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Many exercise protocols are in use in clinical cardiology, but no single test is applicable to the wide range of patients' exercise capacity. A new protocol was devised that starts at a low workload and increases by 15% of the previous workload every minute. This is the first protocol to be based on exponential rather than linear increments in workload. The new protocol (standardised exponential exercise protocol, STEEP) is suitable for use on either a treadmill or a bicycle ergometer. This protocol was compared with standard protocols in 30 healthy male volunteers, each of whom performed four exercise tests: the STEEP treadmill and bicycle protocols, a modified Bruce treadmill protocol, and a 20 W/min bicycle protocol. During the two STEEP tests the subjects' oxygen consumption rose gradually and exponentially and there was close agreement between the bicycle and the treadmill protocols. A higher proportion of subjects completed the treadmill than the bicycle protocol. Submaximal heart rates were slightly higher during the bicycle test. The STEEP protocol took less time than the modified Bruce treadmill protocol, which tended to produce plateaux in oxygen consumption during the early stages. The 20 W/min bicycle protocol does not take account of subjects' body weight and consequently produced large intersubject variability in oxygen consumption. The STEEP protocol can be used on either a treadmill or a bicycle ergometer and it should be suitable for a wide range of patients.

These findings suggest that the perfusion/ventilation mismatch during exercise in CHF is related to the chronic consequences of the syndrome and not directly to limitation of exercise related pulmonary flow. Only when the syndrome of CHF is present can matching between perfusion and ventilation be acutely influenced by changes in pulmonary flow.

A 48 year old woman presented with angina after an anterior myocardial infarction and was found to be hyperthyroid. Coronary angiography showed a stenosis of the left coronary os and a long, severe stenosis of the left anterior descending artery which was partially relieved by glyceryl trinitrate. Three months later, after radioactive iodine treatment had rendered her euthyroid, repeat coronary angiography showed entirely normal coronary arteries. This unusual case establishes an association between hyperthyroidism and coronary vasospasm resulting in myocardial infarction.

We have studied a standardized exercise protocol suitable for use with a treadmill or bicycle (STEEP protocol) and compared it with a modified Bruce treadmill protocol in a group of patients with chronic cardiac failure. The STEEP protocol has been previously validated in normal subjects. Exercise time (6.79 +/- 2.42 vs 5.34 +/- 1.95 min, P < 0.05) and peak VO2 (16.66 +/- 4.09 vs 15.01 +/- 3.72 ml.min-1.kg-1, P < 0.05) were greater with the STEEP treadmill compared with the bicycle protocol, but VO2 was very similar at equal exercise stages in both modalities. Heart rate and respiratory exchange ratio tended to be greater during bicycle exercise at equal stages. Exercise time was greater with the modified Bruce protocol (9.00 +/- 3.02 min, P < 0.05) than with either STEEP protocol, but peak VO2 (17.13 +/- 4.52 ml.min-1.kg-1) was similar to that obtained with the STEEP treadmill test. We conclude that the STEEP protocol may be used to test patients with chronic cardiac failure, and that exercise times relate well in both treadmill and bicycle. The protocol should prove useful in studies involving a wide range of exercise capacities or both bicycle and treadmill exercise.

Objective-To audit the detection and management of hyperlipidaemia in patients who have had coronary bypass surgery. Patients-100 consecutive patients (81 men), mean age 61, who had survived at least 3 months after coronary bypass surgery.Methods-Retrospective review of case notes and computerised biochemistry records. Results-83 patients had at least one lipid measurement in the hospital, and of the remaining 17 patients, 10 had undergone urgent or emergency surgery. The median (range) total cholesterol was 6-7 (4.0-11-7) mmoUl and the triglyceride concentration was 2-1 (0.6-18.4) mmoIl. Only 30 patients were referred to a dietician, and 12 were given a lipid lowering drug-these interventions were no more frequent in patients with a cholesterol concentration above than below the median. grafts are considerably stenosed or occluded within 10 years of the operation and the single most important predictor of vein graft failure is hyperlipidaemia.5 Furthermore, in a randomised placebo controlled study of 162 patients after coronary bypass surgery, drug treatment that reduced the mean total cholesterol from 6-35 to 4-65 mmol/l, also reduced the incidence of new vein graft lesions at angiographic follow up after two and four years.67 We therefore undertook a medical audit to determine current practice in patients who have had coronary bypass surgery at the University Hospital of Wales. Conclusions Patients and methodsThe case notes of 100 consecutive patients who had had coronary bypass surgery under the care of one of three cardiac surgeons were reviewed by a single investigator (AS). Patients are reviewed routinely by their surgeon six weeks after the operation, and the referring cardiologist 12 weeks after the operation, so the audit was conducted after this clinical review process. Plasma triglycerides and total cholesterol were determined after an overnight fast at the time of cardiac catheterisation. Extensive measures were taken to detect any lipid measurements either filed or hand written in the notes or in the computerised biochemistry records. The case notes of patients with no lipid measurement, and a 10% sample of the rest, were checked by a second investigator. Eight of the hundred patients had more than one recorded lipid measurement, and for the purposes of this audit the earliest measurement, which was before surgery in every case, was taken to be representative for that patient. ResultsThere were 81 men and 19 women and the mean (range) age was 61 (44-78). The total number of.patients with a recorded lipid measurement, either in the notes or from biochemistry records, was 83. Of the 17 patients with no lipid record, 10 had had urgent or emergency surgery. The median (range) total cholesterol was 6-7 (4-0-11 7) mmol/l, and the median triglyceride concentration was 2 1 (0.6-18-4) mmol/l. These results were included in either the cardiac or cardiac surgery discharge summary in only 36 (43%) of the cases in whom they were measured.

Adaptations to left ventricular (LV) structure and function appear to be dependent on the type, intensity and duration of exercise training. We therefore studied two clearly defined groups of elite athletes, by M-mode and Doppler echocardiography, with a group of inactive individuals as controls. All groups were age matched. Group 1 comprised ten elite endurance athletes with maximal oxygen consumption (VO2 max) of 74.7 ± 1.43 (mean ± SEM). Group 2 consisted of ten elite weightlifters with V02 max 45.3 + 2.00. Group 3 comprised ten inactive individuals with V02 max 44.5 ± 2.13. Left ventricular end diastolic dimension was significantly higher in group 1 (5.72 ± 0.07) than in groups 2 or 3 (5.29 ± 0.09 and 5.19 ± 0.09 respectively, p < 0.001). Left ventricular mass index was significantly higher in groups 1 and 2 (156.4 ± 5.97 and 138.6 ± 7.27 respectively) than in group 3 (104.1 ± 3.16 p < 0.001). Percentage fractional shortening was used as an index of systolic function and no significant difference was found between groups. Doppler E:A ratio was taken as an index of diastolic function and was found to be significantly elevated in group 1 at rest (3.37 ± 0.24) compared with 2.38 ± 0.16 and 1.99 ± 0.10 in groups 2 and 3 respectively (p < 0.003). On exercise, the E:A ratio in group 1 was significantly higher than in group 3 (1.95 ± 0.14 and 1.23 ± 0.05 respectively p < 0.001), and tended to be higher than group 2 (1.68 ± 0.15 p = ns). These data show that both modes of intense training produce left ventricular hypertrophy. Diastolic function is not impaired in the athletes and may be augmented in the endurance athletes.