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The overwhelming majority of sports-related sudden cardiac deaths in mature athletes is attributed to coronary artery disease (CAD). Coronary plaques of mature athletes appear to be more calcified compared to sedentary individuals and thus may be more stable and less likely to be associated with an acute coronary event. Cardiac computed tomography (CT), including unenhanced CT for coronary artery calcium scoring (CACS) and contrast-enhanced coronary CT angiography, is characterized by very high negative predictive value to rule out CAD. Cardiac CT has been shown to have additional diagnostic value for detection of CAD in athletes over and above exercise electrocardiogram. Moreover, measurement of CACS possibly enables a more precise cardiovascular risk stratification of mature athletes. The main advantage of cardiac CT is its noninvasive nature. Although cardiac CT appears to increase the overall cost of cardiac examinations, this additional cost is much lower than the cost of unnecessary invasive coronary angiographies that would be performed in case of false positive results of exercise electrocardiograms. Radiation exposure may not be a major concern for the application of this modality to pre-participation screening of athletes, since recent technical advancements have resulted in low radiation dose of cardiac CT.

Introduction: A new exercise electrocardiogram (ECG) detection system was investigated in this study to diagnose and analyze cardiopulmonary function and related diseases in a comprehensive and timely manner and improve the accuracy of diagnosis. Besides, its reliability and clinical applicability were judged. Objective: A new type of exercise ECG detection system was constructed by adding parameters such as respiratory mechanics, carbon dioxide, and oxygen concentration monitoring based on the traditional ECG detection system. Methods: The new system constructed in this study carried out the ECG signal detection, ECG acquisition module, blood pressure and respiratory mechanics detection and conducted a standard conformance test. Results: The heart rate accuracy detected by the exercise ECG system was greatly higher than that of the doctor's manual detection (P < 0.05). The accuracy of the new exercise ECG detection system increased obviously in contrast to that of the manual detection result (P < 0.05). The key technical index input noise and input impedance test results (24.5 μV and 12.4 MΩ) of the exercise ECG detection system conformed to the standard (< 30 μV and > 2.5 MΩ). The common-mode rejection and sampling rate test results (103.5 dB and 515 Hz) of key technical indicators in the exercise ECG detection system were all in line with the standards (≥89 dB and ≥500 Hz). Conclusion: The complete exercise ECG detection system was constructed through the ECG acquisition module, blood pressure detection, and respiratory mechanics detection module. In addition, this system could be applied to detect ECG monitoring indicators with high accuracy and reliability, which could also be extensively adopted in clinical diagnosis. Level of evidence II; Therapeutic studies - investigation of treatment results. RESUMO Introdução: Um novo sistema de detecção de eletrocardiograma de exercício (ECG) foi investigado neste estudo para diagnosticar e analisar a função cardiopulmonar e doenças relacionadas de maneira abrangente e oportuna e melhorar a precisão do diagnóstico. Além disso, sua confiabilidade e aplicabilidade clínica foram julgadas. Objetivo: Um novo tipo de sistema de detecção de ECG de esforço foi construído adicionando parâmetros como mecânica respiratória, dióxido de carbono e monitoramento da concentração de oxigênio com base no sistema de detecção de ECG tradicional. Métodos: O novo sistema construído neste estudo realizou a detecção do sinal de ECG, módulo de aquisição de ECG e detecção de pressão arterial e mecânica respiratória, e conduziu um teste de conformidade padrão. Resultados: A precisão da frequência cardíaca detectada pelo sistema de ECG de esforço foi muito maior do que a detecção manual do médico (P 2,5 MΩ). A rejeição do modo comum e os resultados do teste de taxa de amostragem (103,5 dB e 515 Hz) dos indicadores técnicos principais no sistema de detecção de ECG de esforço estavam todos alinhados com os padrões (≥89 dB e ≥500 Hz). Conclusão: O sistema completo de detecção de ECG de esforço foi construído através da combinação de módulo de aquisição de ECG, detecção de pressão arterial e módulo de detecção de mecânica respiratória. Além disso, esse sistema poderia ser aplicado à detecção de indicadores de monitoramento de ECG com alta precisão e confiabilidade, o que poderia ser amplamente adotado no diagnóstico clínico. Nível de evidência II; Estudos terapêuticos- investigação dos resultados do tratamento. RESUMEN Introducción: En este estudio se investigó un nuevo sistema de detección de electrocardiograma de esfuerzo (ECG) para diagnosticar y analizar la función cardiopulmonar y enfermedades relacionadas de manera integral y oportuna, y mejorar la precisión del diagnóstico. Además, se evaluó su confiabilidad y aplicabilidad clínica. Objetivo: Se construyó un nuevo tipo de sistema de detección de ECG de ejercicio agregando parámetros como la mecánica respiratoria, el dióxido de carbono y el monitoreo de la concentración de oxígeno sobre la base del sistema de detección de ECG tradicional. Métodos: El nuevo sistema construido en este estudio llevó a cabo la detección de la señal de ECG, el módulo de adquisición de ECG y la detección de la presión arterial y la mecánica respiratoria, y realizó una prueba de conformidad estándar. Resultados: la precisión de la frecuencia cardíaca detectada por el sistema de ECG de ejercicio fue mucho mayor que la de la detección manual del médico (P 2,5 MΩ). Los resultados de la prueba de frecuencia de muestreo y rechazo en modo común (103,5 dB y 515 Hz) de los indicadores técnicos clave en el sistema de detección de ECG de esfuerzo estaban en línea con los estándares (≥89 dB y ≥500 Hz). Conclusión: El sistema completo de detección de ECG de ejercicio se construyó mediante la combinación del módulo de adquisición de ECG, la detección de la presión arterial y el módulo de detección de la mecánica respiratoria. Además, este sistema podría aplicarse a la detección de indicadores de monitoreo de ECG con alta precisión y confiabilidad, que también podría adoptarse ampliamente en el diagnóstico clínico. Nivel de evidencia II; Estudios terapéuticos- investigación de los resultados del tratamiento.

Efficient diagnostic approaches to detect coronary artery disease (CAD) in elderly patients are necessary to ensure optimal and timely treatment. The population of suspected CAD patients older than 70 years is especially vulnerable and constantly growing. Finding the optimal diagnostic approach is challenging due to certain features of this population, such as high prevalence of comorbidities, existing contraindications to exercise tests or cognitive decline, which hinders correct assessment of the patient’s situation. Moreover, some symptoms of CAD can have variable significance in the elderly compared to younger adult groups. In this review, we present current recommendations of the United States (US) and European cardiologists’ associations and discuss their applicability for diagnostics in the elderly population. Exercise electrocardiogram (ECG) and exercise stress echocardiography (SE) tests are not feasible for a substantial proportion of elderly patients. Coronary computed tomography angiography (CTA) appears to be an attractive alternative for such patients, but is not universally applicable; for instance, it is problematic in patients with significant calcification of the vessels. Moreover, more studies are needed to compare the results delivered by CTA to those of other diagnostic methods. Future efforts should be focused on comparative studies to better understand the limits and advantages of different diagnostic methods and their combinations. It is possible that some of the currently used diagnostic criteria could be improved to better accommodate the needs of the elderly population.

Many causes of noncardiac chest pain (NCCP) have been studied and gastroesophageal reflux disease is considered to be the major cause. However, studies have reported that treatment with a proton pump inhibitor does not effectively provide relief for NCCP-related symptoms, and these symptoms frequently recur. These findings suggest that patients with cardiac disease may be excluded completely from the NCCP group. Several examinations can be conducted to verify the presence of cardiac disease. Such examinations include the assessment of biochemical markers, rest and exercise electrocardiogram, echocardiography, cardiac computed tomography, stress myocardial perfusion imaging, cardiac magnetic resonance imaging, and coronary angiography (CAG). However, the presence of functional coronary artery diseases (CADs), such as vasospastic angina and/or microvascular angina, cannot be detected using these modalities. These functional CADs can be diagnosed by CAG with spasm-provocation testing and/or physiological coronary measurement. Thus, when a patient who is suspected of having NCCP takes a proton pump inhibitor and does not respond well, further examination—including assessment for possible functional CADs—may be needed.

No abstract available Keywords: Biventricular pacing; Cardiac resynchronization therapy; Electrophysiology; Exercise testing; QRS interval.

During early experience with subcutaneous implantable cardioverter-defibrillators (S-ICD), several patients had inappropriate shocks from T-wave oversensing (TWOS) during exercise. This prompted some operators to perform routine treadmill exercise tests after implantation of S-ICD to screen for TWOS. Meanwhile, improvements have been made in the detection algorithms by the manufacturer.To assess whether routine treadmill exercise post S-ICD implantation is warranted.Patients undergoing S-ICD implantation from October 2012 to December 2016 who were able to complete a treadmill exercise were included in the study. The amplitude of R and T waves as assessed by the device programmer at rest and peak exercise was calculated and incidence of TWOS recorded.Eighty-seven patients with complete treadmill exercise test data were included in the final analysis. The majority of the patients received S-ICD for primary prevention. Nine percent of the included patients had hypertrophic obstructive cardiomyopathy. During treadmill exercise, there was significant increase in the heart rate from rest (77 ± 14 beats per minute) to peak exercise (133 ± 14 beats per minute; P.0001). There was no significant difference between R-wave amplitude at rest (2 ± 0.77 mV) and peak exercise (1.88 ± 0.94 mV; P = .36). Similarly, there was no significant difference between T-wave amplitude at rest (0.27 ± 0.19 mV) and peak exercise (0.33 ± 0.23 mV; P = .06). The incidence of TWOS during exercise was zero.With current screening and detection algorithms for S-ICD, routine treadmill exercise does not result in additional discrimination of patients susceptible to TWOS.

Exercise electrocardiogram (ECG) tests boasts of being more widely available, less resource intensive, lower cost and absence of radiation. In the presence of a normal baseline ECG, an exercise ECG test is able to generate a reliable and reproducible result almost comparable to Technitium–99 m sestamibi perfusion imaging. Exercise ECG changes when combined with other clinical parameters obtained during the test has the potential to allow effective redistribution of scarce resources by excluding low risk patients with significant accuracy. As we look towards a future of rising healthcare costs, increased prevalence of cardiovascular disease and the need for proper allocation of limited resources; exercise ECG test offers low cost, vital and reliable disease interpretation. This article highlights the physiology of the exercise ECG test, patient selection, effective interpretation, describe previously reported scores and their clinical application in today’s clinical practice.

Background: Alcohol septal ablation (ASA) is a method of treatment in obstructive hypertrophic car­diomyopathy (HOCM), but there is little data on the long-term results of ASA and the natural course after treatment. The aim of the study was to evaluate the results of ASA in HOCM in multiannual observation, and its impact on patient survival, exercise capacity, electrical complications, and changes in the anatomy and function of the heart. Methods: The study evaluated 47 patients with HOCM with a high left ventricular outflow tract (LVOT gradient) treated between 1997 and 2014 with ASA. Annual examinations evaluated the clinical condi­tion, at rest and with exercise electrocardiogram, Holter monitoring, echocardiography, the evolution of HOCM towards the dilated form, and the frequency of pacemaker implantation. Results: The analysis included data from 34 patients under observation for 3 to 17 (mean 10.8) years. Their age at procedure was 21–65, a mean of 47 years. All patients had permanently reduced LVOT gradient with a mean of 77.36 ± 35.46 to 11.40 ± 10.85 and showed improvement in the performance I to II New York Heart Association. Two out of five deaths had possible cardiac etiology. Fifteen patients received a pacemaker or cardioverter implants. In 4 subjects the long-term observation revealed new wall contractility abnormalities, interpreted as a shift of HOCM to the dilated form. Conclusions: Alcohol septal ablation permanently eliminated the gradient in LVOT and improved the performance of patients, however it did not prevent a shift of HOCM to the dilated form. Pacemaker implantations are relatively frequent. (Cardiol J 2017; 24, 2: 125–130)

Objectives. Exercise electrocardiogram (ExECG) in low risk populations frequently generates false positive ST depression. We aimed to characterize factors that are associated with exercise-induced ST depression in asymptomatic men without coronary artery disease. Design. Cycle ergometer exercise tests from 509 male firefighters without imaging proof of significant coronary artery disease were analysed. Analysed test data included heart rate at rest before exercise, and workload, blood pressure, heart rate, ST depression and ST segment slope at peak exercise. ST depression of amp;gt;0.1 mV was considered significant (STdep). With a mean follow-up of 6.1 +/- 1.7 years, medical records were reviewed for cardiovascular diagnoses, hyperlipidemia and diabetes. Logistic regression analysis was used for risk assessment. Results. In total, 22% had STdep in amp;gt;= 1 lead. Subjects with STdep were older than those with normal ExECG (p amp;lt; .001). Downsloping STdep was more common in extremity leads (9%) than in precordial leads (2%). STdep was categorized according to location (precordial/extremity) and slope direction into eight categories. Larger age-adjusted heart rate increase predicted STdep in seven categories (p amp;lt; .05). Age-adjusted peak heart rate correlated with STdep in five categories, predominantly where the ST slope was positive. Peak blood pressure and exercise capacity were both associated with STdep in few categories. We found no association between STdep and hypertension, hyperlipidemia or diabetes (all p amp;gt; .05). Conclusions. In asymptomatic men with a physically demanding occupation and no coronary artery disease, both age and heart rate response were associated with ST depression, whereas common cardiovascular risk factors, blood pressure response and exercise capacity were not. Funding Agencies|County Council of Ostergotland, Sweden [LIO-711261]; ALF grant [700731]

Exercise stress testing can have a central role in the assessment of cardiovascular disease. Contemporary data, however, has highlighted the added value of imaging modalities over the exercise electrocardiogram in the investigation of coronary artery disease. Given the physiological changes associated with exercise and the possibility to address other parameters such as rhythm changes and the chronotropic response, exercise stress testing with continuous electrocardiographic monitoring can still have an important place in contemporary clinical practice. We report the case of a complete atrioventricular block associated with exercise and discuss the current role of exercise stress testing with continuous electrocardiographic monitoring in this entity.

Objective Although frequently utilized, an exercise electrocardiogram (ECG) provides limited diagnostic accuracy in patients with atypical angina pectoris. The purpose of this study was to determine the possible incremental value of pretest probability (PTP) scores and exercise parameters in discriminating coronary artery disease (CAD) and to identify PTP cutoff values. Methods In a retrospective cohort of 207 patients with atypical angina (76 women, 131 men; mean age: 57.6±8.2 years) who underwent coronary angiography (CAG) after a positive exercise ECG, the PTP was calculated according to the CAD Consortium basic and clinical models along with exercise parameters of blood pressure (BP), heart rate (HR), exercise duration, maximal metabolic equivalents (METs), HR reserve, HR recovery, chronotropic index, BP reserve, BP recovery, and ST/HR ratio. Patients were categorized into true positive (TP) or false positive (FP) groups, depending on the ultimate determination of a presence of obstructive CAD. Results A TP result was associated with older age, male gender, hypertension, diabetes, hyperlipidemia, and higher basic and clinical PTP, as well as higher maximal BP, maximal ST deviation and ST/HR, but lower maximal METs, chronotropic index, and HR recovery. The basic and clinical PTP, and the chronotropic index could predict a TP test result irrespective of gender. Logistic regression analysis revealed that clinical PTP was the only independent predictor of TP results. A cutoff score of 18 for the basic and 21 for the clinical PTP were determined to discriminate CAD. Conclusion This study has shown that, among various electrocardiographic and hemodynamic parameters, the clinical PTP and the chronotropic index are the most helpful tools to discriminate patients with CAD among patients with atypical angina.

Several findings on an exercise electrocardiogram predicted left main and/or 3-vessel coronary arterial disease, which was confirmed by coronary arteriography, and the 56-year-old man underwent a multivessel coronary arterial bypass operation the following day.

Coronary computed tomography angiography (CTA) has excellent diagnostic accuracy for the detection and assessment of coronary artery disease. Its strengths are numerous, but 2 features are particularly noteworthy in the context of patients with suspected unstable coronary heart disease. First, it

Background: The aim of this study was to examine the value of predischarge exercise electrocardiogram (ECG) testing of chest pain patients in whom acute myocardial infarction (MI) had been ruled out by means of high-sensitivity troponins, ECG and history. Methods: All patients hospitalised for chest pain who underwent exercise ECG testing before discharge from the Department of Cardiology, Södersjukhuset, Stockholm, Sweden from January 2011 to June 2012 were included. Endpoints were death, MI and post-discharge revascularisation within 90 and 365 days, respectively. The background one-year risk of death and MI for a corresponding age, gender and calendar time-matched Swedish population was also examined. Results: A total of 951 patients were included. In 585 patients (61.5%) the exercise ECG test was negative, in 94 (9.9%) positive and in 272 (28.6%) inconclusive. There were no significant differences regarding death or MI between patients with a positive or a negative test, neither at 90 ( n=1 (1.1%) vs. n=1 (0.2%)) nor at 365 days ( n=2 (2.1%) vs. n=4 (0.7%)) of follow-up. In total there were nine (0.9%) deaths and 10 (1.1%) MIs within 365 days. The one-year rates of death (1.3%) and MI (0.5%) in a matched Swedish population were comparable. Conclusions: Predischarge exercise ECG testing after rule out of MI did not predict subsequent death or MI in a population of patients hospitalised for chest pain. Furthermore, the risks of death and MI in this population were comparable to a matched Swedish population. These findings suggest that patients could be discharged without this test.

Objectives: To compare the safety and diagnostic efficacy of coronary computed tomography angiography (CTA) with exercise electrocardiography (XECG) in triaging patients of low risk acute chest pain. Background: Noninvasive assessment of coronary stenosis by CTA may improve early and accurate triage of patients presenting with acute chest pain to the emergency department (ED). Methods: Low risk patients of possible acute coronary syndrome (ACS) were included in the study. The patients in CTA arm with significant stenosis (≥50%) underwent catheterization, while those with no or intermediate stenosis (

Given the wide knowledge gaps in the evaluation of patients with low and intermediate pretest probability stable chest pain and the ubiquity of noninvasive imaging the below mentioned largest, most comprehensive and timely randomized clinical trials (RCTs), provide valuable insights into risk stratification, diagnosis, management, prognostication, and outcomes. Rapid clinical assessment of patients with low/intermediate-risk stable chest pain can identify high-risk individuals. However, about 33% of patients labeled as noncardiac chest pain die from cardiovascular disease or develop acute coronary syndrome (ACS) during 5 years' follow-up. About 1.5% of patients with ACS are missed even after extensive testing leading to potential medical, legal, and psychological sequelae. As a result, clinicians have a low threshold to admit even low risk patients for prolonged expensive observation and testing leading to unnecessary admissions, false-positive test results, and unnecessary invasive downstream investigations. This scenario gives a clarion call for improving the diagnostic accuracy, risk stratification, and prognostication in low/intermediate-risk stable chest pain patients. The most common clinical scenario most of us come across is a middle-aged patient with new onset/recurrent low/intermediate-risk stable chest pain attending the emergency department (ED). Issues which are head scratching and mindboggling about this scenario is the ability of the clinician to optimally utilize the appropriate tests from the available armamentarium of functional, anatomical and biochemical diagnostic strategies (exercise electrocardiogram, stress echocardiogram, nuclear stress test, computed tomographic coronary angiography, and circulating biomarkers) to arrive at accurate diagnosis for flawless management. One of the main purposes of the article is to avoid underdiagnosis, overdiagnosis, and misdiagnosis in patients with stable chest pain. We have cherry-picked four large recent landmark RCTs to help the clinician to sharpen his clinical skills, maximize diagnostic accuracy, speed up emergent interventions, assist in surgical planning, and optimize medical therapies. Unfortunately, physical examination for determining the cause of low/intermediate-risk stable chest pain is neither sensitive nor specific to identify obstructive coronary artery disease (CAD). The four recent RCTs are as follows: (1) PROspective Multicenter Imaging Study for Evaluation of Chest Pain trial; (2) Scottish COmputed Tomography of the History, Electrocardiogram, Age, Risk factors, and initial Troponin Trial; (3) Impact on Management of the HEART Risk Score in Chest Pain Patients trial; and (4) Randomized Investigation of Chest Pain Diagnostic Strategies, Shared Decision-Making in the ED: Chest Pain Choice trial.

Postexercise measurement of heart rate (HR) recovery and QT interval dynamics provides prognostic information in various patient populations.The purpose of this study was to assess whether the measurement of the spatial relationship between the depolarization and repolarization wavefronts (total cosine R-to-T [TCRT]) during the postexercise recovery phase would yield prognostic information.The population consisted of 1297 patients (56 ± 13 years; 67% men) who performed a clinically indicated bicycle stress test. The exercise-recovery hysteresis of TCRT was quantified from the 12-lead exercise electrocardiogram by measuring the TCRT/HR loop area bounded by the exercise and first 3-minute postexercise recovery curves. The HR-corrected TCRT/HR hysteresis was calculated by dividing the area with the HR decrement during the first 3 minutes of recovery. HR recovery was measured at 1 minute postexercise recovery. End points were cardiac death and sudden cardiac death.During an average follow-up of 45 ± 12 months, 74 patients died (5.7%); 35 (2.6%) were cardiac deaths and 24 (1.9%) were sudden cardiac deaths. Reduced TCRT/HR loop area and TCRT/HR hysteresis were associated with cardiac mortality (P.001). After adjustments for clinical variables, including ejection fraction, TCRT/HR loop area remained an independent predictor of cardiac death (hazard ratio 5.6; 95% confidence interval 1.6-19.1; P = .007) and sudden cardiac death (10.7; 95% confidence interval 1.4-83.7; P = .024). HR recovery did not remain a significant predictor in the multivariate analysis.Attenuated hysteresis of the depolarization and repolarization wavefronts during postexercise recovery is associated with an increased risk of cardiac and sudden cardiac death. Analysis of repolarization dynamics from exercise electrocardiogram represents a promising tool for risk stratification.

Summary Reasons for performing study: Electrocardiographic reference values of clinically normal horses during exercise are a prerequisite when evaluating horses with poor performance or horses presented with cardiac abnormalities (e.g. valvular regurgitation). No published studies have reported cardiac rhythms of clinically normal showjumping horses. Objectives: To demonstrate the feasibility of obtaining exercise electrocardiogram (ECG) in normal horses during showjumping and also to document the prevalence and frequency of arrhythmias in association with exercise. Methods: Thirty-four healthy showjumping horses aged 4–13 years (mean 7.5 years) underwent clinical examination and resting echocardiography. Modified chest lead ECG examinations were performed during rest, during a standardised showjumping course, as well as for the following 45 min recovery. All ECG recordings were analysed for presence and frequency of arrhythmias. Results: Six horses (17%) were excluded due to ECG recordings of poor diagnostic quality. Echocardiography demonstrated that 11 (39%) horses had one or more mild or moderate valvular regurgitations, but no associations were found between valvular regurgitation and arrhythmias. Supraventricular premature complexes (SVPCs) were found in 9 (32%) horses at rest, 25 (89%) during exercise and 15 (54%) during recovery. Only few arrhythmias occurred in each horse (

Background Conventional analysis of exercise electrocardiogram (EX-ECG) has limited accuracy. This study aims to evaluate the potential impact of improving EX-ECG accuracy on costs of diagnosis and number of misdiagnoses of coronary artery disease (CAD). Methods A decision-tree model was simulated including sequential application of diagnostic procedures for suspected CAD. The model was structured in two main branches (presence or absence of CAD). A probabilistic sensitivity analysis was then performed for several combinations of improvement in test sensitivity and specificity. Results A clear trend in cost reduction was observed at improving EX-ECG specificity (about 8–8.5 million dollars, corresponding to a 5.6–7.6% reduction according to the prevalence level). Wrong diagnoses counted for 9–13% of test. Improvements in test parameters lead to reductions in wrong diagnoses, especially when increasing specificity (8.8–12.5%). Conclusions A proper improvement in EX-ECG sensitivity and specificity would have a relevant impact on the costs of CAD management, while reducing the number of misdiagnoses.

Hypertension (HTN), diabetes (DM), and smoking are known cardiovascular disease risk factors that lead to increased mortality, as do low functional aerobic capacity (FAC), abnormal heart rate recovery (AbnHRR), and abnormal exercise electrocardiogram (AbnECG). We reviewed the Mayo Integrated Stress

Hypertensive patients are more affected by coronary artery disease (CAD) than normotensive patients. Currently, established techniques are able to diagnose myocardial ischemia/CAD in hypertensive patients with suspected CAD. An irrevocable role remains for exercise electrocardiogram (ECG) owing to the many parameters evaluated under physiologic conditions. However, the suboptimal specificity of a positive exercise ECG demands further examination of hypertensive patients with either myocardial single-photon emission computed tomography (SPECT) or stress echocardiography, both more specific than exercise ECG in diagnosing CAD. The high specificity of imaging techniques also makes them highly predictive of cardiac events. Additional techniques to help diagnose CAD are available. Tissue Doppler imaging, strain and other echo-derived techniques may add quantitative elements to recognize CAD in hypertensive hearts. The accuracy of MRI is improving to study myocardial function and perfusion. Positron emission tomography and multislice computed tomography, also in-built with fusion scanners, are playing roles in combining coronary angiography and myocardial function/ischemia assessment. However, no significant application of these additional techniques is available for hypertensive patients. Epicardial CAD assessed by coronary angiography remains the gold standard to decide for revascularization procedures. The presence of microcirculatory dysfunction, a symptom typical of hypertensive hearts, is opening up new areas of noninvasive diagnostic techniques for the detection of coronary flow reserve (CFR) and related myocardial ischemia. The quantification of CFR may render this parameter pivotal to deciding the need for revascularization procedures of intermediate coronary stenosis and it may become an additional gold standard in evaluating coronary vessels. Moreover, even with normal epicardial coronary arteries, microcirculation dysfunction bears prognostic stratification capabilities for hypertensive patients and it may become a promising therapeutic target in the near future.

Computed tomography coronary angiography (CTCA) entered clinical practice around 2005, mainly due to advances in computed tomography (CT) technology, namely the introduction of 64-slice CT scanners, which were the first that could image the heart within a few seconds. Two years later, another significant advance was the introduction of prospective gating, which reduced the radiation dose for CTCA by 70% to around 2 mSv.1 Multi-centre clinical trials using this technology demonstrated very good sensitivity and excellent negative predictive value (NPV) for the diagnosis of coronary artery disease (CAD) compared with invasive coronary angiography (ICA).2–4 The positive predictive values (PPVs) for CTCA have generally been less impressive as the degree of coronary stenosis can appear more severe on CTCA than on ICA, mainly because of calcium blooming artefacts. CTCA has been compared with exercise electrocardiogram (ECG), using ICA as the gold standard, and again, CTCA was found to have an excellent NPV of 100% compared with 64% for exercise ECG.5 Furthermore, three American trials demonstrated that the use of CTCA to rule out CAD in patients presenting with chest pain to the emergency room can reduce the length of stay …

Electrocardiogram showing Wolff-Parkinson-White (WPW) pattern in an asymptomatic patient is common, but it is difficult to assess the potential risk of sudden death in such cases. Although the incidence of sudden death in these patients is extremely low, an interventional approach is suggested for all patients despite its controversial nature. Syncope, despite being induced by various mechanisms, has been considered an alarming sign of sudden death of WPW syndrome. We describe a 16-year-old female patient with an electrocardiogram that demonstrated a WPW pattern combined with unexplained syncope. None of the examinations, including biochemical profiles, brain computed tomography, transthoracic echocardiography, head-up tilt table test and exercise electrocardiogram, clarified her syncope. Consequently, no further electrophysiologic study was performed for this patient. Unfortunately, the patient suffered sudden death while running. The case highlights the need for vigilance when unexplained syncope combined with WPW syndrome. Such cases have high risk of sudden death, and thus, further interventional study and treatment is indicated.

The aim of the study was to evaluate the utility of exercise-induced ECG changes in predicting the degree of myocardial ischemia as compared to angiographic and nuclear scintigraphic images. Four hundred and seventy one patients in whom exercise nuclear scintigraphy and coronary angiography revealed significant coronary narrowing (≧70% luminal diameter narrowing) were studied. Down-sloping ST depression was found to be the best predictor of a large area of reversible ischemia (RI). Time of resolution of ST depression was the second most powerful predictor and the time of onset of ST depression was the third best predictor. RI on nuclear scintigraphy correlated better than angiographic findings with the ECG changes.

In a consecutive series of 7350 myocardial perfusion SPECT studies, 66 (0.9%) nonrevascularized patients with a normal resting ECG had normal scintigraphic findings with a positive ECG in the exercise test. We retrospectively analyzed 33 patients with coronary angiography, 26 of whom were women (P.000). Twenty one of the 26 women (81%) and 1 of the 7 men (14%) had normal coronary angiographic findings (P= .004). Seven out of 11 patients with coronary heart disease had left main coronary artery or multivessel disease. We conclude that the "normal SPET with positive ECG" pattern is infrequent, and is observed predominantly in women with normal coronary angiographic findings. However, severe coronary artery disease cannot be ruled out in these patients, and this pattern should be considered a possible indication for coronary angiography.

This editorial refers to ‘QRS-T morphology measured from exercise electrocardiogram as a predictor of cardiac mortality’ by T. Kentta et al. , on page 701. The benefits of the prophylactic clinical use of implantable cardioverter-defibrillators (ICD) have been documented beyond any reasonable doubt by a multitude of prospective clinical trials.1–3 This does not mean that the present ICDs are without limitations and that further technical advances are not needed. Among other challenges, inappropriate shocks, frequent in some patients, not only limit the broader use of the devices but also pose a risk on their own. Also, attempts at initiating ICD prophylaxis shortly after acute myocardial infarction have so far been unsuccessful.4,5 Whether this relates to the implantation procedures, including test shocks, or whether the recently infarcted myocardium is particularly vulnerable to appropriate shocks and/or to other impacts of ICD implants is unknown. Still, the restriction of ICD implantation in patients with ischaemic heart disease to the chronic post-infarction stages is regrettable. High rates of the sudden cardiac deaths, potentially avoidable by ICD interventions, appear shortly after the infarction.6 These are examples of difficulties in ICD prophylaxis that need to be solved by a combination of further technological and clinical advances. Nevertheless, these challenges are not the major problem of ICD prophylaxis. The major unmet clinical need concerns the selection of candidates for primary ICD prevention. It is well known that the reduced left ventricular ejection fraction (LVEF) is not only the present goal standard of risk stratification for these purposes but it is also the only selection criterion that has gained the acceptance by both the clinical community and healthcare providers. Additional selection criteria, such as the prolonged QRS duration on standard resting electrocardiogram (ECG), that have also been occasionally imposed, are mostly seen …

Preoperative assessment of the cardiac patients before noncardiac surgery is concern in the clinical practice of anesthesiologist, surgeon, and medical consultant. The preferred stress testing is exercise electrocardiogram (ECG) in patients who are able to exercise and have normal ECG; however, either stress myocardial perfusion scintigraphy (MPS) or stress echocardiography is necessary if further testing is appropriately indicated before surgery. Unfortunately, stress MPs or stress echocardiography is not widely available and has some limitations. Coronary computed tomography angiogram (CCTA) has demonstrated excellent diagnostic accuracy in detecting coronary artery disease and accurate left ventricle function measurement. CCTA seems to be feasible, reliable, and has strong potential of becoming sole screening test before surgery.