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Query: UMLS:C0008031 (chest pain)
 17,248 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

A considerable amount of data now exists that indicates that exercise ECG--due to its suboptimal sensitivity and specificity--has limited diagnostic and prognostic value in asymptomatic subjects, patients with chest pain of unclear etiology or those with chronic stable angina pectoris, and in patients recovering from acute myocardial infarction. Because of this and the well-recognized advantages of thallium-201 scintigraphy, there appears to be a strong rationale for recommending exercise perfusion imaging, rather than exercise ECG alone, as the preferred method for detecting CAD and staging its severity. This recommendation seems justified given the fact that (1) thallium-201 scintigraphy is far more sensitive and specific in detecting myocardial ischemia than exercise testing; (2) unlike stress ECG, thallium-201 scintigraphy can localize ischemia to a specific area of areas subtended by a specific coronary artery; and (3) thallium-201 scintigraphy has been shown to be more reliable to risk stratification of individual patients than exercise testing alone. The more optimal prognostic efficiency of thallium-201 scintigraphy is due, in part, to the fact that the error rate in falsely classifying patients as low-risk is substantially and significantly smaller with thallium-201 scintigraphy than with stress ECG.
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PMID:Comparative analysis of the diagnostic and prognostic value of exercise ECG and thallium-201 scintigraphic markers of myocardial ischemia in asymptomatic and symptomatic patients. 267 Feb 27

This study examined the merits of oral dipyridamole SPECT thallium-201 imaging in detecting CAD and multivessel CAD. The 65 patients included in this study (aged 62 +/- 11 years) were not candidates for exercise testing (for the usual reasons). Coronary arteriography revealed no significant CAD in 17 patients and greater than or equal to 50% narrowing of one or more vessels in 48 patients; 12 had one-vessel and 36 had multivessel CAD (high-risk group). Thallium-201 was injected intravenously 45 minutes after an oral dose of 375 mg of dipyridamole, and SPECT imaging was performed within 10 minutes and 4 hours after injection. There were no serious side effects; only six patients (8%) had ST segment depression and 18 patients (28%) had chest pain. The heart rate increased from 74 +/- 15 beats/min at rest to 84 +/- 14 beats/min at peak effect (p = 0.001); the systolic blood pressure did not change (130 +/- 18 and 128 +/- 20 mm Hg, respectively, p = NS). The thallium images were abnormal in 6 of 17 patients (35%) with no CAD, in 7 of 12 patients with one-vessel disease (58%), and in 34 of 36 patients with multivessel CAD (94%) (p = 0.001). Twenty-one of 25 patients (84%) with a perfusion abnormality in more than one vascular territory had multivessel CAD assessed by angiography. Thus oral dipyridamole SPECT thallium-201 imaging is a safe and inexpensive method for the detection of CAD in patients who are otherwise not candidates for exercise testing.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Use of oral dipyridamole SPECT thallium-201 imaging in detection of coronary artery disease. 281 86

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.
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PMID:Exercise testing in women with chest pain. Are there additional exercise characteristics that predict true positive test results? 290 29

To assess the significance and accuracy of noninvasive tests in detecting significant coronary artery disease (CAD; greater than 50% stenosis), the Master's exercise test, treadmill exercise test and dipyridamole-loading myocardial perfusion scintigraphy were performed and their results were compared with coronary angiographic findings in 60 patients with angina but without myocardial infarction. Among these, 27 patients had significant CAD. The Master's test performed in outpatient clinics had an 85% sensitivity and a 76% specificity in detecting significant CAD, when the degree of ST depression was equal to or exceeded 1 mm. The sensitivity further improved to 96% by adding chest pain to the criteria; then all patients with multivessel disease or critical ischemia were identified by the Master's test. Treadmill tests performed after admission had a 78% sensitivity and a 67% specificity. When the severity of ischemia was judged either by exercise capacity or the degree of ST depression or the coronary T wave, the treadmill test was superior to the Master's test. Although patients without significant CAD had longer exercise capacity and the higher maximum heart rate in the treadmill test than did those in the Master's test, these trends were similar but less marked in patients with significant CAD. Dipyridamole-loading myocardial perfusion scintigraphy showed an excellent sensitivity and specificity; 96% and 94%, respectively, in detecting significant CAD. It was particularly useful in distinguishing false positive exercise results due to left ventricular hypertrophy and coronary spasm and that in women, from true positive results. In conclusion, the Master's test is a simple and useful method for screening CAD in community hospitals and in outpatient clinics.
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PMID:[Accuracy of the Master's exercise test in detecting significant coronary artery disease]. 326 34

From 1978 to 1985, 470 consecutive male patients with complaints of chest pain underwent a maximal exercise test with a thallium scan and coronary angiography (CA). Patients with a history of myocardial infarction (MI) were excluded. During the follow-up (from 12 to 96 months), 32 patients died and 30 had a non-fatal MI. Survival (SR) and event-free rates (EFR) were estimated by actuarial methods; the influence of non-invasive and invasive variables were examined in univariate and multivariate models using Cox analysis. The five-year SR was 89% and EFR was 81%. Among historical data, age (less than 0.001), type of complaints (less than 0.01) and pretest likelihood of CAD (less than 0.01) were univariate predictors of EFR; by multivariate analysis, age was the only significant predictor (less than 0.001). Most of the maximal-exercise (MEX) test data were good univariate predictors; by multivariate analysis, workload (less than 0.001) and the maximal-exercise test score (less than 0.001) were the significant predictors. From history and maximal-exercise test data, multivariate analysis indicated that the prognostic information was given by age (less than 0.05) and maximal-exercise test score (less than 0.001). Among the invasive data, the number of diseased vessels (less than 0.001) and ejection fraction were the predictors. The combination of invasive and non-invasive data indicated that age, MEX score, number of diseased vessels and ejection fraction contributed significantly and independently to the estimation of prognosis. Among 242 patients with two or three diseased vessels, the prognosis was determined by the maximal workload (less than 0.01); ejection fraction (less than 0.07) was no longer significant.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Non-invasive data provide independent prognostic information in patients with chest pain without previous myocardial infarction: findings in male patients who have had cardiac catheterization. 338 81

Myocardial perfusion scintigraphy with 201-TL was performed in a group of subjects affected by exercise-induced, rate-dependent left bundle branch block (LBBB). The aim of the study was: to define the significance of the exercise-induced conduction abnormality: "primitive" or "ischemic". 14 patients, aging 28-58 years (x = 42), 8 with chest pain (4 typical angina, 4 atypical angina) and 6 without any symptoms were studied. None had history of prior myocardial infarction or clinical and echocardiographic signs of heart disease. LBBB appeared at a heart rate ranging from 70 to 160 beats/min. 6 patients showed repolarization abnormalities (ST changes, deep and negative T wave) suggestive for ischemia, during successive QRS normalization. 201-TL-uptake was normal in 5 subjects; in the remaining 9 ones reversible TL defects were demonstrated in the septum (6), in the septum and apex (2), in the septum and inferior-apical wall (1). No patients had irreversible impaired perfusion. All the patients had normal coronary angiography, with negative ergonovine test for coronary artery spasm. In conclusion, in the majority of our subjects (64%) with exercise-induced LBBB, a reversible TL-uptake defect, usually located in the septum without diagnostic value of obstructive CAD, has been observed. Further studies will establish if the TL-defect is only an "apparent phenomenon" due to contraction abnormality secondary to LBBB, or, on the contrary, an expression of myocardial ischemia with normal coronary vessels as a consequence of the LBBB.
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PMID:[Study of myocardial perfusion by means of scintigraphy with thallium-210 in left bundle branch block induced by exertion]. 366 78

Increased utilization of ambulatory ST segment monitoring mandates an appreciation of nonischemic variables that may influence the ST segment. While a greater frequency of ST segment depression has been reported with supine vs upright exercise, the relative false positive rate in both positions is not known. Thus, we compared the frequency of exercise ECG abnormalities during upright and supine bicycle exercise in two groups--17 normals and 46 patients with coronary artery disease. Exercise was performed in combination with radionuclide ventriculographic imaging. Peak exercise heart rate, peak systolic blood pressure, and exercise duration time were all slightly higher in the upright vs supine position (p less than 0.05). Nevertheless, the frequency of positive ST segment responses was more common in the supine position, both in the patients with coronary artery disease (54% vs 30%, p less than 0.05) and in the normal subjects (29% vs 6%, p = NS). The corresponding radionuclide ventriculographic responses, however, were normal during upright and supine exercise in 6 of the 11 CAD patients and in all five of the normal subjects with an abnormal ST segment response during supine exercise only. The frequency of exercise-induced chest pain was also similar in the two positions. Thus, we theorize that nonischemic factors may govern some positive ST segment responses in the supine position. This finding is of relevance for understanding the potential sources of physiologic false positive ST segment responses for ambulatory ST segment monitoring.
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PMID:Differences in the frequency of ST segment depression during upright and supine exercise: assessment in normals and in patients with coronary artery disease. 368 84

The heart rate response to standing, cough, hand grip, and deep breathing were examined in normal subjects and coronary artery disease patients (greater than 70% diameter narrowing). The heart rate responses to these maneuvers were reduced in coronary patients and in anginal patients with normal coronary angiograms, as compared to normals. Detection (with the heart rate response to standing) was determined by using an RR interval cutoff of 140 ms for males and 120 ms for females discriminated between normals and CAD patients. In men sensitivity was 0.58, specificity 0.87 and CCR 0.75, and in women sensitivity was 0.67, specificity 0.79 and CCR 0.75. These values are similar to those reported for ST segment depression in similar populations. When separating normals from those with 2 and 3 vessel disease--sensitivity is 0.67, specificity 0.87, predictive value 0.71 and CCR 0.80. The response to cough, hand grip, and deep breathing showed similar trends but had less specificity than the response to standing. Thus, the heart rate response to most autonomic maneuvers is blunted in subjects with coronary disease and in those with pain syndromes sent for coronary angiography. These findings need testing in larger populations but autonomic maneuvers fail to discriminate patients with coronary disease from those with normal angiograms presenting with chest pain syndromes.
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PMID:Autonomic responses in chest pain syndromes as compared to normal subjects. 381 52

The interpretation and selection of exercise tests depends on the pretest probability of CAD. Imperfect tests (like exercise tests) provide probability estimates, not definite statements (such as "the patient has CAD" or "the patient does not have CAD"). In patients with a low pretest probability of CAD (asymptomatic persons or men and women with nonanginal chest pain), abnormal exercise test results provide probability estimates that are much too low to conclude that the patient has CAD. In patients with anginal pain and normal exercise tests, the probability of CAD is too high to conclude that the patient has a normal coronary circulation. Exercise tests are not useful for trying to rule out CAD in patients with anginal pain. In patients with an intermediate pretest probability of CAD (men and women with atypical angina and women with typical angina), abnormal exercise tests (particularly the myocardial scintiscan) provide probability estimates that are high enough to justify starting treatment for CAD. Exercise tests are most useful in this group, a conclusion that has been reached by other methods of analysis. The myocardial scintiscan is much more useful than the exercise ECG in women. When CAD is strongly suspected, exercise tests have relatively little diagnostic value but may be useful for prognosis. However, clinical evidence of poor ventricular function may alone suffice to select patients with angina pectoris for coronary arteriography. Conversely, when clinical indicators of congestive heart failure are absent, the prognosis in chronic stable angina is so favorable that any further testing may be unnecessary. Screening asymptomatic persons for CAD is a very low yield practice. Patients who have no cardiac risk factors (hypercholesterolemia, family history of CAD, cigarette smoking, and hypertension) are at especially low risk of a primary cardiac event. Older men with stable typical angina are particularly likely to have left main coronary artery stenosis or three-vessel disease with poor ventricular function. The exercise ECG can identify groups of older men with a relatively high risk of having left main coronary artery stenosis. Physicians should be cautious when applying these recommendations to a primary care practice. The foregoing analysis is based on data obtained from patients who had been selected for coronary arteriography. There are two principal effects of biased selection of study patients: The pretest probability of CAD in clinical subgroups is probably lower than as shown here.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Exercise testing in suspected coronary artery disease. 385 11

A prospective study on 184 consecutive patients presenting with the chief complaint of recurrent chest pain (RP) for diagnostic coronary arteriography (CA) was conducted utilizing a simple questionnaire of historical, physical and electrocardiographic variables. A linear logistic regression analysis yielded a final data set of 13 variables. Concurrently, staff cardiologists who obtained the questionnaire data through direct questioning rendered a clinical diagnosis of either angina (coronary artery disease [CAD]) or noncardiac chest pain. Utilization of the regression analysis increased diagnostic accuracy from 69 to 86% (p less than 0.0003); sensitivity from 83 to 88% (NS) and specificity from 49 to 84% (p less than 0.0001). The best predictive variables for the presence or absence of obstructive CAD documented by CA were in order of decreasing value: age, electrocardiogram, pain aggravated by sex, sex (gender), pain aggravated by movement, diabetes mellitus, pain described as prickling, pain described as burning, pain relieved by rest, pain with radiation to both arms, associated nausea, associated dyspnea, and a history of a lipid disorder. Four variables were predictive of normal coronary anatomy (NCA), pain aggravated by movement, prickling, nausea, and dyspnea. Although this set of predictor variables may not apply equally well to all populations of cardiac patients, the availability and relative simplicity of the program allow for adding or deleting variables and thus provide for considerable potential in the diagnostic assessment of RP. An inexpensive pocket computer can utilize the coefficients generated by the logistic regression program to calculate the probability of CAD as the cause of RP.
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PMID:Analysis of historical variables, risk factors and the resting electrocardiogram as an aid in the clinical diagnosis of recurrent chest pain. 388 75


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