Prognostic value of early exercise stress testing after successful coronary angioplasty: importance of the degree of revascularization

The prognostic value of early exercise testing after successful coronary angioplasty was determined in 196 and 225 consecutive patients with single-vessel and multivessel coronary disease, respectively, who underwent a symptom-limited exercise test within 30 days of the procedure. The incidence of exercise-induced ST segment depression greater than or equal to 1 mm was significantly greater in patients with multivessel versus single-vessel disease (27% versus 14%; p less than 0.005) and in patients with multivessel coronary disease who had incomplete versus complete revascularization (36% versus 10%; p less than 0.001). An abnormal exercise ECG result was associated with a significantly increased risk of cardiac events in patients with multivessel disease but not in patients with single-vessel disease. Exercise-induced angina occurred in a small and similar proportion of patients with single and multivessel coronary disease (8% versus 12%). The presence of exercise-induced angina was associated with a higher incidence of follow-up cardiac events in patients with multivessel disease and incomplete revascularization (52% versus 33%; p less than 0.05). Exercise duration was significantly less in patients with multivessel disease who had a subsequent cardiac event compared with that in patients who did not have such an event (458 +/- 168 versus 519 +/- 156 seconds; p = 0.01). Thus an abnormal exercise ECG finding within 1 month of successful coronary angioplasty is predictive of subsequent cardiac events in patients who have multivessel disease. The prognostic content of the test might be further improved if the test were performed several months after the procedure when the risk of restenosis is greatest.     

Prognostic value of computer-quantitated exercise thallium imaging early after percutaneous transluminal coronary angioplasty

To develop an approach to predicting adverse events after percutaneous transluminal coronary angioplasty (PTCA), 50 patients had thallium-201 exercise testing within 1 month after successful single vessel coronary angioplasty and were followed up for a mean of 18 months. Adverse events were: 1) clinical events consisting of recurrent angina (17 patients) and myocardial infarction (1 patient); 2) treatment events consisting of repeat coronary angioplasty (10 patients) and coronary bypass surgery (1 patient); and 3) restenosis, defined as a greater than 30% increase in luminal stenosis (15 of 38 recatheterized patients). There were no deaths. Of the clinical, exercise, angiographic and thallium scan variables analyzed by stepwise logistic regression, postangioplasty gradient greater than 20 mm Hg predicted clinical events and treatment events, and the number of segments with slower thallium clearance predicted clinical events, treatment events and restenosis. Using Cox Hazards model regression of survival without events, the number of transient qualitative thallium defects also predicted clinical events and restenosis. At 1 year after angioplasty, 24% of patients with these variables had restenosis compared with only 6% of those without these variables and 36% of patients with these variables had a clinical or treatment event compared with 8% of patients without these variables. Three measures of the adequacy of myocardial perfusion (post-angioplasty gradient, reduced thallium clearance and transient thallium defects) were additive predictors of adverse events after coronary angioplasty with the relative risk being approximately four times greater in patients with these variables than in those without. Such adverse events, therefore, are usually a consequence of inadequate revascularization.     

Prognostic value of radionuclide exercise testing after myocardial infarction

Abnormal systolic ventricular function and persistent ischemia are sensitive indicators of poor prognosis following myocardial infarction. The use of exercise improves the utility of both radionuclide ventriculography and myocardial perfusion scintigraphy in the identification of postinfarction patients at high risk of subsequent cardiac events.     

药物洗脱支架置入后早期冠状动脉支架内血栓的危险因素分析

目的探讨药物洗脱支架(DES)置入后发生早期支架内血栓(EST)的危险因素。方法河北省沧州市中心医院2008—2018年行DES置入的患者共有20 518例,回顾性选取97例明确EST患者为EST组,按照年龄、性别和危险因素相近似的原则,选取194例患者为对照组。分析两组患者的临床和围术期资料,并应用logistic回归分析评估EST的危险因素。结果 DES置入术后EST的发生率为0.5%(107/20 518),病死率为23.4%(25/107)。291例患者中,男性127例(43.6%),年龄18～80岁,平均年龄为(68.1±8.2)岁。两组的糖尿病、高三酰甘油血症、高纤维蛋白原、ST段抬高型急性冠状动脉综合征、弥漫病变、小血管病变、多枚支架串联、支架≥30 mm、第二代药物涂层支架、未高压后扩张及使用血小板膜糖蛋白Ⅱb/Ⅲa受体拮抗剂等均有显著差异(均为P<0.05)。多因素logistic回归分析发现,高三酰甘油血症、弥漫病变、小血管病变、多枚支架串联、支架长度≥30 mm、未应用第二代药物涂层支架、未高压后扩张是EST的危险因素(均为P<0.05),其中直径≤2.75 mm的小血管病变是最强的预测因素(OR=6.37,95%CI:2.51～11.86)。结论 EST有多种危险因素,需规范介入操作及加强围术期抗栓治疗,尤其是小血管及弥漫病变需要多枚支架串联的患者,应选用第二代药物涂层支架,且行高压后扩张,防止支架贴壁不良,减少EST的发生。     

冠状动脉支架置入术后早期血管损伤的变化

目的:观察冠状动脉支架置入术后早期血管损伤的变化情况,探讨冠状动脉支架置入术后再狭窄的机制.方法:选择经冠状动脉造影检查证实为冠心病的患者,随机分为支架组(30例)及对照组(30例).2组患者均于冠状动脉支架置入或冠状动脉造影术前后采集肘静脉血,检测内皮素-1(ET-1)、P-选择素(PS)、纤维蛋白原(Fbg)、CD11b的水平,并进行统计学分析.结果:①支架组中ET-1、PS在术后0.5 h上升至高峰,Fbg、CD11b在术后1 d达到高峰;与术前当天及对照组比较,均差异有统计学意义(P<0.01).②术前水平与术后高峰的差值在ET-1、Fbg、CD11b两两之间呈正相关,年龄及支架长度与ET、Fbg、CD11b术后高峰水平之间无相关性.结论:支架置入术后早期出现了明显的血管损伤反应,伴随着显著的血小板活化及一过性的凝血功能亢进,并诱发了明显的局部炎症反应.     

Prognostic information from early post-infarction exercise testing

Early post-myocardial infarction exercise testing has proved surprisingly safe. S-T elevations portended a bad prognosis as did also marked S-T segment depressions, especially if combined with premature ventricular contractions or short duration of exercise. A poor prognosis was also seen if, at low workloads, blood pressure could not reach 130 mm Hg, the heart rate did not rise above 130 beats per minute, or if there was angina. Complex arrhythmias were only of prognostic value as an independent variable with ambulatory monitoring. Negative findings were of more predictive value than positive results and have important therapeutic implications.     

Prognostic value of exercise echocardiography in patients after coronary artery bypass surgery

To assess the prognostic value of exercise echocardiography in patients with prior coronary artery bypass surgery, follow-up was obtained in 718 patients (591 men [82%] and 127 women [18%], aged 67 +/- 9 years) who underwent clinically indicated exercise echocardiography 5.7 +/- 4.7 years after coronary bypass surgery. Resting wall motion abnormalities were present in 479 patients (67%). New or worsening wall motion abnormalities developed with exercise in 366 patients (51%). During a median follow-up of 2.9 years, cardiac events included cardiac death in 36 patients and nonfatal myocardial infarction in 40 patients. The addition of the exercise echocardiographic variables, abnormal left ventricular end-systolic volume response and exercise ejection fraction to the clinical, resting echocardiographic and exercise electrocardiographic model provided incremental information in predicting cardiac events (chi-square 37 to chi-square 42, p = 0.02) and cardiac death (chi-square 38 to chi-square 43, p <0.02). Exercise echocardiography provides prognostic information in patients after coronary artery bypass surgery, incremental to clinical, rest echocardiographic, and exercise electrocardiographic variables.     

Prognostic importance of early exercise testing in men with suspected unstable coronary artery disease

In 276 men with suspected unstable coronary artery disease i.e.recurring chest pain of new onset, increasing symptoms of anginalchest pain in formerly stable angina pectoris or suspected non-Q-waveinfarction, an exercise test was performed 2–7 days afteradmission. Coronary events i.e. cardiac death (N=4), Q-waveinfarction (N=11) and coronary artery bypass grafting (N=34),were registered during one year follow-up. The indication forbypass grafting was incapacitating angina pectoris despite medication,and suitable coronary anatomy. Stepwise multiple regressionanalysis showed that S–T segment depression and limitingchest pain were the most important prognostic parameters regardingcoronary events. In patients with S–T segment depression>0.1 mV or limiting chest pain (N=94) the occurrence of Q-wavemyocardial infarction or cardiac death was 10.6% (N=10) comparedto 2.8% (N=5) in patients without these criteria (N=182) (P<0.01).Coronary arterty bypass graft surgery was performed in 33% (N=31)of the group with S–T segment depression >0.1mV orlimiting chest pain but in only 1.7% (N=3) of the other patients(P<0.001). Thus, in patients with suspected unstable coronaryartery disease, whose symptoms and signs of ischaemia are stabilizedby medication, an exercise test can safely be performed aftera few days ambulation in the ward. The early exercise test providesimportant prognostic information regarding the risk for severecoronary events within the next year.     

Chest pain after coronary artery stent implantation

A sizeable proportion of patients who undergo successful coronary artery stent implantation experiences chest pain immediately after the procedure and/or in the following months in the absence of in-stent restenosis. We investigated this phenomenon in 57 consecutive patients with stable angina who underwent successful stent implantation. Chest pain characteristics were assessed before stent implantation and during 6-month follow-up. All patients underwent coronary angiography within 6 months of the procedure 48 hours after exercise thallium-201 perfusion scintigraphy. Patients who did not exhibit in-stent restenosis underwent an ergonovine test at the end of routine coronary angiography. During follow-up, 15 patients complained of chest pain. Six of these patients exhibited scintigraphic evidence of myocardial ischemia and in-stent restenosis at angiography. In the remaining 9 patients, chest pain occurred in the absence of in-stent restenosis at angiography. In 8 of these patients intracoronary ergonovine administration reproduced their habitual pain, whereas it did not cause any pain in the 42 patients who were completely asymptomatic at follow-up and without in-stent restenosis. Ergonovine caused more intense vasoconstriction and nitroglycerin caused more intense vasodilation of the reference coronary diameter in patients with than in patients without ergonovine-induced pain (-17 +/- 3 vs -9 +/- 3%, p <0.001; 9 +/- 6 vs 5 +/- 4%, p <0.02, respectively). In conclusion, chest pain with features similar to habitual angina occurs in the absence of in-stent restenosis in 1/5 of patients after stent implantation and appears to be associated with more intense coronary vasoreactivity.     

冠状动脉支架术后的胸部不适与再狭窄

目的 :了解冠状动脉支架术后胸部不适与再狭窄关系。方法 :选择接受冠状动脉支架术并在 6个月内进行了冠状动脉造影检查的 186例患者 ,对术后胸部不适和无胸部不适患者进行冠心病易患因素和术后再狭窄比较。结果 :胸部不适和无胸部不适者术后支架内再狭窄的百分率分别为 2 1.4 %和 15 .2 % ,两组的再狭窄率差异无显著性意义。结论 :冠状动脉支架术后的胸部不适除与再狭窄有关外 ,可能与血管内皮功能紊乱及血管的反应性有关。     

Prognostic importance of early exercise testing in men with suspected unstable coronary artery disease

In 276 men with suspected unstable coronary artery disease i.e.recurring chest pain of new onset, increasing symptoms of anginalchest pain in formerly stable angina pectoris or suspected non-Q-waveinfarction, an exercise test was performed 2–7 days afteradmission. Coronary events i.e. cardiac death (N=4), Q-waveinfarction (N=11) and coronary artery bypass grafting (N=34),were registered during one year follow-up. The indication forbypass grafting was incapacitating angina pectoris despite medication,and suitable coronary anatomy. Stepwise multiple regressionanalysis showed that S–T segment depression and limitingchest pain were the most important prognostic parameters regardingcoronary events. In patients with S–T segment depression>0.1 mV or limiting chest pain (N=94) the occurrence of Q-wavemyocardial infarction or cardiac death was 10.6% (N=10) comparedto 2.8% (N=5) in patients without these criteria (N=182) (P<0.01).Coronary arterty bypass graft surgery was performed in 33% (N=31)of the group with S–T segment depression >0.1mV orlimiting chest pain but in only 1.7% (N=3) of the other patients(P<0.001). Thus, in patients with suspected unstable coronaryartery disease, whose symptoms and signs of ischaemia are stabilizedby medication, an exercise test can safely be performed aftera few days ambulation in the ward. The early exercise test providesimportant prognostic information regarding the risk for severecoronary events within the next year.     

Predictive role of exercise tests in development of restenosis in patients after coronary stent implantation

Bicycle exercise tests were carried out in 2 weeks -- 9 months after successful stent implantation in 1463 patients. Result of exercise test was positive in 472 and negative -- in 991 patients. At control angiography which was performed within 1 week after exercise test binary in-stent restenosis >50% was found in 326 of 1463 patients. Sensitivity, specificity, predictive value of positive and negative results of exercise test for the presence of restenosis were 85, 83, 59 and 5%, respectively.     

Submaximal exercise testing early after myocardial infarction. Prognostic importance of exercise induced ST segment elevation

Seventy four patients (66 men, eight women; mean age 54.3 years) underwent submaximal exercise testing 7-23 days (mean 10.7) after acute myocardial infarction. Follow up was a mean period of 11.3 months. When compared with patients with no exercise induced abnormality, ST segment elevation, ST shift (depression or elevation or both), ST depression, inability to complete five metabolic equivalents, and inadequate blood pressure response to exercise were predictive of subsequent cardiac events (cardiac death, left ventricular failure, recurrent myocardial infarction, angina). When the presence or absence of specific variables was assessed, only ST elevation and ST shift predicted subsequent cardiac events. The presence of exercise induced ST elevation was the only exercise test variable which predicted cardiac death. ST segment elevation was, therefore, the exercise induced abnormality which best predicted the risk of future complications.     

Late coronary stent thrombosis associated with exercise testing.

We report a case of coronary stent thrombosis that occurred 6 months after the primary stenting of the left anterior descending coronary artery for acute myocardial infarction in a 75-year-old man. The reinfarction occurred the day after the demonstration of persistent optimal result of the percutaneous coronary intervention and immediately after exercise testing. A combined approach of a mechanical thrombus burden reduction by using AngioJet thrombectomy with adjunctive glycoprotein IIb/IIIa antagonist was performed, resulting in the complete removal of filling defects on the angiography.