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Kelsey MD, Kelsey AM. Diagnosing Coronary Artery Disease in the Patient Presenting with Stable Ischemic Heart Disease: The Role of Anatomic versus Functional Testing. Med Clin North Am 2024; 108:427-439. [PMID: 38548455 DOI: 10.1016/j.mcna.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
There are unique advantages and disadvantages to functional versus anatomic testing in the work-up of patients who present with symptoms suggestive of obstructive coronary artery disease. Evaluation of these individuals starts with an assessment of pre-test probability, which guides subsequent testing decisions. The choice between anatomic and functional testing depends on this pre-test probability. In general, anatomic testing has particular utility among younger individuals and women; while functional testing can be helpful to rule-in ischemia and guide revascularization decisions. Ultimately, selection of the most appropriate test should be individualized to the patient and clinical scenario.
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Affiliation(s)
- Michelle D Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Anita M Kelsey
- Division of Cardiology, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27710, USA. https://twitter.com/AnitaKelseyMD
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Zeigler Z, Acevedo AM. Re-evaluating the Need for Routine Maximal Aerobic Capacity Testing within Fighter Pilots. Aerosp Med Hum Perform 2024; 95:273-277. [PMID: 38715261 DOI: 10.3357/amhp.6409.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
INTRODUCTION: There is a current belief in aviation suggesting that aerobic training may reduce G-tolerance due to potential negative impacts on arterial pressure response. Studies indicate that increasing maximal aerobic capacity (V˙o₂ max) through aerobic training does not hinder G-tolerance. Moreover, sustained centrifuge training programs revealed no instances where excessive aerobic exercise compromised a trainee's ability to complete target profiles. The purpose of this review article is to examine the current research in the hope of establishing the need for routine V˙o₂-max testing in air force pilot protocols.METHODS: A systematic search of electronic databases including Google Scholar, PubMed, the Aerospace Medical Association, and Military Medicine was conducted. Keywords related to "human performance," "Air Force fighter pilots," "aerobic function," and "maximal aerobic capacity" were used in various combinations. Articles addressing exercise physiology, G-tolerance, physical training, and fighter pilot maneuvers related to human performance were considered. No primary data collection involving human subjects was conducted; therefore, ethical approval was not required.RESULTS: The V˙o₂-max test provides essential information regarding a pilot's ability to handle increased Gz-load. It assists in predicting G-induced loss of consciousness by assessing anti-G straining maneuver performance and heart rate variables during increased G-load.DISCUSSION: V˙o₂-max testing guides tailored exercise plans, optimizes cardiovascular health, and disproves the notion that aerobic training hampers G-tolerance. Its inclusion in air force protocols could boost readiness, reduce health risks, and refine training for fighter pilots' safety and performance. This evidence-backed approach supports integrating V˙o₂-max testing for insights into fitness, risks, and tailored exercise.Zeigler Z, Acevedo AM. Re-evaluating the need for routine maximal aerobic capacity testing within fighter pilots. Aerosp Med Hum Perform. 2024; 95(5):273-277.
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Ohte N, Ishizu T, Izumi C, Itoh H, Iwanaga S, Okura H, Otsuji Y, Sakata Y, Shibata T, Shinke T, Seo Y, Daimon M, Takeuchi M, Tanabe K, Nakatani S, Nii M, Nishigami K, Hozumi T, Yasukochi S, Yamada H, Yamamoto K, Izumo M, Inoue K, Iwano H, Okada A, Kataoka A, Kaji S, Kusunose K, Goda A, Takeda Y, Tanaka H, Dohi K, Hamaguchi H, Fukuta H, Yamada S, Watanabe N, Akaishi M, Akasaka T, Kimura T, Kosuge M, Masuyama T. JCS 2021 Guideline on the Clinical Application of Echocardiography. Circ J 2022; 86:2045-2119. [DOI: 10.1253/circj.cj-22-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nobuyuki Ohte
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Itoh
- Department of Cardiovascular Medicine, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Science
| | - Shiro Iwanaga
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Hiroyuki Okura
- Department of Cardiology, Gifu University Graduate School of Medicine
| | | | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- The Department of Clinical Laboratory, The University of Tokyo Hospital
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health
| | - Kazuaki Tanabe
- The Fourth Department of Internal Medicine, Shimane University Faculty of Medicine
| | | | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital
| | - Kazuhiro Nishigami
- Division of Cardiovascular Medicine, Miyuki Hospital LTAC Heart Failure Center
| | - Takeshi Hozumi
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Satoshi Yasukochi
- Department of Pediatric Cardiology, Heart Center, Nagano Children’s Hospital
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences
| | - Kazuhiro Yamamoto
- Department of Cardiovascular Medicine and Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | - Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Katsuji Inoue
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine
| | | | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | - Akiko Goda
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine
| | - Yasuharu Takeda
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences
| | - Satoshi Yamada
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital Cardiovascular Center
| | | | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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Araújo CGD, Resende MBS, Tupinambás JT, Dias RCTM, Barros FC, Vasconcelos MCM, Januário JN, Ribeiro ALP, Nunes MCP. Testes Ergométricos em Pacientes com Anemia Falciforme: Segurança, Viabilidade e Possíveis Implicações no Prognóstico. Arq Bras Cardiol 2022; 118:565-575. [PMID: 35319606 PMCID: PMC8959037 DOI: 10.36660/abc.20200437] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 03/24/2021] [Indexed: 01/20/2023] Open
Abstract
Fundamento Pacientes com anemia falciforme (AF) têm risco aumentado de complicações cardiovasculares. O teste ergométrico é usado como marcador de prognóstico em uma série de doenças cardiovasculares. Entretanto, há uma escassez de evidências sobre exercícios em pacientes com AF, especialmente em relação à sua segurança, viabilidade e possível função prognóstica. Objetivos Usamos o teste em esteira máximo para determinar a segurança e a viabilidade do teste ergométrico em pacientes com AF. Além disso, os fatores associados à duração do exercício, bem como o impacto das alterações causadas pelo exercício em resultados clínicos, também foram avaliados. Métodos 113 pacientes com AF que passaram pelo teste ergométrico e por uma avaliação cardiovascular abrangente incluindo um ecocardiograma e os níveis do peptídeo natriurético do tipo B (BNP). O desfecho de longo prazo foi uma combinação de eventos incluindo morte, crises álgicas graves, síndrome torácica aguda ou internações hospitalares por outras complicações associadas â doença falciforme. A análise de regressão de Cox foi realizada para identificar as variáveis associadas ao resultado. Um p valor <0,05 foi considerado estatisticamente significativo. Resultados A média de idade foi de 36 ± 12 anos (intervalo, 18-65 anos), e 62 pacientes eram do sexo feminino (52%). A presença de alterações isquêmicas ao esforço e resposta pressórica anormal ao exercício foram detectadas em 17% e 9 % da´população estudada respectivamente. Dois pacientes apresentaram crise álgica com necessidade de internação hospitalar no período de 48 horas da realização do exame. Fatores associados à duração do exercício foram idade, sexo, velocidade máxima de regurgitação tricúspide (RT), e relação E/e’, após a padronização quanto aos marcadores da gravidade da doença. Durante o período médio de acompanhamento de 10,1 meses (variando de 1,2 a 26), 27 pacientes (23%) apresentaram desfechos clínicos adversos. Preditores independentes de eventos adversos foram a concentração de hemoglobina, velocidade do fluxo transmitral tardio (onda A), e a resposta da PA ao exercício. Conclusões A realização de testes ergométricos em pacientes com AF, clinicamente estáveis, é viável. A duração do exercício estava associada à função diastólica e a pressão arterial pulmonar. A resposta anormal da PA foi um preditor independente de eventos adversos.
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Blood pressure response during treadmill exercise testing and the risk for future cardiovascular events and new-onset hypertension. J Hypertens 2022; 40:143-152. [PMID: 34857707 DOI: 10.1097/hjh.0000000000002991] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The physiologic response to exercise may provide valuable prognostic information. We investigated the association of blood pressure (BP) measurements during exercise stress testing (EST) with long-term risk of myocardial infarction, stroke or death (major adverse cardiovascular event, MACE), as well as the development of new-onset hypertension. METHODS A retrospective analysis of treadmill ESTs (years 2005-2019) performed by the Bruce protocol in patients aged 35-75 years without a history of cardiovascular disease (n = 14 792; 48% women). BP was documented at rest, submaximal exercise (Bruce stage-2), peak exercise and recovery (2 min). Association of SBP measures with study outcomes during median follow-up of 6.5 years was investigated. RESULTS Highest vs. lowest SBP quartile at rest (≥140 vs. <120 mmHg), submaximal-exercise (≥170 vs. <130 mmHg), peak-exercise (≥180 vs. ≤145 mmHg) and recovery (≥160 vs. <130 mmHg) was associated with an increase in the adjusted hazard ratio and 95% confidence interval (CI) for MACE: 1.53 (1.23-1.88), 1.33 (1.01-1.76), 1.30 (1.05-1.61), 1.35 (1.09-1.68), respectively. The association between SBP at submaximal exercise and recovery with MACE displayed a J-shaped pattern. Among nonhypertensive patients (n = 8529), excessive SBP response to peak exercise (≥190 mmHg in women and ≥210 mmHg in men) was an independent predictor of hypertension [hazard ratio (95% CI)]: 1.87 (1.41-2.48), as were SBPs during submaximal exercise [>160 vs. ≤130 mmHg: 2.44 (1.97-3.03)] and recovery [≥140 vs. ≤120 mmHg: 1.65 (1.37-1.98)]. CONCLUSION BP measurement during rest, exercise and recovery phases of EST provides incremental prognostic information regarding long-term risk for cardiovascular events and the probability for developing hypertension.
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Performance and Interpretation of Office Exercise Stress Testing. Prim Care 2021; 48:627-643. [PMID: 34752274 DOI: 10.1016/j.pop.2021.07.009] [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: 11/23/2022]
Abstract
In an era where cardiovascular disease continues to increase in prevalence, chest pain is a commonly encountered complaint in the outpatient setting. Clinicians are often tasked with the challenge of selecting the most appropriate screening tool in the evaluation of a patient with suspected coronary artery disease. With proper consideration of indications and contraindications, exercise electrocardiogram (ECG) stress testing is an accessible, cost-conscious, and validated outpatient diagnostic modality for predicting coronary artery disease.
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Sasaki T, Kawasaki Y, Takajo D, Sriram C, Ross RD, Kobayashi D. Blood Pressure Response to Treadmill Cardiopulmonary Exercise Test in Children with Normal Cardiac Anatomy and Function. J Pediatr 2021; 233:169-174.e1. [PMID: 33631169 DOI: 10.1016/j.jpeds.2021.02.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe blood pressure (BP) responses during cardiopulmonary exercise testing (CPET) and propose criteria for abnormal BP responses in children with normal hearts. STUDY DESIGN Treadmill CPET data of children <18 years with normal hearts were retrospectively analyzed to evaluate BP responses to exercise at the Children's Hospital of Michigan over an 8-year period (2011-2018). RESULTS Our cohort included 1085 children (boys, 59%) aged 7-17 years. Analysis of variance for systolic BP at peak exercise (peak SBP) and SBP change (Δ) showed significant age and sex effects and age-sex interaction effects (P < .01). In the multiple linear regression model (P < .001, R square 0.298, standard error of the estimate 17.15), peak SBP (mm Hg) was predicted as 132.27 + 1.37 × age (years) + (3.31 × age (years) - 31.88) × sex [boys 1, girls 0]. The following criteria for abnormal BP responses in children were proposed: hypertensive BP response was defined by peak SBP with a 90% CI upper limit of reference values based on age and sex, and blunted BP response as ΔSBP <10 mm Hg for aged 7-11 years, <20 mm Hg for boys aged 12-17 years, and ΔSBP <10 mm Hg in girls. CONCLUSIONS BP responses to treadmill CPET depend on age and sex in children with normal hearts. The proposed criteria for abnormal BP responses in children during CPET will need to be verified in a large pediatric cohort.
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Affiliation(s)
- Takeshi Sasaki
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI; Department of Pediatric Cardiology, Osaka City General Hospital Pediatric Medical Center, Miyakojima-hondori, Miyakojima-ku, Osaka, Japan
| | - Yuki Kawasaki
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI; Department of Pediatric Cardiology, Osaka City General Hospital Pediatric Medical Center, Miyakojima-hondori, Miyakojima-ku, Osaka, Japan
| | - Daiji Takajo
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI
| | - Chenni Sriram
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI
| | - Robert D Ross
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI
| | - Daisuke Kobayashi
- Division of Cardiology, Children's Hospital of Michigan, Detroit, MI; Department of Pediatrics, Central Michigan University College of Medicine, Mt. Plesant, MI.
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Aghamohammadzadeh R, El-Omar SM, Rowlands D, El-Omar M. ST elevation in recovery post exercise with normal coronary arteries. BMJ Case Rep 2019; 12:12/7/e229766. [PMID: 31289167 DOI: 10.1136/bcr-2019-229766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 45-year-old healthy man who successfully completed three stages of the Bruce protocol but developed inferolateral ST segment elevation in the recovery phase. The ECG change was associated with a marked drop in blood pressure. He underwent emergency coronary angiography which revealed normal coronary arteries. It is likely that post-exercise hypotension triggered coronary spasm which caused the ST segment elevation. Alternatively, coronary spasm may have been the primary event, inducing sufficient myocardial ischaemia to cause a marked drop in blood pressure. Exercise tolerance testing is often a reliable test to rule out reversible myocardial ischaemia. While the physician is focused on ischaemic changes or rhythm abnormalities developing during the exercise phase, the recovery period is just as important and requires as much vigilance. Coronary vasospasm can result in significant ST changes and haemodynamic compromise at any point during the test, and the ECG traces can be indistinguishable from a classic ST elevation myocardial infarction, as in the present case.
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Affiliation(s)
| | - Suhaib Magdi El-Omar
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Derek Rowlands
- Manchester Heart Center, Manchester Royal Infirmary, Manchester, UK
| | - Magdi El-Omar
- Manchester Heart Center, Manchester Royal Infirmary, Manchester, UK
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Currie KD, Floras JS, La Gerche A, Goodman JM. Exercise Blood Pressure Guidelines: Time to Re-evaluate What is Normal and Exaggerated? Sports Med 2018; 48:1763-1771. [PMID: 29574665 DOI: 10.1007/s40279-018-0900-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Blood pressure responses to graded exercise testing can provide important diagnostic and prognostic information. While published guidelines outline what constitutes a "normal" and "abnormal" (i.e., exaggerated) blood pressure response to exercise testing, the widespread use of exaggerated blood pressure responses as a clinical tool is limited due to sparse and inconsistent data. A review of the original sources from these guidelines reveals an overall lack of empirical evidence to support both the normal blood pressure responses and their upper limits. In this current opinion, we critically evaluate the current exercise blood pressure guidelines including (1) the normal blood pressure responses to graded exercise testing; (2) the upper limits of this normal response; (3) the blood pressure criteria for test termination; and (4) the thresholds for exaggerated blood pressure responses. We provide evidence that exercise blood pressure responses vary according to subject characteristics, and subsequently a re-evaluation of what constitutes normal and abnormal responses is necessary to strengthen the clinical utility of this assessment.
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Affiliation(s)
- Katharine D Currie
- Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord Street, Toronto, ON, M5S 2W6, Canada
| | - John S Floras
- University Health Network and Mount Sinai Hospital Division of Cardiology, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Andre La Gerche
- Sports Cardiology and Cardiac Magnetic Resonance Imaging Lab, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC, 3004, Australia.,Cardiology Department, St. Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jack M Goodman
- Faculty of Kinesiology and Physical Education, University of Toronto, 55 Harbord Street, Toronto, ON, M5S 2W6, Canada. .,University Health Network and Mount Sinai Hospital Division of Cardiology, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
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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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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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Schultz MG, La Gerche A, Sharman JE. Blood Pressure Response to Exercise and Cardiovascular Disease. Curr Hypertens Rep 2017; 19:89. [DOI: 10.1007/s11906-017-0787-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Hecht I, Arad M, Freimark D, Klempfner R. Blood pressure dynamics during exercise rehabilitation in heart failure patients. Eur J Prev Cardiol 2017; 24:818-824. [DOI: 10.1177/2047487317690951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Idan Hecht
- Cardiac Rehabilitation Institute, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Michael Arad
- Heart Failure Institute, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Dov Freimark
- Heart Failure Institute, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
| | - Robert Klempfner
- Cardiac Rehabilitation Institute, Leviev Heart Center, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Israel
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Schultz MG. The clinical importance of exercise blood pressure. Artery Res 2017. [DOI: 10.1016/j.artres.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Bouzas-Mosquera MC, Bouzas-Mosquera A, Peteiro J. Excessive blood pressure increase with exercise and risk of all-cause mortality and cardiac events. Eur J Clin Invest 2016; 46:833-9. [PMID: 27505135 DOI: 10.1111/eci.12665] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 08/08/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND The association of an excessive blood pressure increase with exercise (EBPIE) on cardiovascular outcomes remains controversial. We sought to assess its impact on the risk of all-cause mortality and major cardiac events in patients with known or suspected coronary artery disease (CAD) referred for stress testing. MATERIALS AND METHODS Exercise echocardiography was performed in 10 047 patients with known or suspected CAD. An EBPIE was defined as an increase in systolic blood pressure with exercise ≥ 80 mmHg. The endpoints were all-cause mortality and major cardiac events (MACE), including cardiac death or nonfatal myocardial infarction (MI). RESULTS Overall, 573 patients exhibited an EBPIE during the tests. Over a mean follow-up of 4·8 years, there were 1950 deaths (including 725 cardiac deaths), 1477 MI and 1900 MACE. The cumulative 10-year rates of all-cause mortality, cardiac death, nonfatal MI and MACE were 32·9%, 13·1%, 26·9% and 33% in patients who did not develop an EBPIE vs. 18·9%, 4·7%, 17·5% and 20·7% in those experiencing an EBPIE, respectively (P < 0·001 for all comparisons). In Cox regression analyses, an EBPIE remained predictive of all-cause mortality (hazard ratio [HR] 0·73, 95% confidence interval [CI] 0·59-0·91, P = 0·004), cardiac death (HR 0·67, 95% CI 0·46-0·98, P = 0·04), MI (HR 0·67, 95% CI 0·52-0·86, P = 0·002) and MACE (HR 0·69, 95% CI 0·56-0·86, P = 0·001). CONCLUSIONS An EBPIE was associated with a significantly lower risk of mortality and MACE in patients with known or suspected CAD referred for stress testing.
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Affiliation(s)
| | | | - Jesús Peteiro
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
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Kim J, Al-Mallah M, Juraschek SP, Brawner C, Keteyian SJ, Nasir K, Dardari ZA, Blumenthal RS, Blaha MJ. The association of clinical indication for exercise stress testing with all-cause mortality: the FIT Project. Arch Med Sci 2016; 12:303-9. [PMID: 27186173 PMCID: PMC4848360 DOI: 10.5114/aoms.2016.59255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/19/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION We hypothesized that the indication for stress testing provided by the referring physician would be an independent predictor of all-cause mortality. MATERIAL AND METHODS We studied 48,914 patients from The Henry Ford Exercise Testing Project (The FIT Project) without known congestive heart failure who were referred for a clinical treadmill stress test and followed for 11 ±4.7 years. The reason for stress test referral was abstracted from the clinical test order, and should be considered the primary concerning symptom or indication as stated by the ordering clinician. Hierarchical multivariable Cox proportional hazards regression was performed, after controlling for potential confounders including demographics, risk factors, and medication use as well as additional adjustment for exercise capacity in the final model. RESULTS A total of 67% of the patients were referred for chest pain, 12% for shortness of breath (SOB), 4% for palpitations, 3% for pre-operative evaluation, 6% for abnormal prior testing, and 7% for risk factors only. There were 6,211 total deaths during follow-up. Compared to chest pain, those referred for palpitations (HR = 0.72, 95% CI: 0.60-0.86) and risk factors only (HR = 0.72, 95% CI: 0.63-0.82) had a lower risk of all-cause mortality, whereas those referred for SOB (HR = 1.15, 95% CI: 1.07-1.23) and pre-operative evaluation (HR = 2.11, 95% CI: 1.94-2.30) had an increased risk. In subgroup analysis, referral for palpitations was protective only in those without coronary artery disease (CAD) (HR = 0.75, 95% CI: 0.62-0.90), while SOB increased mortality risk only in those with established CAD (HR = 1.25, 95% CI: 1.10-1.44). CONCLUSIONS The indication for stress testing is an independent predictor of mortality, showing an interaction with CAD status. Importantly, SOB may be associated with higher mortality risk than chest pain, particularly in patients with CAD.
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Affiliation(s)
- Joonseok Kim
- Division of Cardiology, Department of Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Mouaz Al-Mallah
- Henry Ford Health System, Detroit, MI, USA
- King Abdul-Aziz Cardiac Center, Riyadh, Saudi Arabia
| | - Stephen P. Juraschek
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | | | | | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Zeina A. Dardari
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA
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18
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Abstract
Stress testing remains the cornerstone for noninvasive assessment of patients with possible or known coronary artery disease (CAD). The most important application of stress testing is risk stratification. Most patients who present for evaluation of stable CAD are categorized as low risk by stress testing. These low-risk patients have favorable clinical outcomes and generally do not require coronary angiography. Standard exercise treadmill testing is the initial procedure of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise.
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Affiliation(s)
- Todd D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA.
| | - J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
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19
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Bouzas-Mosquera MC, Bouzas-Mosquera A, Peteiro J. Association Between an Exaggerated Exercise Blood Pressure Response and Mortality and Cardiovascular Events in Older Adults with Known or Suspected Coronary Artery Disease. J Am Geriatr Soc 2015; 63:2635-2637. [PMID: 26691707 DOI: 10.1111/jgs.13859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Jesús Peteiro
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
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20
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O'Neal WT, Qureshi WT, Blaha MJ, Ehrman JK, Brawner CA, Nasir K, Al-Mallah MH. Relation of Risk of Atrial Fibrillation With Systolic Blood Pressure Response During Exercise Stress Testing (from the Henry Ford ExercIse Testing Project). Am J Cardiol 2015; 116:1858-62. [PMID: 26603907 DOI: 10.1016/j.amjcard.2015.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 11/19/2022]
Abstract
Decreases in systolic blood pressure during exercise may predispose to arrhythmias such as atrial fibrillation (AF) because of underlying abnormal autonomic tone. We examined the association between systolic blood pressure response and incident AF in 57,442 (mean age 54 ± 13 years, 47% women, and 29% black) patients free of baseline AF who underwent exercise treadmill stress testing from the Henry Ford ExercIse Testing project. Exercise systolic blood pressure response was examined as a categorical variable across clinically relevant categories (>20 mm Hg: referent; 1 to 20 mm Hg, and ≤0 mm Hg) and per 1-SD decrease. Cox regression, adjusting for demographics, cardiovascular risk factors, medications, history of coronary heart disease, history of heart failure, and metabolic equivalent of task achieved, was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between systolic blood pressure response and incident AF. Over a median follow-up of 5.0 years, a total of 3,381 cases (5.9%) of AF were identified. An increased risk of AF was observed with decreasing systolic blood pressure response (>20 mm Hg: HR 1.0, referent; 1 to 20 mm Hg: HR 1.09, 95% CI 0.99, 1.20; ≤0 mm Hg: HR 1.22, 95% CI 1.06 to 1.40). Similar results were obtained per 1-SD decrease in systolic blood pressure response (HR 1.08, 95% CI 1.04 to 1.12). The results were consistent when stratified by age, sex, race, hypertension, and coronary heart disease. In conclusion, our results suggest that a decreased systolic blood pressure response during exercise may identify subjects who are at risk for developing AF.
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Affiliation(s)
- Wesley T O'Neal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Waqas T Qureshi
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland
| | - Jonathan K Ehrman
- Division of Cardiovascular Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Khurram Nasir
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, Maryland; Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, Florida
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Wayne State University, Detroit, Michigan; Department of Cardiac Imaging, King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia.
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21
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Abstract
Stress testing remains the cornerstone for noninvasive assessment of patients with possible or known coronary artery disease (CAD). The most important application of stress testing is risk stratification. Most patients who present for evaluation of stable CAD are categorized as low risk by stress testing. These low-risk patients have favorable clinical outcomes and generally do not require coronary angiography. Standard exercise treadmill testing is the initial procedure of choice in patients with a normal or near-normal resting electrocardiogram who are capable of adequate exercise. Stress imaging is recommended for patients with prior revascularization, uninterpretable electrocardiograms, or inability to adequately exercise.
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Affiliation(s)
- Todd D Miller
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA.
| | - J Wells Askew
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
| | - Nandan S Anavekar
- Division of Cardiovascular Diseases, Mayo Clinic, Gonda 6, 200 First Street, Southwest, Rochester, MN 55905, USA
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22
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O'Neal WT, Qureshi WT, Blaha MJ, Keteyian SJ, Brawner CA, Al-Mallah MH. Systolic Blood Pressure Response During Exercise Stress Testing: The Henry Ford ExercIse Testing (FIT) Project. J Am Heart Assoc 2015; 4:JAHA.115.002050. [PMID: 25953655 PMCID: PMC4599430 DOI: 10.1161/jaha.115.002050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The prognostic significance of modest elevations in exercise systolic blood pressure response has not been extensively examined. Methods and Results We examined the association between systolic blood pressure response and all-cause death and incident myocardial infarction (MI) in 44 089 (mean age 53±13 years, 45% female, 26% black) patients who underwent exercise treadmill stress testing from the Henry Ford ExercIse Testing (FIT) Project (1991–2010). Exercise systolic blood pressure response was examined as a categorical variable (>20 mm Hg: referent; 1 to 20 mm Hg, and ≤0 mm Hg) and per 1 SD decrease. Cox regression was used to compute hazard ratios (HR) and 95% CI for the association between systolic blood pressure response and all-cause death and incident MI. Over a median follow-up of 10 years, a total of 4782 (11%) deaths occurred and over 5.2 years, a total of 1188 (2.7%) MIs occurred. In a Cox regression analysis adjusted for demographics, physical fitness, and cardiovascular risk factors, an increased risk of death was observed with decreasing systolic blood pressure response (>20 mm Hg: HR=1.0, referent; 1 to 20 mm Hg: HR=1.13, 95% CI=1.05, 1.22; ≤0 mm Hg: HR=1.21, 95% CI=1.09, 1.34). A trend for increased MI risk was observed (>20 mm Hg: HR=1.0, referent; 1 to 20 mm Hg: HR=1.09, 95% CI=0.93, 1.27; ≤0 mm Hg: HR=1.19, 95% CI=0.95, 1.50). Decreases in systolic blood pressure response per 1 SD were associated with an increased risk for all-cause death (HR=1.08, 95% CI=1.05, 1.11) and incident MI (HR=1.09, 95% CI=1.03, 1.16). Conclusions Our results suggest that modest increases in exercise systolic blood pressure response are associated with adverse outcomes.
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Affiliation(s)
- Wesley T O'Neal
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC (W.T.N.)
| | - Waqas T Qureshi
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC (W.T.Q.)
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD (M.J.B.)
| | - Steven J Keteyian
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K., C.A.B., M.H.A.M.)
| | - Clinton A Brawner
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K., C.A.B., M.H.A.M.)
| | - Mouaz H Al-Mallah
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI (S.J.K., C.A.B., M.H.A.M.) Department of Internal Medicine, Wayne State University, Detroit, MI (M.H.A.M.) Department of Cardiac Imaging, King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia (M.H.A.M.)
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Barlow PA, Otahal P, Schultz MG, Shing CM, Sharman JE. Low exercise blood pressure and risk of cardiovascular events and all-cause mortality: systematic review and meta-analysis. Atherosclerosis 2014; 237:13-22. [PMID: 25190307 DOI: 10.1016/j.atherosclerosis.2014.08.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 08/08/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The independent prognostic significance of abnormally low systolic blood pressure (SBP) during exercise stress testing (LowExBP) across different clinical and exercise conditions is unknown. We sought by systematic review and meta-analysis to determine the association between cardiovascular/all-cause outcomes and LowExBP across different patient clinical presentations, exercise modes, exercise intensities and categories of LowExBP. METHODS Seven online databases were searched for longitudinal studies reporting the association of LowExBP with risk of fatal and non-fatal cardiovascular events and/or all-cause mortality. LowExBP was defined as either: SBP drop below baseline; failure to increase >10 mmHg from baseline or; lowest SBP quantile among reporting studies. RESULTS After review of 13,257 studies, 19 that adjusted for resting SBP were included in the meta-analysis, with a total of 45,895 participants (average follow-up, 4.4 ± 3.0 years). For the whole population, LowExBP was associated with increased risk for fatal and non-fatal cardiovascular events and all-cause mortality (hazard ratio [HR]: 2.01, 95% confidence interval [CI]: 1.59-2.53, p < 0.001). In continuous analyses, a 10 mmHg decrease in exercise SBP was associated with higher risk (n = 9 HR: 1.13, 95% CI: 1.06-1.20, p < 0.001). LowExBP was associated with increased risk regardless of clinical presentation (coronary artery disease, heart failure, hypertrophic cardiomyopathy or peripheral artery disease), exercise mode (treadmill or bike), exercise intensity (moderate or maximal), or LowExBP category (all p < 0.05). However, bias toward positive results was apparent (Eggers test p < 0.001 and p = 0.009). CONCLUSION Our data show that irrespective of clinical or exercise conditions, LowExBP independently predicts fatal and non-fatal cardiovascular events and all-cause mortality.
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Affiliation(s)
- Paul A Barlow
- Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia; School of Human Life Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Petr Otahal
- Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia
| | - Martin G Schultz
- Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia
| | - Cecilia M Shing
- School of Human Life Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - James E Sharman
- Menzies Research Institute Tasmania, University of Tasmania, Medical Science 1 Building, Liverpool Street, Hobart 7000, Tasmania, Australia.
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Bouzas-Mosquera MDC, Bouzas-Mosquera A, Peteiro J, Broullón FJ, Alvarez-García N, Castro-Beiras A. Exaggerated exercise blood pressure response and risk of stroke in patients referred for stress testing. Eur J Intern Med 2014; 25:533-7. [PMID: 24930070 DOI: 10.1016/j.ejim.2014.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/22/2014] [Accepted: 05/27/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVES There is some evidence to suggest that exercise systolic blood pressure (SBP) may be associated with future risk of stroke in subjects without a history of coronary artery disease (CAD). However, the value of an exaggerated exercise SBP response (EESBPR) for predicting stroke in patients referred for stress testing for clinical reasons has not been investigated. METHODS We evaluated a community-based sample of 10,047 patients with known or suspected CAD who underwent treadmill exercise echocardiography. An EESBPR was defined as a peak exercise SBP of >220mmHg. The ratio of the increase in SBP during exercise to exercise workload (ΔSBPeEW) was also estimated. The endpoints were stroke of any type, ischemic stroke and hemorrhagic stroke. Median follow-up was 3.5years. RESULTS Annualized rates of stroke of any type, ischemic stroke and hemorrhagic stroke were 0.6% (95% CI 0.53-0.67), 0.49% (95% CI 0.42-0.56) and 0.12% (95% CI 0.09-0.15) in patients without EESBPR vs. 0.69% (95% CI 0.37-1), 0.49% (95% CI 0.23-0.76) and 0.19% (95% CI 0.02-0.35) in those with EESBPR (p=0.68, 0.90 and 0.39, respectively). Similarly, there was no significant univariate association between ΔSBPeEW and the occurrence of any endpoint. In multivariate analysis, hypertension, male sex, age, diabetes mellitus and resting SBP remained predictors of stroke of any type. EESBPR and ΔSBPeEW were not predictors of any of the endpoints evaluated. CONCLUSION We did not observe any significant association between exercise SBP and the future occurrence of stroke in patients with known or suspected CAD referred for exercise echocardiography.
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Affiliation(s)
| | | | - Jesús Peteiro
- Department of Cardiology, Hospital Universitario A Coruña, A Coruña, Spain
| | - Francisco J Broullón
- Department of Health Information Technology, Hospital Universitario A Coruña, A Coruña, Spain
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25
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Abstract
Coronary artery disease (CAD) is the leading cause of death worldwide. There are several presenting clinical syndromes, including sudden cardiac death. Risk factor analysis can help the primary care provider identify patients who may need more extensive evaluation or treatment. Treatment may be medical or surgical and depends on the individual patient's comorbidities and preferences. In the future, growth of new blood vessels or cardiac cells may aid in the treatment of CAD.
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Affiliation(s)
- Michele A Hanson
- Department of Family Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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26
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Low DA, da Nóbrega AC, Mathias CJ. Exercise-induced hypotension in autonomic disorders. Auton Neurosci 2012; 171:66-78. [DOI: 10.1016/j.autneu.2012.07.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 07/25/2012] [Accepted: 07/26/2012] [Indexed: 11/30/2022]
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Juan Ramón SS. Rol del laboratorio cardiovascular en la detección precoz de enfermedad coronaria. REVISTA MÉDICA CLÍNICA LAS CONDES 2012. [DOI: 10.1016/s0716-8640(12)70367-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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28
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Blunted heart rate recovery is associated with exaggerated blood pressure response during exercise testing. Heart Vessels 2012; 28:750-6. [DOI: 10.1007/s00380-012-0298-6] [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] [Received: 05/23/2012] [Accepted: 09/28/2012] [Indexed: 01/20/2023]
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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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30
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Abstract
Exercise testing is not limited to observation of ischemic electrocardiographic findings during exercise, but also abnormal findings in blood pressure, heart rate, and exercise capacity are valuable. Individuals with exaggerated exercise blood pressure tend to develop future hypertension. Extensive elevation in systolic blood pressure during exercise has been found to increase the risk of left ventricular hypertrophy, myocardial infarction, cerebrovascular stroke, and cardiovascular death. Previous studies have revealed that blood pressure response to exercise is dependent on underlying heart disease and peripheral resistance. Therefore, subjects with documented cardiovascular disease may not be capable of generating a work-load to allow the manifestation of exercise-induced systolic hypertension. Systolic hypotension during exercise is associated with left ventricular dysfunction and inadequate cardiac output, and it is a marker of severe heart disease. Exercise testing with the definition of blood pressure can be performed in a logical way with test results used to decide on therapies and treatment strategies in addition to blood pressure at rest. A modest increment in blood pressure rise corresponding to work-load achieved during the exercise testing is the best sign from the prognostic point of view. The normal limits of exercise blood pressure response could be very helpful for clinicians.
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Affiliation(s)
- Jari A Laukkanen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Finland.
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31
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Berent R, Auer J, von Duvillard S, Sinzinger H, Schmid P. Komplikationen bei der Ergometrie. Herz 2011; 35:267-72. [DOI: 10.1007/s00059-011-3449-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2009] [Accepted: 01/11/2010] [Indexed: 11/29/2022]
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32
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Association of blood pressure and heart rate response during exercise with cardiovascular events in the Heart and Soul Study. J Hypertens 2010; 28:2236-42. [DOI: 10.1097/hjh.0b013e32833d455b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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33
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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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34
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Exercise hypertension: an adverse prognosis? ACTA ACUST UNITED AC 2009; 3:366-73. [DOI: 10.1016/j.jash.2009.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2009] [Accepted: 10/15/2009] [Indexed: 11/17/2022]
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35
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HAGHJOO MAJID, FAGHFURIAN BABAK, TAHERPOUR MEHDI, FAZELIFAR AMIRFARJAM, MOHAMMADZADEH SHABNAM, ALIZADEH ABOLFATH, SADR-AMELI MOHAMMADALI. Predictors of Syncope in Patients with Hypertrophic Cardiomyopathy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:642-7. [DOI: 10.1111/j.1540-8159.2009.02338.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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36
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Prognostic value of hypotensive blood pressure response during single-stage exercise test on long-term outcome in patients with known or suspected peripheral arterial disease. Coron Artery Dis 2009; 19:603-7. [PMID: 19005295 DOI: 10.1097/mca.0b013e328316e9ed] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A decline in systolic blood pressure during exercise is thought to be a sign of severe coronary artery disease. However, no studies have yet examined this effect in patients with known or suspected peripheral arterial disease. Therefore, we investigated the prognostic value of hypotensive blood pressure response after single-stage exercise test on long-term mortality, major adverse cerebrovascular and cardiac events (MACCE) and the effects of statin, beta-blocker and aspirin use in patients with known or suspected peripheral arterial disease. METHODS A total of 2022 patients were enrolled in an observational study with a mean follow-up of 5 years. Hypotensive blood pressure response, 4.6% of the total population, was defined as a drop in exercise systolic blood pressure below resting systolic blood pressure. RESULTS Our study showed that hypotensive blood pressure response was associated with an increased risk of all-cause mortality [hazard ratio (HR): 1.74, 95% confidence interval (CI): 1.10-2.73] and MACCE (HR: 1.85, 95% CI: 1.14-3.00), independent of other clinical variables. Additionally, after adjustments for clinical risk factors and propensity score, baseline statin use was associated with a reduced risk of all-cause mortality (HR: 0.60, 95% CI: 0.44-0.80). Besides, statin and aspirin use were both also associated with a reduced risk of MACCE (HR: 0.65, 95% CI: 0.47-0.89 and HR: 0.69, 95% CI: 0.53-0.88, respectively). CONCLUSION Hypotensive blood pressure response after single-stage treadmill exercise tests in patients with known or suspected peripheral arterial disease was associated with a higher risk for all-cause long-term mortality and MACCE, which might be reduced by statin and aspirin use.
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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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Le VV, Mitiku T, Sungar G, Myers J, Froelicher V. The Blood Pressure Response to Dynamic Exercise Testing: A Systematic Review. Prog Cardiovasc Dis 2008; 51:135-60. [PMID: 18774013 DOI: 10.1016/j.pcad.2008.07.001] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Vy-Van Le
- Cardiology Division, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304-1207, USA.
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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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40
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Barnabei L, Marazìa S, De Caterina R. Receiver operating characteristic (ROC) curves and the definition of threshold levels to diagnose coronary artery disease on electrocardiographic stress testing. Part I: The use of ROC curves in diagnostic medicine and electrocardiographic markers of ischaemia. J Cardiovasc Med (Hagerstown) 2007; 8:873-81. [PMID: 17906471 DOI: 10.2459/jcm.0b013e3280126615] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A common problem in diagnostic medicine, when performing a diagnostic test, is to obtain an accurate discrimination between 'normal' cases and cases with disease, owing to the overlapping distributions of these populations. In clinical practice, it is exceedingly rare that a chosen cut point will achieve perfect discrimination between normal cases and those with disease, and one has to select the best compromise between sensitivity and specificity by comparing the diagnostic performance of different tests or diagnostic criteria available. Receiver operating characteristic (or receiver operator characteristic, ROC) curves allow systematic and intuitively appealing descriptions of the diagnostic performance of a test and a comparison of the performance of different tests or diagnostic criteria. This review will analyse the basic principles underlying ROC curves and their specific application to the choice of optimal parameters on exercise electrocardiographic (ECG) stress testing. Part I will focus on theoretical description and analysis along with reviewing the common problems related to the diagnosis of myocardial ischaemia by means of exercise ECG stress testing. Part II will be devoted to applying ROC curves to available diagnostic criteria through the analysis of ECG stress test parameters.
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Affiliation(s)
- Luca Barnabei
- Institute of Cardiology, G. d'Annunzio University, Ospedale San Camillo de Lellis, Via Forlanini 50, Chieti, Italy
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41
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Ciampi Q, Betocchi S, Losi MA, Ferro A, Cuocolo A, Lombardi R, Villari B, Chiariello M. Abnormal blood-pressure response to exercise and oxygen consumption in patients with hypertrophic cardiomyopathy. J Nucl Cardiol 2007; 14:869-75. [PMID: 18022114 DOI: 10.1016/j.nuclcard.2007.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 08/01/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Abnormal blood-pressure response during exercise occurs in about one third of patients with hypertrophic cardiomyopathy (HCM), and it has been associated with a high risk of sudden cardiac death. We assessed the hemodynamics of exercise in HCM patients with abnormal blood-pressure response by using ambulatory radionuclide monitoring (VEST) of left-ventricular (LV) function, and exercise tolerance by oxygen consumption. METHODS Twenty-two HCM patients underwent treadmill exercise during VEST monitoring. A cardiopulmonary exercise test was performed a few days after. The VEST data were averaged for 1 minute. Stroke volume, cardiac output, and systemic vascular resistance were expressed as percent of baseline. Exercise tolerance was assessed as maximal oxygen consumption. RESULTS In eight HCM patients (36%) with an abnormal blood-pressure response, end-systolic volume increased more (52% +/- 21% vs 31% +/- 28%, P = .012), and the ejection fraction (-31% +/- 17% vs -14% +/- 22%, P = .029) and stroke volume (-21% +/- 21% vs 3% +/- 28%, P = .026) fell more, than in patients with normal response. Cardiac output increased less in the former patients (49% +/- 44% vs 94% +/- 44%, P = .012). Systemic vascular resistance decreased similarly, irrespective of blood-pressure response (-28% +/- 26% vs -34% +/- 26%, P = N.S.). Percent of maximal predicted oxygen consumption was lower in HCM patients with an abnormal blood-pressure response (63% +/- 11% vs 78% +/- 15%, P = .025). CONCLUSIONS In HCM patients, abnormal blood-pressure response was associated with exercise-induced LV systolic dysfunction and impairment in oxygen consumption. This may cause hemodynamic instability, associated with a high risk of sudden cardiac death.
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Affiliation(s)
- Quirino Ciampi
- Department of Clinical Medicine, Federico II University School of Medicine, Naples, Italy
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Kobal SL, Pollick C, Atar S, Miyamoto T, Aslanian N, Neuman Y, Tolstrup K, Naqvi TZ, Luo H, Macrum B, Siegel RJ. Stress Echocardiography in Octogenarians: Transesophageal Atrial Pacing is Accurate, Safe, and Well Tolerated. J Am Soc Echocardiogr 2006; 19:1012-6. [PMID: 16880096 DOI: 10.1016/j.echo.2006.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Indexed: 11/25/2022]
Abstract
The feasibility and diagnostic accuracy of transesophageal pacing stress echocardiography for detection of inducible myocardial ischemia were evaluated in 161 patients 80 years of age or older (mean 84 +/- 3.9, range 80-97). The pacing time was 5.5 +/- 2.5 minutes with a total test time of 37 +/- 7 minutes. The mean achieved heart rate was 96 +/- 7% (83%-121%) of maximum predicted with an average rate pressure product of 21,560 +/- 5175 beats/min x mm Hg. There were minor adverse events in 8% of cases and no major complications occurred. Patient acceptance was high. When compared with myocardial single photon emission computed tomography, pacing stress echocardiography had a sensitivity of 89% and a specificity of 93% for the detection of myocardial ischemia, and 91% agreement (kappa = 0.80, P < .001). We demonstrate that pacing stress echocardiography is safe and accurate for detection of myocardial ischemia and, thus, a reliable substitute to exercise and pharmacologic stress testing in octogenarians.
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Affiliation(s)
- Sergio L Kobal
- Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Ciampi Q, Betocchi S, Lombardi R, Manganelli F, Storto G, Losi MA, Pezzella E, Finizio F, Cuocolo A, Chiariello M. Hemodynamic determinants of exercise-induced abnormal blood pressure response in hypertrophic cardiomyopathy. J Am Coll Cardiol 2002; 40:278-84. [PMID: 12106932 DOI: 10.1016/s0735-1097(02)01950-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES We sought to assess the hemodynamics of exercise in patients with hypertrophic cardiomyopathy (HCM), with and without an exercise-induced abnormal blood pressure (BP) response, by ambulatory radionuclide monitoring of left ventricular (LV) function with the VEST device (Capintec Inc., Ramsey, New Jersey). BACKGROUND Blood pressure fails to increase >20 mm Hg during exercise in about one-third of patients with HCM. This carries a high risk of sudden death. METHODS Forty-three patients with HCM and 14 control subjects underwent maximal symptom-limited exercise on a treadmill during VEST. The VEST data were averaged for 1 min and analyzed at baseline, 3 min and peak exercise. The LV end-diastolic, end-systolic and stroke volumes, cardiac output and systemic vascular resistance were expressed as the percentage of baseline. RESULTS Ejection fraction and stroke volume fell in patients with HCM, although they increased in control subjects (p < 0.001 and p = 0.002, respectively). Cardiac output increased significantly more in control subjects than in patients with HCM (p = 0.001). In 17 patients with HCM (39%) with an abnormal BP response, ejection fraction and stroke volume fell more (p = 0.032 and p = 0.009, respectively) and cardiac output increased less (p = 0.001) than they did in patients with HCM with a normal BP response. Systemic vascular resistance decreased similarly in patients with HCM, irrespective of the BP response. CONCLUSIONS In patients with HCM with and without an abnormal BP response, abnormal hemodynamic adaptation to exercise was qualitatively similar but quantitatively different. An abnormal BP response was associated with exercise-induced LV systolic dysfunction. This causes hemodynamic instability, associated with a high risk of sudden cardiac death.
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Affiliation(s)
- Quirino Ciampi
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences, Federico II University School of Medicine, Via S. Pansini 5, Naples, I-80131 Italy
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Elhendy A, van Domburg RT, Vantrimpont P, Poldermans D, Bax JJ, van Gelder T, Baan CC, Schinkel A, Roelandt JRTC, Balk AHMM. Prediction of mortality in heart transplant recipients by stress technetium-99m tetrofosmin myocardial perfusion imaging. Am J Cardiol 2002; 89:964-8. [PMID: 11950436 DOI: 10.1016/s0002-9149(02)02247-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cardiac allograft vasculopathy is a major cause of mortality in heart transplant recipients. The aim of this study was to assess the prognostic value of stress myocardial perfusion imaging in heart transplant recipients. We studied 166 patients (age 54 +/- 10 years, 140 men) by symptom-limited bicycle exercise or dobutamine (up to 40 microg/kg/min) stress myocardial perfusion imaging 7.4 +/- 2.5 years after heart transplantation. An intravenous dose of 370 MBq of technetium-99m tetrofosmin was injected at peak stress and 24 hours after the stress test. An abnormal test was defined as reversible or fixed perfusion defects. Perfusion abnormalities were detected in 55 patients (33%). During a median follow-up of 2.5 years, 54 deaths (33%) occurred, 16 of which were due to cardiac causes. The incidence of perfusion abnormalities was higher in patients with subsequent cardiac death than in patients without subsequent cardiac death (69% vs 29%, p = 0.01). In an incremental multivariate Cox analysis, cardiac death was not predicted by age, gender, duration of transplantation, number of rejection episodes, or cytomegalovirus infection. In the next step, stress test parameters were added. The peak rate-pressure product was the only significant predictor at this step (risk ratio 0.84, 95% confidence interval 0.73 to 0.97, chi-square 7.7, p = 0.006). In the final step, the presence of abnormal myocardial perfusion was an independent predictor of cardiac death (risk ratio 3.5, 95% confidence interval 1.6 to 11.7, chi-square 4.7, incremental to clinical and stress test variables, p = 0.01). It is concluded that stress myocardial perfusion imaging with technetium-99m tetrofosmin single-photon emission computed tomography provides incremental data for the prediction of cardiac death in heart transplant recipients.
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Affiliation(s)
- Abdou Elhendy
- Heart Transplant Unit, Thoraxcenter, Rotterdam, The Netherlands.
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Prakash M, Myers J, Froelicher VF, Marcus R, Do D, Kalisetti D, Atwood JE. Clinical and exercise test predictors of all-cause mortality: results from > 6,000 consecutive referred male patients. Chest 2001; 120:1003-13. [PMID: 11555539 DOI: 10.1378/chest.120.3.1003] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE To report the prevalence of abnormal treadmill test responses and their association with mortality in a large consecutive series of patients referred for standard exercise tests, with testing performed and reported in a standardized fashion. BACKGROUND Exercise testing is widely performed, but few databases exist of large numbers of consecutive tests performed on patients referred for routine clinical purposes using standardized methods. Even fewer of the available databases have information regarding all-cause mortality as an outcome. METHODS All patients referred for evaluation at two university-affiliated Veterans Affairs medical centers who underwent exercise treadmill testing for clinical indications between 1987 and 2000 were determined to be dead or alive using the Social Security death index after a mean 6.2 years (median, 7 years) of follow-up. Clinical and exercise test variables were collected prospectively according to standard definitions; testing and data management were performed in a standardized fashion using a computer-assisted protocol. All-cause mortality was utilized as the end point for follow-up. Standard survival analysis was performed, including Kaplan-Meier curves and a Cox hazard model. RESULTS There were 6,213 male patients (mean +/- SD age, 59 +/- 11 years) who underwent standard exercise ECG treadmill testing over the study period with a mean follow-up duration of 6.2 +/- 3.7 years. There were no complications of testing in this clinically referred population, 78% of whom were referred for chest pain, or risk factors or signs or symptoms of ischemic heart disease. Overlapping thirds had typical angina or history of myocardial infarction (MI). Five hundred seventy-nine patients had prior coronary artery bypass surgery, and 522 patients had a history of congestive heart failure (CHF). Indications for testing were in accordance with published guidelines. Twenty percent died over the follow-up period, for an average annual mortality rate of 2.6%. Cox hazard function chose the following variables in rank order as independently and significantly associated with time to death: exercise capacity (metabolic equivalents < 5, age > 65 years, history of CHF, and history of MI. A score based on these variables (summing up the four variables [if yes = 1 point]) classified patients into low-risk, medium-risk, and high-risk groups. The high-risk group (score > or = 3) has a hazard ratio of 5.0 (95% confidence interval, 4.7 to 5.3) and a 5-year mortality rate of 31%. CONCLUSION This comprehensive analysis provides rates of various abnormal responses that can be expected in patients referred for exercise testing at a typical medical center. Four simple variables combined as a score powerfully stratified patients according to prognosis.
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Affiliation(s)
- M Prakash
- Division of Cardiovascular Medicine, Stanford University Medical Center and the University of California Irvine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA
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Evans CH, Harris G, Mendold V, Ellestad MH. A basic approach to the interpretation of the exercise test. Prim Care 2001; 28:73-98 ,vi. [PMID: 11346499 DOI: 10.1016/s0095-4543(05)70008-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To interpret the exercise test, the following parameters need to be evaluated: the heart rate and blood pressure response, symptoms, dysrhythmias, aerobic capacity, and evidence for myocardial ischemia. When analyzing the ST segment for ischemia, the amount and type of ST depression and the time of onset and resolution are examined. The exercise test results are best used to determine a post-test probability that the patient has significant coronary disease, predict its severity, and provide a prognosis of the patient. The test allows primary care physicians to decide which patients with coronary artery disease can be safely managed medically and which high-risk patients need further evaluation and consideration for revascularization.
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Affiliation(s)
- C H Evans
- The Family Practice Residency Program, Bayfront Medical Center, 700 Sixth Street South, St. Petersburg, FL 33701, USA
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Abstract
In patients with limited exercise capacity and (relative) contraindications to direct vasodilators such as dipyridamole or adenosine, dobutamine stress nuclear myocardial perfusion imaging (DSMPI) represents an alternative, exercise-independent stress modality for the detection of coronary artery disease (CAD). Nondiagnostic test results (absence of reversible perfusion defects with submaximal stress) do occur in approximately 10% of patients. Serious side effects during DSMPI are rare, with no death, myocardial infarction or ventricular fibrillation reported in three DSMPI safety reports for a total of 2,574 patients. On the basis of a total number of 1,014 patients reported in 20 studies, the sensitivity, specificity and accuracy of the test for the detection of CAD were 88%, 74% and 84%, respectively. Mean sensitivities for one-, two- and three-vessel disease were 84%, 95% and 100%, respectively. The sensitivity for detection of left circumflex CAD (50%) was lower, compared with that for left anterior descending CAD (68%) and right CAD (88%). The sensitivity of predicting multivessel disease by multiregion perfusion abnormalities varied widely, from 44% to 89%, although specificity was excellent in all studies (89% to 94%). In direct diagnostic comparisons, DSMPI was more sensitive, but less specific, than dobutamine stress echocardiography and comparable with direct vasodilator myocardial perfusion imaging. In the largest prognostic study, patients with a normal DSMPI study had an annual hard event rate less than 1%. An ischemic scan pattern provided independent prognostic value, with a direct relationship between the extent and severity of the perfusion defects and prognosis. In conclusion, DSMPI seems a safe and useful nonexercise-dependent stress modality to detect CAD and assess prognosis.
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Affiliation(s)
- M L Geleijnse
- Thoraxcenter Rotterdam, University Hospital, Rotterdam-Dijkzigt, The Netherlands.
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Naughton J, Dorn J, Oberman A, Gorman PA, Cleary P. Maximal exercise systolic pressure, exercise training, and mortality in myocardial infarction patients. Am J Cardiol 2000; 85:416-20. [PMID: 10728943 DOI: 10.1016/s0002-9149(99)00765-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The relation of maximal exercise systolic pressure to physical conditioning and to mortality was determined in 641 men with > or =1 myocardial infarctions. Each performed a standardized multistage exercise test before randomized assignment either to an exercise group or a control group and at scheduled periodic intervals over 3 years. This study compares 123 men with maximal exercise systolic pressures (MESP) of < or =140 mm Hg with 518 men whose maximal exercise systolic pressure was > or =140 mm Hg. At baseline, the 2 groups were comparable for age, entry time since the occurrence of the qualifying cardiac event, and reported use of antihypertensive medications. Men with low MESP used more beta blockers, had lower systolic pressure measurements at rest and by definition at maximal exercise, and lower work capacity than men with higher levels of MESP. Men with low MESP experienced: (1) no reduction in mortality with exercise conditioning (p<0.86), and (2) a significantly higher mortality rate over 3 years (p<0.003) compared with men with higher levels of MESP. The relation of a low MESP to mortality persisted: (1) whether MESP or work capacity increased from the baseline exercise test to the last performed exercise test, and (2) whether it was measured at low (<6 METs) or high (> or =6 METs) levels of work capacity. We conclude that low maximal exercise systolic blood pressure is a predictor of mortality and is associated with an ineffective training response in men with myocardial infarction.
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Affiliation(s)
- J Naughton
- State University of New York at Buffalo, School of Medicine and Biomedical Sciences, 14214, USA
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Michaels AD, Goldschlager N. Risk stratification after acute myocardial infarction in the reperfusion era. Prog Cardiovasc Dis 2000; 42:273-309. [PMID: 10661780 DOI: 10.1053/pcad.2000.0420273] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Historically, risk stratification for survivors of acute myocardial infarction (AMI) has centered on 3 principles: assessment of left ventricular function, detection of residual myocardial ischemia, and estimation of the risk for sudden cardiac death. Although these factors still have important prognostic implications for these patients, our ability to predict adverse cardiac events has significantly improved over the last several years. Recent studies have identified powerful predictors of adverse cardiac events available from the patient history, physical examination, initial electrocardiogram, and blood testing early in the evaluation of patients with AMI. Numerous studies performed in patients receiving early reperfusion therapy with either thrombolysis or primary angioplasty have emphasized the importance of a patent infarct related artery for long-term survival. The predictive value of a variety of noninvasive and invasive tests to predict myocardial electrical instability have been under active investigation in patients receiving early reperfusion therapy. The current understanding of the clinically important predictors of clinical outcomes in survivors of AMI is reviewed in this article.
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Affiliation(s)
- A D Michaels
- Department of Medicine, University of California at San Francisco Medical Center, 94143-0124, USA.
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Olivotto I, Maron BJ, Montereggi A, Mazzuoli F, Dolara A, Cecchi F. Prognostic value of systemic blood pressure response during exercise in a community-based patient population with hypertrophic cardiomyopathy. J Am Coll Cardiol 1999; 33:2044-51. [PMID: 10362212 DOI: 10.1016/s0735-1097(99)00094-7] [Citation(s) in RCA: 176] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The present study was designed to prospectively evaluate the prognostic relevance of abnormal blood pressure response to exercise (ABPR), defined as hypotension or failed blood pressure increase (<20 mm Hg) with exercise, in a community-based hypertrophic cardiomyopathy (HCM) population representative of the overall disease spectrum. BACKGROUND Abnormal blood pressure response to exercise has been proposed as a marker for hemodynamic instability and increased risk for disease-related mortality in highly selected patient populations with HCM. METHODS The study population comprised 126 patients (aged 42+/-14 years) who underwent maximal symptom-limited cycloergometer exercise testing as part of the standard evaluation at our institution, and who were followed systematically for 4.7+/-3.7 years after testing. RESULTS Of the 126 study patients, 98 (78%) had a normal blood pressure response during exercise, whereas the other 28 (22%) had ABPR, including nine with hypotension and 19 with failed blood pressure rise. During the follow-up period, nine patients (7%) died of HCM-related causes (three suddenly and six heart failure-related), of whom four had ABPR. In those patients aged < or =50 years, survival analysis after exercise testing showed a significantly increased risk for cardiovascular mortality associated with ABPR compared with a normal exercise response (p = 0.04), with an odds ratio of 4.5 (95% confidence interval: 1.1, 20.1). However, ABPR showed low positive predictive accuracy for cardiovascular mortality (i.e., 14%), whereas negative predictive accuracy was high (i.e., 95%). CONCLUSIONS A hypotensive blood pressure response during exercise occurred in over 20% of a community-based patient cohort with HCM, and was associated with adverse long-term prognosis in patients <50 years old. However, the positive predictive accuracy of this blood pressure response is too low to justify modifications of clinical management or to allow identification of the high-risk patient based solely on an abnormal test result. By virtue of its high negative predictive accuracy for HCM-related mortality, the blood pressure response to exercise appears to be most valuable (in conjunction with the absence of other well recognized risk factors) as a screening test for the identification of low-risk subsets of patients.
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Affiliation(s)
- I Olivotto
- Cardiologia di S. Luca and Medicina Generale III, Ospedale di Careggi, Florence, Italy
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