ACC/AHA 2002 guideline update for exercise testing: summary article

Chang

et al. 2016

JAHA

BackgroundThe structure of the aorta is considered to influence exercise systolic blood pressure (SBP) response, which, in turn, might impact upon adverse outcomes. The current study sought to investigate the relationship of aortic calcification and exercise SBP with adverse outcomes among elderly individuals.Methods and ResultsWe retrospectively reviewed 702 elderly individuals (>65 years of age) without obstructive coronary artery disease (CAD; luminal stenosis <50%) who underwent coronary computed tomography (CT) and exercise treadmill testing. ΔSBP stage2 and ΔSBP peak were defined as the difference in systolic blood pressure (SBP) between rest and stage 2 or peak exercise, respectively. Thoracic aortic calcium score (TACS) and coronary artery calcium score (CACS) were measured using CT scanning procedures. The primary endpoints were defined as all‐cause death, admission for heart failure, obstructive CAD requiring coronary intervention, and stroke. In multivariable models, ΔSBP stage2 and ΔSBP peak were positively related with log(TACS+1), even after adjusting for various clinical variables, baseline SBP, and CACS (P<0.001). During a median follow‐up period of 65 months, there were 59 events (8.4%). In a multivariate Cox regression model, independent predictors for all events were age (hazard ratio [HR], 1.12; 95% CI, 1.05–1.19; P<0.001), dyslipidemia (HR, 1.96; 95% CI, 1.14–3.37; P=0.015), and the 4th quartile of TACS (HR, 1.24; 95% CI, 1.03–1.49; P=0.024). Among individual events, the 4th quartile of TACS was the only independent predictor for stroke (HR, 2.15; 95% CI, 1.09–5.13; P=0.044), whereas CACS ≥400 mm3 was an independent predictor for obstructive CAD requiring intervention (HR, 7.04; 95% CI, 1.58–31.36; P=0.010).ConclusionsAortic calcification was related to SBP response during exercise and was an independent predictor for outcomes, especially stroke, regardless of resting SBP or CACS.

“…A symptom‐limited exercise treadmill test was performed according to the Bruce protocol 21. Resting SBP and DBP were measured in the brachial artery in the seated position.…”

Section: Methodsmentioning

confidence: 99%

Association of Thoracic Aorta Calcium Score With Exercise Blood Pressure Response and Clinical Outcomes in Elderly Individuals: Differential Impact of Aorta Calcification Compared With Coronary Artery Calcification

Chang

et al. 2016

JAHA

Journal of Cardiovascular Magnetic Resonance

“…Patient symptoms, rest and peak heart rate, blood pressure, and any ECG changes were noted. The test was discontinued for limiting symptoms (angina, dyspnea, fatigue), abnormalities of rhythm or blood pressure, or marked ST-segment deviation (>0.2 mV in the presence of typical angina), or attainment of age-predicted maximal heart rate (calculated as 220 – age) [12]. …”

Section: Methodsmentioning

confidence: 99%

“…The ECG criterion for a positive test was greater than or equal to 1 mm of horizontal or downsloping ST-segment deviation (depression or elevation) in any lead except aVR for at least 60 to 80 milliseconds (ms) after the end of the QRS complex, either during or after exercise. Patients with left-bundle branch block on resting ECG, which interferes with interpretation of the exercise test, were considered non-diagnostic and were not included in the final analysis [12]. …”

Section: Methodsmentioning

confidence: 99%

“…The Duke Treadmill Score (DTS) was calculated based on the METs, the amount of ST-segment deviation, and exercise angina index [12,19]. The largest net ST-deviation, either elevation or depression in any lead except avR was entered into the formula, if ST-segment deviation was less than 1 mm, the value entered was 0.…”

Section: Methodsmentioning

confidence: 99%

“…This test appears to be less accurate in women for the diagnosis of CAD, and both lower sensitivities and specificities have been reported compared to men [9,10]. This gender difference remains even when combining the interpretation of ST-segment deviation with exercise time and exercise induced symptoms into the Duke Treadmill Score (DTS) [11,12]. These difficulties posed on the clinical determination of CAD probability have led to speculation that stress imaging approaches may be an efficient initial alternative to exercise ECG in women [13], however few data are available to support this approach.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Comparison of exercise electrocardiography and stress perfusion CMR for the detection of coronary artery disease in women

Greulich

Bruder

Parker

et al. 2012

BackgroundExercise electrocardiography (ECG) is frequently used in the work-up of patients with suspected coronary artery disease (CAD), however the accuracy is reduced in women. Cardiovascular magnetic resonance (CMR) stress testing can accurately diagnose CAD in women. To date, a direct comparison of CMR to ECG has not been performed.Methods and resultsWe prospectively enrolled 88 consecutive women with chest pain or other symptoms suggestive of CAD. Patients underwent a comprehensive clinical evaluation, exercise ECG, a CMR stress test including perfusion and infarct imaging, and x-ray coronary angiography (CA) within 24 hours. CAD was defined as stenosis ≥70% on quantitative analysis of CA.Exercise ECG, CMR and CA was completed in 68 females (age 66.4 ± 8.8 years, number of CAD risk factors 3.5 ± 1.4). The prevalence of CAD on CA was 29%. The Duke treadmill score (DTS) in the entire group was −3.0 ± 5.4 and was similar in those with and without CAD (−4.5 ± 5.8 and −2.4 ± 5.1; P = 0.12). Sensitivity, specificity and accuracy for CAD diagnosis was higher for CMR compared with exercise ECG (sensitivities 85% and 50%, P = 0.02, specificities 94% and 73%, P = 0.01, and accuracies 91% and 66%, P = 0.0007, respectively). Even after applying the DTS the accuracy of CMR was higher compared to exercise ECG (area under ROC curve 0.94 ± 0.03 vs 0.56 ± 0.07; P = 0.0001).ConclusionsIn women with intermediate-to-high risk for CAD who are able to exercise and have interpretable resting ECG, CMR stress perfusion imaging has higher accuracy for the detection of relevant obstruction of the epicardial coronaries when directly compared to exercise ECG.

Utility of Stress Testing and Coronary Calcification Measurement for Detection of Coronary Artery Disease in Women

Nasir¹,

Redberg²,

Budoff³

et al. 2004

Arch Intern Med

Accurate and safe diagnostic testing provides the crucial link between detection and optimal management of coronary artery disease (CAD). Noninvasive diagnostic testing for CAD may be less accurate in women than in men. Many noninvasive diagnostic modalities are available for this purpose. An exercise tolerance test provides an assessment of functional capacity and has the advantages of wide availability and low initial cost. However, exercise echocardiography may be the most cost-effective method for the initial assessment of coronary artery disease in intermediate-risk women owing to its higher sensitivity and specificity. Recent studies with electron-beam computed tomography reveal that women with no coronary calcification are very unlikely to have obstructive CAD. In symptomatic women with an intermediate likelihood of CAD, either an exercise treadmill test or exercise echocardiography is appropriate for initial screening and can provide useful prognostic information. Alternatively, an electron-beam computed tomographic scan with a 0 calcium score may spare many women with atypical chest pain or equivocal findings on an exercise tolerance test from undergoing more expensive stress imaging studies or coronary angiography. For high-risk symptomatic women, a more aggressive approach involving coronary angiography appears to be the preferred initial diagnostic strategy.