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Coleman JA, Doste R, Beltrami M, Coppini R, Olivotto I, Raman B, Bueno-Orovio A. Electrophysiological mechanisms underlying T wave pseudonormalisation on stress ECGs in hypertrophic cardiomyopathy. Comput Biol Med 2024; 169:107829. [PMID: 38096763 DOI: 10.1016/j.compbiomed.2023.107829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/09/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Pseudonormal T waves may be detected on stress electrocardiograms (ECGs) in hypertrophic cardiomyopathy (HCM). Either myocardial ischaemia or purely exercise-induced changes have been hypothesised to contribute to this phenomenon, but the precise electrophysiological mechanisms remain unknown. METHODS Computational models of human HCM ventricles (n = 20) with apical and asymmetric septal hypertrophy phenotypes with variable severities of repolarisation impairment were used to investigate the effects of acute myocardial ischaemia on ECGs with T wave inversions at baseline. Virtual 12-lead ECGs were derived from a total of 520 biventricular simulations, for cases with regionally ischaemic K+ accumulation in hypertrophied segments, global exercise-induced serum K+ increases, and/or increased pacing frequency, to analyse effects on ECG biomarkers including ST segments, T wave amplitudes, and QT intervals. RESULTS Regional ischaemic K+ accumulation had a greater impact on T wave pseudonormalisation than exercise-induced serum K+ increases, due to larger reductions in repolarisation gradients. Increases in serum K+ and pacing rate partially corrected T waves in some anatomical and electrophysiological phenotypes. T wave morphology was more sensitive than ST segment elevation to regional K+ increases, suggesting that T wave pseudonormalisation may sometimes be an early, or the only, ECG feature of myocardial ischaemia in HCM. CONCLUSIONS Ischaemia-induced T wave pseudonormalisation can occur on stress ECG testing in HCM before significant ST segment changes. Some anatomical and electrophysiological phenotypes may enable T wave pseudonormalisation due to exercise-induced increased serum K+ and pacing rate. Consideration of dynamic T wave abnormalities could improve the detection of myocardial ischaemia in HCM.
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Affiliation(s)
- James A Coleman
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Ruben Doste
- Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Matteo Beltrami
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Coppini
- Department of NeuroFarBa, University of Florence, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Meyer Children's Hospital IRCCS, Florence, Italy
| | - Betty Raman
- Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, United Kingdom
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Carvalho TD, Freitas OGAD, Chalela WA, Hossri CAC, Milani M, Buglia S, Precoma DB, Falcão AMGM, Mastrocola LE, Castro I, Albuquerque PFD, Coutinho RQ, Brito FSD, Alves JDC, Serra SM, Santos MAD, Colombo CSSDS, Stein R, Herdy AH, Silveira ADD, Castro CLBD, Silva MMFD, Meneghello RS, Ritt LEF, Malafaia FL, Marinucci LFB, Pena JLB, Almeida AEMD, Vieira MLC, Stier Júnior AL. Brazilian Guideline for Exercise Test in the Adult Population - 2024. Arq Bras Cardiol 2024; 121:e20240110. [PMID: 38896581 DOI: 10.36660/abc.20240110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
- Universidade do Estado de Santa Catarina, Florianópolis, SC - Brasil
| | | | - William Azem Chalela
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Mauricio Milani
- Universidade de Brasília (UnB), Brasília, DF, Brasil
- Hasselt University, Hasselt - Bélgica
- Jessa Ziekenhuis, Hasselt - Bélgica
| | - Susimeire Buglia
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | - Andréa Maria Gomes Marinho Falcão
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | | | - Iran Castro
- Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | | | | | | | | | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | - Mauro Augusto Dos Santos
- Instituto Nacional de Cardiologia do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
- Linkcare Saúde, Rio de Janeiro, RJ - Brasil
| | | | - Ricardo Stein
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport, Florianópolis, SC - Brasil
| | - Anderson Donelli da Silveira
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brasil
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | - Claudia Lucia Barros de Castro
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
- CLINIMEX - Clínica de Medicina de Exercício, Rio de Janeiro, RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Instituto D'Or de Pesquisa e Ensino, Salvador, BA - Brasil
- Hospital Cárdio Pulmonar, Salvador, BA - Brasil
| | - Felipe Lopes Malafaia
- Hospital Samaritano Paulista, São Paulo, SP - Brasil
- UnitedHealth Group Brasil, São Paulo, SP - Brasil
| | - Leonardo Filipe Benedeti Marinucci
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (InCor-HCFMUSP), São Paulo, SP - Brasil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Arnaldo Laffitte Stier Júnior
- Universidade Federal do Paraná (UFPR), Curitiba, PR - Brasil
- Secretaria Municipal de Saúde Curitiba, Curitiba, PR - Brasil
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Fuentes Mendoza JA, Gonzalez Galvan LM, Guizar Sanchez CA, Pimentel-Esparza JA, Fuentes Jaime J, Cervantes-Nieto JA. Pseudo-Normalization of the T-wave During Stress and Its Relationship With Myocardial Ischemia: Evaluation by Myocardial Perfusion Single Photon Emission Computed Tomography (SPECT). Cureus 2023; 15:e38428. [PMID: 37273398 PMCID: PMC10234040 DOI: 10.7759/cureus.38428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Background The T-wave alterations are suggestive of ischemia, among them there is the pseudo-normalization (positivization of the T-wave, previously negative, during stress exercise). Myocardial single photon emission computed tomography (SPECT) at rest and stress is usually performed with Technetium 99 (Tc-99), which has high sensitivity and specificity for the detection of ischemic heart disease. In this study, we decided to investigate the patients who pseudo-normalized the T-wave in the stress test to correlate with the existence of ischemia diagnosed by myocardial perfusion study, specifically myocardial SPECT in perfusion and rest with Tc-99. Methodology T - wave pseudo-normalization patients who underwent a myocardial perfusion SPECT between January 2018 and June 2019 were included in this retrospective study. We analyzed 81 patients: 50 patients with pseudo-normalization of T-waves and 31 patients, as a control group, without pseudo-normalization. A descriptive analysis of the quantitative variables was performed using Student's t-test or Mann-Whitney U test, and for the qualitative variables, the χ2 test or Fisher's exact test was performed. Results The degree of ischemia according to the presence or absence of pseudo-normalization of the T-wave. The pseudo-normalization of the T-wave in the group without ischemia (48.4% vs. 36%), for the mild degree the proportions were the same (38.7% vs. 38%), the moderate degree it was slightly higher in the pseudo-normalization of the T-wave (9.7% vs. 18%) and severe (3.2% vs. 6%). Conclusions In this study, the relationship between pseudo-normalization of the T waveform and ischemia, predominantly moderate to severe, was demonstrated. However, it was not statistically significant due to the size of the sample studied.
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Affiliation(s)
- Juan Alan Fuentes Mendoza
- Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, MEX
- Cardiology, Policlinica Integral del Bajio, Irapuato, MEX
| | | | | | | | | | - Jorge Antonio Cervantes-Nieto
- Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, MEX
- Cardiology, PEMEX Regional Hospital Salamanca, Salamanca, MEX
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Pinkstaff S, Peberdy MA, Fabiato A, Finucane S, Arena R. The Clinical Utility of Cardiopulmonary Exercise Testing in Suspected or Confirmed Myocardial Ischemia. Am J Lifestyle Med 2010. [DOI: 10.1177/1559827610362955] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heart disease is a major cause of morbidity and mortality in the United States, with coronary artery disease (CAD) representing more than half of all cardiovascular events. Stable patients presenting with symptoms suggestive of CAD are likely to undergo an exercise electrocardiogram (ECG) and/ or imaging study as a first-line diagnostic assessment. A cardiopulmonary exercise test (CPX) is an ECG stress test plus ventilatory gas analysis. Recently, CPX has been used to detect exercise-induced myocardial ischemia (EIMI) suggestive of underlying CAD. Two CPX variables, oxygen pulse (VO2/HR) and the slope of oxygen consumption versus work rate (Δ VO2/ Δ WR), have been identified to be especially indicative of EIMI. Currently, there are a number of diagnostic tests available for the identification of CAD, with the most widely used being stress ECG, stress myocardial perfusion imaging (MPI) and echocardiography, and cardiac catheterization. Exercise ECG, although inexpensive, has a number of well-recognized limitations, including low sensitivity resulting in false-negative results. Stress (exercise or pharmaceutically induced) MPI and catheterization are more accurate but also more invasive and expensive. It appears that CPX may improve the diagnostic accuracy of exercise ECG. This review will address the potential utility of CPX in patients with suspected or confirmed myocardial ischemia.
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Affiliation(s)
- Sherry Pinkstaff
- Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia, , Department of Physiology and Biophysics, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia
| | - Mary Ann Peberdy
- Department of Internal Medicine Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia
| | - Alexander Fabiato
- Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia, Department of Physiology and Biophysics, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia
| | - Sheryl Finucane
- Department of Internal Medicine, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia
| | - Ross Arena
- Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia, Department of Physiology and Biophysics, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia
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Ajisaka R, Watanabe S, Masuoka T, Yamanouchi T, Saitoh T, Toyama M, Takeda T, Itai Y, Sugishita Y. Relationship between normalization of negative T waves on exercise ECG and residual myocardial viability in patients with previous myocardial infarction and no post-infarction angina. JAPANESE CIRCULATION JOURNAL 1998; 62:153-9. [PMID: 9583439 DOI: 10.1253/jcj.62.153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The usefulness of normalization of negative T waves in exercise ECG was investigated as an index of myocardial viability in patients with previous myocardial infarction with no symptoms or ischemic ST-segment change during exercise test. A total of 39 patients, 20 with T-wave normalization (POS group) and 19 without T-wave normalization (NEG group) on exercise ECG. were studied. Myocardial viability was evaluated by thallium-201 single-photon emission computed tomography (SPECT) during exercise or at rest. We also assessed left ventricular ejection fraction (LVEF) by contrast ventriculography before (n=39) and after percutaneous transluminal coronary angioplasty (PTCA) (n=17). SPECT detected myocardial viability in 16 (80%) of the 20 patients in the POS group and in 4 (21%) of the 19 patients in the NEG group (p<0.01). LVEF increased after successful PTCA in the POS group (from 53+/-13% to 63+/-8%, p<0.025), but fell in the NEG group (from 57+/-10% to 51+/-8%). It is concluded that normalization of negative T waves on exercise ECG is a useful, simple index of myocardial viability in patients with previous myocardial infarction with no symptoms or ischemic ST-segment change during exercise testing.
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Affiliation(s)
- R Ajisaka
- Department of Medicine, Institute of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
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Lavie CJ, Gibbons RJ, Zinsmeister AR, Gersh BJ. Interpreting results of exercise studies after acute myocardial infarction altered by thrombolytic therapy, coronary angioplasty or bypass. Am J Cardiol 1991; 67:116-20. [PMID: 1987711 DOI: 10.1016/0002-9149(91)90431-j] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Numerous studies have assessed the ability of exercise modalities to predict patient outcome after acute myocardial infarction (AMI). Implicit in the use of these prior data to assess the prognosis of patients currently undergoing exercise studies is the assumption that patients selected for exercise assessment are similar over time and that the data generated in the past are therefore applicable to the current patient populations. This study retrospectively assessed the clinical, exercise, and rest and exercise radionuclide angiographic data in 791 consecutive patients referred for exercise radionuclide angiography within 1 month after AMI during a 5-year period to determine if the clinical and exercise characteristics of patients referred for exercise evaluation after infarction have changed significantly over time. Most parameters examined demonstrated significant increasing trends, including thrombolytic therapy at the time of AMI, revascularization procedure between AMI and exercise assessment, age, beta-blocker usage, Q-wave AMI, inferior infarction, exercise double product, exercise capacity, significant ST-segment depression with exercise, peak ejection fraction, and change in ejection fraction with exercise. These data indicate that the characteristics of patients selected to undergo exercise after AMI in a large referral center have changed significantly over time. If these data are applicable to other referral centers and to other exercise testing modalities, previously published results regarding exercise assessment after AMI will need to be reconfirmed in patients currently selected for testing, since these results may no longer be applicable in this current era of aggressive medical and interventional management.
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Affiliation(s)
- C J Lavie
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Lavie CJ, Ventura HO, Murgo JP. Assessment of stable ischemic heart disease. Which tests are best for which patients? Postgrad Med 1991; 89:44-50, 57-60, 63. [PMID: 1985319 DOI: 10.1080/00325481.1991.11700785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
An understanding of the importance of various risk factors, the pathogenesis of myocardial ischemia, and the appropriate use of various noninvasive and invasive tests is essential for management of patients with known or suspected coronary artery disease (CAD). Although coronary angiography remains the "gold standard" for diagnosis of CAD, much of the data obtained from risk factor assessment, medical history, and various noninvasive tests provides information that may be even more important than cardiac catheterization data alone for defining prognosis and directing management.
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Affiliation(s)
- C J Lavie
- Ochsner Clinic, New Orleans, LA 70121
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