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Zhang J, Zhang H, Wei T, Kang P, Tang B, Wang H. Predicting angiographic coronary artery disease using machine learning and high-frequency QRS. BMC Med Inform Decis Mak 2024; 24:217. [PMID: 39085823 PMCID: PMC11292994 DOI: 10.1186/s12911-024-02620-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
AIM Exercise stress ECG is a common diagnostic test for stable coronary artery disease, but its sensitivity and specificity need to be further improved. In this paper, we construct a machine learning model for the prediction of angiographic coronary artery disease by HFQRS analysis of cycling exercise ECG. METHODS AND RESULTS This study prospectively included 140 inpatients and 59 healthy volunteers undergoing cycling exercise ECG. The CHD group (N=104) and non-CHD group (N=95) were determined by coronary angiography gold standard. Automated HF QRS analysis was performed by the blinded method. The coronary group was predominantly male, with a higher prevalence of age, BMI, hypertension, and diabetes than the non-coronary group ( P < 0.001 ), higher lipid levels in the coronary group ( P < 0.005 ), significantly longer QRS duration during exercise testing ( P < 0.005 ), more positive leads ( P < 0.001 ), and a greater proportion of significant changes in HFQRS ( P < 0.001 ). Age, Gender, Hypertension, Diabetes, and HF QRS Conclusions were screened by correlation analysis and multifactorial retrospective analysis to construct the machine learning models of the XGBoost Classifier, Logistic Regression, LightGBM Classifier, RandomForest Classifier, Artificial Neural Network and Support Vector Machine, respectively. CONCLUSION Male, elderly, with hypertension, diabetes mellitus, and positive exercise stress test HFQRS conclusions suggested a high risk of CHD. The best performance of the Logistic Regression model was compared, and a column line graph for assessing the risk of CHD was further developed and validated.
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Affiliation(s)
- Jiajia Zhang
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China
- Key Laboratory of Basic and Clinical Cardiovascular and Cerebrovascular Diseases, Bengbu Medical University, Bengbu, Anhui Province, 233030, China
| | - Heng Zhang
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China
| | - Ting Wei
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China
| | - Pinfang Kang
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China
- Key Laboratory of Basic and Clinical Cardiovascular and Cerebrovascular Diseases, Bengbu Medical University, Bengbu, Anhui Province, 233030, China
| | - Bi Tang
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China
| | - Hongju Wang
- Department of Cardiovascular Disease, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui Province, 233099, China.
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2
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ZHANG PF, TIAN JW, ZHU TG, WU JF, LENG XP, WANG Y, LI MM, LI XH, WANG QQ, FENG XP, LV JY, YIN LX, ZHANG Y, ZHANG M. Stress Echocardiography for Chronic Coronary Syndrome: Clinical Practice Guidelines (2023). J Geriatr Cardiol 2024; 21:475-505. [PMID: 38948890 PMCID: PMC11211908 DOI: 10.26599/1671-5411.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Affiliation(s)
- Peng-Fei ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jia-Wei TIAN
- The Second Affiliated Hospital of Harbin Medical University, Haerbin, China
| | | | - Jue-Fei WU
- Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiao-Ping LENG
- The Second Affiliated Hospital of Harbin Medical University, Haerbin, China
| | - Yi WANG
- Sichuan Province People's Hospital, Chengdu, China
| | - Meng-Meng LI
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xin-Hao LI
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qian-Qian WANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiao-Peng FENG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jia-Yan LV
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Li-Xue YIN
- Sichuan Province People's Hospital, Chengdu, China
| | - Yun ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Mei ZHANG
- State Key Laboratory for Innovation and Transformation of Luobing Theory; Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
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3
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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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4
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Mansour M, Alqaisi O, Gautam N, Vallurupalli S. Significance of abnormal stress electrocardiography with normal cardiac imaging during stress testing-a meta-analysis. J Electrocardiol 2024; 83:64-70. [PMID: 38340487 DOI: 10.1016/j.jelectrocard.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/19/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND AND AIMS Diagnostic testing for coronary artery disease frequently involves functional stress testing where imaging is often coupled with electrocardiogram (ECG) analysis. While decision-making is straightforward when both functional testing and ECG are either positive or negative, interpretation is challenging and prognostic importance uncertain with positive ECG and negative imaging since imaging is considered more sensitive. Prior studies have demonstrated mixed results. We sought to perform a meta-analysis of published studies to determine the significance of this particular type of discordant stress test result. METHODS AND RESULTS PubMed, Cochrane, and Google Scholar were searched to identify studies reporting results of functional imaging (pharmacological exercise echocardiography or SPECT) and ECG analysis, along with the major adverse cardiovascular events (MACE) at patient follow-up. Studies were stratified based on functional imaging modality used. Primary outcome was a composite of all-cause death or myocardial infarction, and secondary outcome was the need for coronary revascularization. Random effects model was used to calculate risk ratios (RR), and heterogeneity among studies was assessed using the Higgins I2 value. Nine studies with a total of 23,715 patients were included. Primary end point was more common with discordant results with exercise stress echocardiography (RR 1.33, 95% confidence intervals [1.08-1.63]) or pharmacological SPECT (RR 6.53 95% CI [2.31-18.48]). CONCLUSIONS Patients in the discordant exercise stress echocardiography and pharmacological SPECT groups were more likely to suffer the primary end point than those with a normal stress test. Discordant results should be interpreted carefully in the clinical context, given their prognostic impact based on the stress modality used.
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Affiliation(s)
- Munthir Mansour
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Omar Alqaisi
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nitesh Gautam
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Srikanth Vallurupalli
- Department of Medicine, Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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5
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Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L, Van De Heyning CM, Celutkiene J, Gaibazzi N, Ciampi Q, Senior R, Neskovic AN, Henein M. The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. Eur Heart J Cardiovasc Imaging 2024; 25:e65-e90. [PMID: 37798126 DOI: 10.1093/ehjci/jead250] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology of the National Research Council, CNR, Via Moruzzi 1, 56124 Pisa, Italy
| | - Luc Pierard
- University of Liège, Walloon Region, Belgium
| | - Jesus Peteiro
- CHUAC-Complexo Hospitalario Universitario A Coruna, CIBER-CV, University of A Coruna, 15070 La Coruna, Spain
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Centre of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center UPMC Heart & Vascular Institute, Pittsburgh, PA, USA
| | | | | | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, 43100 Parma, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy
| | - Roxy Senior
- Imperial College, UK
- Royal Brompton Hospital Imperial College London, UK
- Northwick Park Hospital, London, UK
| | - Aleksandar N Neskovic
- Department of Cardiology, University Clinical Hospital Center Zemun-Belgrade Faculty of Medicine, University of Belgrade, Serbia
| | - Michael Henein
- Department of Public Health and Clinical Medicine Units: Section of Medicine, Umea University, Umea, Sweden
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Ranasinghe S, Tjoe B, Shufelt C, Wei J, Lauzon M, Luu J, Asif A, Lewis J, Pepine CJ, Shaw LJ, Handberg E, Merz CNB. Association of abnormal electrocardiography response on dobutamine stress echocardiogram with longer-term major adverse cardiovascular events in women with symptoms of ischemic heart disease. Cardiovasc Diagn Ther 2023; 13:948-955. [PMID: 38162097 PMCID: PMC10753239 DOI: 10.21037/cdt-23-296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 01/03/2024]
Abstract
Background Prior work demonstrates patients with positive (+) electrocardiogram (ECG) but negative (-) echocardiogram wall motion abnormalities (WMAs) on dobutamine stress echocardiography (DSE) testing have an elevated of major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the long-term prognosis of women with suspected ischemia with no obstructive coronary artery (INOCA) disease by utilizing core lab read DSE, specifically focusing on those with + ECG findings. Methods Among women with signs and symptoms of myocardial ischemia undergoing clinically indicated coronary angiography enrolled in the Women's Ischemia Syndrome Evaluation (WISE) [1997-2001], a prospective cohort study, 99 underwent standardized DSE by site design. Women with positive DSE (n=17), defined as an increase in score based on wall motion scoring index were excluded except for akinetic to dyskinetic (n=10), providing 82 patients in this analysis. ECG was assessed by core laboratory and (+) ECG was defined as >1 mm ST change. Non-obstructive coronary artery disease (CAD) was assessed by core laboratory quantitative coronary angiography and defined as <50% epicardial stenosis. All-cause death follow-up was an average of 8 years, while adjudicated MACE [all-cause mortality, nonfatal myocardial infarction (MI), nonfatal stroke, heart failure hospitalization] was an average of 5.5 years. Comparisons among subject groups [i.e., (+) ECG and (-) ECG] were made using chi-square or Fisher's exact tests for categorical variables and t-test or Wilcoxon rank-sum test for continuous variables. Results Demographic profile included a mean age 59±10 years; 55% had hypertension (HTN), 29% diabetes mellitus (DM), and 72% non-obstructive CAD. Overall, 9/82 women (11%) had (+) ECG in the absence of WMAs. There were significant differences in family history of CAD (P=0.009) and vasodilator (P=0.042) use between the (+) ECG and (-) ECG groups, but otherwise had no significant demographic or clinical differences. At longer-term follow up, patients with (+) ECG had higher risk of MACE [unadjusted hazard ratio (HR): 4.91, 95% confidence interval (CI): 1.83, 13.19, P=0.002]. Conclusions Abnormal stress ECG findings on dobutamine stress testing with a negative DSE should be viewed as an indicator of longer-term risk in women with signs and symptoms of ischemia.
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Affiliation(s)
- Sachini Ranasinghe
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Benita Tjoe
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Chrisandra Shufelt
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marie Lauzon
- Bioststatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Judy Luu
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anum Asif
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jannet Lewis
- Division of Cardiology, The George Washington University Medical Center, Washington, DC, USA
| | - Carl J. Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Leslee J. Shaw
- Division of Cardiology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eileen Handberg
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - C. Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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7
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Chow BJ, Galiwango P, Poulin A, Raggi P, Small G, Juneau D, Kazmi M, Ayach B, Beanlands RS, Sanfilippo AJ, Chow CM, Paterson DI, Chetrit M, Jassal DS, Connelly K, Larose E, Bishop H, Kass M, Anderson TJ, Haddad H, Mancini J, Doucet K, Daigle JS, Ahmadi A, Leipsic J, Lim SP, McRae A, Chou AY. Chest Pain Evaluation: Diagnostic Testing. CJC Open 2023; 5:891-903. [PMID: 38204849 PMCID: PMC10774086 DOI: 10.1016/j.cjco.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 01/12/2024] Open
Abstract
Chest pain/discomfort (CP) is a common symptom and can be a diagnostic dilemma for many clinicians. The misdiagnosis of an acute or progressive chronic cardiac etiology may carry a significant risk of morbidity and mortality. This review summarizes the different options and modalities for establishing the diagnosis and severity of coronary artery disease. An effective test selection algorithm should be individually tailored to each patient to maximize diagnostic accuracy in a timely fashion, determine short- and long-term prognosis, and permit implementation of evidence-based treatments in a cost-effective manner. Through collaboration, a decision algorithm was developed (www.chowmd.ca/cadtesting) that could be adopted widely into clinical practice.
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Affiliation(s)
- Benjamin J.W. Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Paul Galiwango
- Department of Medicine, Scarborough Health Network and Lakeridge Health, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Poulin
- Department of Medicine, Quebec Heart and Lung Institute, Laval University, Quebec, Quebec, Canada
| | - Paolo Raggi
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gary Small
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniel Juneau
- Department of Radiology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Mustapha Kazmi
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Ayach
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Rob S. Beanlands
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Anthony J. Sanfilippo
- Department of Medicine, Lakeridge Health, Queen’s University, Kingston, Ontario, Canada
| | - Chi-Ming Chow
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D. Ian Paterson
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Chetrit
- Department of Cardiovascular Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Davinder S. Jassal
- Department of Physiology and Pathophysiology, Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim Connelly
- Division of Cardiology, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eric Larose
- Department of Medicine, Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Quebec, Canada
| | - Helen Bishop
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Malek Kass
- Department of Internal Medicine, Rady Faculty of Health Sciences, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd J. Anderson
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Haissam Haddad
- Division of Cardiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Katie Doucet
- Peterborough Regional Health Centre, Kawartha Cardiology Clinic, Peterborough, Ontario, Canada
| | - Jean-Sebastien Daigle
- Department of Internal Medicine, Dr Everett Chalmers Hospital, Fredericton, New Brunswick, Canada
| | - Amir Ahmadi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Leipsic
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Siok Ping Lim
- Mayfair Diagnostics, Saskatoon, Saskatchewan, Canada
| | - Andrew McRae
- Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Annie Y. Chou
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Radiology, St. Paul’s Hospital, Vancouver, British Columbia, Canada
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8
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Martins-Santos CB, Duarte LTA, Ferreira-Junior CR, Feitosa AGT, Oliveira EVG, Campos ICMB, Melo EVD, Andrade SM, Sousa ACS, Oliveira JLM. Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography. Arq Bras Cardiol 2023; 120:e20230047. [PMID: 38126513 PMCID: PMC10773463 DOI: 10.36660/abc.20230047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 09/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Central Illustration : Exaggerated Systolic Blood Pressure Increase with Exercise and Myocardial Ischemia on Exercise Stress Echocardiography ESBPRE: exaggerated systolic blood pressure response to exercise; HR: heart rate; SBP: systolic blood pressure. BACKGROUND The association between exaggerated systolic blood pressure response to exercise (ESBPRE) and myocardial ischemia is controversial and little studied in patients with established or suspected chronic coronary syndrome. OBJECTIVE To verify the relationship between myocardial ischemia and ESBPRE in patients undergoing exercise stress echocardiography (ESE). METHODS This is a cross-sectional study with 14,367 patients undergoing ESE, from January 2000 to January 2022, divided into the following 2 groups: G1, composed of patients whose peak systolic pressure increased ≥ 90 mmHg (value corresponding to the 95th percentile of the study population), and G2, patients who did not demonstrate an exaggerated hypertensive response. The groups were compared using Student's t and chi-square tests. P values < 0.05 were considered significant. Logistic regression was also performed to identify independent risk factors for myocardial ischemia, ESBPRE, complaints of typical chest pain prior to the exam, and angina during the test. RESULTS Of the 14,367 patients, 1,500 (10.4%) developed ESBPRE, and 7,471 (52.0%) were female. The percentages of previous complaints of typical chest pain, angina during the test, and myocardial ischemia in patients with ESBPRE were 5.8%, 2.4% and 18.1%, compared to 7.4%, 3.9%, and 24.2%, in patients without ESBPRE, respectively (p = 0.021,p = 0.004, p < 0.001). In multivariate analysis, ESBPRE was independently associated with a lower probability of myocardial ischemia (odds ratio: 0.73; 95% confidence interval: 0.58 to 0.93; p = 0.009). CONCLUSION Exaggerated increase in systolic blood pressure during ESE may be a marker for excluding myocardial ischemia.
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Affiliation(s)
| | | | | | | | | | - Iana Carine Machado Bispo Campos
- Rede D'Or São Luiz - Clínica e Hospital São Lucas , Aracaju , SE - Brasil
- Rede Primavera - Setor de Métodos Gráficos do Hospital Primavera , Aracaju , SE - Brasil
- Fundação de Beneficência Hospital de Cirurgia - Setor de Métodos Gráficos , Aracaju , SE - Brasil
| | | | - Stephanie Macedo Andrade
- Rede D'Or São Luiz - Clínica e Hospital São Lucas , Aracaju , SE - Brasil
- Rede Primavera - Setor de Métodos Gráficos do Hospital Primavera , Aracaju , SE - Brasil
| | - Antônio Carlos Sobral Sousa
- Universidade Federal de Sergipe , São Cristóvão , SE - Brasil
- Rede D'Or São Luiz - Clínica e Hospital São Lucas , Aracaju , SE - Brasil
| | - Joselina Luzia Menezes Oliveira
- Universidade Federal de Sergipe , São Cristóvão , SE - Brasil
- Rede D'Or São Luiz - Clínica e Hospital São Lucas , Aracaju , SE - Brasil
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9
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Vilela EM, Oliveira C, Oliveira C, Torres S, Sampaio F, Primo J, Ribeiro J, Teixeira M, Oliveira M, Bettencourt N, Viamonte S, Fontes-Carvalho R. Sixty years of the Bruce protocol: reappraising the contemporary role of exercise stress testing with electrocardiographic monitoring. Porto Biomed J 2023; 8:e235. [PMID: 37846299 PMCID: PMC10575366 DOI: 10.1097/j.pbj.0000000000000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 09/18/2023] [Indexed: 10/18/2023] Open
Abstract
The cardiovascular response to exercise has long been a focus of interest. Over a century ago, the first descriptions of electrocardiographic changes occurring during exercise highlighted the possible relevance of this dynamic assessment. In this background, the inception of the Bruce protocol circa 60 years ago allowed for a major leap in this field by providing a standardized framework with which to address this issue, by means of an integrated and structured methodology. Since then, exercise stress testing with electrocardiographic monitoring (ExECG) has become one of the most widely appraised tests in cardiovascular medicine. Notably, past few decades have been profoundly marked by substantial advances in the approach to cardiovascular disease, challenging prior notions concerning both its physiopathology and overall management. Among these, the ever-evolving presentations of cardiovascular disease coupled with the development and implementation of several novel diagnostic modalities (both invasive and noninvasive) has led to a shifting paradigm in the application of ExECG. This technique, however, has continuously shown to be of added value across various momentums of the cardiovascular continuum, as depicted in several contemporary guidelines. This review provides a pragmatical reflexion on the development of ExECG, presenting a comprehensive overview concerning the current role of this modality, its challenges, and its future perspectives.
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Affiliation(s)
- Eduardo M. Vilela
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Cátia Oliveira
- Cardiology Department, Hospital de Braga, Braga, Portugal
- Faculty of Medicine, Minho University, Braga, Portugal
| | - Cláudia Oliveira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Susana Torres
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Francisco Sampaio
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Cardiovascular Research Center (UniC@RISE), Faculty of Medicine, University of Porto, Porto, Portugal
| | - João Primo
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - José Ribeiro
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Madalena Teixeira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Marco Oliveira
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Nuno Bettencourt
- Cardiovascular Research Center (UniC@RISE), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sofia Viamonte
- North Rehabilitation Centre, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ricardo Fontes-Carvalho
- Cardiology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Cardiovascular Research Center (UniC@RISE), Faculty of Medicine, University of Porto, Porto, Portugal
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10
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Barbieri A, Bursi F, Santangelo G, Mantovani F. Exercise Stress Echocardiography for Stable Coronary Artery Disease: Succumbed to the Modern Conceptual Revolution or Still Alive and Kicking? Rev Cardiovasc Med 2022; 23:275. [PMID: 39076615 PMCID: PMC11266956 DOI: 10.31083/j.rcm2308275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 07/31/2024] Open
Abstract
The modern conceptual revolution in managing patients with stable coronary artery disease (CAD), based on improvement in preventive and pharmacological therapy, advocates coronary artery revascularization only for smaller group of patients with refractory angina, poor left ventricular systolic function, or high-risk coronary anatomy. Therefore, our conventional wisdom about stress testing must be questioned within this new and revolutionary paradigm. Exercise stress echocardiography (ESE) is still a well-known technique for assessing known or suspected stable CAD, it is safe, accessible, and well-tolerated, and there is an widespread evidence base. ESE has been remarkably resilient throughout years of innovation in noninvasive cardiology. Its value is not to be determined over the short portion of diagnostic accuracy but mainly through its prognostic value evident in a wide range of patient subsets. It is coming very close to the modern profile of a leading test that should include, in addition to an essential accettable diagnostic and prognostic accuracy, qualities of low cost, no radiation exposure, and minor environmental traces. In this review, we will discuss advantages, diagnostic accuracy, prognostic value in general and special populations, cost-effectiveness, and changes in referral patterns of ESE in the modern era.
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Affiliation(s)
- Andrea Barbieri
- Division of Cardiology, Department of Diagnostics, Clinical and Public Health Medicine, Policlinico University Hospital of Modena, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Francesca Bursi
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, 20122 Milan, Italy
- Department of Health Sciences, University of Milan, 20122 Milan, Italy
| | - Gloria Santangelo
- Division of Cardiology, Heart and Lung Department, San Paolo Hospital, ASST Santi Paolo and Carlo, 20122 Milan, Italy
| | - Francesca Mantovani
- Division of Cardiology, Azienda USL–IRCCS di Reggio Emilia, 42122 Reggio Emilia, Italy
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11
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Fitzgerald BT, Smith E, Scalia GM. What are the prognostic implications and factors relating to exercise induced electrocardiographic ST segment changes in the setting of a non-ischemic stress echocardiogram? Int J Cardiol 2022; 364:157-161. [PMID: 35716939 DOI: 10.1016/j.ijcard.2022.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/24/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) changes during stress testing are a common and perplexing finding during non-ischemic stress echocardiography (niSE). Research has provided conflicting results regarding the implications. METHODS SE was performed after maximal Bruce protocol treadmill exercise. RESULTS 3020 consecutive patients, mean age 58 ± 12 years, 36% female, were followed-up for up to 9 years (mean 36 ± 21 months) post niSE. Time to first cardiac event (composite of heart failure admission, worsening New York Heart Association class, worsening ejection fraction, acute coronary syndrome, revascularization, angina or cardiovascular death) was analysed and adjusted using Cox proportional hazards regression. Prognostic significance was found with 1.5 mm of downsloping or horizontal ST depression. Adjusting for baseline differences, increased risk of composite major adverse cardiac events was shown with at least 1.5 mm of exercise induced ST depression (Hazard ratio [HR] of 2.47, 95% Confidence ratio [CI] 1.67-3.72, p < 0.0001). Patients achieving high level exercise capacity (≥13 metabolic equivalents or METs) with ST depression lower risk of cardiac events during follow-up. CONCLUSION Patients with ST segment depression but non-ischemic stress imaging have a poorer prognosis compared to patients with niSE with normal stress ECGs. ST depression of 1.5 mm or more was established as a prognostically significance value. High exercise capacity was associated with an improved prognosis, and ECG changes in that setting can be regarded as false positives. All niSE have low risk of a cardiac event in the very short term (<12 months). Overall, ST depression during non-ischaemic stress imaging is not a benign finding.
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Affiliation(s)
- Benjamin T Fitzgerald
- GenesisCare Cardiology, Australia; The Wesley Hospital, Australia; The Prince Charles Hospital, Australia.
| | - Erin Smith
- GenesisCare Cardiology, Australia; The Wesley Hospital, Australia
| | - Gregory M Scalia
- GenesisCare Cardiology, Australia; The Wesley Hospital, Australia; The Prince Charles Hospital, Australia; University of Queensland, Australia
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12
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Significance of indeterminate and abnormal stress electrocardiography despite normal imaging in patients with suspected coronary artery disease – An analysis of the PROMISE trial. J Electrocardiol 2022; 73:79-86. [DOI: 10.1016/j.jelectrocard.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/02/2022] [Accepted: 05/22/2022] [Indexed: 11/22/2022]
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13
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Lopez DM, Divakaran S, Gupta A, Bajaj NS, Osborne MT, Zhou W, Hainer J, Bibbo CF, Skali H, Dorbala S, Taqueti VR, Blankstein R, Di Carli MF. Role of Exercise Treadmill Testing in the Assessment of Coronary Microvascular Disease. JACC Cardiovasc Imaging 2022; 15:312-321. [PMID: 34419395 PMCID: PMC8831663 DOI: 10.1016/j.jcmg.2021.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The authors aimed to study the sensitivity and specificity of exercise treadmill testing (ETT) in the diagnosis of coronary microvascular disease (CMD), as well as the prognostic implications of ETT results in patients with CMD. BACKGROUND ETT is validated to evaluate for flow-limiting coronary artery disease (CAD), however, little is known about its use for evaluating CMD. METHODS We retrospectively studied 249 consecutive patients between 2006 and 2016 who underwent ETT and positron emission tomography within 12 months. Patients with obstructive CAD or left ventricular systolic dysfunction were excluded. CMD was defined as a coronary flow reserve <2. Patients were followed for the occurrence of a first major adverse event (composite of death or hospitalization for myocardial infarction or heart failure). RESULTS The sensitivity and specificity of a positive ETT to detect CMD were 34.7% (95% CI: 25.4%-45.0%) and 64.9% (95% CI: 56.7%-72.5%), respectively. The specificity of a positive ETT to detect CMD increased to 86.8% (95% CI: 80.3%-91.7%) when only classifying studies with ischemic electrocardiogram changes that lasted at least 1 minute into recovery as positive, although at a cost of lower sensitivity (15.3%; 95% CI: 8.8%-24.0%). Over a median follow-up of 6.9 years (IQR: 5.1-8.2 years), 30 (12.1%) patients met the composite endpoint, including 13 (13.3%) with CMD (n = 98). In patients with CMD, ETT result was not associated with the composite endpoint (P = 0.076). CONCLUSIONS Our data suggest limited sensitivity of ETT to detect CMD. However, a positive ETT with ischemic changes that persist at least 1 minute into recovery in the absence of obstructive CAD should raise suspicion for the presence of CMD given a high specificity. Further study is needed with larger patient sample sizes to assess the association between ETT results and outcomes in patients with CMD.
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Affiliation(s)
- Diana M Lopez
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/DMLopez5
| | - Sanjay Divakaran
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/SanjayDivakaran
| | - Ankur Gupta
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Navkaranbir S Bajaj
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Osborne
- Cardiovascular Imaging Research Center, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wunan Zhou
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney F Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Viviany R Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/RonBlankstein
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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14
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Ananthasubramaniam G, Ananthasubramaniam K. Stress Electrocardiography Testing in Coronary Artery Disease: Is It Time for Its Swan Song or To Redefine Its Role in the Modern Era ? Indian Heart J 2022; 74:81-85. [PMID: 35167825 PMCID: PMC9039687 DOI: 10.1016/j.ihj.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/27/2022] Open
Abstract
Stress electrocardiography (sECG) or treadmill stress testing is a well validated noninvasive diagnostic modality available to clinicians at low cost yet providing valuable functional data for coronary artery disease (CAD) diagnostic and prognostic evaluation. With the advances in cardiac imaging in both functional and anatomic fronts and the existing limitations of sECG testing, this modality appears less favored worldwide as reflected in some recent guideline updates. We review the past present and future of sECG to provide a viewpoint on where it stands in CAD evaluation and if it will remain relevant as a diagnostic modality or be retired going forward. We also provide our perspectives on how sECG can co-exist with other modalities such as calcium scoring and discuss the role of such testing in the Indian population.
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15
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Reynolds HR. Rethinking the Goal of Exercise Tolerance Testing: Identifying Ischemic Heart Disease, Whether Epicardial or Microvascular. JACC Cardiovasc Imaging 2021; 15:322-324. [PMID: 34922862 DOI: 10.1016/j.jcmg.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Harmony R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA.
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16
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Mehta PK, Wei J, Shufelt C, Quesada O, Shaw L, Bairey Merz CN. Gender-Related Differences in Chest Pain Syndromes in the Frontiers in CV Medicine Special Issue: Sex & Gender in CV Medicine. Front Cardiovasc Med 2021; 8:744788. [PMID: 34869650 PMCID: PMC8635525 DOI: 10.3389/fcvm.2021.744788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/13/2021] [Indexed: 12/30/2022] Open
Abstract
Coronary artery disease (CAD) is the leading cause of morbidity and mortality among both women and men, yet women continue to have delays in diagnosis and treatment. The lack of recognition of sex-specific biological and socio-cultural gender-related differences in chest pain presentation of CAD may, in part, explain these disparities. Sex and gender differences in pain mechanisms including psychological susceptibility, the autonomic nervous system (ANS) reactivity, and visceral innervation likely contribute to chest pain differences. CAD risk scores and typical/atypical angina characterization no longer appear relevant and should not be used in women and men. Women more often have ischemia with no obstructive CAD (INOCA) and myocardial infarction, contributing to diagnostic and therapeutic equipoise. Existing knowledge demonstrates that chest pain often does not relate to obstructive CAD, suggesting a more thoughtful approach to percutaneous coronary intervention (PCI) and medical therapy for chest pain in stable obstructive CAD. Emerging knowledge regarding the central and ANS and visceral pain processing in patients with and without angina offers explanatory mechanisms for chest pain and should be investigated with interdisciplinary teams of cardiologists, neuroscientists, bio-behavioral experts, and pain specialists. Improved understanding of sex and gender differences in chest pain, including biological pathways as well as sociocultural contributions, is needed to improve clinical care in both women and men.
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Affiliation(s)
- Puja K Mehta
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute and Emory Women's Heart Center, Emory University School of Medicine, Atlanta, GA, United States
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Chrisandra Shufelt
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Odayme Quesada
- Women's Heart Center, The Christ Hospital Heart Institute, Cincinnati, OH, United States
| | - Leslee Shaw
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
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17
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Relationship of Stress Test Findings to Anatomic or Functional Extent of Coronary Artery Disease Assessed by Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6674144. [PMID: 33681370 PMCID: PMC7929671 DOI: 10.1155/2021/6674144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/08/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022]
Abstract
Background In the United States, functional stress testing is the primary imaging modality for patients with stable symptoms suspected to represent coronary artery disease (CAD). Coronary computed tomography angiography (CTA) is excellent at identifying anatomic coronary artery disease (CAD). The application of computational fluid dynamics to coronary CTA allows fractional flow reserve (FFR) to be calculated noninvasively (FFRCT). The relationship of noninvasive stress testing to coronary CTA and FFRCT in real-world clinical practice has not been studied. Methods We evaluated 206 consecutive patients at Loyola University Chicago with suspected CAD who underwent noninvasive stress testing followed by coronary CTA and FFRCT when indicated. Patients were categorized by stress test results (positive, negative, indeterminate, and equivocal). Duke treadmill score (DTS), METS, exercise duration, and chest pain with exercise were analyzed. Lesions ≥ 50%stenosis were considered positive by coronary CTA. FFRCT < 0.80 was considered diagnostic of ischemia. Results Two hundred and six patients had paired noninvasive stress test and coronary CTA/FFRCT results. The median time from stress test to coronary CTA was 49 days. Average patient age was 60.3 years, and 42% were male. Of the 206 stress tests, 75% were exercise (70% echocardiographic, 26% nuclear, and 4% EKG). There were no associations of stress test results with CAD > 50% or FFRCT < 0.80 (p = 0.927 and p = 0.910, respectively). Of those with a positive stress test, only 30% (3/10) had CAD > 50% and only 50% (5/10) had FFRCT < 0.80. Chest pain with exercise did not correlate with CAD > 50% or FFRCT < 0.80 (p = 0.66 and p = 0.12, respectively). There were no significant correlations between METS, DTS, or exercise duration and FFRCT (r = 0.093, p = 0.274; r = 0.012, p = 0.883; and r = 0.034, p = 0.680; respectively). Conclusion Noninvasive stress testing, functional capacity, chest pain with exercise, and DTS are not associated with anatomic or functional CAD using a diagnostic strategy of coronary CTA and FFRCT.
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Peteiro J, Bouzas-Mosquera A. Implications of ST Changes During Normal Echocardiography. JAMA Intern Med 2020; 180:1256-1257. [PMID: 32597921 DOI: 10.1001/jamainternmed.2020.1832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jesús Peteiro
- Laboratory of Stress Echocardiography, Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, CIBER-CV, University of A Coruña, A Coruña, Spain
| | - Alberto Bouzas-Mosquera
- Laboratory of Stress Echocardiography, Department of Cardiology, Complejo Hospitalario Universitario de A Coruña, CIBER-CV, University of A Coruña, A Coruña, Spain
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19
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Daubert MA, Velazquez EJ, Wang TY. Implications of ST Changes During Normal Echocardiography-Reply. JAMA Intern Med 2020; 180:1257-1258. [PMID: 32597923 DOI: 10.1001/jamainternmed.2020.1844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Melissa A Daubert
- Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
| | | | - Tracy Y Wang
- Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Durham, North Carolina
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20
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bs. [Not Available]. MMW Fortschr Med 2020; 162:19. [PMID: 32124371 DOI: 10.1007/s15006-020-0192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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