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Background: Left atrial appendage (LAA) closure (LAAC) is a viable alternative to anticoagulation for stroke prevention in non-valvular atrial fibrillation. However, device-associated thrombosis (DAT) is known as a complication of LAAC as observed within the first few weeks after implantation. A noninvasive method is needed to predict the progress for endothelialization surveillance. The aim of the study was to develop a noninvasive visual contrast-enhanced transesophageal echocardiography (cTEE) method for monitoring the communication between left atrium (LA) and LAA post-LAAC by cTEE-score evaluating the contrast enhancement in LAA. Methods: A total of 29 healthy dogs were studied by LAAC at < 24 h and 1, 2, 3 and 6-months. The LAAC procedure was assessed by TEE with color Doppler flow imaging (CDFI) and contrast imaging. The cTEE score was calculated based on the differential contrast opacification of LA and LAA cavities, the CDFI on the width of peri-device color flow, and that of histology on the level of occluder surface endothelialization in postmortem histological examination. Spearman’s correlation analysis was used to correlate these scores. Results : The correlation between cTEE and histology scores was superior to that between CDFI and histology scores. The trend of average cTEE score was tracked with that of histology, while that of CDFI was far from that of histology. The correlation coefficient of CDFI and histology scores was not significant (p > 0.05). Conclusions: The noninvasive visual cTEE is feasible and reliable to monitor communication between the LA and LAA post-LAAC. cTEE is superior to CDFI as a tool in predicting the progress for endothelialization surveillance.

Aim This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Fulminant myocarditis (FM) is a rare disease characterized by acute hemodynamic impairment and ventricular arrhythmias due to severe myocardial inflammation. It is typically preceded by a viral infection but any of multiple other toxic and infective agents may also be the inciting agent. Diagnosis is based on biomarkers and/or cardiac imaging, but endomyocardial biopsy is the standard test for confirming the diagnosis. FM usually requires therapeutic support of cardiac function and treatment of malignant arrhythmias. Contrary to prior concepts, recent evidence has revealed that patients with FM are more likely to die or need heart transplantation than those with the nonfulminant form of the disease. Early recognition and aggressive management are essential for favorable outcomes.

We present the case of a 93-year-old woman with dementia, with no pertinent cardiac history except for hyperlipidemia, who presented to the emergency department with six months of progressive dysphagia, weakness, and falls. While she had no seemingly cardiac symptoms and or remarkable cardiovascular examination features, the patient's initial electrocardiogram (ECG) showed occasional brief pauses with no atrial or ventricular activity. Computer interpretation of the rhythm was "sinus pause," but upon closer investigation, the true diagnosis was different, but with potential to be equally ominous if not accurately recognized and appropriately managed.

The case of a 60-year-old man illustrates a number of important features of rheumatic heart disease (RHD). The patient’s age of presentation was late (>50 yo) and he had no history of predisposing condition for RHD but served in the South Pacific when he was in the US Navy. RHD was limited to mitral stenosis in this patient and his presentation of heart failure was late. His ECG revealed ample evidence of right ventricular enlargement, and echocardiography demonstrated severe mitral stenosis, enlarged right ventricle and right atrium and marked pulmonary hypertension. Because percutaneous balloon mitral valve commissurotomy was precluded by the degree of mitral valve calcification, he underwent successful surgical valve replacement with relief of symptoms. Although RHD is rarely encountered in North America and Europe, it remains a major cause of mortality in the developing nations.

The rapidly expanding field of preventive cardiology has brought with it several major advances in the past decade. Changes in guidelines for cholesterol mangement focusing on the identification of "statin eligible groups" and removal of actual low-density lipoprotein cholesterol (LDL-C) targets, in particular, as well as lower targets for blood pressure in updated hypertension guidelines, have made a major impact on healthcare. The availability of the sodium glucose transport protein-2 (SGLT2) inhibitors and glucagon-like peptide -1 receptor antagonists (GLP1-RA) for managing diabetes have shifted our focus in diabetes care beyond glucose lowering to addressing cardiovascular risk reduction. While many prior trials of fish oil therapy have failed to show benefit, the recent Reduction of Cardiovascular Events With EPA - Intervention Trial (REDUCE-IT) testing the efficacy of icosapent ethyl has shown dramatic benefit in further addressing residual atherosclerotic cardiovascular disease (ASCVD) risk beyond statin therapy not only in those with known ASCVD, but also in diabetic patients with multiple risk factors. The past decade also ushered in confirmation of the inflammation hypothesis of atherosclerosis with the Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS) using canakinumab, despite the fact the therapy was not approved by the Food and Drug Administration (FDA) for cardiovascular risk reduction. Also, to improve our understanding of heart disease in women, the emergence of novel concepts of ischemia or myocardial infarction in those with normal or nonobstructive atherosclerotic disease has been a major advance. Moreover, the past decade brought the emergence of proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody therapy and the cardiovascular risk reduction benefits seen in the Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk (FOURIER) and Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab (ODYSSEY OUTCOMES) trials, providing further evidence-based therapy for additional reduction of ASCVD risk beyond statin therapy. The PCSK9 monoclonal antibodies have facilitated the attainment of LDL-C levels never previously thought possible. Finally with the mRNA interference therapy inclisiran in development, we may soon have a "vaccine-like" approach for addressing dyslipidemia and atherosclerosis.

Carcinoid heart disease (CHD) is a rare and potentially lethal manifestation of an advanced carcinoid (neuroendocrine) tumor. The pathophysiology of CHD is related to vasoactive substances secreted by the tumor, of which serotonin is most prominent in the pathophysiology of CHD. Serotonin stimulates fibroblast growth and fibrogenesis, which can lead to cardiac valvular fibrosis. CHD primarily affects right heart valves, causing tricuspid and pulmonic regurgitation and less frequently stenosis of these valves. Left heart valves are usually spared because vasoactive substances such as serotonin are enzymatically inactivated in the lung vasculature. The pathology of CHD is characterized by plaque-like deposition of fibrous tissue on valvular cusps, leaflets, papillary muscles, chordae, and ventricular walls. Symptomatic CHD usually presents between 50 and 70 years of age, initially as dyspnea and fatigue. Echocardiography is the mainstay of imaging and demonstrates thickened right heart valves with limited mobility and regurgitation. Treatment focuses on control of the underlying carcinoid syndrome, targeting subsequent valvular heart disease and managing consequent heart failure. Surgical valve replacement and catheter-directed valve procedures may be effective for selected patients with CHD.

Background Exercise treadmill testing (ETT) is frequently utilized for noninvasive detection of myocardial ischemia and coronary artery disease. The frequency of electrocardiogram (ECG) artifacts (ECGA) during ETT and their influence on the identification of exercise-induced ischemia are not known. Methods We reviewed all ETTs with ST segment depression in the University of California, Davis, Medical Center treadmill database during each of the years 2012 and 2016 to identify tests with exercise-induced ST segment depression in the inferior and inferolateral leads. We identified cases with ECGA during progressive phases of the test, and we assessed the influence of comorbidities and the impact of ECGA on the diagnosis of coronary artery disease. Tests were considered false or true positive based on the result of confirmatory tests. Results Of 2,100 tests, we identified 123 patients with exercise-induced ST segment depression in inferior or inferolateral leads (men, 43%; mean age, 59 ± 10 years; white, 59%). Tests were symptom-limited: maximum heart rate, 153 ± 18; peak METs (metabolic equivalents of resting total oxygen consumption), 9.4 ± 2.7; ECGA occurred in 91% of tests at peak exercise with earlier occurrence among females. Tests were less likely to be true positive with peak ECGA than those without ECGA (13% vs. 50%, p = 0.05). Conclusions ECGA at peak exercise are frequent and related to peak heart rate and peak metabolic equivalents of resting total oxygen consumption, suggesting a motion effect. ECGA affected the diagnostic accuracy of ETT examinations, indicating that algorithms to reduce artifact for improved diagnosis of ETT require further investigation.

Atrial fibrillation (AF) is associated with the comorbidities of a sedentary lifestyle. Endurance athletes also show an increased incidence of AF. The role of exercise in the treatment of AF is unknown so this study aimed to examine the effects of supervised exercise on AF.A meta-analysis of randomized controlled trials (RCTs) examining supervised exercise training in participants with AF was performed. The primary outcome was AF recurrence and burden. Secondary outcomes included AF symptoms, quality of life, and cardiorespiratory fitness (CRF).Thirteen RCTs, involving 1155 participants, were included. Paroxysmal AF was present in 34% and persistent AF in 64%. The types of exercise were diverse and included cardiac rehabilitation (64%), aerobic training (7%), Qi Gong (4%), interval training (11%), and yoga (15%). Exercise training reduced AF recurrence (relative risk = 0.77: 95% CI, 0.60-0.99), improved quality of life in 5 of the 10 components of the Short Form 36 survey, and improved CRF (standardized mean difference [SMD] = 0.56: 95% CI, 0.27-0.85). The AF burden was reduced only in studies that included continuous ambulatory monitoring (SMD =-0.49: 95% CI, -0.96 to -0.01) but not when all studies were included (SMD =-0.12: 95% CI, -0.61 to 0.38). There was no difference in adverse events between exercise and control.Supervised exercise training is safe, reduces AF recurrence, and improves quality of life and CRF in participants with AF. Further large RCTs with ambulatory monitoring and robust exercise regimens are needed to assess the effects of exercise training on AF burden and AF symptoms.

Aim:This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.Methods:A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.Structure:Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

Fulminant myocarditis (FM) is a rare, distinct form of myocarditis that has been difficult to classify. Since 1991, the definition of FM has evolved, and it is currently considered an acute illness with hemodynamic derangement and arrhythmias due to a severe inflammatory process requiring support of cardiac pump function and/or urgent management of serious arrhythmias. Diagnosis is aided through use of biomarkers and cardiac imaging, but endocardial biopsy remains the gold standard. Recent evidence has revealed that patients with FM are significantly more likely to die or require heart transplantation than those with the nonfulminant form, refuting previous studies proposing a paradoxically low mortality in patients with FM. Acute hemodynamic derangement is managed by intensive contemporary pharmacologic and interventional approaches, whereas the role of immunosuppressive therapy has not been clarified. Early recognition and aggressive management are essential for favorable outcomes. In conclusion, FM is an inflammatory process requiring intensive support, and it causes a higher morbidity and mortality than acute nonfulminant myocarditis.

Predischarge cardiac testing (PDT) in low-risk patients evaluated for acute coronary syndrome in a chest pain unit (CPU) remains a challenge. It is unclear whether PDT varies by gender. We analyzed consecutive low-risk women and men evaluated in our CPU over a 2-year period and compared the utilization of PDT (exercise treadmill test, myocardial stress perfusion scintigraphy, exercise stress echocardiography, invasive coronary angiography, or no test), and incidence of major adverse cardiac events (MACE) at 30 days and 6 months. The study group comprised 619 patients (54% women). A large proportion of both genders did not undergo PDT, although this finding was more frequent in women (50% women vs 40% men, p = 0.01). At 30 days, there were no MACE in either gender. After 6 months of follow-up, MACE remained very low in both women and men (2 [1%] vs 2 [1%]), and in patients who did and did not receive PDT (2 [1%] vs 2 [1%]). Mean length of stay in the CPU was 5.4 hours in patients without PDT and 9.8 hours in those with PDT (p0.0001) without altering postdischarge MACE. When referred for PDT, women more often underwent myocardial stress perfusion scintigraphy than men (22% vs 14%, p = 0.005) and less often received exercise treadmill test (20% vs 39%, p0.0001). Yield of abnormal PDT was low in both women and men although it was lower in women (1% vs 5%, p = 0.02). In conclusion, many low-risk women and men evaluated in a CPU for acute coronary syndrome can be safely and rapidly discharged without PDT and with low risk for MACE at 30 days and at 6 months. Exclusion of PDT was associated with significantly reduced length of stay while maintaining safety in terms of postdischarge MACE.

Exercise electrocardiography (EECG) remains one of the most frequently utilized, highly informative, and safest of cardiac tests. This noninvasive method provides information essential to diagnosis, prognosis, and management of cardiac disease through its evaluation of symptoms, detection of myocardial ischemia, quantitation of cardiac reserve, and the clinical implications of these features. The outstanding safety record of EECG is attributable to appropriate patient referral, meticulous test implementation, and expert interpretation of results. Based on both its ECG and non-ECG data, exercise testing has furthered understanding of normal and abnormal cardiovascular responses to physical stress and unmasked symptoms and provided objective evidence of the potential presence of obstructive coronary artery disease (CAD), the leading cause of mortality in our society. Physiological investigations have demonstrated that characteristic exercise-induced deviation of the electrocardiographic ST segment is a hallmark of ischemia reflecting an imbalance between myocardial oxygen demand and supply typically related to ≥70% coronary artery diameter narrowing which impairs coronary blood flow reserve. Thus, the exercise laboratory provides a controlled setting for exercise stress testing with continuous monitoring of patient, ECG, heart rate, and blood pressure in which ischemia and other abnormalities can be safely induced, observed, and interpreted. These findings importantly complement the clinical evaluation. It is emphasized that recognition of the value of EECG also requires appreciation of its limitations. Posttest probability of CAD based on results of EECG is closely related to an individual’s pre-test probability of CAD. This relationship is the basis for continuing concerns regarding the use of EECG as a screening test for CAD in healthy, asymptomatic individuals in which the rate of false positive results is inordinately high. Although ECG data have dominated clinical interest in exercise testing, recognition has increased regarding the unique non-ECG prognostic information derived from this method. The clinical utility of EECG for detection of CAD is comparable in men and women 10 years beyond menopause, especially if non-ECG variables are included. However, if localization of myocardial ischemia is the goal or the baseline ECG is abnormal, a stress imaging study is indicated. Finally, despite the array of clinical information obtainable from EECG, it remains underutilized in both women and men with adequate functional capacity, in favor of stress imaging tests, which are costly, some of which use ionizing radiation.

Case Presentation A 70-year-old man presented to the ED with sudden onset of left thigh pain followed by transient chest discomfort. His history included cerebrovascular disease, hypertension, and cocaine and methamphetamine use. Physical examination revealed an uncomfortable male subject with a temperature of 37 °C, heart rate of 129 beats/min, BP of 130/65 mm Hg, and 98% oxygen saturation on room air. There was point tenderness in the left lateral thigh without erythema, swelling, or overlying skin changes. His cardiac examination revealed an irregular tachycardia at 129 beats/min and normal first and second heart sounds without murmurs, gallops, or rubs. The remainder of the examination was unremarkable.

Acromegalic cardiomyopathy is the leading cause of morbidity and all-cause mortality in patients with acromegaly. Though acromegaly is a rare condition, the associated derangements are vast and severe. Stemming from an increase in circulating growth hormone (GH) and insulin-like growth factor-1 levels (IGF-1), acromegalic cardiomyopathy results in pathological changes in myocyte growth and structure, cardiac contractility, and vascular function. These molecular changes manifest commonly as biventricular hypertrophy, diastolic and systolic dysfunction, and valvular regurgitation. Early recognition of the condition is paramount, though the insidious progression of the disease commonly results in a late diagnosis. Biochemical testing, based on IGF-1 measurements, is the gold standard of diagnosis. Management should be centered on normalizing serum levels of both IGF-1 and GH. Transsphenoidal resection remains the most cost-effective and permanent treatment for acromegaly, though medical therapy possesses benefit for those who are not surgical candidates. Ultimately, achieving control of hormone levels results in a severe reduction in mortality rate, underscoring the importance of early recognition and treatment.

OBJECTIVES Our aims were to examine the prevalence and genetic predictors of aspirin and clopidogrel high on-treatment platelet reactivity (HoTPR), and associated adverse cardiovascular outcomes in patients with peripheral arterial disease (PAD). BACKGROUND The association of aspirin and clopidogrel HoTPR with outcomes in PAD remains unclear. METHODS This is a prospective cohort study of patients with angiographically documented PAD involving carotid and lower extremity arteries. Aspirin and clopidogrel HoTPR (using the VerifyNow Assay) and associated genetic predictors were compared to clinical outcomes. The primary end-point was a composite of major adverse cardiovascular events: all-cause mortality, myocardial infarction, stroke, target vessel revascularization (TVR) and limb-loss in patients who underwent extremity intervention. RESULTS The study was stopped prematurely due to slow patient enrolment. Of 195 patients enrolled, the primary analysis was performed in 154 patients taking both drugs. Aspirin HoTPR was present in 31 (20%) and clopidogrel HoTPR in 76 (49%) patients. There was a trend toward more primary composite outcome events with PRU ≥ 235 (52% freedom-from-event rate vs. 70% for PRU

The impact of heart failure (HF) on long-term survival in patients with critical limb ischemia (CLI) has not been well described. Outcomes stratified by left ventricular ejection fraction (EF) are also unknown. A single center retrospective chart review was performed for patients who underwent treatment for CLI from 2006 to 2013. Baseline demographics, procedural data and outcomes were analyzed. HF diagnosis was based on appropriate signs and symptoms as well as results of non-invasive testing. Among 381 CLI patients, 120 (31%) had a history of HF and 261 (69%) had no history of heart failure (no-HF). Within the HF group, 74 (62%) had HF with preserved ejection fraction (HFpEF) and 46 (38%) had HF with reduced ejection fraction (HFrEF). The average EF for those with no-HF, HFpEF and HFrEF were 59±13% vs 56±9% vs 30±9%, respectively. The likelihood of having concomitant coronary artery disease (CAD) was lowest in the no-HF group (43%), higher in the HFpEF group (70%) and highest in the HFrEF group (83%) ( p=0.001). Five-year survival was on average twofold higher in the no-HF group (43%) compared to both the HFpEF (19%, p=0.001) and HFrEF groups (24%, p=0.001). Long-term survival rates did not differ between the two HF groups ( p=0.50). There was no difference in 5-year freedom from major amputation or freedom from major adverse limb events between the no-HF, HFpEF and HFrEF groups, respectively. Overall, the combination of CLI and HF is associated with poor 5-year survival, independent of the degree of left ventricular systolic dysfunction.

Ankle–brachial indices (ABIs) are important for the assessment of disease burden among patients with peripheral artery disease. Although low values have been associated with adverse clinical outcomes, the association between non-compressible ABI (ncABI) and clinical outcome has not been evaluated among patients with critical limb ischemia (CLI). The present study sought to compare the clinical characteristics, angiographic findings and clinical outcomes of those with compressible (cABI) and ncABI among patients with CLI. Consecutive patients undergoing endovascular evaluation for CLI between 2006 and 2013 were included in a single center cohort. Major adverse cardiovascular events (MACE) were then compared between the two groups. Among 284 patients with CLI, 68 (24%) had ncABIs. These patients were more likely to have coronary artery disease ( p=0.003), diabetes ( p

OBJECTIVE We examined low risk (LR) patients admitted to our chest pain unit (CPU) with negative cardiac injury markers, normal electrocardiogram, and clinical stability. We hypothesized that there is a sub-group of intermediate risk (IR) patients within the larger LR population. METHODS Criteria for IR were the aforementioned 3 indicators of LR and ≥1 of the following: (1) known coronary artery disease (CAD), (2) men ≥45 yo, women ≥55 yo, and (3) ≥3 cardiac risk factors. We compared patient characteristics, use of pre-discharge testing (PDT), and major adverse cardiac events (MACE). RESULTS IR patients numbered 371, whereas LR patients totaled 70. IR patients were older (61 vs 46 years), more had known CAD (28 vs. 0%), had a higher median number of risk factors (2 vs. 1) and were less likely to be women (49 vs. 81%), all P < 0.0001. IR patients received a greater median number of tests compared with LR patients (1 vs. 0, P < 0.0001). CONCLUSIONS Among the IR group, 16 patients (4%) had a cardiac event at the index CPU visit, 2 (0.5%) experienced MACE at 30-day follow-up, and 2 (0.5%) had MACE at 6 months follow-up. No LR patients had MACE at any point in the study. Thus, the majority of CPU patients are IR, have more risk factors than LR group, and are more likely to receive PDT. IR patients were managed safely in a CPU, while maintaining low rates of MACE post-discharge.

The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol retains focus on recommendations for statin treatment in the original four statin-eligible groups [those with atherosclerotic cardiovascular disease (ASCVD), diabetes, low-density lipoprotein cholesterol (LDL-C) ≥ 190 mg/dL, and higher risk primary prevention] without the use of treatment initiation or target LDL-C levels from the earlier 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline, but has several new features. First, patients with primary prevention are divided into those who are at low (

Background High-sensitivity cardiac troponin T (hs-cTnT) is individually associated with incident hypertension (HTN) and cardiovascular disease (CVD) events. We hypothesize that the increases in hs-cTnT with increases in blood pressure will be related to higher incidence of CVD. METHODS The Cardiovascular Health Study is a longitudinal cohort of older adults. Those with hs-cTnT data and CVD risk factors at baseline and follow-up (2–3 years later) were stratified based on systolic blood pressure (SBP; optimal: RESULTS Among 2,219 adults, 510 (23.0 %) had decreased hs-cTnT, 1,279 (57.6 %) had stable hs-cTnT, and 430 (19.4 %) had increased hs-cTnT. Those with increased hs-cTnT had a higher CVD risk with stable SBP (hazard ratio [HR]: 1.28 [1.04–1.57], P = 0.02) or decreased SBP (HR: 1.57 [1.08–2.28], P = 0.02) compared to those within the same SBP group but a stable hs-cTnT. In those with lower SBP at follow-up, there was an inverse relation between diastolic blood pressure (DBP) and risk of CVD events in those with increased hs-cTnT (HR: 0.44 per 10 mm Hg increase, P < 0.01). CONCLUSION An increase in hs-cTnT over time is associated with a higher risk of CVD even when the blood pressure is stable or decreases over time.

Exercise electrocardiography (ExECG) is widely employed to assess patients for coronary artery disease but it has limited diagnostic accuracy. Many patients with positive (ischemic) tests based on exercise-induced ST depression undergo secondary evaluation by noninvasive stress imaging. We hypothesized that high functional capacity in patients with positive ExECG could predict: (1) negative results in secondary evaluation by exercise echocardiography (ESE) or myocardial perfusion scintigraphy (MPS) and (2) low mortality on late follow-up. We evaluated 511 consecutive patients (312 men, 199 women; age 51 ± 9 years) referred for ESE or MPS after an ischemic ExECG at a treadmill workload of ≥10 metabolic equivalents. All-cause mortality was also obtained. Of 511 patients, 401 underwent ESE and 110 had MPS for secondary study. ESE was negative in 94% (376 of 401) and positive in 6% (25 of 401). MPS was also negative in 94% (103 of 110) and positive in 6% (7 of 110). Total stress imaging results were negative in 92% (286 of 312) of men and 97% (193 of 199) of women. During follow-up of approximately 6 years, there were 3 deaths with total all-cause mortality of 0.6% and average annual mortality of 0.1%. In conclusion, high functional capacity in patients with an ischemic ExECG predicts a negative ESE or MPS in a large majority of patients and very favorable late survival in both men and women. These results suggest that patients with ischemic ExECGs and a workload of ≥10 metabolic equivalents during ExECG may not require additional noninvasive or invasive evaluation.