Echocardiographic evaluation of left and right ventricular function in mild hypertension

Thirty-one cases of untreated `mild hypertension' and equal number of age and sex matched controls with `normal' blood pressure were evaluated by echocardiography. Patients with mild hypertension had significantly increased left ventricular mass index, concentric remodeling, and diastolic dysfunction. Thickness of right ventricular anterior wall, flow velocities across tricuspid and pulmonary valves were also significantly higher in hypertensives. Pulmonary flow acceleration time was significantly less in hypertensives. On multiple regression analysis, mitral valve `A' wave velocity alone correlated with systolic blood pressure. Other echocardiographic variables did not have any relation with blood pressure readings. Height, weight, body surface area and body mass index could also explain only around 50% of variability in echocardiographic parameters. Cardiac structure and functions in hypertensives are affected by factors other than blood pressure reading, body surface area or body mass index. Routine echocardiography can be useful in identifying those patients of mild hypertension who have disproportionate increase in left ventricular mass or disproportionate impairment of diastolic functions.     

Wall motion abnormalities in male elite orienteers are aggravated by exercise

During the period 1979–92, 16 (15 men and one woman) sudden unexpected cardiac deaths occurred among young Swedish orienteers. This finding indicated a sharp increase in the death rate of orienteers, and necropsy demonstrated that myocarditis was a common histopathological finding. Therefore, an extensive non-invasive cardiac investigation was performed. A total of 59 male élite orienteers (mean age 23 years) and 36 cross-country skiers and middle-distance runners (mean age 22 years), serving as controls, were examined by both echocardiography at rest and radionuclide ventriculography at rest and during exercise. Wall motion abnormalities were found in eight orienteers using echocardiography. The purpose of this study was to examine whether the group of orienteers with wall motion abnormalities found using echocardiography had a smaller increase in ejection fraction from rest to exercise using radionuclide ventriculography than the rest of the orienteers and the controls, indicating an aggravation of the wall motion abnormalities during exercise. There were no significant differences in the ejection fraction at rest between the groups. In the orienteers with wall motion abnormalities (group 1), 62% (five out of eight) had less than a 0·05 unit increase in left ventricular ejection fraction compared with 27% (14 out of 51) of the remaining orienteers (group 2) and 19% (7 out of 36) of the controls (group 3). A comparison of athletes in group 1 with those in groups 2 and 3 combined revealed a statistically significant difference (P < 0·05). The divergent response in left ventricular ejection fraction during exercise suggests an aggravation of the wall motion abnormalities with exercise. Both the echocardiographic and the radionuclide ventriculographic findings indicate that the orienteers in group 1 had concealed left ventricular damage.     

An echocardiographic study of right ventricular adaptation to physical exercise in elite male orienteers

Considerably more publications appear on left ventricular morphology than on the right ventricle. The reasons for this imbalance are related to the complex shape of the right ventricular cavity and its position beneath the sternum, making imaging, measurement and functional assessment much more complex than the left ventricular chamber. Little attention has been directed towards right ventricular changes because of training, therefore the present study was designed to assess right ventricular changes due to extensive training by comparing cavity and wall dimensions in 29 sedentary men (mean age 23 years) and 82 elite male orienteers (mean age 22 years). The elite orienteers had on average significantly larger right ventricular outflow (10%) and right ventricular inflow (12%) tract 2 and 3 dimensions. The right ventricular wall measurements were on average 13% larger in the orienteers than the sedentary men. The right ventricular enlargement in endurance athletes probably reflects the increased haemodynamic loading that is caused by prolonged and extensive physical training. The thicker right ventricular wall in endurance athletes increases the contractile reserve and decreases wall stress in the right ventricle.     

Behavior of Hepatocellular Adenoma on Real‐time Low‐Mechanical Index Contrast‐Enhanced Ultrasonography With a Second‐Generation Contrast Agent

Objective. The purpose of this study was to describe the behavior of histologically proven hepatocellular adenoma (HCA) on low‐mechanical index (MI) contrast‐enhanced ultrasonography (CEUS). Methods. A review of the databases from 4 academic hospitals revealed 18 patients (15 female and 3 male; mean age, 40 years; range, 25–71 years) with 25 histologically proven HCA lesions who were studied with CEUS at a low MI (0.04–0.1). Results. Twenty‐four of 25 lesions (96%; 95% confidence interval [CI], 80.5%–99.3%) showed high‐intensity enhancement, scored as 3 on a scale of 0 to 3, whereas only 1 lesion (4%; 95% CI, 0.7%–19.5%) was scored as 2. The time of peak enhancement ranged between 10 and 19 seconds (average, 13 seconds). All but 1 of the 25 lesions (96%; 95% CI, 80.5%–99.3%) showed early homogeneous and centripetal enhancement during the hepatic arterial phase. No portal venous phase enhancement was observed in any lesion because all showed rapid wash‐out (100%; 95% CI, 86.7%–100%). Twenty lesions (80%; 95% CI, 60.9%–91.1%) were found to be isoechoic to slightly hypoechoic during the portal phase, and 19 (76%; 95% CI, 56.6%–88.5%) were isoechoic to mildly hypoechoic, whereas 7 (24%; 95% CI, 11.5%–43.4%) were hypoechoic during the late phase. Conclusions. Contrast‐enhanced ultrasonography is an effective technique for identifying the microvascular and macrovascular characteristics of HCA. Typically, HCA shows early (10–19 seconds) and centripetal enhancement during the arterial phase and isoechogenicity or mild hypoechogenicity during the portal phase, remaining slightly hypoechoic or isoechoic during the late phase in most cases.     

Heart rate dynamics and cardiorespiratory coordination in diabetic and breast cancer patients

Objective of this study was to evaluate cardiac autonomic function in female breast cancer patients on the basis of linear and non‐linear heart rate variability (HRV) as well as on musical heart rate rhythmicity. The latter method has been recently developed and enables particularly the quantification of cardiorespiratory coordination solely on the basis of ECG recordings. To provide a broad basis of comparability, 37 breast cancer patients were compared with 37 age‐matched healthy women and 40 age‐matched female diabetic patients who serve as pathological controls. During night sleep, all parameters showed a tendency towards lower variability, complexity or rhythmicity of HRV in cancer patients. The most prominent alterations were found for the binary pattern predominance (PP) and for the ratio of heart rate and respiration. In particular, when comparing metastasized and non‐metastasized cancer patients, the discriminatory power of binary heart rate rhythmicity emerges: the histograms of 1‐h intervals during night sleep with a predominance of cyclically recurrent phase locking patterns unveiled a clear transition from higher to lower cardiorespiratory coordination ratios and to a loss of coordination capability in metastasized patients.     

High‐dosage medical exercise therapy in patients with long‐term subacromial shoulder pain: a randomized controlled trial

Background and Purpose. Exercise therapy is a commonly used conservative therapy for long‐term subacromial pain. However, there is no consensus regarding what type of exercises and dosage is most effective. The aim of this study was to compare the effect of two exercise programmes: 1) high‐dosage (HD) medical exercise therapy versus 2) low‐dosage (LD) exercise therapy programme for subjects with long‐term subacromial pain. Methods. This study used a randomized, controlled clinical trial with an intention‐to‐treat analysis. Sixty‐one subjects were randomly assigned by concealment either to an HD medical exercise therapy group (n = 31) or to an LD exercise therapy group (n = 30). Pain (visual analogue scale [VAS]) and function (Shoulder Rating Questionnaire [SRQ]) were measured at inclusion, at end of treatment and at 6 and 12 months follow‐up. Results. There were no differences between groups at inclusion (baseline) regarding any variables. During the three months treatment period, five subjects (8%) dropped out, and another seven (11%) dropped out at one‐year follow‐up. At the end of treatment, both pain and function had improved significantly in favour of the HD therapy, between‐group differences in VAS were ?2.7 (?3.9 to 0.9), and for activity limitations, the between‐group differences in the SRQ increased by 24.5 points (14.5–35.7). The differences between groups were both statistically and clinically significant at 6 and 12 months follow‐up. Conclusion. In subjects with long‐term subacromial pain syndrome, HD medical exercise therapy is superior to a conventional LD exercise programme. For clinicians to obtain similar positive results with HD medical exercise therapy, factors such as good communication skills, constant close personal supervision during exercise treatment and having from three to five subjects in a group setting are important. Copyright © 2010 John Wiley & Sons, Ltd.     

Epitope‐based matching for HLA‐alloimmunized platelet refractoriness in patients with hematologic diseases

BACKGROUND: For HLA‐alloimmunized patients, platelet (PLT) concentrations are provided either at matched HLA‐A and HLA‐B loci or by serologic cross‐reactivity groups (CREG) matching strategy. However, this method has some limitations. STUDY DESIGN AND METHODS: In this study, the epitope‐based matching (EBM) method was evaluated for selecting proper HLA‐typed PLTs for patients with PLT transfusion refractoriness. Bead‐based single‐antigen HLA antibody detection method and HLAMatchmaker software were used to define the epitopes recognized by HLA‐specific antibodies and to select compatible PLTs for nine patients with alloimmunized refractoriness. Corrected count increments (CCIs) were prospectively determined to compare successful transfusion rates among different matching methods in 142 PLT transfusions. In addition, HLA antibodies were serially detected to see whether any emerging antibodies appeared after receiving the EBM‐matched PLTs. RESULTS: The transfusion success rates evaluated with 1‐hour CCIs for perfect matching or lacking any mismatching at HLA‐A and ‐B locus (A/BU)‐matched, CREG‐matched, and EBM‐matched PLTs were 85.2, 63.2, and 83.7%, respectively. Compared to CREG‐matched PLTs, EBM‐matched PLTs showed better transfusion results (p = 0.035). In the follow‐up study (7 months; range, 3‐13 months), no emerging HLA‐specific antibodies were detected after receiving EBM‐matched PLTs. CONCLUSIONS: EBM performed on the basis of bead‐based single‐antigen HLA antibody detection coupled with the HLAMatchmaker program is recommended in choosing proper PLTs for refractory patients when A/BU‐matched PLTs were not available.     

Aging and hypertension decrease endothelial NO‐related dilating function and gamma‐glutamyl transferase activity but not S‐nitrosoglutathione‐induced aortic vasodilation

S‐nitrosoglutathione (GSNO), which is involved in the transport and the storage of NO, induces vasorelaxation. It requires gamma‐glutamyl transferase (GGT), an enzyme present on the endothelium, to transfer NO into the cell. We evaluated whether aging and hypertension, which induce NO‐related dilating dysfunction, are associated with decreased vascular GGT activity and modify the vasorelaxant effect of GSNO. Thoracic aortic rings isolated from male spontaneous hypertensive rats (SHR) and Wistar‐Kyoto rats (WKY) aged 20–22 (adult) or 57–60 weeks (mature) were preconstricted with phenylephrine, then submitted to concentration‐vasorelaxant response curves (maximal response: E_max; pD₂) to GSNO and carbachol (the latter to measure NO‐related dilating function). GGT activity was measured using chromogenic substrate. Both aging and hypertension lowered E_max values for carbachol (E_max ?8% in adult SHR, ?42% in mature SHR vs. age‐matched WKY, p_age and p_hypertension < 0.05) demonstrating NO‐related dilating dysfunction. Aortic GGT activity also decreased with aging and hypertension (?22% in adult and ?75%, reaching 3 nmol/min/g of tissue, in mature SHR vs. 12 in age‐matched WKY and 23 in adult WKY, p_age and p_hypertension < 0.05). The pD₂ values of GSNO were similar in mature SHR and WKY but higher in adult SHR (p_interaction < 0.05). Aging in hypertensive rats decreased NO‐related vasorelaxant function and vascular GGT activity, but did not lower the vasorelaxant response to GSNO. This opens perspectives for GSNO‐based therapeutics restoring nitric oxide bioavailability and vascular protection in a context of endothelial dysfunction.     

Out‐of‐home Placement of School‐age Children with Disabilities and High Support Needs

Background This study explored the relationship between family life variables and out‐of‐home placement tendency for families of school‐age children with disabilities and high support needs. Method This study was a prospective cohort study of 81 families with children with disabilities and high support needs aged between 6 and 13 years. There were two waves of data collection 12–18 months apart involving in‐depth interviews with the primary carer. Results Out‐of‐home placement tendency was associated with three interrelated family life variables: (i) difficulty balancing the demands of caring and the needs of other family members; (ii) sharing workload and responsibility; and (iii) integrating the child into the everyday world. Conclusion Family capacity to continue balancing the demands of caring and the needs of other family members is central to maintaining family‐based placement.     

Predictive model for progression of hearing loss: meta‐analysis of multi‐state outcome

Rationale, aims and objectives To develop a multi‐state Markov model to predict multi‐state progression of age‐related hearing loss (ARHL). Method A systematic searching of literature from Medline (1966–2005) was performed. The disease process for hearing loss was modelled as a four‐state continuous‐time Markov process. We estimated the progression rates for each study separately, then calculated weighted averages over all studies across age groups, weighting for each study by the inverse of variance. The pooled estimates were obtained and transition probabilities between states were illustrated. Results The progression of hearing loss increased with the ascending frequencies across all age groups. Men had significantly faster progression rates in all frequencies and age groups except for the age group of 90 years or older. In comparison between ears, the progression of hearing would be slightly faster in left ears initially in early elder life and did not show any difference in further ageing and later hearing declines. With the pooled estimates of progression rates, the probabilities of hearing deterioration could be obtained. Conclusions The multi‐state model can quantify the nature course of hearing progression in ARHL. Predictions of hearing status can be simulated either at population or individual level with this model.     

Population pharmacokinetics of oral baclofen at steady‐state in alcoholic‐dependent adult patients

Baclofen has been proposed for few years to help treating alcohol dependence at higher doses than those used in neurology. Baclofen pharmacokinetics has been previously well described at low oral or intravenous doses but remains poorly investigated with such high oral doses. We here describe dose regimens of baclofen in 143 alcohol‐dependent patients treated with steady‐state oral doses of baclofen. Plasma baclofen levels were measured in blood samples using liquid chromatography coupled with tandem mass spectrometry. One hundred and forty‐nine baclofen concentrations were sampled 30 min to 15 h after the last dose, and baclofen pharmacokinetics was determined using population pharmacokinetics approach. Our population, whose average age and BMI were 51.5 years and 25.5 kg/m², respectively, was composed of two‐thirds of men. Daily baclofen doses ranged from 15 to 250 mg and 26% were higher than 120 mg. A one‐compartment model with first‐order absorption and elimination allowed to determine mean values for clearance (CL/F), volume of distribution (V/F) and absorption rate constant at 8.0 L/h, 44.5 L and 2.23 h^?1, respectively. Inter‐individual variability on CL/F and V/F was 27.4 and 86% for the parameters. None of the demographic and biological covariates significantly decreased inter‐individual variability. A proportional relationship between oral dose and plasma baclofen exposure indicated a linear pharmacokinetics of baclofen even at doses over 120 mg/day. Our large population study evidenced a linear pharmacokinetics of oral baclofen even at high daily doses with an inter‐individual variability of baclofen exposure that could not be explained by demographic and biological data.     

Expiratory and inspiratory forced vital capacity and one‐second forced volume in asymptomatic never‐smokers in Norway

The objectives of this study were to examine within and between individual variation detected during forced expiratory (FE) and forced inspiratory (FI) manoeuvers in a general population and to investigate the dependence of these variables on age, body size, and gender. A random sample of asymptomatic never smokers who had never been exposed occupationally to quartz or asbestos and who were living on the south‐western coast of Norway were examined by spirometry; 81% of the individuals invited to attend did so. Of the 488 subjects between 18 and 73 years of age, 98% contributed three acceptable recordings for forced expiratory vital capacity (FVC) and one‐second forced expiratory volume (FEV₁), 94% contributed three acceptable recordings for forced inspiratory vital capacity (FIVC) and 85% contributed three acceptable recordings for one‐second forced inspiratory volume (FIV₁). The within‐subject variation increased with body height and was considerably larger for FIV₁ than for FVC, FEV₁ or FIVC. A four‐parameter model of pulmonary function measurement divided by height squared, including a gender term and a linear and quadratic term of age, fit the median of the observed values well. The residuals had a close‐to‐normal distribution, and the fifth‐percentile values were estimated as the lower limit of normal. The peak value of dynamic lung volumes was observed into the middle of the fourth decade of life, and the decline thereafter did not differ greatly between the genders or among the different indices. The forced inspiratory volumes are the first reported in any reference population.     

Performance of age‐adjusted D‐dimer cut‐off to rule out pulmonary embolism

Summary: Background: Age‐adjusted D‐dimer cut‐off has recently been proposed to increase D‐dimer usefulness in older patients suspected of pulmonary embolism (PE). Objective: We externally validated this age‐adjusted D‐dimer cut‐off using different D‐dimer assays in a multicenter sample of emergency department patients. Methods: Secondary analysis of three prospectively collected databases (two European, one American) of patients suspected of having PE. D‐dimer performance for ruling out PE was assessed by calculating negative likelihood ratio (nLR) for D‐dimer with age‐adjusted D‐dimer cut‐off (< age × 10 in patients over 50 years) and with conventional cut‐off (< 500 μg dL^?1). Test efficiency was assessed by the number needed to test (NNT) to rule out PE in one patient. Results: Among 4537 patients included, overall PE prevalence was 10.1%. In the overall population, nLR was 0.06 (95% confidence interval, 0.03–0.09) with conventional cut‐off and 0.08 (0.05–0.12) with age‐adjusted cut‐off. Using age‐adjusted cut‐off, nLR was 0.08, 0.09 and 0.06 for Vidas^®, Liatest^® and MDA^® assays, respectively. Use of age‐adjusted cut‐off produced a favorable effect on NNT in the elderly; the greatest decrease was observed in patients > 75 years: NTT halved from 8.1 to 3.6. The proportion of patients over 75 years with normal D‐dimer was doubled (27.9% vs. 12.3%). Conclusions: Our study shows that age‐adjusted D‐dimer had low nLR, allowing its use as a rule‐out PE strategy in non‐high pretest clinical probability patients, as well as using Vidas^®, Liatest^® or MDA^® assays. This age‐adjusted cut‐off increased clinical usefulness of D‐dimer in older patients. A large prospective study is required to confirm these results.     

Construct and criterion validity of the SF‐12 health questionnaire in patients with acute myocardial infarction and unstable angina

Background The aim of the study was to determine the construct and criterion validity of the 12‐item short‐form questionnaire (SF‐12) in coronary patients with either acute myocardial infarction or unstable angina in Spain. Method A total of 186 patients hospitalized with coronary heart disease have been studied. The construct validity has been analysed by means of the association between the SF‐12v.1 and sociodemographic and clinical variables; and the criterion validity was tested by the correlations between 36‐item short‐form question (SF‐36) and SF‐12 summary scores. The equivalence between both health questionnaires was examined by means of the proportion of variance in the SF‐36 physical and mental component summary (PCS‐36 and MCS‐36) scores explained by the 12 items adjusted by age and sex. Results The validation result was as expected: female patients and those with poor education level, worse mental health, unstable angina, cardiovascular risk factor and co‐morbidity obtained a lower score in the SF‐12. The correlations between SF‐36 and SF‐12 summary scores were high. The equivalence between the SF‐12 and SF‐36 was good, because the models explained 87% of the variation in PCS‐36 score and 93% of the variation in MCS‐36. Conclusion The SF‐12 is a valid tool in studies assessing health‐related quality of life in coronary patients. The use of the SF‐12 may be especially useful in patients where the clinical situation make difficult the application of the longer instrument.     

Emotional loneliness is associated with mortality among mentally intact nursing home residents with and without cancer: a five‐year follow‐up study

Aims and objectives. Hypothesised that sociodemographic factors and illness variables would be associated with mortality and that emotional and social loneliness measured using the Social Provisions Scale would influence mortality among nursing homes residents with cancer. Background. Studies are lacking on how emotional and social loneliness influence mortality among cognitively intact older people in nursing homes with and without a diagnosis of cancer. Design. A cross‐sectional design was used at baseline with a five‐year follow‐up of mortality. Methods. A cohort of 227 cognitively intact (Clinical Dementia Rating scale score ≤0·5) older residents (60 with cancer and 167 without) from 30 nursing homes were followed from 2004–2005 to 2010. Data were collected by face‐to‐face interview. Sociodemographic variables and medical diagnoses were obtained from the records. Results. Survival did not differ significantly between residents with and without cancer. After adjustment for sociodemographic and illness variables, increasing age, higher education and comorbidity were associated with mortality. In the final model from a backward selection procedure, attachment (emotional loneliness) was associated with mortality. Conclusions. Independent of a cancer diagnosis or not, emotional loneliness, age, education and comorbidity influenced mortality among nursing homes residents without cognitive impairment. Relevance to clinical practice. Nurses should pay attention to emotional loneliness among nursing homes residents independent of cancer and especially give attention to the importance to have a close confidant who provides emotional support.     

Age‐dependent decreases in serum soluble interleukin‐1 receptor type I (sIL‐1RI) in healthy individuals: a population study of serum sIL‐1RI levels in Japanese subjects

The levels of several soluble cytokine receptors in body fluids of healthy individuals change with age. Clinical application of the measurement of the serum soluble interleukin‐1 receptor type I (sIL‐1RI) level depends critically on the samples used as the controls. At present, there is no information regarding the levels of serum sIL‐1RI in healthy subjects. The purpose of this study is to reveal the age‐related changes that occur in the serum sIL‐1RIlevels of healthy individuals. We determined the serum sIL‐1RI levels of healthy Japanese children using ELISA. The serum sIL‐1RI level of children (0–14 years) was significantly higher than that of adults (more than 15 years) (P=0.0138, n=90). Thus, it is recommended that when the serum sIL‐1RI level of patients is evaluated, it should be compared against age‐matched controls. J. Clin. Lab. Anal. 23:175–178, 2009. © 2009 Wiley‐Liss, Inc.     

Evaluation of anti‐emetic use in chemotherapy‐induced nausea and vomiting in a third‐world country (Lebanon)

Rationale In Lebanon, the appropriateness of anti‐emetic use is questionable in large measure because of the absence of published multicentre trials. Aim and objectives To evaluate the extent of appropriateness of anti‐emetic use in patients on chemotherapy among several Lebanese hospitals. Appropriateness of chemotherapy‐induced nausea and vomiting (CINV) prophylaxis was determined as per National Comprehensive Cancer Network guidelines. Methods A multicentre, cross‐sectional study was conducted over a 3‐month period. Data were collected from medical charts of cancer patients. The main outcome measure was to evaluate the appropriateness of prophylactic use of anti‐emetics in CINV in terms of selected drug regimen, dosage and route of administration, and to investigate the role of several pre‐specified variables (including hospital type and size, type of insurance coverage and patient‐related factors) in influencing the appropriateness of anti‐emetic practice. Results A total of 493 patients' forms were analysed. The median age was 58.8 ± 13.9 years, 290 (58.8%) patients were female. Around 211 (42.8%) patients received inappropriate anti‐emetic regimen, and only 17 (6%) patients of those receiving appropriate regimen received the appropriate dose, and just 55 (19.5%) patients were treated for the appropriate duration. Factors that may affect the relative effectiveness of treatment were identified. Conclusion This study reflected substantial flaws in CINV prophylaxis practice in Lebanon which should alert health care professionals of the adverse consequences resulting from non‐adherence to guidelines. Our study also highlighted areas for improvement and suggested recommendations in order to minimize patient risk and optimize safe and effective CINV management.     

Behavioural disturbance requiring medical referral: A case of anti‐N‐methyl‐D‐aspartate receptor encephalitis in the emergency department

A 17‐year‐old woman presented to the ED with behavioural disturbance and psychotic features. Brief dystonic jerks were noted so she was referred to the medical team. A diagnosis of anti‐N‐methyl‐D‐aspartate receptor encephalitis was made. Immunotherapy was instituted early and the clinical outcome was excellent. It is important to consider this condition in young women presenting with acute behavioural or psychotic symptoms.     

A new method to quantify postexercise ST‐deviation – the ST‐deficit. A study in men at high and low‐risk for coronary heart disease

Background Quantitative heart rate adjusted exercise ST criteria like μV/beats per minute (bpm) improve the diagnostic accuracy of the exercise ECG. However, there are few quantitative HR adjusted postexercise variables available. The aim of the present exercise study was to evaluate a new such variable from computerized averaging of the postexercise ECG. Methods The presence of possible myocardial ischaemia in a population based sample of 74 elderly male hypertensives at high‐risk of coronary heart disease, and in 42 age‐matched clinically healthy males (reference group) at low‐risk was assessed by exercise ECG. All men had a normal resting ECG without signs of ischaemia. Variables studied: standard ST‐criteria, ST/HR slope ≤–2·4 μV · bpm^–1, shape of the rate‐recovery loop, the latter also with a new quantitative variable, the ST‐deficit. Results In spite of a normal resting ECG many subjects showed an abnormal ST/HR slope during exercise, 43% in the hypertension group and 26% in the reference group. An abnormal rate‐recovery loop (ST‐deficit) also contributed substantially to identify patients with possible myocardial ischaemia, 30 vs. 10%, respectively (P<0·02); cumulatively for the two HR adjusted criteria 53% vs. 29%, respectively (P<0·02). Mean ST‐deficit was significantly lower in the high‐risk group. Conclusions Effort‐related myocardial ischaemia is frequently silent in elderly high‐risk hypertensives and necessitates testing, preferably with computerized exercise ECG and heart rate adjusted ST criteria. A new quantitative variable to assess the postexercise rate‐recovery loop in the time domain, the ST‐deficit is described. This variable seems to effectively discriminate between subjects with low and high‐risk for coronary heart disease and thus provides new information. Further studies are warranted to validate this variable against myocardial perfusion scintigraphy and coronary angiography.