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Stress testing is by no means perfect as far diagnosing coronary artery disease, but at this time it is the single best noninvasive method for establishing the presence of ischemic heart disease. From the data shown here, one can see that it adds some important prognostic features as well. The American Heart Association has published a "Coronary Risk Handbook" which can be used to predict the likelihood of a future coronary event by means of accepted risk factors such as hypertension, cholesterol level, and smoking. If we include a positive stress test as a risk factor and compare it to the others, it is clear that a positive stress test has a much higher correlation with future coronary events than any of the other risk factors alone or in combination (Figure 12). Physicians should pay close attention to all of the mentioned factors while carrying out a stress test rather than just looking for ST depression alone. The occurrence of anginal pain, the time of onset, the degree of ST depression, and the patient's pulse and blood pressure response are all useful in assessing the degree of coronary involvement and in predicting an individual's chances of suffering some form of coronary event.
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PMID:Stress testing in the prognosis and management of ischemic heart disease. 86 78

To access left ventricular function and compare pulmonary capillary wedge pressure and left ventricular end-diastolic pressure in the supine and sitting positions, 20 men with angina pectoris secondary to coronary artery disease underwent hemodynamic studies at rest and during exercise in the two positions. At rest the values for cardiac index, stroke index, systolic ejection rate index and left ventricular stroke work index were lower in the sitting position; heart rate, left ventricular end-diastolic pressure and pulmonary capillary wedge pressure were similar in the two positions. All patients experienced angina during both exercise periods. At angina during supine exercise, stroke index, systolic ejection rate index and left ventricular stroke work index did not increase significantly from the resting values. In contrast, during sitting exercise, significant increases in these variables were observed. Comparison of data during exercise revealed higher values for heart rate, mean systemic pressure, cardiac index, systolic ejection rate index, left ventricular stroke work index and rate-pressure product and lower values for mean pulmonary capillary wedge pressure (20 +/- 3 versus 27 +/- 3 [mean +/- standard error of the mean] mm Hg, P is less than 0.001), and left ventricular end-diastolic pressure (24+/- 3 versus 31 +/- 3 mm Hg, P is less than 0.02) in the sitting position; stroke index and S-T segment depression were similar during the two exercise periods. Four patients had insignificant increases in left ventricular filling pressure during both exercise periods. Of the 16 patients with abnormal left ventricular filling pressure during supine exercise, only 10 had a similar response during exercise in the sitting position. There was a good correlation between left ventricular end-diastolic pressure and mean pulmonary capillary wedge pressure at rest and during exercise in the two postures.
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PMID:Hemodynamics at rest and during supine and sitting bicycle exercise in patients with coronary artery disease. 87 Nov 6

Variations in clinical noninvasive systolic pressure at the point of symptom-limited exercise on a treadmill were examined in six groups of subjects: 5,459 men and 749 women classified into three categories each. Among the men, 2,532 were asymptomatic healthy, 592 were hypertensive and 1,586 had clinical manifestations of coronary heart disease (that is, typical angina pectoris, prior myocardial infarction or sudden cardiac arrest with resuscitation). Among the women, 244, 158 and 347 were in the corresponding clinical categories. None had had cardiac surgery; all had follow-up status ascertained by periodic mail questionnaires. Reported deaths were reviewed and classified by three cardiologists; 140 deaths were attributed to coronary heart disease, 118 of them in the men classified as having coronary heart disease. The majority of maximal systolic blood pressure readings were reported to the nearest centimeter rather than millimeter of pressure. Retesting of 156 persons from 1 to 32 months later showed that pressure values agreed within 10 percent in two thirds, the overall mean difference was only 8.6 mm Hg and the correlation at maximal exercise was superior to that of the resting observations just before exercise. Hypertensive patients had a significantly greater body weight than normotensive persons. Among men, the lowest maximal systolic pressure was observed in the group with coronary heart disease; among women, the lowest mean pressure was found in the healthy group. Patients with coronary heart disease were slightly older, and only the women showed a significant correlation in maximal pressure with age. Only 5 percent of the variation in maximal systolic pressure in the patients with coronary heart disease was due to a shortened duration of exercise. Maximal systolic pressures correlated fairly well (r equals 0.46 to 0.68 for the various groups) with resting systolic pressure, and this relation was independent of the diagnosis of cardiovascular disease in both men and women. Relations between pressure and the number of stenotic coronary arteries and imparied ejection fraction at rest were examined in 22 men without and 182 men with coronary artery disease. Lower maximal systolic pressures were often associated with two or three vessel disease or reduced ejection fraction, or both. The prognostic value of maximal systolic pressure for subsequent death due to coronary heart disease was examined in the men with coronary heart disease. The annual rate of sudden cardiac death decreased from 97.9 per 1,000 men to 25.3 and 6.6 per 1,000 men as the range of maximal systolic pressure increased from less than 140 to 140 to 199 and to 200 mm Hg or more, respectively. Cardiomegaly, Q waves in the resting electrocardiogram and persistent postexertional S-T depression were more common in men with the lowest systolic pressure at maximal exercise.
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PMID:Variations in and significance of systolic pressure during maximal exercise (treadmill) testing. 87 Nov 10

Twenty-one long-term survivors of out of hospital sudden cardiac death due to ventricular fibrillation underwent radionuclide angiography and myocardial imaging with thallium-201. In 13 patients images were obtained at rest and after maximal treadmill exercise; 11 of these 13 (85 percent) had an image defect in one or both studies. Eleven of the 21 patients (52 percent) had a defect in the image obtained at rest. The magnitude of myocardial image defects was typically great; some patients had an image abnormality without other clinical evidence (angina, S-T depression) of ischemia. The mean ejection fraction, assessed in 16 patients with radionuclide angiography, was 0.41 +/- 0.15 (standard deviation); in 5 of the 16 ejection fraction was normal (more than 0.50) and in 3 it was severely abnormal (less than 0.25). Thus, noninvasive radionuclide studies defined a broad spectrum of ischemic and ventriculographic abnormalities in survivors of sudden cardiac death. Further application of these noninvasive studies may identify those at high risk.
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PMID:Myocardial imaging and radionuclide angiography in survivors of sudden cardiac death due to to ventricular fibrillation: preliminary report. 87 Nov 11

To evaluate whether elevated arterial free fatty acids (FFA) increase myocardial oxygen demand and ischemia, 15 fasting patients with coronary artery disease underwent a standardized atrial pacing test before (PTI) and during (PT2) heparin infusion. The patients were monitored for clinical and electrocardiographic (ECG) manifestations of ischemia. Myocardial extraction of lactate, inorganic phosphate, oxygen and FFA was measured before and during each PT. The control arterial FFA was 0.65 +/- 0.03 micromole/ml and rose to 1.83 +/- 0.16 micromole/ml during heparin influsion. Myocardial oxygen extraction at rest and during PT was not affected by the increase in arterial FFA. Seven patients asymptomatic during PT1 did not develop ischaemic manifestations during PT2. In eight patients with angina during both PTs, increased arterial FFA concentration did not modify the severity of anginal pain, the amount of ST-segment depression and the myocardial balance of lactate or inorganic phosphate. Elevation of arterial FFA by heparin neither increased myocardial oxygen extraction at rest or during pacing nor accentuated ischemic manifestations during PT.
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PMID:Effect of increased free fatty acids on myocardial oxygen extraction and angina threshold during atrial pacing. 87 27

The hemodynamic, coronary sinus blood flow and myocardial metabolic effects of 0.15 mg/kg body weight of intravenously administered propranolol were studied in 19 patients with coronary artery disease and 6 normal patients. Atrial pacing was performed in all patients and produced angina in 15 of the 19 patients with coronary artery disease. In these patients propranolol reduced heart rate from 78 to 69 beats/min, cardiac index from 3.0 to 2.6 liters/min per m2 and left ventricular stroke work index from 47 to 43 g-m/m2; it increased total peripheral resistance from 24 to 28 units and lactate extraction from 16.3 to 22.5%. There was no significant change in mean arterial pressure, left ventricular end-diastolic pressure, coronary sinus blood flow or myocardial oxygen consumption. During a second pacing stress propranolol produced clinical improvement in 9 of the 15 patients who experienced angina initially. The improvement was associated with less severe abnormalities in S-T depression and left ventricular end-diastolic pressure, increased lactate extraction and no significant change in coronary sinus blood flow or myocardial oxygen consumption. Thus, propranolol appears to be capable of modifying the anginal threshold as determined with atrial pacing, and the clinical response appears to be independent of global changes in coronary sinus blood flow and myocardial oxygen consumption.
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PMID:Effects of propranolol on the hemodynamic, coronary sinus blood flow and myocardial metabolic response to atrial pacing. 87 19

In 311 patients (269 men and 42 woman, 20 to 65 years old) without transmural myocardial infarction the results of exercise tests in supine position were compared with the results of coronary angiography. 1. Patients having ischemic ST-segment depression (greater than or equal to 0.1 mV) and angina pectoris during exercise (n = 108) showed a greater than or equal to 50% stenosis of at least one vessel in 86.1%. In men the number of a greater than or equal to 50% stenosis was significantly higher than in women (91.3 vs. 56.2%). In patients without digitalis agreement with coronary angiographic findings is higher than in patients with digitalis (92.7 vs. 79.2%). After excluding women, patients under digitalis and those with an intramural myocardial infarction, agreement was 96.8%. 2. In patients having ischemic ST-segment depression agreement was 30% and in those with angina pectoris 36.8%. 3. In patients having neither ischemic ST-segment depression nor angina pectoris during exercise up to a heart rate of 80% of the age-dependent heart rate limit a coronary angiogram without a greater than or equal to 50% stenosis was found in 87.6%. After excluding patients with an intramural myocardial infarction, women and patients under digitalis, agreement increased to 97.9%. 4. In patients having both ischemic ST-segment depression and angina pectoris during exercise a 2- or 3-vessel disease was more often found than in patients having either ischemic ST-segment depression or angina pectoris, or in those having neither ischemic ST-segment depression nor angina pectoris respectively (57.5% vs. 16.6, 8.9 and 1.9%). 5. The number of positive coronary angiograms, especially of 2- and 3-vessel disease, increases with the degree of an ischemic ST-segment depression and the reduction of exercise tolerance.
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PMID:[Relationship between coronary angiographic findings and exercise Ecg in patients without transmural myocardial infarction (author's transl)]. 89 23

A group of 215 men and 272 women aged 62 to 90 forming a randomly-selected sample of the older population was studied by cardiovascular survey methods and followed for 5 years. The 5-year mortality of 28 per cent was related to age and was higher in men. Ischaemic heart disease was the certified cause of 28 per cent of the deaths. Mortality was greater in those with systolic hypertension. Among electrocardiographic features ST depression, T inversion, and atrial fibrillation increased overall and ischaemic heart disease mortality independently of their association with age. A positive response to an angina and infarct questionnaire was poorly related to subsequent mortality. Re-examination of 72 per cent of 5-year survivors was possible. Systolic and diastolic blood pressures were significantly lower and the frequency of electrocardiographic abnormalities, particularly left axis deviation, left ventricular hypertrophy, and ST and T wave changes, was increased.
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PMID:Longitudinal survey of ischaemic heart disease in randomly selected sample of older population. 90 84

Ergonovine maleate (Ergotrate) was given to 57 patients undergoing coronary arteriography for investigation of angina occurring at rest or without provocation when routine study showed normal arteries or insufficient occlusive disease to explain their symptoms. This provocative test induced coronary arterial spasm in 13 patients, 10 of whom had definite Prinzmetal's angina. The spasm was easily reversed with sublingually administered nitroglycerin. The spasm was occlusive or nearly occlusive in nine patients, and there was associated reproduction of the chest pain and S-T elevation similar to the spontaneous episodes. One patient with Prinzmetal's angina had S-T depression rather than elevation in association with the chest pain. The other three patients without Prinzmetal's angina had focal narrowing without coronary occlusion, reproduction of the chest pain or electrocardiographic changes. Of the 44 patients who did not demonstrate coronary spasm in response to ergonovine, 29 had normal coronary arteries and 15 had various degrees of atherosclerotic occlusive disease. We conclude that cautious administration of ergonovine maleate during coronary arteriography can be safely used to elicit coronary spasm in some patients who have insufficient fixed occlusive disease to explain their symptoms.
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PMID:Provocation of coronary spasm with ergonovine maleate. New test with results in 57 patients undergoing coronary arteriography. 91 Jul 12

A 40 year old man with far advanced coronary heart disease consistently experienced pain and exhibited marked S-T segment depression after 44 crossings during a Master two-step test. When the number of times traversed was miscounted so that he exercised less, the pain occurred at the precise count of 44 and he showed the same marked degree of S-T depression. However, when the count was accurate, he had neither pain nor S-T segment deviation at the reduced exercise level. The possible basis for verbal conditioning provoking angina pectoris is explored.
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PMID:Verbal conditioning of angina pectoris during exercise testing. 91 Jul 28


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