with lifestyle-related disease. [ABSTRACT FROM AUTHOR]

Quantitative analysis of electrocardiographic ST-segment/heart rate relationship (ST/HR loop) during early recovery phase of exercise stress test provides a sensitive tool for the detection of coronary artery disease (CAD). This study evaluates the effect of data sampling frequency on the diagnostic performance of ST/HR loop in 1876 patients undergoing a routine exercise test on a bicycle ergometer. CAD was verified angiographically in 668 patients and excluded by coronary angiography ( n = 119), myocardial scintigraphy ( n = 250) and on clinical grounds ( n = 839) in 1208 patients. The normalized ST/HR loop area was calculated in all cases by integration of ST-segment amplitude difference from the end of exercise to the end of the first 3 min of recovery period over HR and dividing the integral by the HR difference over the integration period. The effect of different sampling rates (one, two and five samples per minute) on the CAD discrimination ability of ST/HR loop area was subsequently evaluated using receiver operating characteristic (ROC) curves. Reduction in ST/HR data sampling frequency from two to one sample per minute resulted in a significantly decreased diagnostic performance of the ST/HR loop whereas no differences in CAD discrimination capacity were observed between sampling frequencies of two and five samples per minute. The choice of ST/HR data sampling frequency may have a significant impact on the CAD diagnostic ability of the ST/HR loop. The use of sampling frequency below two samples per minute results in a significantly diminished diagnostic performance, a fact that should be taken into consideration when employing ST/HR diagnostic procedures. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: In previous studies we have consistently shown a significant increase of platelet reactivity after exercise in patients with obstructive coronary artery disease (CAD). We also observed a significant individual variability in the response to exercise of platelet reactivity in these patients. Whether exercise-induced changes in platelet reactivity correlate with changes in platelet membrane receptors in patients with CAD is unknown. Methods: We studied 26 patients with stable CAD and 10 matched healthy controls who underwent a symptom-limited treadmill exercise stress test. Venous blood samples were collected at rest and within 5 min of peak exercise. Platelet reactivity was measured by the PFA-100 method as time to occlude (closure time, CT) a ring coated with collagen/adenosine diphosphate (C/ADP). Platelet expression of glycoprotein (GP) IIb/IIIa, in both global (CD41) and active form (PAC-1), and P-selectin (CD62P) and formation of leukocyte–platelet aggregates were assessed by flow cytometry. Results: After exercise CT did not change in controls (85.4±12 to 84.0±9 s, p =0.37), whereas it decreased in CAD patients (98.8±24 to 91.4±25 s, p <0.001). After exercise, CD41 and PAC-1 platelet expression increased significantly in CAD patients (p =0.04 for both), but not in controls (p =0.39 and p =0.98, respectively). To evaluate the relationship between the response to exercise of platelet reactivity and of platelet receptor expression, CAD patients were divided into two groups: CAD group 1 (16 patients, decrease in CT >5 s after exercise) and CAD group 2 (10 patients no increase in platelet reactivity after exercise). CD41 and PAC-1 expression increased in CAD group 1 (p =0.008 and p =0.026, respectively) but not in CAD group 2 (p =0.39 and p =0.50, respectively). No significant differences were observed between the 2 groups for changes in CD62P and leukocyte–platelet aggregates. Conclusions: Our data show that, in patients with stable CAD, an increased platelet reactivity to C/ADP stimulation after exercise, as assessed by the PFA-100 method, is specifically associated with an increased expression of platelet GP IIb/IIIa receptor. [Copyright &y& Elsevier]

The article presents a randomized controlled trial which examines the compliance of low-risk chest pain patients with follow-up outpatient exercise testing after discharge from the emergency department (ED). In the study, the patients were grouped in two which includes the intervention group and the control group and were required to complete an exercise test at 30 days. Results revealed that patients are more likely to complete the test if it is booked before the patient was discharged.

Background: The N-terminal-pro-B natriuretic peptide (Nt-pro-BNP) is of diagnostic and prognostic value in coronary artery disease (CAD). We assessed the relationship between Nt-pro-BNP and (1) the extent of ischemia on stress myocardial perfusion imaging (MPI), and (2) changes between the basal and postexercise ejection fraction (EF), in stable patients with a normal EF.Methods and Results: One hundred and two patients with stable, documented CAD (EF, 62% +/- 8%) underwent an exercise-rest thallium-201 gated-MPI and serial Nt-pro-BNP assays. Myocardial perfusion imaging produced abnormal results in 57 patients (56%; group 1), and normal results in 45 patients (44%; group 2). Median baseline, immediate postexercise, and 3-hour postexercise Nt-pro-BNP values were higher in group 1 than in group 2: 182 vs 85, 201 vs 86, and 212 vs 99 pg/mL, respectively (P < .001 for all). Postexercise EF decreased in group 1 (53% +/- 11% vs 62% +/- 10%, P < .001), but not in group 2 (61% +/- 9% vs 62% +/- 7%, NS). The Nt-pro-BNP ruled out significant ischemia with a negative predictive value of 0.90, whereas patients within the higher tertile of Nt-pro-BNP had a fivefold higher risk of ischemia compared with patients within the lower tertile.Conclusions: The post-stress increase in Nt-pro-BNP is related to myocardial ischemia and to postischemic left-ventricular dysfunction, and accurately predicts the presence or absence of myocardial perfusion defects. [ABSTRACT FROM AUTHOR]

Objectives: To get insight in the mechanism of exercise-induced ST-segment elevation (STE) in patients with Q/QS waves at the electrocardiogram (ECG). Methods: We performed exercise stress test in 13 patients with anterior acute myocardial infarction treated by successful primary percutaneous coronary intervention (PCI). Results: Compared to rest, an additional STE 1 mm in one or more precordial ECG leads during exercise occurred in nine patients (69%), in the absence of symptoms. Conclusions: In acute myocardial infarction (MI) patients, treated by primary PCI and showing optimal coronary blood flow restoration at angiography, STE can still be induced by exercise in Q/QS wave ECG leads. This finding lends further support to the theory that exercise-induced STE in this clinical context is unlikely to represent by itself transient myocardial ischemia or viability. [ABSTRACT FROM AUTHOR]

Aim: The objective of this study is to investigate the significance of erectile dysfunction in males with a positive exercise treadmill test (ETT) to predict the severity of coronary artery disease (CAD). Materials and Method: With no previous marked CAD, and applying to our clinic with chest pain, 105 male patients (mean age: 56 ± 8 years) underwent coronary angiography after the ETT. These patients met our criteria and were included in our study. All patients were requested to complete a brief, 5-item form by the International Index of Erectile Function, and the Sexual Health Inventory for Men (SHIM), and were classified into four groups according to coronary angiography results as follows: normal coronary artery (NCA), single-vessel CAD (1 V), two-vessel CAD (2 V) and three-vessel CAD (3 V). The relation between SHIM scores and the number of arteries with significant lesions was evaluated. Results: The median SHIM score was found to be significantly lower in both the 2 V, 15 (IQR: 12–20) and 3 V, 13 (IQR: 11–16) groups compared to the NCA, 22 (IQR: 17–23) and the 1 V, 22 (IQR: 17–23) groups ( P < 0.05). Grouped as group I (NCA + 1 V) and group II (2 V + 3 V), the patients were recompared. The SHIM score is an independent parameter to define the presence of significant lesions in two or more coronary arteries (odds ratio, 0.84; 95% CI, 0.73–0.97; P = 0.019). Conclusion: The fact that the SHIM score is <18 in ETT positive males may suggest that the probability of multivessel CAD should be high. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The hemodynamic response to exercise is affected by diverse factors such as age, gender and exercise load as well as concomitant pathogenic conditions including smoking, hyperlipidemia, hypertension and possibly diabetes. In this study the hemodynamic response to a graded exercise has been evaluated in diabetic and non-diabetic individuals. Design and method: In 3170 consecutive non-smoker normolipidemic normotensive patients, referred for the treadmill exercise test (age 25–70 years), the exercise-induced change in heart rate (ΔHR) and blood pressure (ΔSBP and ΔDBP) was evaluated in 176 diabetics (DM) compared to non-diabetics (NDM). Results: The results demonstrated that while resting HR and SBP were higher in DM, they had an impaired ΔHR (62.1±20.5 versus 76.4±24.2; P <0.0001), ΔSBP (35.5±29.3 versus 42.2±24.5; P <0.01) and ΔDBP (−0.4±9.8 versus 2.1±15.9; P <0.05) in response to exercise compared to NDM, even among individuals with negative results for exercise test. DM had also lower heart rate reserve, circulatory power and rate-pressure product than NDM (all P <0.0001). While DM were slightly older (57 versus 54.5) and had lower exercise capacity (7.1 versus 8.6 MET) than NDM (both P <0.01), the impact of DM on the hemodynamic changes remained independent and significant after multivariate adjustment for age, exercise load and gender for ΔHR and ΔSBP (P <0.01). Exercise-induced ΔSBP was directly correlated with exercise load and inversely associated with resting pulse pressure (rPP) (P <0.0001). Furthermore, rPP was the second strongest independent predictor for ΔSBP (ß=−0.22, p <0.0001). Conclusion: The impaired hemodynamic response of DM to exercise and its inverse association with rPP supports the early development of arterial and ventricular stiffness in DM, unrelated to other likely risk factors such as hypertension and hyperlipidemia. [Copyright &y& Elsevier]

Abstract: Benefits derived from sporting activities by the healthy or pathological child are now well known. To prevent a child from practicing sport is as serious a decision as authorizing a child at risk to do so. In this article, we will explain the criteria used to assess children''s sporting aptitude. Through traditional cardiological investigatory methods, we can assess the cardiological risk for each and every child. This measurement must be compounded with the risk factor inherent to the specific sport practised, because the cardiological involvement varies depending not only on the type of sport practised, but also on a number of other variables such as age, training habits, strain levels, technical proficiency…. which makes risk classification difficult. The exercise stress test (± maximal oxygen uptake) remains the reference test to assess sport aptitude. Provided that no contra indications for sport have been found, the selection of the proper sport practice will depend on genetic, psychological, morphological, physiological and educational factors. Once a personalized diagnostic has been established, we recommend that the most discriminating attitude be adopted. In rare cases, there can still be absolute cardiological contra-indications for sport, but most often we have to deal with partial contra-indications. Today, it is much more appropriate to speak of selective aptitude to particular sports rather than of contra-indication. [Copyright &y& Elsevier]

Abstract: Introduction: Evidence is accumulating in favour of a link between erectile dysfunction (ED) and coronary artery disease (CAD). This review attempts to identify which patients, among those with ED and no cardiovascular (CV) disease, should be screened for early, subclinical CAD, which coronary targets should be investigated, and which tests should be used. Materials and methods: A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1988 to January 2006. Results: Initial screening of patients with ED may adopt risk assessment office-based approaches to score patients into low, intermediate, or high risk of future cardiovascular events. Attention should be drawn to patients at intermediate risk. Targets for the assessment of subclinical CAD in this subset of patients should include both obstructive (flow-limiting) and nonobstructive (non–flow-limiting) CAD. Some tests address obstructive atherosclerosis by directly assessing coronary flow reserve (i.e., standard exercise stress test, rest/stress myocardial scintigraphy or echocardiography). Other tests are general measures of atherosclerosis burden (not necessarily obstructive) either in the coronary circulation (i.e., coronary calcium score by electron-beam computed tomography), or in extracoronary vessels (i.e., ankle brachial index, carotid intima-media thickness by B-mode ultrasound) as surrogate markers of CAD. Although a systematic use of these measures of nonobstructive atherosclerosis burden has not yet been recommended in the guidelines for coronary risk assessment, their use is progressively being extended from the research area to clinical practice. Conclusions: ED is definitely a vascular disorder and all men with ED should be considered at risk of CV disease until proven otherwise. Available risk assessment charts should be used to stratify (low, intermediate, and high) the coronary risk score in each patient with ED. [Copyright &y& Elsevier]

Abstract: Background: Hypertensive response at peak-exercise and during the recovery phase of exercise stress test (ET) is associated with poor cardiovascular prognosis. We investigated whether decrease in blood pressure (BP) from peak to post-exercise would identify a subgroup at higher cardiovascular risk. Methods: Eighty-six non-hypertensive patients (0–4 cardiovascular risk factors) with hypertensive reaction at peak-ET (systolic>180 mm Hg and/or diastolic>100 mm Hg) were divided based on BP 5 min after exercise termination into two groups: Normal response (NrmR) (<160/90 mm Hg), Hypertensive response (HypR) (≥160/90 mm Hg). Five years later the prevalence of cardiovascular risk factors and cardiovascular morbidity and mortality was assessed for each group. Results: Both groups had similar pre- and peak-exercise BP. However the HypR group had higher post-exercise BP (systolic: 163±13 vs. 125±14 mm Hg, respectively, p <0.01, and diastolic: 74±6 vs. 75±4 mm Hg, respectively, p <0.01), smaller decrease in BP after exercise (Δ systolic: 46.9±3.1 vs. 73.9±3.6 mm Hg, respectively, p <0.01, Δ diastolic: 12.4±1.5 vs. 26.5±2.2 mm Hg, respectively, p <0.01), and higher post- than pre-exercise BP (Δ systolic: 24.5±3.5 vs. −6±4.1 mm Hg, respectively, p <0.01, Ä diastolic: 19±2.1 vs. −13±2.3 mm Hg, respectively, p <0.01). Five years later, HypR group had higher prevalence of abnormal cholesterol serum level (p <0.01), hypertension (p <0.01) and combined ischemic heart disease and cerebrovascular disease (RR 1.32, 95% CI=1.13–1.54, p <0.01). Conclusion: During ET evaluation, it is important to evaluate the BP at 5 min after exercise because reduced BP drop, at this routinely measured point, identifies a subgroup with higher cardiovascular risk. [Copyright &y& Elsevier]

The need for a preoperative cardiac evaluation depends on the presence of clinical predictors of risk (major, such as unstable coronary syndromes; intermediate, such as mild angina; or minor, such as advanced age), the patient's functional capacity, and the riskiness of the proposed surgery. Noninvasive options for cardiac evaluation include exercise stress testing with or without perfusion imaging, pharmacologic stress testing with perfusion imaging, and pharmacologic stress testing with echocardiography. beta-Blockers can help prevent postoperative myocardial ischemia in patients at high risk for cardiac complications who are undergoing major noncardiac surgery. Preoperative coronary artery revascularization is appropriate only for patients who would require the procedure even if they were not having surgery. [ABSTRACT FROM AUTHOR]

Objectives: The aim of our study was to determine the relation between exercise stress test and aspirin resistance in patients with stable coronary artery disease. Background: Clinically aspirin resistance is defined as having thrombotic and embolic cardiovascular events despite regular aspirin therapy. Methods: We studied platelet functions of 62 patients with stable coronary artery disease and 20 subjects with normal coronary arteries by Platelet Function Analyzer (PFA-100, Dade Behring, Germany) at rest and after exertion with collagen and/or epinephrine (Col/Epi) and collagen and/or ADP cartridges. Closure time (CT) < 186 seconds was defined as aspirin resistance with Col/Epi cartridges of PFA-100. Symptom limited treadmill stress test (protocol of Bruce) was performed with Oxford Streslink TD-1 system. Results: 8 (12.9%) patients were aspirin resistant by PFA-100 (CT < 186s despite regular aspirin therapy) at rest. At the first minute of the recovery period of exercise stress test 14 (22.5%) patients were aspirin resistant by PFA-100. CTs with Col/ADP were respectively 89 ± 6 s (83–100s) and 89 ± 5 s (82–104s) at rest and after exercise ( p = 0.107). 20.3% (11/54) of patients known as in vitro aspirin sensitives at rest had shorter CTs and 11.1% (6/54) had aspirin resistance after exercise ( p = 0.004). There was no statistically significiant difference in platelet functions in the control group after exertion. Conclusion: We conclude that 11.1% of in vitro aspirin sensitive subjects at rest had aspirin resistance after exercise by PFA-100. In some individuals, exercise induced platelet activation is aspirin insensitive at usual antiplatelet doses. We need further clinical trials to optimize antiplatelet therapy in patients with coronary artery disease. [ABSTRACT FROM AUTHOR]

Abstract: Congenital long QT syndrome (LQTS) is known to be a critical syndrome associated with a bizarre T wave, prolonged QT interval, and ventricular arrhythmias and is followed by syncope and/or sudden death. Body surface mapping, especially QRST isointegral departure mapping, was used after exercise to assess exercise-induced repolarization changes in patients with this syndrome. This study included 12 patients with the Romano-Ward syndrome (LQTS group, 9 women, 30 ± 19 years) and 19 healthy adults (control group, 5 women, 24 ± 5 years). In the LQTS group, there was a significant increase in the number of local extrema and abnormal points after exercise in the departure maps. In the LQTS group, QRST isointegral departure mapping presented more marked abnormalities of repolarization after an exercise stress test. In mild cases that revealed abnormalities only after the exercise stress, such testing may be helpful for LQTS diagnosis. [Copyright &y& Elsevier]

Objective: Although after pacing animal and human studies have demonstrated a rate-dependent effect of sotalol on ventricular repolarization, there is little information on the effects of sotalol on ventricular repolarization during exercise. This study attempted to show the effects of sotalol on ventricular repolarization during physiological exercise. Methods: Thirty-one healthy volunteers (18 males, 13 females) were enrolled in the study. Each performed a maximal treadmill exercise test according to the Bruce protocol after random treatment with sotalol, propranolol and placebo. Results: Sotalol significantly prolonged QTc (corrected QT) and JTc (corrected JT) intervals at rest compared with propranolol ( QTc 324.86 ms. vs 305.21 ms, P<0.001; JTc 245.04 ms vs 224.17 ms, P<0.001) and placebo ( QTc 324.86 ms vs 314.06 ms, P<0.01; JTc 245.04 ms vs 232.69 ms, P<0.001). The JTc percent reduction increased progressively with each stage of exercise and correlated positively with exercise heart rate ( r=0.148, P<0.01). The JTc percent reduction correlation with exercise heart rate did not exist with either propranolol or placebo. Conclusions: These results imply that with sotalol ventricular repolarization is progressively shortened after exercise. Thus the specific class III antiarrhythmic activity of sotalol, present as delay of ventricular repolarization, may be attenuated during exercise. Such findings may imply the need to consider other antiarrythmic therapy during periods of stress-induced tachycardia. [ABSTRACT FROM AUTHOR]

As it is under debate if determination of lactate during cycle ergometry (lactate stress testing, LST) under a continuous, unadjusted, low workload is a valuable diagnostic tool for mitochondrial myopathy (MMP), the present study aimed to investigate how sensitive the LST is in a large cohort of patients with indications for MMP (MMP patients). Serum lactate was determined once before, three times during, and once after a 15-min, constant 30 W-workload on a bicycle ergometer in 115 healthy controls, 166 patients with neurological disorders other than MMP, and 291 MMP patients. Serum lactate's upper reference limit at rest, 5, 10, 15 min after starting, and 15 min after finishing the exercise was 2.0, 2.0, 2.1, 2.0 and 1.7 mmol/l, respectively. Resting lactate was increased in 75 MMP patients (26%). The specificity of resting lactate determination was 84%. The sensitivity of the LST was 66% and the specificity 84%. Among the 192 MMP patients with abnormal LST, 120 (63%) had a normal resting lactate. The LST is abnormal in two thirds of the MMP patients. The sensitivity of the LST is higher than that of resting lactate determination. The LST is a simple and cheap but effective and reliable screening method for detecting the impaired oxidative metabolism in MMP. [ABSTRACT FROM AUTHOR]

Erectile dysfunction (ED) is defined as the inability to reach or maintain erection sufficient for satisfactory sexual performance. Evidence is accumulating to consider ED as a vascular problem. Common risk factors for atherosclerosis are frequently found in ED and ED is frequently found in vascular syndromes such as coronary artery disease, hypertension, cerebrovascular disease, peripheral arterial disease and diabetes. Finally, a similar pathogenic involvement of NO-pathway leading to impairment of endothelium-dependent vasodilatation and late structural vascular abnormalities is shared by ED and vascular disorders. [Copyright &y& Elsevier]

Background: Patients with a normal stress technetium 99m sestamibi study were shown to have a favorable outcome at intermediate-term follow-up. However, long-term survival has not been studied. The aim of this study was to evaluate the incidence and predictors of mortality and cardiac events at long-term follow-up after a normal exercise stress sestamibi study. Methods and results We studied 218 patients (mean age, 53 +/- 10 years, 108 men) who had normal myocardial perfusion assessed by Tc-99m sestamibi single photon emission computed tomography at rest and during symptom-limited bicycle exercise stress test. Endpoints during a follow-up period of 7.4 +/- 1.8 years were hard cardiac events (cardiac death and nonfatal myocardial infarction) and all-cause mortality. During follow-up, 13 patients died of various causes (cardiac death in 1 patient). Ten patients had nonfatal myocardial infarction (a total of 11 hard cardiac events). By multivariate analysis, independent predictors of cardiac events were history of coronary artery disease (chi(2) = 5, P =.03) and lower exercise heart rate (chi(2) = 12, P =.001). Independent predictors of all-cause mortality were age (chi(2) = 4, P =.05) and exercise heart rate (chi(2) = 5, P =.03). The annual mortality rate was 0.6% in the first 5 years and 1.8% between the sixth and eighth years. The annual hard cardiac event rate was 0.7% in the first 5 years and 1.5% between the sixth and eighth years. Receiver operating characteristic curves identified an exercise heart rate lower than 130 beats/min as the cutoff value that separated patients with regard to their risk for mortality and hard cardiac events.Conclusions: It is concluded that the annual mortality and cardiac event rate is less than 1% during 5-year follow-up after a normal exercise sestamibi study. Therefore repeated testing would not be required unless there is a change in symptoms. Follow-up should be closer in patients with a history of coronary artery disease and in those who fail to achieve an exercise heart rate of 130 beats/min or greater. [ABSTRACT FROM AUTHOR]

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: Twenty patients with fibromyalgia syndrome (FMS) and 20 matched healthy controls were subjected to an exercise stress test above their anaerobic threshold. Serum samples for the measurement of growth hormone (GH), insulin-like growth factor-1 (IGF-1), prolactin (PRL), adrenocorticotrophic hormone (ACTH) and cortisol were taken prior to and after the test at 30-min intervals. Compared to the controls, the patients with FMS displayed significantly lower basal GH levels and slightly, though significantly, higher prolactin levels. Following the exercise test there was a significant increase in the mean GH level in the patient group (P = 0.0474) and a significant decrease in the control group (P = 0.0286) 1 hour after the exercise. A slight decrease in ACTH levels in the control group was observed (P= 0.0002), but there was no significant change in FMS patients. Cortisol levels were significantly lower in both groups after the exercise (P= 0.0001). These results suggest the possibility of a perturbation in hormonal response to exercise in patients with FMS. [ABSTRACT FROM AUTHOR]

Aim of the present study was to investigate the diagnostic yield of the lactate-stress-test in unselected patients with suspected respiratory-chain disorder (RCD). Serum lactate was determined before, during and after a 15-minute, constant 30W workload on a bicycle in 48 controls and 160 patients with suspected RCD. 122 had definite RCD 38 neurological disorders other than RCD. The sensitivity, specificity, positive predictive value, negative predictive value and pre-test likelihood of the test was 69, 74, 89, 42 and 76 % respectively. In conclusion, the lactate-stress-test proved a powerful tool to assess impaired oxidative metabolism in RCDs. [ABSTRACT FROM AUTHOR]