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The generally accepted indications for stress testing in patients with coronary artery disease include confirming the diagnosis of angina, determining the limitation of activity caused by angina, assessing prognosis in patients with known coronary artery disease, assessing perioperative risk, and evaluating responses to therapy. In patients with a clinical scenario strongly suggestive of angina, testing is not necessary to diagnose coronary artery disease. The exercise treadmill-electrocardiogram test is the oldest and most extensively used stress test and can be reliably performed in patients who are clinically stable and who have an interpretable resting electrocardiogram. The addition of myocardial imaging agents such as thallium 201, technetium Tc 99m sestamibi, and technetium Tc 99m teboroxime increases the sensitivity and specificity for detecting coronary disease. Pharmacologic agents such as dipyridamole, adenosine, and dobutamine may be used in patients who cannot exercise adequately. Myocardial ischemia can also be evaluated by echocardiography, computed tomography, or magnetic resonance imaging, especially when additional information such as left ventricular and valvular function is desired. We review the indications for the noninvasive evaluation of coronary artery disease and the rationale for selecting a diagnostic test., Since the introduction of exercise testing in the 1920s, the noninvasive evaluation of coronary artery disease (CAD) has continued to evolve. In this review we will discuss the place of [...]

Adequate consideration of cardiac structure and function, prognostic implications and the use of other diagnosticmethods are essential to the proper evaluation and management of individuals suffering from ventricular arrythmia (VA). VAs are categorized as significant, prognostically important, of unknown importance or insignificant. Tests are performed on patients suspected of having VA to establish its frequency or existence, create a prognosis, assess the effectiveness of drug therapy or correlate the VA with symptoms. Among the most frequently used tests are exercise testing, ambulatory electrocardiographic monitoring and electrophysiologic testing.

INTRODUCTION We evaluated the cardio-circulatory risk of cocaine body packing during the medical management of McCarron type 2 body-packers [1] without evidence of acute cocaine intoxication on initial examination. We [...]

OBJECTIVE: New portable devices have become available for home monitoring of fetal heart rates; these devices have the potential to immediately transmit these tracings to a medical facility. The null hypothesis of this study is the inability of mothers to perform their own nonstress tests (self-nonstress tests) and that such tests are not comparable to those performed by professional medical personnel (assisted nonstress tests). STUDY DESIGN: The feasibility of maternal self-testing was established in 50 high-risk patients followed by a controlled clinical trial conducted in 60 patients. The latter study represents the first controlled trial in which patients performed self-nonstress tests at their homes and transmitted the tracings via telecommunication to our perinatal unit. In all cases these patients came to our hospital within 60 minutes after the self-nonstress tests to have a perinatal nurse perform a second nonstress test. The pairs of self and assisted fetal heart rate tracings were independently reviewed by two investigators. RESULTS: The self and assisted tracing pairs were judged satisfactory for interpretation in 100% and 90%, respectively; self and assisted were interpreted by each examiner to be nonreactive in 20% and 14%, respectively. However, both examiners were unable to distinguish between tracings generated by assisted nonstress and self-nonstress tests. Furthermore, cost analysis revealed an estimated twofold savings with self-nonstress testing compared with the assisted nonstress test. CONCLUSION: Self-nonstress testing is a reliable and accurate method of antepartum fetal heart rate testing. This method of fetal assessment not only introduces a new approach to fetal surveillance with added convenience to patients, but may also significantly reduce medical cost without compromising the results of fetal testing. (Am J Obstet Gynecol 1992;166:489-92.)

To determine the relation between myocardial ischemic indexes on exercise testing and on ambulatory Holter recording, 60 patients with stable coronary artery disease who exhibited an ischemic response to both testing procedures were studied. All patients performed a Bruce protocol exercise test and underwent 24-hour Holter recording within 2 weeks without antianginal medications. Mean exercise duration was 7.4 +/- 2.8 minutes, mean heart rate at 1 -mm ST depression was 118 +/- 20 beats/min and mean maximal ST depression during exercise was 2.2 +/- 1 mm. During Hofter recording the average number of ischemic episodes was 4.7 +/- 2.6 per patient, mean duration of dally ischemia was 62 +/- S4 minutes, mean maximal ST depression was 3.2 +/- 1.3 mm and average heart rate at 1mm ST depression was 93 +/- 17 beats/min. Overall, the correlations between ischemic indexes on both testing procedures were very weak (mean r.sup.2 = O.Or4). The only exercise variable that had a significant correlation (p Thus, ischemic indexes on exercise testing cannot accurately predict ischemic indexes on ambulatory Holter recording in patients with stable coronary artery disease who exhibit ischemic changes on both tests. These findings indicate that a great portion of the variability of Holter ischemic indexes is dependent on factors other than those represented by exercise testing indexes, and that Holter recording in the ambulatory setting might provide clinically relevant information in addition to that obtained by exercise testing in selected subsets of patients. (Am J Cardiol 1991;68:176-180), Coronary artery disease is a condition in which the arteries supplying blood to the heart become clogged, usually with fatty atherosclerotic deposits. The resulting diminution of cardiac blood supply (myocardial ischemia) can cause pain and damage to the heart. During exercise, when the workload on the heart is increased, the ischemia is frequently made worse. The relationship between the prevalence of episodes of ischemia during standardized hospital exercise testing and during everyday activities is not known; it is assumed that the former predicts the latter with a reasonable degree of accuracy, but well controlled studies on which this assumption can be based have not been done. To further investigate the relationship between ischemia during exercise testing and during normal daily activities, a study was carried out involving 60 patients with documented, stable coronary artery disease, all of whom exhibited myocardial ischemia both during the course of everyday exercise and during formal exercise testing. Exercise testing lasted an average of 7.4 minutes, during which all patients exhibited ischemia (as indicated by characteristic changes in the electrocardiographic record). During 24-hour ambulatory monitoring of cardiovascular parameters, patients experienced ischemia for an average of 62 minutes (4.7 episodes per patient). Overall, the correlations between indices of ischemia in exercise-induced and spontaneous situations were very weak. Hence, ischemic indices on exercise testing do not accurately predict ischemic indices during everyday activities, and 24-hour ambulatory monitoring can provide useful clinical data which exercise testing does not yield. (Consumer Summary produced by Reliance Medical Information, Inc.)

Heart-Rate Variability and Cardiac Autonomic Function in Diabetes With the advent of simple noninvasive cardiovascular reflex tests, it became apparent that autonomic degeneration in diabetes was not only more common [...]

Invasive electrophysiologic studies are rarely required for nonlethal forms of ventricular arrhythmias when Holter monitoring is routinely used For lethal arrhythmias, however, arrhythmia characterization cannot be accomplished without electrophysiologic studies, and such studies are indispensable when nondrug treatment is required Moreover, electrophysiologic studies may not be needed to guide all drug therapy, nor do they indicate that Holter monitoring and exercise testing are uniformity inferior means of guiding therapy.

Diabetic patients with autonomic neuropathy (disease of the nerves controlling heart, blood vessels, and other involuntary activities) have higher rates of silent myocardial infarction (asymptomatic heart attack) than diabetics who do not have neuropathy. A higher incidence of myocardial ischemia (reduced blood flow to the heart muscle, causing tissue damage) is also suspected among these patients. To determine the prevalence of silent myocardial ischemia, ambulatory electrocardiographic monitoring of 41 diabetic men was undertaken. Seventeen of the men had autonomic neuropathy; silent ischemia was significantly more common among these men than it was among those without autonomic neuropathy. For some of the patients with autonomic neuropathy, silent myocardial ischemia was the only sign of coronary artery disease. The reduced ability of diabetic patients to feel the warning pains of angina is a problem in accurate diagnosing heart disease in these patients. Twenty-four hour ambulatory electrocardiographic monitoring may be useful in identifying diabetic patients with autonomic neuropathy who also have myocardial ischemia. This would be an important step toward treating and preventing a frequent cause of death among these patients. (Consumer Summary produced by Reliance Medical Information, Inc.)