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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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Sonaglioni A, Lombardo M, Nicolosi GL, Grasso E, Ambrosio G. The wide spectrum of determinants of false-positive results on exercise stress echocardiography. J Cardiovasc Med (Hagerstown) 2023; 24:585-588. [PMID: 37409605 DOI: 10.2459/jcm.0000000000001515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Affiliation(s)
| | | | | | - Enzo Grasso
- Division of Cardiology, MultiMedica IRCCS, Milan
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Pathophysiology, Azienda Ospedaliero-Universitaria 'S. Maria Della Misericordia', Perugia, Italy
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3
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Johnson CL, Woodward W, McCourt A, Dockerill C, Krasner S, Monaghan M, Senior R, Augustine DX, Paton M, O'Driscoll J, Oxborough D, Pearce K, Robinson S, Willis J, Sharma R, Tsiachristas A, Leeson P. Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study. Echo Res Pract 2023; 10:8. [PMID: 37254216 DOI: 10.1186/s44156-023-00020-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 05/11/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines. METHODS Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level. RESULTS Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually. CONCLUSION This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.
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Affiliation(s)
- Casey L Johnson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - William Woodward
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Annabelle McCourt
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Cameron Dockerill
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Samuel Krasner
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Mark Monaghan
- Kings College Hospital NHS Foundation Hospital, London, UK
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Hospital, Bath, UK
- Department for Health, University of Bath, Bath, UK
| | | | | | - David Oxborough
- Research Institute for Sports and Exercise Science, Liverpool John Moores University/Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - Keith Pearce
- Manchester University NHS Foundation Hospital, Manchester, UK
| | - Shaun Robinson
- North West Anglia NHS Foundation Hospital, Peterborough, UK
| | - James Willis
- Royal United Hospitals Bath NHS Foundation Hospital, Bath, UK
| | - Rajan Sharma
- St. George's University Hospitals NHS Foundation Hospital, London, UK
| | - Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Paul Leeson
- Cardiovascular Clinical Research Facility, RDM Division of Cardiovascular Medicine, University of Oxford, Oxford, OX3 9DU, UK.
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4
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Prevalence and prognostic implications of hypertensive response to exercise in patients with hypertrophic cardiomyopathy. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 16:200166. [PMID: 36874040 PMCID: PMC9975236 DOI: 10.1016/j.ijcrp.2022.200166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023]
Abstract
Objective Hypertensive response to exercise (HRE) is observed in patients with hypertrophic cardiomyopathy (HCM) with normal resting blood pressure (BP). However, the prevalence or prognostic implications of HRE in HCM remain unclear. Methods In this study, normotensive HCM subjects were enrolled. HRE was defined as systolic BP > 210 mmHg in men or >190 mmHg in women, or diastolic BP > 90 mmHg, or an increase in diastolic BP > 10 mmHg during treadmill exercise. All participants were followed for subsequent development of hypertension, atrial fibrillation (AF), heart failure (HF), sustained ventricular tachycardia/fibrillation (VT/VF), and all-cause death. Six hundred and eighty HCM patients were screened. Results 347 patients had baseline hypertension, and 333 patients were baseline normotensive. 132 (40%) of the 333 patients had HRE. HRE was associated with female sex, lower body mass index and milder left ventricular outflow tract obstruction. Exercise duration and metabolic equivalents were similar between patients with or without HRE, but the HRE group had higher peak heart rate (HR), better chronotropic response and more rapid HR recovery. Conversely, non-HRE patients were more likely to exhibit chronotropic incompetence and hypotensive response to exercise. After a mean follow-up of 3.4 years, patients with and without HRE had similar risks of progression to hypertension, AF, HF, sustained VT/VF or death. Conclusion HRE is common in normotensive HCM patients during exercise. HRE did not carry higher risks of future hypertension or cardiovascular adverse outcomes. Conversely, the absence of HRE was associated with chronotropic incompetence and hypotensive response to exercise.
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Pewowaruk RJ, Hein AJ, Hansen KM, Barnes JN, Chesler NC, Korcarz CE, Gepner AD. Exercise increases arterial stiffness independent of blood pressure in older Veterans. J Hypertens 2023; 41:316-325. [PMID: 36479879 PMCID: PMC9805522 DOI: 10.1097/hjh.0000000000003334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Exercise-induced changes in arterial function could contribute to a hypertensive response to exercise (HRE) in older individuals. We performed the present analysis to define the acute arterial stiffness response to exercise in ambulatory older adults. METHODS Thirty-nine Veterans (>60 years old), without known cardiovascular disease, participated in this study, including 19 Veterans who were hypertensive (70.8 ± 6.8 years, 53% women) and 20 Veterans who were normotensive (72.0 ± 9.3 years, 40% women). Arterial stiffness parameters were measured locally with carotid artery ultrasound and regionally with carotid-femoral pulse wave velocity (cfPWV) before and during the 10 min after participants performed a Balke maximal exercise treadmill stress test. RESULTS The arterial stiffness response to exercise was similar for control and hypertensive participants. At 6 min postexercise, cfPWV was significantly increased (Δ1.5 ± 1.9 m/s, P = 0.004) despite mean blood pressure (BP) having returned to its baseline value (Δ1 ± 8 mmHg, P = 0.79). Arterial mechanics modeling also showed BP-independent increases in arterial stiffness with exercise ( P < 0.05). Postexercise cfPWV was correlated with postexercise SBP ( r = 0.50, P = 0.004) while baseline cfPWV ( r = 0.13, P = 1.00), and postexercise total peripheral resistance ( r = -0.18, P = 1.00) were not. CONCLUSION In older Veterans, exercise increases arterial stiffness independently of BP and the arterial stiffness increase with exercise is associated with increased postexercise SBP. BP-independent increases in arterial stiffness with exercise could contribute to a HRE in older adults.
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Affiliation(s)
- Ryan J Pewowaruk
- William S. Middleton Memorial Veterans Hospital
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Amy J Hein
- William S. Middleton Memorial Veterans Hospital
| | - Kristin M Hansen
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Jill N Barnes
- Department of Kinesiology, University of Wisconsin, Madison, Wisconsin
| | - Naomi C Chesler
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center and Department of Biomedical Engineering, University of California - Irvine, California, USA
| | - Claudia E Korcarz
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health
| | - Adam D Gepner
- William S. Middleton Memorial Veterans Hospital
- Division of Cardiovascular Medicine, Department of Medicine, University of Wisconsin School of Medicine and Public Health
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6
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Tian Y, Zhang Y. The relationship between hypertension and physical activity in middle-aged and older adults controlling for demographic, chronic disease, and mental health variables. Medicine (Baltimore) 2022; 101:e32092. [PMID: 36451488 PMCID: PMC9704945 DOI: 10.1097/md.0000000000032092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
To explore the relationship between hypertension and physical activity (PA) in the middle-aged and elderly after controlling demographic characteristics, chronic diseases and mental health variables. The 2018 China Health and Retirement Longitudinal Study (CHARLS) was used to collect the data. A baseline survey of middle-aged and older people was carried out nationally using the PPS sample method to look into their demographic, health state, and other information. The investigation included 4593 adults over 50 with complete data on PA level and hypertension prevalence. Z-test, logistic regression analysis, and linear hierarchical regression analysis were performed on the gathered data using the SPSS 27.0 program. The prevalence of hypertension among middle-aged and senior persons was 12.2%, and the percentage of those who did not have it was 87.8%. Males were more likely than females to have hypertension. Participants who reported high levels of PA made up 49.2% of the total, while those who reported low levels of PA made up 50.8% of the total. High levels of PA were significantly inversely correlated with hypertension (P < .05). There was still a statistically significant relationship between PA and hypertension (P < .05) after controlling demographic factors (gender, age, household registration type, education level, widowhood), chronic disease (arthritis, diabetes, disability, asthma, self-assessment of health, memory disease, stroke, hyperlipidemia) and mental health variables (bad mood and depression). High-level PA is significantly related to the low risk of hypertension. After controlling demographic characteristics, chronic diseases and mental health variables, this correlation is still significant.
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Affiliation(s)
- Ying Tian
- College of Sports Science, Shenyang Normal University, Shenyang, China
| | - Yaqun Zhang
- College of Sports Science, Anshan Normal University, Anshan, China
- *Correspondence: Yaqun Zhang, College of Sports Science, Anshan Normal University, No.43, Tiedong District, Anshan, Liaoning, China (e-mail: )
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7
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Lemos MM, Cavalini GR, Pugliese Henrique CR, Perli VAS, de Moraes Marchiori G, Marchiori LLDM, Sordi AF, Franzói de Moraes SM, de Paula Ramos S, Valdés-Badilla P, Mota J, Magnani Branco BH. Body composition and cardiorespiratory fitness in overweight or obese people post COVID-19: A comparative study. Front Physiol 2022; 13:949351. [PMID: 36213222 PMCID: PMC9532828 DOI: 10.3389/fphys.2022.949351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
The present study aimed to evaluate the body composition and cardiorespiratory fitness of overweight or obese people after COVID-19. 171 volunteers of both sexes (men, n = 93 and women, n = 78) between 19 and 65 years old were allocated into three groups according to the severity of their symptoms of COVID-19: non-hospitalized people/mild symptoms (n = 61), hospitalized (n = 58), and hospitalized in an intensive care unit-ICU (n = 52). Two laboratory visits were carried out 24 h apart. First, a medical consultation was carried out, with subsequent measurement of body weight and height (calculation of body mass index) and body composition assessment via electrical bioimpedance. After 24 h, a cardiorespiratory test was performed using the Bruce protocol, with a direct gas exchange analysis. Hospitalized individuals had significantly higher values for fat mass and body fat percentage than non-hospitalized individuals (p < 0.05). Significantly higher values were found for heart rate (HR) and peak oxygen consumption (VO2peak) for individuals who were not hospitalized when compared to those hospitalized in the ICU (p < 0.05). Significantly higher values for distance, ventilation, and the relationship between respiratory quotient were found for non-hospitalized individuals compared to hospitalized individuals and those in the ICU (p < 0.05). After the cardiorespiratory test, higher values for peripheral oxygen saturation (SpO2) were observed for non-hospitalized individuals than for all hospitalized individuals (p < 0.05). Diastolic blood pressure was significantly higher at the tenth and fifteenth minute post-Bruce test in hospitalized than in non-hospitalized participants (p < 0.05). Based on these results, proposals for cardiopulmonary rehabilitation are indispensable for hospitalized groups considering the responses of blood pressure. Monitoring HR, SpO2, and blood pressure are necessary during rehabilitation to avoid possible physical complications. Volume and intensity of exercise prescription should respect the physiologic adaptation. Given lower physical conditioning among all the groups, proposals for recovering from health conditions are urgent and indispensable for COVID-19 survivors.
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Affiliation(s)
- Maurício Medeiros Lemos
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
- Postgraduate Program in Health Promotion, Cesumar University, Paraná, Brazil
| | - Gustavo Rocha Cavalini
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
- Medicine Course, Department of Health Sciences, Cesumar University, Maringá, Brazil
| | - Carlos Renato Pugliese Henrique
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
- Medicine Course, Department of Health Sciences, Cesumar University, Maringá, Brazil
| | - Victor Augusto Santos Perli
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
- Medicine Course, Department of Health Sciences, Cesumar University, Maringá, Brazil
| | | | | | - Ana Flávia Sordi
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
| | | | | | - Pablo Valdés-Badilla
- Department of Physical Activity Sciences, Faculty of Education Sciences, Universidad Católica del Maule, Talca, Chile
- Sports Coach Career, School of Education, Universidad Viña del Mar, Viña del Mar, Chile
| | - Jorge Mota
- Research Centre of Physical Activity, Health and Leisure, Faculty of Sports; Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal
| | - Braulio Henrique Magnani Branco
- Interdisciplinary Laboratory of Intervention in Health Promotion, Cesumar Institute of Science, Maringá, Brazil
- Postgraduate Program in Health Promotion, Cesumar University, Paraná, Brazil
- Medicine Course, Department of Health Sciences, Cesumar University, Maringá, Brazil
- Research Centre of Physical Activity, Health and Leisure, Faculty of Sports; Laboratory for Integrative and Translational Research in Population Health (ITR), University of Porto, Porto, Portugal
- Physiology and Nutrition Department, Clinisport Prime, Maringa, Brazil
- *Correspondence: Braulio Henrique Magnani Branco,
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8
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Coronary flow velocity reserve is reduced in patients with an exaggerated blood pressure response to exercise. Hypertens Res 2022; 45:1653-1663. [DOI: 10.1038/s41440-022-00995-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/18/2022] [Accepted: 06/23/2022] [Indexed: 11/09/2022]
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9
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Thein PM, Mirzaee S, Cameron JD, Nasis A. Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review. Intern Med J 2022; 52:186-197. [PMID: 35015318 DOI: 10.1111/imj.14995] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 07/02/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022]
Abstract
An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.
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Affiliation(s)
- Paul M Thein
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Sam Mirzaee
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - James D Cameron
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Arthur Nasis
- Monash Cardiovascular Research Centre, MonashHEART, Monash Health, Monash University, Melbourne, Victoria, Australia
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Resting global myocardial work can improve interpretation of exercise stress echocardiography. Int J Cardiovasc Imaging 2021; 37:2409-2417. [PMID: 33721155 DOI: 10.1007/s10554-021-02216-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
Sensitivity and specificity of ESE to determine hemodynamically significant coronary artery disease (CAD) is limited by subjective qualitative interpretation resulting in false-positive results. The objective of this study was to determine whether resting myocardial work estimated from non-invasive left ventricular pressure-strain loops can help improve the interpretation of exercise stress echocardiography (ESE). Resting global myocardial work was performed on 288 patients referred for clinically indicated ESE with no resting regional wall motion abnormalities and normal ejection fraction (≥ 55%). Coronary angiography was used to validate the presence of significant CAD in those with a positive ESE. Resting global myocardial work index (GWI) was significantly reduced (p < 0.001) in patients with true-positive (1544 ± 354 mmHg%) compared to negative (1819 ± 317 mmHg%) and false-positive (1857 ± 344 mmHg%) ESE. A GWI of ≤ 1391 mmHg (AUC 0.73; sensitivity 94%; specificity 73%) predicted true-positive ESE. Predictors of a true-positive ESE were (1) lower myocardial work efficiency (odds ratio 0.731, 95% CI 0.58-0.92, p = 0.007), (2) lower GWI (odds ratio 0.997, 95% CI 0.996-0.999, p = 0.006) (3) male gender (odds ratio 5.47, 95% CI 1.84-16.31, p = 0.002) and (4) E/e' ratio (odds ratio 1.15, CI 1.01-1.31, p = 0.032). Myocardial work is a potentially valuable quantitative parameter that provides incremental value over qualitative ESE interpretation and improves appropriate patient selection for coronary angiography.
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11
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Mohammed LLM, Dhavale M, Abdelaal MK, Alam ABMN, Blazin T, Prajapati D, Mostafa JA. Exercise-Induced Hypertension in Healthy Individuals and Athletes: Is it an Alarming Sign? Cureus 2020; 12:e11988. [PMID: 33437543 PMCID: PMC7793423 DOI: 10.7759/cureus.11988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Exercise-induced hypertension (EIH) is defined as elevated blood pressure (BP) > 190mm Hg for females and > 210 mmHg for males during exercise. EIH is prevalent among athletes and healthy individuals with no cardiovascular (CV) risk factors. While previous data corroborates exercise in reducing hypertension and cardiovascular risk, the development of EIH and its attendant cardiovascular risk necessitates a review of the pathophysiological mechanisms resulting in EIH. To date, these mechanisms causing EIH are not fully understood, nor are there any established guidelines on the management of EIH. In this article, we discuss in detail the pathophysiological mechanisms, the prognostic value, clinical implications, possible treatment, and future directions in managing EIH.
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Affiliation(s)
- Linha Lina M Mohammed
- Miscellaneous, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Meera Dhavale
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mohamed K Abdelaal
- Surgery/General and Visceral Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - A B M Nasibul Alam
- Miscellaneous, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Tatjana Blazin
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhruvil Prajapati
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jihan A Mostafa
- Psychiatry/Psychotherapy, California Institute of Behavorial Neurosciences & Psychology, Fairfield, USA
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12
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Aftab W, Motabar A, Pai RG, Varadarajan P. Frequency of hypertensive response to dobutamine stress and diminished diagnostic value in patients with end-stage renal disease awaiting renal transplant. Echocardiography 2020; 38:162-168. [PMID: 33231883 DOI: 10.1111/echo.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/27/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with end-stage renal disease (ESRD) have a cardiovascular mortality about 15-30 times the general population and this is reduced by about 70% with renal transplant. Dobutamine stress echocardiography (DSE) is commonly performed for preoperative cardiac evaluation before renal transplantation. Hypertensive response during DSE occurs in about 1%-5% of DSE studies. However, it seems to be more frequent in patients with ESRD. But its frequency and clinical implications are not known. METHODS AND RESULTS Of the 249-consecutive adult ESRD patients undergoing DSE for pre-kidney transplant cardiac risk assessment at our dedicated clinic, 53 (21%) had a hypertensive response. Half of the patients with a hypertensive response had stress-induced segmental wall motion abnormalities, of whom only half had angiographically significant coronary artery disease by quantitative coronary angiography. The hypertensive response was not a predictor of survival. Stress-induced segmental wall motion abnormalities predicted poor survival in those with a normotensive response, but not in those with a hypertensive response. The main and independent predictor of a hypertensive response was higher baseline systolic blood pressure (P < .0001). CONCLUSIONS Hypertensive response to dobutamine stress is common in ESRD patients and is not a predictor of survival. Stress-induced segmental wall motion abnormalities occur nearly thrice as frequently with a hypertensive response, but this is a poor predictor of angiographically significant coronary artery disease and does not predict survival.
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Affiliation(s)
- Waqas Aftab
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA.,University of California Riverside School of Medicine, Riverside, CA, USA
| | - Ali Motabar
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA.,University of California Riverside School of Medicine, Riverside, CA, USA
| | - Ramdas G Pai
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA.,University of California Riverside School of Medicine, Riverside, CA, USA
| | - Padmini Varadarajan
- Department of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA.,University of California Riverside School of Medicine, Riverside, CA, USA
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Phoemsapthawee J, Sriton B. Combined exercise training improves blood pressure at rest and during exercise in young obese prehypertensive men. J Sports Med Phys Fitness 2020; 61:468-479. [PMID: 32975391 DOI: 10.23736/s0022-4707.20.11222-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Regular exercise is an effective intervention to yield health-related benefits, though an optimal dosage and its ability to improve hemodynamics at rest and during exercise are yet to be established. Therefore, this study aimed to assess the effects of a combined (aerobic and resistance) exercise training program on hemodynamic variables at rest and during exercise in young obese prehypertensive men. METHODS Twenty obese prehypertensive men (age: 20±1.2 years) were randomly assigned to either the combined exercise training group (CBT, N.=10), or the control group (CON, N.=10). The CBT underwent a supervised combined exercise training program incorporating four 60-min sessions per week over 12 weeks, whereas the CON remained in habitual activities. We assessed BP, peak oxygen consumption (V̇O<inf>2peak</inf>), body composition, muscular strength, and hemodynamic responses to incremental exercise at baseline and post intervention. RESULTS The study revealed significant improvements in resting systolic blood pressure (SBP) of 4.3% (P<0.05), and rate-pressure product (RPP) of 11.3% (P<0.05) following 12 weeks of training. Significant reductions in SBP and RPP during exercise were also present at every exercise intensity. Moreover, the CBT training improved V̇O<inf>2peak</inf> by 18.2% (P<0.01), upper body muscle strength by 15.1% (P<0.01), and reduced body fat (P<0.01). CONCLUSIONS The CBT is effective in reducing SBP and myocardial oxygen demand at rest and during exercise. It can also improve cardiorespiratory fitness, muscular strength, and reduce body fat; especially in terms of abdominal obesity. Thus, we suggest the use of the CBT program for the prevention of future hypertension in young obese prehypertensive men.
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Affiliation(s)
- Jatuporn Phoemsapthawee
- Department of Sports Science and Health, Faculty of Sports Science, Kasetsart University, Nakhon Pathom, Thailand -
| | - Bhuwanat Sriton
- Department of Sports Science and Health, Faculty of Sports Science, Kasetsart University, Nakhon Pathom, Thailand
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Pellikka PA, Arruda-Olson A, Chaudhry FA, Chen MH, Marshall JE, Porter TR, Sawada SG. Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:1-41.e8. [DOI: 10.1016/j.echo.2019.07.001] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rachwan RJ, Mshelbwala FS, Dardari Z, Batal O. False-positive stress echocardiograms: Predictors and prognostic relevance. Int J Cardiol 2019; 296:157-163. [PMID: 31477317 DOI: 10.1016/j.ijcard.2019.08.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent studies indicate that the pretest likelihood of significant coronary artery disease (CAD) (≥50% luminal stenosis) is over-estimated and that the frequency and severity of positive stress tests have been decreasing. This suggests an increased prevalence of false-positive (FP) stress tests. The aims of this retrospective study were to investigate the predictors of FP stress echocardiography (SE) and to compare the outcomes of patients with FP results to those with true-positive (TP) results. METHODS Patients who underwent SE between 2013 and 2017 in a tertiary-care center were reviewed. Included were patients aged ≥40years who had cardiac catheterization (CC) within 1year of the index stress test. SE was considered FP if a new or worsening wall motion abnormality was present in the absence of significant corresponding CAD. RESULTS Of the 5100 patients with SE, 1069 satisfied inclusion criteria. A total of 305 patients had positive SE results; of which 162 (53%) were FP. Logistic regression revealed that female gender (p=0.009), the absence of diabetes (p=0.03), the absence of a personal history of CAD (p=0.004), and lower stress WMSI (p=0.03) were independently associated with FP results. Patients with FP results on SE had similar all-cause mortality to those with TP results. CONCLUSIONS Accounting for predictors of FP findings on SE could improve the interpretation of SE results and limit the use of unnecessary CC. Furthermore, patients with FP results on SE could benefit from aggressive risk factor control and careful clinical follow-up.
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Affiliation(s)
- Rayan Jo Rachwan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Fakilahyel S Mshelbwala
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Zeina Dardari
- Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Omar Batal
- Division of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America.
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16
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Xu B, Dobson L, Mottram PM, Nasis A, Cameron J, Moir S. Is exercise stress echocardiography useful in patients with suspected obstructive coronary artery disease who have resting left bundle branch block? Clin Cardiol 2018; 41:360-365. [PMID: 29574887 DOI: 10.1002/clc.22875] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/23/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Current guidelines support exercise stress echocardiography (ESE) for evaluation of suspected obstructive coronary artery disease (OCAD) in ambulant patients with left bundle branch block (LBBB). Data regarding the diagnostic utility of ESE in patients with LBBB are limited. HYPOTHESIS We hypothesized that the diagnostic performance of ESE for the assessment of suspected OCAD is reduced in the context of LBBB. METHODS We studied 191 consecutive patients with resting LBBB undergoing ESE for the investigation of suspected OCAD between 2008 and 2015 at our center. The studies were categorized as inconclusive, normal, or abnormal. Patients with an abnormal response were subcategorized as regional ischemic response or globally abnormal. RESULTS Eighty-two patients (43%) demonstrated a normal left ventricular contractile response (LVCR) to exercise; 92 (48%) developed an abnormal LVCR to exercise, including 70 patients with globally abnormal and 22 patients with regional ischemic responses. Of the patients with abnormal responses, 62 patients had anatomic imaging, only 29 of whom had significant OCAD, conferring an overall specificity of ESE for significant OCAD of 21% and accuracy of 52%. Of patients who developed a regionally abnormal response, 89% had significant OCAD. CONCLUSIONS For patients with LBBB who develop a globally abnormal LVCR during ESE, the specificity of ESE for reliably excluding significant OCAD is significantly reduced. ESE appears to be a suboptimal test for the evaluation of OCAD in patients with resting LBBB, as about 50% of patients will have an abnormal response, the majority due to globally abnormal contraction where OCAD cannot be reliably diagnosed. Alternative testing should be considered for the investigation of suspected OCAD in patients with resting LBBB.
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Affiliation(s)
- Bo Xu
- MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Laura Dobson
- MonashHeart, Monash Health, Clayton, Victoria, Australia
| | | | - Arthur Nasis
- MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - James Cameron
- MonashHeart, Monash Health, Clayton, Victoria, Australia
| | - Stuart Moir
- MonashHeart, Monash Health, Clayton, Victoria, Australia
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Abstract
Abnormal noninvasive stress test (NIST) findings do not always correlate with angiographically significant (luminal obstruction ≥50%) coronary artery disease. Positive predictive value (PPV) of NIST in the real clinical practice is not well known. The goal of this retrospective study was to determine the PPV of NIST and assess the factors affecting PPV in a US community hospital. This study included all consecutive patients (n = 355) who underwent invasive coronary angiography after a positive NIST within ~1-year duration at our institution. Three hundred twenty-four patients were included in the analysis after exclusion of 31 patients. Sixty percent of patients were female and mean age was 63.2 (SD 12.4). Myocardial perfusion imaging, echocardiogram (treadmill or dobutamine), and treadmill electrocardiogram were the tests of choice in 95% (n = 307), 4% (n = 14), and 1% (n = 3) of patients, respectively. Overall PPV of NIST was 36.4% (118/324). When patients were stratified by age (<50 years, 50-65 years, ≥65 years), older age groups had significantly higher PPV (<0.001). When patients were grouped by body mass index (<25, 25-30, ≥30), those in lower body mass index groups had higher PPV (P = 0.01). Stress echocardiogram had significantly higher PPV compared with myocardial perfusion imaging stress test (71% vs. 35%; P < 0.005). Stress test site (in-hospital vs. outpatient office) or specialty of interpreting physician did not significantly impact PPV. Multivariable logistic regression analysis revealed that older age, male sex, and total number of cardiac risk factors were significant determinants of higher PPV. Our single-center study revealed that overall PPV of NIST is poor (36.4%), more notably in young, female, or obese patients.
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Bouzas-Mosquera C, Bouzas-Mosquera A, Peteiro J. Respuesta hipertensiva exagerada al ejercicio e isquemia miocárdica en pacientes con enfermedad coronaria conocida o sospechada. Rev Clin Esp 2018; 218:7-12. [DOI: 10.1016/j.rce.2017.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/12/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
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19
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Bouzas-Mosquera C, Bouzas-Mosquera A, Peteiro J. Exaggerated hypertensive response to exercise and myocardial ischemia in patients with known or suspected coronary artery disease. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Keller K, Stelzer K, Geyer M, Münzel T, Ostad MA. Gender differences in bicycle exercise stress echocardiography testing. Artery Res 2018. [DOI: 10.1016/j.artres.2018.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abram S, Arruda-Olson AM, Scott CG, Pellikka PA, Nkomo VT, Oh JK, Milan A, Abidian MM, McCully RB. Frequency, Predictors, and Implications of Abnormal Blood Pressure Responses During Dobutamine Stress Echocardiography. Circ Cardiovasc Imaging 2017; 10:e005444. [PMID: 28351907 PMCID: PMC5408460 DOI: 10.1161/circimaging.116.005444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 02/15/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND It is not known whether abnormal blood pressure (BP) responses during dobutamine stress echocardiography (DSE) are associated with abnormal test results, nor if such results indicate obstructive coronary artery disease (CAD). We sought to define the frequency of abnormal BP responses during DSE and their impact on accuracy of test results. METHODS AND RESULTS We studied 21 949 patients who underwent DSE at Mayo Clinic, Rochester, MN, grouped by peak systolic BP achieved during the test. We also analyzed a subgroup who underwent coronary angiography within 30 days after positive DSE. The positive predictive value of DSE was calculated for each BP group. Patients with hypertensive response (n=1905; 9%) were more likely to have positive DSE than those with normal (n=19 770; 90%) or hypotensive (n=274; 1%) BP responses (32% versus 21% versus 23%, respectively; P<0.0001). Angiography, performed in 1126 patients, showed obstructive CAD (≥50% stenosis) in 814 patients and severe CAD (≥70% stenosis) in 708 patients. Positive predictive value of DSE was similar for patients who had hypertensive and normal BP responses (69% versus 73%; P=0.3), considering 50% stenosis cut point. The proportion of severe CAD (≥70% stenosis) was lower in patients who had hypertensive response compared with those who had normal BP response (54% versus 65%; P=0.005). CONCLUSIONS Patients with hypertensive response during DSE are more likely to have stress-induced myocardial ischemia compared with those with normal or hypotensive BP responses but are not more likely to have false-positive DSE results. They are, however, less likely to have higher grade or multivessel CAD.
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Affiliation(s)
- Sara Abram
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Adelaide M Arruda-Olson
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Christopher G Scott
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Patricia A Pellikka
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Vuyisile T Nkomo
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Jae K Oh
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Alberto Milan
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Mohamed M Abidian
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.)
| | - Robert B McCully
- From the Department of Cardiovascular Diseases (S.A., A.M.A.-O., P.A.P., V.T.N., J.K.O., M.M.A., R.B.M.) and Division of Biomedical Statistics and Informatics (C.G.S.), Mayo Clinic, Rochester, MN; and Department of Medical Sciences, University of Torino, Turin, Italy (S.A., A.M.).
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Peters F, Khandheria BK. Unraveling the Significance of Abnormal Blood Pressure Responses During Dobutamine Stress Echocardiography. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.117.006268. [PMID: 28351908 DOI: 10.1161/circimaging.117.006268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ferande Peters
- From the Division of Cardiology, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand, Johannesburg, South Africa (F.P.); and Aurora Cardiovascular Services, Aurora Sinai/Aurora St Luke's Medical Centers, Milwaukee, WI (B.K.K.).
| | - Bijoy K Khandheria
- From the Division of Cardiology, Chris Hani Baragwanath Academic Hospital and the University of the Witwatersrand, Johannesburg, South Africa (F.P.); and Aurora Cardiovascular Services, Aurora Sinai/Aurora St Luke's Medical Centers, Milwaukee, WI (B.K.K.)
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Hypertensive response to exercise: mechanisms and clinical implication. Clin Hypertens 2016; 22:17. [PMID: 27468357 PMCID: PMC4962449 DOI: 10.1186/s40885-016-0052-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/20/2016] [Indexed: 11/24/2022] Open
Abstract
A hypertensive response to exercise (HRE) is frequently observed in individuals without hypertension or other cardiovascular disease. However, mechanisms and clinical implication of HRE is not fully elucidated. Endothelial dysfunction and increased stiffness of large artery contribute to development of HRE. From neurohormonal aspects, excess stimulation of sympathetic nervous system and augmented rise of angiotensin II seems to be important mechanism in HRE. Increasing evidences indicates that a HRE is associated with functional and structural abnormalities of left ventricle, especially when accompanied by increased central blood pressure. A HRE harbors prognostic significance in future development of hypertension and increased cardiovascular events, particularly if a HRE is documented in moderate intensity of exercise. As supported by previous studies, a HRE is not a benign phenomenon, however, currently, whether to treat a HRE is controversial with uncertain treatment strategy. Considering underlying mechanisms, angiotensin receptor blockers and beta blockers can be suggested in individuals with HRE, however, evidences for efficacy and outcomes of treatment of HRE in individuals without hypertension is scarce and therefore warrants further studies.
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Heart Rate and Blood Pressure Assessment by Physical Therapists in the Outpatient Setting—An Observational Study. Cardiopulm Phys Ther J 2016. [DOI: 10.1097/cpt.0000000000000033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Keller K, Stelzer K, Munzel T, Ostad MA. Hypertension is strongly associated with false-positive bicycle exercise stress echocardiography testing results. Blood Press 2016; 25:351-359. [PMID: 27163258 DOI: 10.1080/08037051.2016.1182419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Exercise echocardiography is a reliable routine test in patients with known or suspected coronary artery disease. However, in ∼15% of all patients, stress echocardiography leads to false-positive stress echocardiography results. We aimed to investigate the impact of hypertension on stress echocardiographic results. METHODS We performed a retrospective study of patients with suspected or known stable coronary artery disease who underwent a bicycle exercise stress echocardiography. Patients with false-positive stress results were compared with those with appropriate results. RESULTS 126 patients with suspected or known coronary artery disease were included in this retrospective study. 23 patients showed false-positive stress echocardiography results. Beside comparable age, gender distribution and coronary artery status, hypertension was more prevalent in patients with false-positive stress results (95.7% vs. 67.0%, p = 0.0410). Exercise peak load revealed a borderline-significance with lower loads in patients with false-positive results (100.0 (IQR 75.0/137.5) vs. 125.0 (100.0/150.0) W, p = 0.0601). Patients with false-positive stress results showed higher systolic (2.05 ± 0.69 vs. 1.67 ± 0.39 mmHg/W, p = 0.0193) and diastolic (1.03 ± 0.38 vs. 0.80 ± 0.28 mmHg/W, p = 0.0165) peak blood pressure (BP) per wattage. In a multivariate logistic regression test, hypertension (OR 17.6 [CI 95% 1.9-162.2], p = 0.0115), and systolic (OR 4.12 [1.56-10.89], p = 0.00430) and diastolic (OR 13.74 [2.46-76.83], p = 0.00285) peak BP per wattage, were associated with false-positive exercise results. ROC analysis for systolic and diastolic peak BP levels per wattage showed optimal cut-off values of 1.935mmHg/W and 0.823mmHg/W, indicating false-positive exercise echocardiographic results with AUCs of 0.660 and 0.664, respectively. CONCLUSIONS Hypertension is a risk factor for false-positive stress exercise echocardiographic results in patients with known or suspected coronary artery disease. Presence of hypertension was associated with 17.6-fold elevated risk of false-positive results.
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Affiliation(s)
- Karsten Keller
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Kathrin Stelzer
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Thomas Munzel
- a Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany.,c German Center for Cardiovascular Research, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
| | - Mir Abolfazl Ostad
- b Department of Cardiology I , Center of Cardiology, University Medical Center of the Johannes Gutenberg-University of Mainz , Mainz , Germany
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Marwick TH, Gillebert TC, Aurigemma G, Chirinos J, Derumeaux G, Galderisi M, Gottdiener J, Haluska B, Ofili E, Segers P, Senior R, Tapp RJ, Zamorano JL. Recommendations on the Use of Echocardiography in Adult Hypertension: A Report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). J Am Soc Echocardiogr 2016; 28:727-54. [PMID: 26140936 DOI: 10.1016/j.echo.2015.05.002] [Citation(s) in RCA: 235] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Roxy Senior
- Biomedical Research Unit, Imperial College, London, UK; Royal Brompton Hospital, London, UK
| | | | - Jose L Zamorano
- University Hospital Ramón y Cajal, Carretera de Colmenar Km 9.100, Madrid 28034, Spain
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Prada-Delgado O, Barge-Caballero E, Peteiro J, Bouzas-Mosquera A, Estévez-Loureiro R, Barge-Caballero G, López-Pérez M, Vázquez-González N, Castro-Beiras A. Valor pronóstico de la disfunción ventricular izquierda inducida por el ejercicio en pacientes hipertensos sin enfermedad arterial coronaria. Rev Esp Cardiol (Engl Ed) 2015. [DOI: 10.1016/j.recesp.2014.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Prada-Delgado O, Barge-Caballero E, Peteiro J, Bouzas-Mosquera A, Estévez-Loureiro R, Barge-Caballero G, López-Pérez M, Vázquez-González N, Castro-Beiras A. Prognostic value of exercise-induced left ventricular systolic dysfunction in hypertensive patients without coronary artery disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2015; 68:107-114. [PMID: 25499955 DOI: 10.1016/j.rec.2014.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/06/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES We sought to assess the prognostic value of exercise-induced left ventricular systolic dysfunction in hypertensive patients with normal resting echocardiography and absence of coronary artery disease. METHODS From our database of patients referred for treadmill exercise echocardiography, we identified 93 hypertensive patients with preserved resting left ventricular ejection fraction (≥ 50%), no evidence of structural heart disease, and absence of coronary artery disease on angiography. Overall, 39 patients developed exercise-induced left ventricular systolic dysfunction (defined as a decrease in left ventricular ejection fraction below 50% at peak exercise) and 54 exhibited a normal left ventricular ejection fraction response to exercise. The mean follow-up was 6.1 (3.7) years. End points were all-cause mortality, cardiac death, heart failure, and the composite event of cardiac death or heart failure. RESULTS Patients who developed exercise-induced left ventricular systolic dysfunction were at higher risk of death from any cause (hazard ratio=3.4; 95% confidence interval, 1.1-10.3), cardiac death (hazard ratio=5.6; 95%CI, 1.1-29.4), heart failure (hazard ratio=8.9; 95% confidence interval, 1.8-44.2), and the composite end point (hazard ratio=5.7; 95% confidence interval, 1.7-19.0). In the multivariate analysis, exercise-induced left ventricular systolic dysfunction remained an independent predictor of both heart failure (hazard ratio=6.9; 95% CI, 1.3-37.4) and the composite event of cardiac death or heart failure (hazard ratio=4.5; 95% confidence interval, 1.2-16.0). CONCLUSIONS In hypertensive patients with preserved resting left ventricular ejection fraction and absence of coronary artery disease, exercise-induced left ventricular systolic dysfunction is a strong predictor of cardiac events and may represent early hypertensive heart disease.
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Affiliation(s)
- Oscar Prada-Delgado
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain.
| | - Eduardo Barge-Caballero
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | - Jesús Peteiro
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | - Alberto Bouzas-Mosquera
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | | | - Gonzalo Barge-Caballero
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | - Manuel López-Pérez
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | | | - Alfonso Castro-Beiras
- Servicio de Cardiología, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
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Marwick TH. Abnormal contractile reserve to exercise: a stress echocardiographic abnormality that may be associated with myocardial rather than coronary artery disease. J Am Soc Echocardiogr 2015; 28:106-7. [PMID: 25559476 DOI: 10.1016/j.echo.2014.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas H Marwick
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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Abnormal left ventricular contractile response to exercise in the absence of obstructive coronary artery disease is associated with resting left ventricular long-axis dysfunction. J Am Soc Echocardiogr 2014; 28:95-105. [PMID: 25450014 DOI: 10.1016/j.echo.2014.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND The etiology of reduced left ventricular (LV) ejection fraction after exercise, without obstructive coronary artery disease or other established causes, is unclear. The aims of this study were to determine whether patients undergoing treadmill stress echocardiography with this abnormal LV contractile response to exercise (LVCRE) without established causes have resting LV long-axis dysfunction or microvascular dysfunction and to determine associations with this abnormal LVCRE. METHODS Of 5,275 consecutive patients undergoing treadmill stress echocardiography, 1,134 underwent cardiac computed tomography angiography or invasive angiography. Having excluded patients with obstructive coronary artery disease, hypertensive response, submaximal heart rate response, resting LV ejection fraction < 50%, and valvular disease, 110 with "abnormal LVCRE" and 212 with "normal LVCRE" were analyzed. Resting mitral annular velocities were measured to assess LV long-axis function. Myocardial blush grade and corrected Thrombolysis In Myocardial Infarction frame count were determined angiographically to assess microvascular function. RESULTS Comparing normal LVCRE with abnormal LVCRE, age (mean, 59.7 ± 11.1 vs 61.4 ± 10.0 years), hypertension (53% vs 55%), diabetes (16% vs 20%), and body mass index (mean, 29.1 ± 5.4 vs 29.5 ± 6.4 kg/m(2)) were similar (P > .05). Abnormal LVCRE had reduced resting LV long-axis function with lower septal (mean, 6.1 ± 1.9 vs 7.7 ± 2.2 cm/sec) and lateral (mean, 8.1 ± 2.9 vs 10.4 ± 3.0 cm/sec) e' velocities (P < .001) and larger resting left atrial volumes (mean, 37.3 ± 10.1 vs 31.1 ± 7.2 mL/m(2), P < .001). On multivariate analysis, female gender (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.15-1.99; P < .001), exaggerated chronotropic response (OR, 1.49; 95% CI, 1.09-2.05; P < .001), resting left atrial volume (OR, 2.38; 95% CI, 1.63-3.47; P < .001), and resting lateral e' velocity (OR, 1.70; 95% CI, 1.22-2.49; P = .003) were associated with abnormal LVCRE, but not myocardial blush grade or corrected Thrombolysis In Myocardial Infarction frame count. CONCLUSIONS An abnormal LVCRE in the absence of established causes is associated with resting LV long-axis dysfunction and is usually seen in women.
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Fletcher GF, Ades PA, Kligfield P, Arena R, Balady GJ, Bittner VA, Coke LA, Fleg JL, Forman DE, Gerber TC, Gulati M, Madan K, Rhodes J, Thompson PD, Williams MA. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation 2013; 128:873-934. [PMID: 23877260 DOI: 10.1161/cir.0b013e31829b5b44] [Citation(s) in RCA: 1205] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Bocelli A, Favilli S, Pollini I, Bini RM, Ballo P, Chiappa E, Zuppiroli A. Prevalence and long-term predictors of left ventricular hypertrophy, late hypertension, and hypertensive response to exercise after successful aortic coarctation repair. Pediatr Cardiol 2013; 34:620-9. [PMID: 23052661 DOI: 10.1007/s00246-012-0508-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 08/26/2012] [Indexed: 01/06/2023]
Abstract
Controversial data exist about the long-term results of aortic coarctation (AC) repair. This study explored the prevalence and predictors of left ventricular (LV) hypertrophy, late hypertension, and hypertensive response to exercise in 48 subjects (age, 15.1 ± 9.7 years) currently followed in the authors' tertiary care hospital after successful AC repair. Data on medical history, clinical examination, rest and exercise echocardiography, and ambulatory blood pressure monitoring were collected. The time from AC repair to follow-up evaluation was 12.9 ± 9.2 years. The prevalence of LV hypertrophy ranged from 23 to 38 %, based on the criteria used to identify LV hypertrophy, and that of concentric geometry was 17 %. One sixth of the patients without residual hypertension experienced late-onset hypertension. One fourth of those who remained normotensive without medication showed a hypertensive response to exercise. Age at AC repair was the strongest independent predictor of LV hypertrophy, defined using indexation either for body surface area (odds ratio [OR], 1.03; p = 0.0090) or for height(2.7) (OR 1.02; p = 0.029), and it was the only predictor of late hypertension (OR 1.06; p = 0.0023) and hypertensive response to exercise (OR 1.09; p = 0.029). The risk of LV hypertrophy was 25 % for repair at the age of 3.4 years but rose to 50 and 75 % for repair at the ages of 5.9 and 8.4 years, respectively. Similar increases were found for the risk of late-onset hypertension and hypertensive response to exercise. A considerable risk of LV hypertrophy, late hypertension, and hypertensive response to exercise exists after successful AC repair. Older age at intervention is the most important predictor of these complications.
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Affiliation(s)
- Arianna Bocelli
- Pediatric Cardiology Unit, A. Meyer Hospital, Florence, Italy
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Jurrens TL, From AM, Kane GC, Mulvagh SL, Pellikka PA, McCully RB. An Exaggerated Blood Pressure Response to Treadmill Exercise does not Increase the Likelihood that Exercise Echocardiograms are Abnormal in Men or Women. J Am Soc Echocardiogr 2012; 25:1113-9. [DOI: 10.1016/j.echo.2012.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Indexed: 10/28/2022]
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Heydari B, Jerosch-Herold M, Kwong RY. Assessment of myocardial ischemia with cardiovascular magnetic resonance. Prog Cardiovasc Dis 2011; 54:191-203. [PMID: 22014487 DOI: 10.1016/j.pcad.2011.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Assessment of myocardial ischemia in symptomatic patients remains a common and challenging clinical situation faced by physicians. Risk stratification by presence of ischemia provides important utility for both prognostic assessment and management. Unfortunately, current noninvasive modalities possess numerous limitations and have limited prognostic capacity. More recently, ischemia assessment by cardiovascular magnetic resonance (CMR) has been shown to be a safe, available, and potentially cost-effective alternative with both high diagnostic and prognostic accuracy. Cardiovascular magnetic resonance has numerous advantages over other noninvasive methods, including high temporal and spatial resolution, relatively few contraindications, and absence of ionizing radiation. Furthermore, studies assessing the clinical utility and cost effectiveness of CMR in the short-term setting for patients without evidence of an acute myocardial infarction have also demonstrated favorable results. This review will cover techniques of ischemia assessment with CMR by both stress-induced wall motion abnormalities as well as myocardial perfusion imaging. The diagnostic and prognostic performance studies will also be reviewed, and the use of CMR for ischemia assessment will be compared with other commonly used noninvasive modalities.
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Affiliation(s)
- Bobak Heydari
- Department of Cardiology, Brigham and Women's Hospital, Boston, MA 02215, USA
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Jang JY, Sohn IS, Kim JN, Park JH, Park CB, Jin ES, Cho JM, Kim CJ, Bae JH. Treadmill exercise stress echocardiography in patients with no history of coronary artery disease: a single-center experience in korean population. Korean Circ J 2011; 41:528-34. [PMID: 22022328 PMCID: PMC3193044 DOI: 10.4070/kcj.2011.41.9.528] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 12/21/2010] [Accepted: 01/24/2011] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives Treadmill exercise stress echocardiography (TSE) has superior diagnostic accuracy than exercise electrocardiography (ECG). The objectives of the study are 1) to define the diagnostic accuracy and safety of TSE in patients without a history of coronary artery disease (CAD), 2) to identify the clinical characteristics that predict positive TSE results and 3) to assess the differential predictive value between TSE and concomitant exercise ECG in a Korean population. Subjects and Methods A total of 1,287 patients among 1,500 consecutive patients with no prior history of CAD and who were referred for TSE during a 4-year 3-month period were enrolled. Results Of the 1,287 patients, 95 (7.4%) showed positive TSE results (newly developed regional wall motion abnormality). Among the 154 patients with coronary angiography, 94 patients (61%) showed significant CAD (30 of 77 patients with negative TSE results and 64 of 77 patients with positive TSE results). The TSE positive population had more cardiovascular risk factors and showed a higher Duke treadmill score and wall motion score index than the TSE negative group. TSE showed relatively good sensitivity (68%), specificity (78%) and positive and negative predictive values (83% and 61%, respectively), and TSE also had higher diagnostic accuracy than concomitant exercise ECG (72% vs. 64%, respectively). Conclusion TSE is safe and offers greater diagnostic power for CAD than exercise ECG in Korean population without a history of CAD. Its prognostic value in this population needs to be confirmed in a larger prospective study.
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Affiliation(s)
- Jeong Yoon Jang
- Department of Cardiology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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36
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Kucukler N, Yalçin F, Abraham TP, Garcia MJ. Stress induced hypertensive response: should it be evaluated more carefully? Cardiovasc Ultrasound 2011; 9:22. [PMID: 21846346 PMCID: PMC3167747 DOI: 10.1186/1476-7120-9-22] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 08/16/2011] [Indexed: 12/02/2022] Open
Abstract
Various diagnostic methods have been used to evaluate hypertensive patients under physical and pharmacological stress. Several studies have shown that exercise hypertension has an independent, adverse impact on outcome; however, other prognostic studies have shown that exercise hypertension is a favorable prognostic indicator and associated with good outcome. Exercise hypertension may be encountered as a warning signal of hypertension at rest and future hypertensive left ventricular hypertrophy. The results of diagnostic stress tests support that hypertensive response to exercise is frequently associated with high rate-pressure product in hypertensives. In addition to the observations on high rate-pressure product and enhanced ventricular contractility in patients with hypertension, evaluation of myocardial contractility by Doppler tissue imaging has shown hyperdynamic myocardial function under pharmacological stress. These recent quantitative data in hypertensives suggest that hyperdynamic myocardial function and high rate-pressure product response to stress may be related to exaggerated hypertension, which may have more importance than that it has been already given in clinical practice.
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Affiliation(s)
- Nagehan Kucukler
- Johns Hopkins Medical Institutions, Department of Cardiology, Baltimore, MD, USA
| | - Fatih Yalçin
- Johns Hopkins Medical Institutions, Department of Cardiology, Baltimore, MD, USA
| | - Theodore P Abraham
- Johns Hopkins Medical Institutions, Department of Cardiology, Baltimore, MD, USA
| | - Mario J Garcia
- Montefiore Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, New York, NY, USA
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Fine NM, Pellikka PA. Stress echocardiography for the detection and assessment of coronary artery disease. J Nucl Cardiol 2011; 18:501-15. [PMID: 21431999 DOI: 10.1007/s12350-011-9365-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Nowell M Fine
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Bursikov AV, Valiulina ES, Birtseva LN. Ergometric principles of cardiovascular function assessment in arterial hypertension. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2011. [DOI: 10.15829/1728-8800-2011-2-29-34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Aim. To investigate hemodynamic and ergometric parameters and their agreement with metabolic demand during veloergometry in patients with Stage I-II arterial hypertension (AH). Material and methods. In total, 80 18-59-year-old men, with Stage I-II AH were examined, together with 25 healthy men of comparable body weight. All participants underwent standard veloergometry, with achievement of sub-maximal heart rate (HR), or development of test-termination criteria, such as excess blood pressure (BP) elevation, dyspnoea, or fatigue. Results. A significant increase in myocardial oxygen consumption, disagreeing with metabolic demand, was observed both at rest and during veloergometry test. The qualitative criteria reflecting myocardial workload due to peripheral vascular resistance and functional myocardial remodelling were developed. These criteria differed at different AH stages, and included hemodynamic parameters (levels of systolic and diastolic BP) and ergometric characteristics (double product and its increase, pressure load index, and cardiac load index). Conclusion. In Stage I-II AH patients, myocardial oxygen consumption during standard veloergometry was significantly higher than in healthy individuals, disagreed with metabolic demand, and increased with AH progression.
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Jhawar MB, Balla S, Alpert MA, Chockalingam A. Left ventricular outflow tract and mid-cavity obstruction may cause false-positive dobutamine stress echocardiograms. ACTA ACUST UNITED AC 2010; 12:E14. [PMID: 20977996 DOI: 10.1093/ejechocard/jeq158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Left ventricular (LV) outflow tract obstruction (LVOTO) occurs in up to 20% of patients undergoing dobutamine stress echocardiography (DSE). Mid-cavity LV obstruction occurs less commonly during DSE. LV regional wall motion abnormalities during DSE may occur despite normal coronaries due to hypertensive blood pressure response and takotsubo stress cardiomyopathy. We describe herein two cases of LVOTO and one case of mid-cavity LV obstruction during DSE associated with transient apical hypokinesis.
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Affiliation(s)
- Manish B Jhawar
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO 65212, USA
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From AM, Kane G, Bruce C, Pellikka PA, Scott C, McCully RB. Characteristics and outcomes of patients with abnormal stress echocardiograms and angiographically mild coronary artery disease (<50% stenoses) or normal coronary arteries. J Am Soc Echocardiogr 2010; 23:207-14. [PMID: 20152703 DOI: 10.1016/j.echo.2009.11.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Indexed: 10/19/2022]
Abstract
BACKGROUND Abnormal cardiac stress imaging findings are not always associated with angiographically significant coronary artery disease. The outcomes of patients with such false-positive findings have not been extensively examined. The aim of this retrospective study was to describe the characteristics and outcomes of patients with abnormal stress echocardiographic findings who had false-positive results compared with those who had true-positive results. METHODS Of 1,477 consecutive patients (mean age, 66 +/- 12 years; 61% men) with abnormal stress echocardiographic findings who underwent coronary arteriography within 30 days, death from any cause was ascertained. RESULTS At coronary arteriography, 997 patients (67.5%) had true-positive results, defined by the presence of angiographically significant coronary artery disease (> or = 50% stenoses), and 480 (32.5%) had false-positive results, defined by <50% stenoses or normal coronary arteries. Of the subgroup of patients with markedly abnormal stress echocardiographic findings (n = 605), 28% had <50% stenoses or normal coronary arteries. During an average follow-up period of 2.4 +/- 1.0 years, there were 140 deaths. The adjusted likelihood of subsequent death for patients with <50% stenoses compared to patients with > or = 50% stenoses after abnormal stress echocardiography was 1.05 (95% confidence interval, 0.86-1.31; P = .62). CONCLUSIONS A sizable proportion of patients with abnormal stress echocardiographic results who are referred for coronary angiography have false-positive findings. The outcomes of patients with false-positive results were similar to those of patients with true-positive results. This finding suggests that patients with false-positive results on stress echocardiography should still receive intensive risk factor management and careful clinical follow-up.
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Affiliation(s)
- Aaron M From
- Echocardiography Laboratory, Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Chen JK, Chen TW, Chen CH, Huang MH. Preliminary Study of Exercise Capacity in Post-acute Stroke Survivors. Kaohsiung J Med Sci 2010; 26:175-81. [DOI: 10.1016/s1607-551x(10)70026-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 11/05/2009] [Indexed: 10/19/2022] Open
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Prognostic value of an exaggerated exercise blood pressure response in patients with diabetes mellitus and known or suspected coronary artery disease. Am J Cardiol 2010; 105:780-5. [PMID: 20211319 DOI: 10.1016/j.amjcard.2009.10.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 11/20/2022]
Abstract
The prognostic value of an exaggerated exercise systolic blood pressure response (EESBPR) remains controversial. Our aim was to assess whether an EESBPR is associated with the long-term outcome in patients with diabetes mellitus and known or suspected coronary artery disease (CAD). From an initial population of 22,262 patients with known or suspected CAD who underwent treadmill exercise electrocardiography or exercise echocardiography at our institution, 2,591 patients with a history of diabetes mellitus were selected for the present study. EESBPR was defined as systolic blood pressure >220 mm Hg during exercise. The end points were all-cause mortality and hard events (ie, death or myocardial infarction). A total of 236 patients (9.1%) developed an EESBPR during the tests. During a mean follow-up of 6.5 +/- 3.9 years, 484 patients died and 646 experienced hard events. The 10-year mortality rate was 16.6% in patients with an EESBPR compared to 30.9% in those without an EESBPR (p <0.001). The 10-year hard event rate was also lower in patients with an EESBPR (23.2% vs 38.9% in patients without an EESBPR; p <0.001). On multivariate analysis, an EESBPR remained independently associated with a lower risk of all-cause mortality (hazard ratio 0.53, 95% confidence interval 0.36 to 0.78, p = 0.001) and hard events (hazard ratio 0.57, 95% confidence interval 0.41 to 0.79; p <0.001). These results remained consistent in the subgroup of patients without a known history of CAD. In conclusion, an EESBPR was associated with improved survival and a lower rate of death or myocardial infarction in patients with diabetes mellitus and known or suspected CAD.
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Kane GC, Xu N, Mistrik E, Roubicek T, Stanson AW, Garovic VD. Renal artery revascularization improves heart failure control in patients with atherosclerotic renal artery stenosis. Nephrol Dial Transplant 2010; 25:813-820. [DOI: 10.1093/ndt/gfp393] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Yang HS, Mookadam F, Warsame TA, Khandheria BK, Tajik JA, Chandrasekaran K. Evaluation of right ventricular global and regional function during stress echocardiography using novel velocity vector imaging. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:157-64. [DOI: 10.1093/ejechocard/jep190] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Gastwirth VG, Yang HS, Steidley DE, Scott RL, Chandrasekaran K. Dobutamine Stress–induced Cardiomyopathy in an Orthotopic Heart Transplant Patient. J Heart Lung Transplant 2009; 28:968-70. [DOI: 10.1016/j.healun.2009.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 02/02/2009] [Accepted: 03/05/2009] [Indexed: 11/29/2022] Open
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From AM, Prasad A, Pellikka PA, McCully RB. Are some false-positive stress echocardiograms a forme fruste variety of apical ballooning syndrome? Am J Cardiol 2009; 103:1434-8. [PMID: 19427442 DOI: 10.1016/j.amjcard.2009.01.352] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Revised: 01/21/2009] [Accepted: 01/21/2009] [Indexed: 10/21/2022]
Abstract
The mechanisms for abnormal stress echocardiograms (SEs) in patients with normal coronary arteries have not been clearly elucidated. We hypothesized that in some patients, this phenomenon may represent a forme fruste of apical ballooning syndrome (ABS). The aim of the study was to evaluate the characteristics of patients with strongly false-positive SEs and determine whether there were similarities to ABS. Thirty-one patients from the Mayo Clinic stress echocardiography database who had normal function at rest, extensive regional wall motion abnormalities in association with an abnormal response of left ventricular end-systolic cavity size at peak stress, and angiographically normal coronary arteries were evaluated. Eighty-four percent were women with a mean age of 61 +/- 12 years, 6% had a positive stress electrocardiogram, and only 26% had a hypertensive response to stress. In 81%, left ventricular ejection fraction decreased with stress and 97% developed new regional wall motion abnormalities in > or =4 segments. Peak wall motion score index was 1.65 +/- 0.39. Midventricular (100%) and apical (87%) segments were most often involved with relative sparing of the basal segments (77%; p = 0.01). There were no deaths during follow-up (2.3 +/- 0.7 years). In conclusion, the major findings of this study were that strongly false-positive SEs occurred predominantly in postmenopausal women, and frequently involved the apical and mid-left ventricular segments, features that were similar to ABS. Data were consistent with the hypothesis that some false-positive SEs may represent a forme fruste of ABS.
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Arena R, Myers J, Guazzi M. The Clinical Significance of Aerobic Exercise Testing and Prescription: From Apparently Healthy to Confirmed Cardiovascular Disease. Am J Lifestyle Med 2008. [DOI: 10.1177/1559827608323210] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aerobic exercise testing clearly provides valuable clinical information in apparently healthy adults as well as a number of patient populations. Maximal aerobic capacity, either estimated from workload or measured directly, is perhaps the most frequently analyzed variable ascertained from such testing. This practice is warranted given the consistent prognostic significance of maximal aerobic capacity. Other variables obtained from the aerobic exercise test, such as the heart rate response during exercise and into recovery, the systolic and diastolic blood pressure responses during exercise, oxygen consumption at anaerobic threshold, and the ventilatory response to exercise, also provide important insight into an individual's health and prognosis. Furthermore, the aerobic exercise test is highly valuable in developing an individualized and safe exercise prescription. Aerobic exercise training goals, with respect to frequency, duration, frequency, and mode of exercise, are well established for the apparently healthy population as well as individuals at risk for or diagnosed with cardiovascular disease. Adherence to these physical activity recommendations clearly provides numerous health benefits, perhaps most important of which is a significant decrease in the risk for cardiovascular events and mortality. This review addresses concepts of aerobic exercise testing and training and discusses their clinical implications.
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Affiliation(s)
- Ross Arena
- Departments of Internal Medicine, Physiology, and Physical Therapy, Virginia Commonwealth University, Richmond, Virginia,
| | - Jonathan Myers
- VA Palo Alto Health Care System, Cardiology Division, Stanford University, Palo Alto, California
| | - Marco Guazzi
- San Paolo Hospital, Cardiopulmonary Laboratory, Cardiology Division, University of Milano, Milano, Italy
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Dhoble A, Abdelmoneim SS, Bernier M, Oh JK, Mulvagh SL. Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: is there a common hypersympathetic mechanism? Cardiovasc Ultrasound 2008; 6:37. [PMID: 18638372 PMCID: PMC2490681 DOI: 10.1186/1476-7120-6-37] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 07/18/2008] [Indexed: 11/16/2022] Open
Abstract
Objective To describe two cases of Takotsubo like myocardial contractile pattern during exercise stress test secondary to hypertensive response. Background Treadmill exercise testing is known to cause sympathetic stimulation, leading to increased levels of catecholamine, resulting in alteration in vascular tone. Hypertensive response during exercise testing can cause abnormal consequences, resulting in false positive results. Cases We present the cases of two patients experiencing apical and basal akinesis during exercise stress echocardiography, in whom normal wall motion response was observed on subsequent pharmacologic stress testing. The first patient developed transient left ventricular (LV) apical akinesis during exercise stress echocardiography. Due to high suspicion that this abnormality might be secondary to hypertensive response, pharmacologic stress testing was performed after three days, which was completely normal and showed no such wall motion abnormality. Qualitative assessment of myocardial perfusion using contrast was also performed, which showed good myocardial blood flow, indicating low probability for significant obstructive coronary artery disease. The second patient developed LV basal akinesis as a result of hypertensive response during exercise testing. Coronary angiogram was not performed in either patient due to low suspicion for coronary artery disease, and subsequently negative stress studies. Results Transient stress induced cardiomyopathy can develop secondary to hypertensive response during exercise stress testing. Conclusion These cases provide supporting evidence to the hyper-sympathetic theory of left ventricular ballooning syndrome.
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Affiliation(s)
- Abhijeet Dhoble
- Echocardiographic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Demir H, Tan YZ, Isgoren S, Gorur GD, Kozdag G, Ural E, Berk F. Comparison of exercise and pharmacological stress gated SPECT in detecting transient left ventricular dysfunction. Ann Nucl Med 2008; 22:403-9. [PMID: 18600418 DOI: 10.1007/s12149-008-0119-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 01/16/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Transient left ventricular contractile dysfunction (TLVD) is observed owing to post-exercise stunning in patients with coronary artery disease (CAD). Pharmacological stimulation differs from exercise stress because it does not cause demand ischemia. The aim of this study was to determine whether TLVD could also be seen after pharmacological stress (dipyridamole). METHODS Of the patients in whom gated single-photon emission computed tomography (GSPECT) was performed in our institution from January 2004 to April 2007, 439 subjects with known or suspected CAD were included in the study. GSPECT was performed for all patients following exercise (group I, n = 220) or pharmacological stress (group II, n = 219) according to a 2-day (stress-rest) protocol after injection of Tc-99m methoxyisobutyl-isonitrile (MIBI). Stress, rest, and difference (stress-rest value) left ventricular ejection fractions (SLVEF, RLVEF, and DLVEF) and transient ischemic dilatation (TID) ratio were derived automatically. Summed stress score, summed rest score, and summed difference score (SDS) for myocardial perfusion were calculated using a 20-segment model and a five-point scoring system. An SDS > 3 was considered as ischemic. On the basis of the perfusion findings, patients were subdivided into a normal (group A, n = 216) and ischemia group (group B, n = 223). DLVEF and perfusion scores of all groups were compared. Relationships between DLVEF and perfusion, and between TID ratio and DLVEF were also evaluated. RESULTS Stress-induced ischemia was observed in 223 of 439 patients (50.8%). In group A, the difference between stress and rest LVEF values was not significant (P = 0.670 and P = 0.200 for groups IA and IIA, respectively). However, LVEF was significantly decreased after stress compared with rest values for group B (P < 0.0001 for groups IB and IIB). TLVD (< or =-5% for DLVEF) was observed in 20 of 216 (9%) and 81 of 223 subjects (36%) in patients in groups A and B, respectively (P < 0.0001). In group I, we found TLVD in 46 of 119 (39%) and 12 of 101 (12%) subjects, in patients with and without ischemia, respectively (P < 0.0001). On the other hand, in group II, TLVD was detected in 35 of 104 (34%) and 8 of 115 (7%) patients with and without ischemia, respectively (P < 0.0001). And also, we found significant good correlations between TID ratios and DLVEF values in four subgroups (r = -0.55, r = -0.62, r = -0.59, and r = -0.41; for groups IA, IB, IIA, and IIB, respectively, P < 0.0001 for all). CONCLUSIONS Dipyridamole is believed to be less likely than exercise to induce ischemia. However, in this study, TLVD after stress was observed following not only exercise but also pharmacological stress, consistent with ischemia.
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Affiliation(s)
- Hakan Demir
- Department of Nuclear Medicine, Kocaeli University School of Medicine, Umuttepe Yerleskesi, 41380 Kocaeli, Turkey.
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Kane GC, Askew JW, Chareonthaitawee P, Miller TD, Gibbons RJ. Hypertensive response with exercise does not increase the prevalence of abnormal Tc-99m SPECT stress perfusion images. Am Heart J 2008; 155:930-7. [PMID: 18440344 DOI: 10.1016/j.ahj.2007.12.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 12/11/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Systemic hypertension and an exaggerated blood pressure (BP) response with exercise have been associated with 'false-positive' findings on stress electrocardiography and echocardiography; however, limited data is available for stress myocardial perfusion imaging (MPI). The purpose of this study was to investigate whether an exaggerated elevation in BP with exercise is associated with an increased prevalence of abnormal MPI. METHODS BP responses to exercise were assessed in a cohort of 7,205 patients who underwent stress testing with technetium 99m-SPECT MPI (7/1999-6/2005) for the evaluation of chest pain or dyspnea. RESULTS A hypertensive response, defined as a peak systolic BP > or = 220 mmHg, occurred in 355 (4.9%) and was not associated with higher rates of ischemic ECG changes (16.1 versus 16.6%; P = .7), differences in Duke treadmill scores (4.7 +/- 4 versus 5.1 +/- 5; P = .3) or an increased prevalence of abnormal perfusion images (30.1% versus 32.9%; P = .3) to those without a hypertensive exercise response. Patients with a hypertensive response and either intermediate or high-risk MPI (on the basis of summed-difference-scores) referred for coronary angiography, had a high prevalence of coronary artery disease which was similar to those without a hypertensive response (88% versus 83%; P = .5). In an analysis of a community-based patient subset, a hypertensive response was not associated with a difference in either all-cause mortality or subsequent myocardial infarction, coronary revascularization or cardiac death (8% versus 9%; P = .7). CONCLUSION A hypertensive BP response to exercise is not associated with increased rates of ischemic ECG changes, higher-risk Duke treadmill scores, greater degrees of abnormal MPI or worse clinical outcome.
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Affiliation(s)
- Garvan C Kane
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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