Diagnostic usefulness of postexercise systolic blood pressure response for detection of coronary artery disease in patients with echocardiographic left ventricular hypertrophy

BACKGROUND: Although exercise-induced electrocardiographic ST segment changes are used to detect coronary artery disease (CAD), their diagnostic value is markedly decreased in patients with left ventricular (LV) hypertrophy. There have been no reports concerning postexercise systolic blood pressure (SBP) response in patients with ultrasound echocardiographic (UCG) LV hypertrophy and CAD. METHODS: Sixty-six patients with both UCG-LV hypertrophy (LV mass index 134 g/m2 or greater for men or 110 g/m2 or greater for women) and positive ST depression of at least 0.1 mV during treadmill exercise testing were studied. Coronary cineangiograms showed normal coronary arteries in 19 patients (group 1) and significant CAD in 47 patients (group 2). The SBP ratio was calculated by dividing the SBP 3 min after exercise (3 min SBP) by the SBP at peak exercise (peak SBP). RESULTS: There were no significant differences between the two groups in LV mass index, SBP at rest, exercise duration, ST depression (at rest and exercise-induced) or 3 min SBP. However, the SBP ratio was significantly higher in group 2 compared with group 1 (0.87+/-0.11 versus 1.01+/-0.18; P=0.004). Analysis of relative cumulative frequency distributions revealed an SBP ratio of 0.92 as the cutoff point for distinguishing a UCG-LV hypertrophy patient with CAD from one without CAD. The sensitivity, specificity and accuracy with an SBP ratio of 0.92 and an ST segment depression of at least 0.1 mV on treadmill exercise testing for detecting CAD in patients with UCG-LV hypertrophy were 77%, 74% and 76%, respectively. CONCLUSION: These findings suggest that the ratio of early post-exercise SBP to peak exercise SBP may be diagnostically useful in detecting CAD in patients with positive ST depression during an exercise test and UCG-LV hypertrophy.     

Studies on ergometer exercise testing. I. Significance of the type of ST-segment response, sex, and chest pain

Ergometer exercise electrocardiographic (EECG) data were surveyed in a series of 328 patients (277 men and 51 women) subjected to coronary arteriography. The sensitivity and specificity of EECG for coronary artery disease (CAD) were 84% and 54%, respectively. The predictive accuracy of a positive test for CAD was 95% in men and 81% in women. The predictive accuracy of a negative test was 25% in men and 62% in women. When slowly ascending ST depression was considered insignificant, the sensitivity of EECG declined to 71%, with an increase in specificity to 64%. CAD was present in 89% of the patients with slowly ascending ST depression and 65% of them had a multivessel disease. Seventy-two subjects had postexercise ST-segment elevation. The predictive value of this sign for CAD was 94%. Exercise-induced chest pain had quite a similar diagnostic significance as EECG. The prevalence of CAD in patients with a history of typical angina was 94% in both sexes. Atypical chest pain was associated with normal coronary arteriography in 59% of males and 100% of females.     

急性冠状动脉综合征血清缺血修饰白蛋白的动态变化

目的:探讨血清缺血修饰白蛋白(IMA)对急性冠状动脉综合征早期的诊断价值。方法:将56例急性冠状动脉综合征患者分为三组,不稳定性心绞痛组(n=25),ST抬高心肌梗死组(n=20),非ST抬高心肌梗死组(n=11),另选50例健康体检者为正常对照组。分别于胸痛发作2、4、6、12及24 h抽血检测56例急性冠状动脉综合征患者的血清缺血修饰白蛋白、肌钙蛋白Ⅰ(cTnI)、肌酸激酶MB同工酶(CK-MB),分析缺血修饰白蛋白对急性冠状动脉综合征的诊断价值。结果:在急性冠状动脉综合征患者中缺血修饰白蛋白水平于胸痛发作2小时已明显增高并达高峰,4小时仍持续增高,明显高于正常对照组(P<0．01),6小时降至正常。而CK-MB、cTnI水平在胸痛发作4小时开始增高,6小时明显增高,以后逐步递增并在24小时达高峰。不稳定型心绞痛、ST抬高的心肌梗死、非ST抬高的心肌梗死三组中,缺血修饰白蛋白水平升高以不稳定型心绞痛组最明显。结论:缺血修饰白蛋白是诊断急性冠状动脉综合征的早期敏感指标,是目前唯一的诊断心肌缺血的生化标志物。     

缺血修饰白蛋白对急性心肌缺血早期诊断价值的探讨

目的探讨缺血修饰白蛋白（IMA）测定对急性心肌缺血的早期诊断价值。方法采用白蛋白钴结合试验检测830例健康体检者（健康对照组）、492例急性冠状动脉综合征患者（ACS组）、74例单纯性高血压病患者（高血压组）、78例病毒性心肌炎患者（病毒性心肌炎组）、395例急性胸痛者（急性胸痛组,包括急诊ACS患者133例与随诊胸痛患者262例）和68例接受经皮冠状动脉介入治疗术患者（PCI组）血清或血浆IMA水平,并对其中急诊ACS患者进行IMA水平动态观察及血清肌钙蛋白I（cTnI）和心电图检测。结果根据ROC曲线,当临界值为0．45时综合评价最佳。ACS组和病毒性心肌炎组IMA水平分别为（0．55±0．11）吸光度单位（ABSU）和（0．38±0．11）ABSU,高于健康对照组[（0．34±0．08）ABSU,P〈0．05],且ACS组和病毒性心肌炎组之间IMA差异有统计学意义（P〈0．05）。急性胸痛组中急诊ACS患者IMA水平及阳性率分别为（0．54±0．12）ABSU和77．4％,高于随诊者的（0．44±0．12）ABSU和39．3％（P〈0．01）。在133例急诊ACS患者中,首诊1h内IMA阳性率为82．O％,高于同期cTnI阳性率40．6％（P〈0．01）,就诊后6—24hIMA与cTnI水平及阳性率较首诊1h内显著升高（P〈0．01）。在72例急性胸痛发作3h内入院且cTnI均为阴性的ACS患者中,首诊IMA阳性率为86．1％,心电图阳性率为72．2％,两者联合测定阳性率为93．1％。PCI术后即刻患者动脉血浆IMA水平较术前IMA明显升高（P〈0．05）。首诊ACS患者IMA水平高于临界值,于入院1天达峰值,且持续升高,后缓慢下降,入院14天IMA均值接近正常水平。结论IMA早期诊断急性心肌缺血具有临床应用价值。     

Significance of silent myocardial ischemia during exercise testing in patients with coronary artery disease

To evaluate the significance of ischemic ST-segment depression without associated chest pain during exercise testing, data were analyzed from 2,982 patients from the Coronary Artery Surgery Study (CASS) registry who underwent coronary arteriography and exercise testing and were followed up for 7 years. Patients with proved coronary artery disease (CAD) (at least 70% diameter narrowing) were grouped according to whether they had at least 1 mm of ST-segment depression or anginal chest pain during exercise testing. Four hundred twenty-four had ischemic ST depression without angina (group 1); 232 had angina but no ischemic ST depression (group 2); 456 had both ischemic ST depression and angina (group 3); and 471 had neither ischemic ST depression nor angina (group 4). Sixty-three percent of patients in group 1 and 55% in group 2 had multivessel CAD (difference not significant). The 7-year survival rates were similar for patients in groups 1 (76%), 2 (77%), and 3 (78%), but were significantly better for patients in group 4 (88%, p less than 0.001). Among group 1 patients, survival was related to severity of CAD (p less than 0.001). The 7-year survival rate in group 1 was significantly worse than that in a separate group of 282 patients with ischemic ST depression without angina during exercise testing who had no CAD (95% survival, p less than 0.001). Thus, in patients with silent myocardial ischemia during exercise testing, the extent of CAD and the 7-year survival rate are similar to those of patients with angina during exercise testing. Prognosis is determined primarily by the severity of CAD. In patients without CAD, the survival rate is excellent.     

Different recovery process of st depression on postexercise electrocardiograms in women in standing and supine positions

False-positive exercise test responses are frequently observed in women. To differentiate a false-positive from a true-positive test response, the effect of postures for recording a postexercise electrocardiogram to the recovery process of ST depression was investigated in 26 women with nonischemic ST depression and in 14 patients with typical angina pectoris. Exercise tests were performed twice, and the postexercise electrocardiogram was recorded while standing during the first test and in the supine position during the second test. In the false-positive test, maximal ST depression occurred immediately after exercise and showed a rapid re covery process In the early recovery phase. However, ST depression persisted without complete recovery, or increased in the late recovery phase as long as subjects were kept standing. In contrast, ST depression returned to the control level when subjects changed to the supine position after exercising. This discrepant pattern in the recovery process of ST depression by changing postures was not observed in the true-positive test results. Changing postures for recording postexercise electrocardiograms could be helpful in differentiating a falsepositive response from a true ischemic response.     

Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain

The incremental value of clinical assessment, exercise electrocardiography (ECG) and biplane radionuclide ventriculography (RVG) in the prediction of coronary artery disease (CAD) was assessed in 105 men without myocardial infarction who were undergoing coronary angiography for investigation of chest pain. Independent clinical assessment of chest pain was made prospectively by 2 physicians. Graded supine bicycle exercise testing was symptom-limited. Right anterior oblique ECG-gated first-pass RVG and left anterior oblique ECG-gated equilibrium RVG were performed at rest and exercise. Regional wall motion abnormalities were defined by agreement of 2 of 3 blinded observers. A combined strongly positive exercise ECG response was defined as greater than or equal to 2 mm ST depression or 1.0 to 1.9 mm ST depression with exercise-induced chest pain. A multivariate logistic regression model for the preexercise prediction of CAD was derived from the clinical data and selected 2 variables: chest pain class and cholesterol level. A second model assessed the incremental value of the exercise test in prediction of CAD and found 2 exercise variables that improved prediction: RVG wall motion abnormalities, and a combined strongly positive ECG response. Applying the derived predictive models, 37 of the 58 patients (64%) with preexercise probabilities of 10 to 90% crossed either below the 10% probability threshold or above the 90% threshold and 28 (48%) also moved across the 5 and 95% thresholds. Supine exercise testing with ECG and biplane RVG together, but neither test alone, effectively adds to clinical prediction of CAD. It is most useful in men with atypical chest pain and when the ECG and RVG results are concordant.     

Exercise testing in women with chest pain. Are there additional exercise characteristics that predict true positive test results?

Women have a notoriously high rate of false positive exercise test results. Since the exercise ST segment response has low specificity in predicting CAD in women, we examined additional exercise parameters in 200 women with a history of chest pain compatible with angina and having ST segment depression greater than or equal to 1 mm recorded during a Bruce treadmill test. All subsequently had coronary arteriography. Two groups were compared: group A (n = 80) with CAD (greater than or equal to 70 percent stenosis of one or more coronary artery) and group B (n = 120) with angiographically confirmed normal coronary arteries (normal or minimal placquing). The exercise criteria analyzed included: (1) chest pain during exercise, (2) percent target heart rate, (3) extent of ST shift, (4) morphology of the ST segment slope, (5) time to normalization of the ST segment, and (6) total exercise duration. Multivariate analysis (using a stepwise logistic regression model) identified four independent exercise variables associated with the likelihood of CAD: (absence of MVP, p = .003; exercise duration less than 5 min, p = .02; ability to reach target heart rate, p = .027; time to ST normalization greater than or equal to 6 min, p less than .001). False positive exercise test results were more likely to occur when the following exercise test variables were present: ability to exercise to stage 3 of the Bruce protocol and a rapid (less than or equal to 4 minutes) normalization of ST shift after cessation of exercise. Attention to these additional exercise variables allows more careful selection of women requiring more definitive (and expensive) testing.     

Correlation between exercise electrocardiography test and coronary flow reserve in patients without organic coronary artery stenosis

OBJECTIVES: The exercise electrocardiography (ECG) test is frequently positive in patients without organic coronary artery stenosis. Although the reason for this false positive ST depression is not fully understood, one possibility may be related to coronary microvascular abnormality. The present study investigated the relationship between the exercise ECG test and coronary flow reserve (CFR) in patients with angiographically normal coronary arteries, but with positive ECG ST depression. METHODS: This study included 67 patients, 32 with chest pain syndrome, and 35 with vasospasm. The exercise ECG test was performed without drug administration in all patients, and the CFR was determined after diagnostic cardiac catheterization. RESULTS: Although a significant correlation was recognized between ST depression and CFR in patients with chest pain syndrome (p < 0.05), there was no correlation in patients with epicardial coronary vasospasm. CONCLUSIONS: In patients with chest pain syndrome, ST depression detected by the exercise ECG test may suggest coronary microvascular dysfunction. However, in patients with coronary vasospasm, ST depression may occur without decreased CFR, suggesting that coronary spasm or other mechanism (s) relating to ST changes are present during the exercise ECG test, and careful interpretation is needed.     

平板运动试验中室性早搏ST段下移诊断冠状动脉病变的价值

探讨平板运动试验中室性早搏(VPCs)ST段下移程度对反映冠状动脉(简称冠脉)病变的价值。将休息和平板运动试验中均发生VPCs并且在3个月内进行冠脉造影的92例患者按冠脉造影结果分成冠心病组和非冠心病组,比较两组VPCsST段下移程度,下移程度与冠脉狭窄程度的关系以及VPCsST段下移诊断冠心病的价值。结果:冠心病组运动中VPCsST段下移及ST/R均大于非冠心病组。其中ST/R>10%对冠心病诊断灵敏度为91%,特异度为75%;对单支、2支、3支血管病变诊断灵敏度分别为84%、91%、100%。冠脉狭窄≥90%组运动中VPCsST段下移和ST/R大于狭窄为50%~69%组。结论:运动试验中VPCsST段下移可作为诊断冠心病的有效参考指标,其下移程度可能与冠脉狭窄程度有关。     

Detection of Exercise‐Induced Myocardial Ischemia by Multichannel Magnetocardiography in Single Vessel Coronary Artery Disease

Background: Detection of myocardial ischemia was studied with multichannel exercise magneto‐cardiography (MCG). A surface gradient method was applied to analyze cardiac magnetic fields. Methods: We studied 27 patients with single vessel coronary artery disease (CAD) and 17 healthy volunteers. The MCG was recorded over anterior chest during supine bicycle ergometry. The two‐dimensional direction of the maximum spatial magnetic field gradient was determined during the ST segment and at the T‐wave apex at different phases of stress test. Results: The CAD patient group was separated from controls by the orientation of the magnetic field gradient during the ST segment at cessation of exercise (CAD 167 ± 68° vs controls 106 ± 49°; P < 0.005) and at 4 minutes postexercise, but not at rest. The‐CAD patient group was separated from controls also by the orientation of the magnetic field gradient at the T‐wave apex at 4 minutes postexercise (CAD 87 ± 60° vs controls 58 ± 18° P < 0.05), but not at rest. The change in the orientation of the field gradient at the T‐wave apex 4 minutes postexercise, compared to baseline, was greater in CAD patients (31 ± 43°) than in controls (9 ± 8° P < 0.05). This change was larger in the patient group with stenosis in the right than in the left coronary artery (P < 0.05). Conclusions: Transient acute myocardial ischemia causes well‐recognizable changes in the magnetocardiogram at the ST segment and the T wave. The orientation of the maximum spatial gradient of the magnetic field can be used as a parameter to determine these changes.     

Thallium-201 scintigraphy after dipyridamole infusion with low-level exercise. III. Clinical significance and additional diagnostic value of ST segment depression and angina pectoris during the test

Intravenous dipyridamole thallium testing is a useful alternativeprocedure for assessing coronary artery disease (CAD) in patientswho are unable to perform maximal exercise tests. IschaemicST segment depression and angina pectoris are frequently observedduring the test, in particular when exercise is added to dipyridamoleinfusion. To establish the clinical significance and additionaldiagnostic value of these markers of ischaemia during dipyridamolelow-level exercise testing (DXT) 57 patients with CAD (groupA), 21 patients with normal or near-normal coronary arteriesat coronary arteriography (group B), and 20 healthy subjectswith low likelihood of CAD (group C) were studied. During DXT ischaemic ST segment depression was observed in 28patients (47%) of group A and in two patients (10%) of groupB. Angina pectoris was experienced by 35 patients (61%) of groupA and by five patients (24%) of group B. The positive predictivevalue of both ST depression and angina pectoris was high (88and 93%, respectively), but the negative predictive values werelow (42 and 40%, respectively). Combining ST segment analysiswith the findings of thallium imaging significantly increasedthe diagnostic accuracy of the test. ST segment depression, angina pectoris, and thallium abnormalitieswere highly specific findings if the study population consistedof asymptomatic subjects with a low likelihood of CAD (groupC). Sensitivity for the detection of the presence of CAD increasedwith the extent of CAD for all parameters studied. Thus, STdepression and angina pectoris, alone or in combination, duringDXT have little diagnostic significance, although sensitivityis increased in patients with triple-vessel CAD. Analysis ofthe ST segment provides additional information and should thereforebe included in the overall interpretation of the test results.A marked difference in the false positive rates for all parameterswas observed between asymptomatic subjects and angiographicallynormal patients with chest pain syndromes, which can be explainedby selection bias.     

Ischemia-modified albumin in relation to exercise stress testing.

OBJECTIVES: We examined whether ischemia-modified albumin (IMA) plasma levels change during exercise stress testing (EST) in patients with known coronary artery disease and whether the induced changes differ between positive and negative exercise tests. BACKGROUND: Ischemia modified albumin is considered a marker of myocardial ischemia and increases after coronary angioplasty and in acute coronary syndromes. METHODS: We studied 40 consecutive patients with established coronary artery disease who underwent EST. Venous samples, for IMA measurement, were collected before the stress test (baseline), at peak exercise, and 60 min after the completion of the exercise test. RESULTS: There was significant difference in the IMA values at the 3 prespecified time points (p = 0.012), whereas there was no interaction between the IMA changes and the result of the stress test, whether positive or negative (p for the interaction term = 0.94). Baseline, peak EST, and post-EST IMA levels were similar in patients with positive and negative exercise tests (p = 0.61). The IMA significantly decreased at peak exercise compared with baseline values in positive (p < 0.0001) and in negative EST (p = 0.012). Moreover, IMA concentration increased 60 min after EST compared with peak-EST values in positive (p < 0.0001) and in negative tests (p = 0.003), returning to pre-EST levels in both groups. CONCLUSIONS: The IMA plasma levels change significantly during exercise testing in patients with coronary artery disease, but there is no difference between positive and negative stress tests; this possibly implies that the observed changes do not reflect myocardial ischemia.     

平板运动试验不同导联ST改变对冠心病的诊断价值

目的:总结平板运动试验中不同导联ST改变对冠心病的诊断价值。方法:2001年1月至2005年12月在我科行平板运动试验阳性患者300例,进行了冠脉造影检查,回顾性总结分析其平板运动试验中不同导联ST段变化对冠心病的诊断价值。结果:平板运动试验阳性患者300例。冠脉造影检查阳性231例,其中肢体导联阳性组37例,胸导联阳性组89例,肢体导联 胸导联阳性组105例,胸导联ST改变较单纯肢体导联ST改变有显著的差异性(P<0.05)。结论:平板运动试验诊断中胸导联ST改变较单纯肢体导联ST改变对冠心病的诊断有较好的预测价值。     

Study of silent myocardial ischemia using exercise stress test among diabetic and non-diabetic patients with documented coronary artery disease

IntroductionProspective studies have documented an increased likelihood of sudden cardiac death and unrecognized myocardial infarction in patients with diabetes.Aim of the workTo study silent myocardial ischemia using exercise stress test among diabetic and non-diabetic patients with angiographically documented coronary artery disease.Patients and methodsPatients with contra-indications to exercise test were excluded.All patients were subjected to treadmill test using modified Bruce protocol & were considered to have silent ischemia if ECG shows ischemic changes without chest pain.StatisticsData were collected & analyzed statistically.ResultsThe study included 80 patients with CAD (40 diabetics & 40 non-diabetics).Their mean age was 58 years old, including males (73.8%).According to stress test patients were classified:

• 1-Group 1: 28 patients (35%), showed no ST depression no chest pain during exercise test, 10 patients of them (35.7%) were diabetic.
• 2-Group 2: two patients (2.5%) who were diabetic showed chest pain without stress induced ST depression (only pain).
• 3-Group 3: 26 patients (32.5%) showed stress ST depression without chest pain (silent ischemia), 18 patients of them (69.2%) were diabetic.
• 4-Group 4: 24 patients (30%) showed ST depression and chest pain during exercise test (symptomatic ischemia), 10 patients of them (41.7%) were diabetic.

All patients underwent coronary angiography (100%) and all of them had significant coronary artery disease (more than 50% stenosis).ConclusionDiabetics with coronary artery disease have a higher prevalence of silent myocardial ischemia than non-diabetics.     

Pattern of exercise-induced ST change is related to coronary flow reserve in patients with chest pain and normal coronary angiogram

OBJECTIVE: To evaluate the usefulness of exercise treadmill test in determining the true microvasculature-induced ischemia, we compared the pattern of ST depression with coronary flow reserve (CFR) using transthoracic Doppler echocardiography (TTE) in patients with chest pain and normal coronary angiogram. DESIGN: Fifty-nine subjects (M/F=21:38, mean age 55+/-9 years) with chest pain and normal coronary angiogram underwent maximal symptom-limited exercise treadmill test (ETT). CFR was estimated with TTE and dipyridamole. Patients with a history of acute myocardial infarction, regional wall motion abnormalities, hypertrophic cardiomyopathy, ejection fraction less than 50%, or primary valvular heart disease were excluded from this study. RESULTS: No ST change was observed in 20 of 59 (34%) patients, up slope depression was observed in 20 (34%), flat depression in 13 (22%), and down slope depression in 6 (10%). Eleven of thirty nine (28%) exercise positive patients had decreased CFR <2.1. CFR was 3.1+/-0.6 in group with no ST change, 3.1+/-0.6 in group with up slope depression, 2.1+/-0.6 in group with flat depression (p<0.05 versus group with no change and group with upslope depression, respectively), and 2.0+/-0.4 in group with down slope depression (p<0.05 versus group with no change and group with up slope depression, respectively). Flat to down slope depression of ST change during ETT had sensitivity of 58% and specificity of 95% for predicting CFR <2.1. CONCLUSION: Flat and down slope depression of ST segment during ETT might increase the sensitivity and specificity to detect the true microvasculature-induced ischemia that is defined as CFR less than 2.1 in patients with chest pain and normal coronary angiogram.     

Can the exercise test with nitroglycerin be useful for differentiation of patients with and without changes in coronary arteries--syndrome X?

The aim of this study was to compare the results of ECG exercise test performed before and after oral administration of nitroglycerine (NTG) in patients with coronary artery disease (CAD), and patients with typical chest pain without any changes in coronary arteriography--syndrome X. We examined 98 patients with typical chest pain, positive result of ECG exercise test, then accordingly to results of coronary arteries assessed with coronary arteriography, patients (pts.) were divided into two groups: group 1--35 pts. without any changes in coronary arteriography--syndrome X, and group 2--48 pts. with significant stenosis present in one or more coronary vessels. Each patient underwent two ECG exercise tests: first without any medication and second performed average 30 minutes after first test, and 5 min after oral administration of 1 table of nitroglycerine. During both tests the following parameters were evaluated: test duration, presence of chest pain, max. ST-T changes, heart rate (HR), and systolic blood pressure (SBP). RESULTS: In group 1 after NTG time of test duration had shortened from 5.9 +/- 0.4 min to 5.7 +/- 0.6 min. We also observed an increase in max. ST-T complex depression (2.2 +/- 0.5 mm vs 2.4 +/- 0.4 mm) but these differences were not statistically significant. In CAD group, duration of test after NTG was longer (6.2 +/- 1 vs 7.4 +/- 1.2), and normalization of max. ST-T complex depressions (2.7 +/- 0.5 vs 2.0 +/- 0.3 mm) was observed p < 0.01. CONCLUSION: Our study suggests that ECG exercise test with NTG may be useful in differentiation of patients with syndrome X and patients with typical coronary artery disease.     

The effect of hypolipemic therapy with diet and simvastatin on the course of angina pectoris and the results of exercise stress test in patients with coronary artery disease

Statins are the multi-directorial acting drugs in atherosclerosis prevention, which decrease the overall and cardiovascular mortality. The aim of this study was to estimate the effect of six-month long hypolipemic therapy with diet and 20 mg of simvastatin on clinical intensity of angina pectoris and the course of exercise stress test. Patients and methods: We studied 44 patients with typical anginal chest pain. In all blood sampling and treadmill stress test were made, and next in all hypolipemic diet and simvastatin 20 mg were recommended. After four weeks and six months of treatment clinical assessment and exercise test were made. Results: After four weeks and six month long observation period the decrease of total and LDL cholesterol, triglycerides and fibrinogen were found. Moreover, we have observed the improvement in frequency of anginal symptoms, their intensity in CCS classification and number of nitroglycerin tablets taken per week. The course of exercise test was also ameliorated: the percentage of patients, in whom stress test was finished because of chest pain was decreased, time of chest pain duration after exercise cessation was shorter, the percentage of patients with significant ST interval depression diminished, maximal ST interval depression as well as the time of significant ST interval depression duration also decreased. Although improvement in values of mentioned parameters, after six months long therapy with simvastatin the percentage of patients with Duke's treadmill score value showing intermediate cardiovascular risk (between -10 and +4) increased. In conclusion, therapy with hypolipemic diet and simvastatin already after four weeks decreased plasma lipids and fibrinogen levels and improved the course of angina pectoris and exercise stress test, what suggested its effectiveness not only as the treatment improving atherosclerosis risk factors, but also with prompt and clinical important effect ameliorating the handicapped coronary reserve.     

Electrocardiographically and symptomatically silent myocardial ischemia during exercise testing

Certain patients with coronary artery disease (CAD) may have neither ST depression nor chest pain during exercise despite the presence of myocardial ischemia. The frequency and characteristics of such electrocardiographically and symptomatically silent ischemia were studied in 171 patients with both angiographically documented CAD and scintigraphically documented ischemia. Fifty-six (33%) of 171 patients had neither ST depression nor chest pain (Group N), and 115 (67%) had ST depression and/or chest pain (Group P). The two groups were similar with respect to age, gender, the prevalence of prior infarction, and peak systolic blood pressure. Group N patients, however, had a higher mean peak heart rate and rate-pressure product, less severe scintigraphic ischemia, a lower lung thallium-201 uptake, and a smaller number of diseased vessels. Stepwise discriminant analysis showed a history of effort angina, lung thallium-201 uptake, and scintigraphic severity of ischemia to be significant discriminators between Groups N and P. In conclusion, electrocardiographically and symptomatically silent ischemia may be common during exercise in patients with CAD, and less severe ischemia may be one of important determinants.     

Role of coronary spasm for a positive noninvasive stress test result in angina pectoris patients without hemodynamically significant coronary artery disease

BACKGROUND: A positive noninvasive stress test result is often considered as a false-positive indicator of coronary artery disease (CAD) when coronary angiography reveals no hemodynamically significant CAD. METHODS: From January 2001 through December 2004, 5474 patients scheduled to undergo exercise electrocardiogram (ECG) [exercise ECG without imaging or exercise ECG with thallium-201 (201Tl) single photon emission tomography (SPECT)] or dipyridamole 201Tl tomography at our outpatient clinic because of chest oppressive sensation were included in this prospective study. Coronary angiography was performed when a noninvasive test result was positive for ischemia or when ischemic chest pain was suspected. Intracoronary methylergonovine testing was performed when spastic angina was suspected and coronary angiography showed no hemodynamically significant CAD. RESULTS: Noninvasive stress testing was positive in 113 (67%) patients with coronary spasm. Of the 53 patients who had positive exercise ECG (exercise ECG with or without imaging), ST depression was found in 50 patients and ST elevationin in 3 patients. Multivessel spasm was found in 6 (15%), 6 (15%), and 7 (21%) of the patients with a positive result on exercise ECG without imaging, exercise ECG with 201Tl SPECT, and dipyridamole 201Tl SPECT, respectively. There was no significant difference in the results of noninvasive stress testing and the number of vessels with coronary spasm (1-vessel spasm versus multivessel spasm) among these 3 noninvasive stress testing groups. CONCLUSION: Intracoronary ergonovine testing induced coronary spasm in over 50% of patients who had suspected ischemic chest pain, a positive noninvasive stress test, and no hemodynamically significant CAD.