Identification of patients with coronary artery disease by assessing diastolic abnormalities during isometric exercise

Abstract

Background: Previous clinical studies using invasive and noninvasive methods have shown handgrip‐induced diastolic abnormalities in patients with coronary artery disease (CAD). Hypothesis: The study was undertaken to determine the utility of Doppler echo‐ and pressocardiography during handgrip in discriminating patients with coronary artery disease (CAD) and in those with normal coronary arteries. Methods: Both methods were obtained in 96 patients with suspected CAD within 24 h before coronary angiography. An abnormal handgrip‐Doppler was defined by an early (E) to late (A) transmittal flow velocities ratio (E/A) < 1 during handgrip and a positive handgrip pressocardiographic test (HAT) by an abnormal increase in the A wave/total excursion or prolongation of the absolute or relative (heart‐rate corrected) total relaxation time during isometric exercise. Results: Of the 96 patients studied, 23 had normal coronary arteries and 73 showed CAD. In patients with normal coronary arteries, handgrip‐Doppler showed an abnormal average E/A at rest and during handgrip, whereas all variables of HAT were within normal limits. In patients with CAD, handgrip‐Doppler showed only a moderate handgrip‐induced increase in average A (+ 19%, p < 0.001), whereas HAT showed a significant (p < 0.001) increase in mean A wave/total excursion (+ 60%) and decrease in the relative total relaxation time (‐17%). Furthermore, handgrip‐Doppler and HAT were abnormal in 15 of 23 (65%, specificity 35%) and the HAT in 5 of 23 (22%, specificity 78%) patients with normal coronary arteries, as well as in 57 of 73 (sensitivity 78%) and 69 of 73 (95%) patients with CAD. Conclusions: Our study demonstrates that these noninvasive stress tests can become a useful new diagnostic modality for detecting patients with unknown or suspected CAD.

Invasive and Noninvasive Assessment of Exercise-induced Ischemic Diastolic Response Using Pressure Transducers

“…It has been shown that these recordings reflect unidirectionally corresponding temporal and amplitude changes of the LVP curve both at rest [15-23] and during exercise [24-26]. A high-magnitude increase of the pressocardiographic relative/“pulse” A wave amplitude has been shown with exercise [24-35] in CAD patients, which was very similar to the corresponding dramatic LVEDP rise in the presence of ischemia. …”

“…In patients with angiographically verified CAD, a positive presso test (ischemic or non-ischemic) has been found in 86-93% of outpatients [30-34] and 95% of hospitalized patients with CAD [35]. Moreover, patients with hypertension [41, 42], hypertrophic cardiomyopathy [43, 44] and syndrome X [45] showed a positive presso test in 70%, 95% and 100%, respectively.…”

“…An “ischemic pattern” was found in 72% of outpatients [34] and in 61% of hospitalized patients with at least one significant coronary stenosis (>70%) without infarction [35] and less frequently (52%) in patients with prior myocardial infarction [35]. The lower prevalence of an ischemic pattern in hospitalized patients could be explained by bed rest, less catecholamines, preceding anti-ischemic or other drug treatments.…”

Reply

“…Dr. Manolas correctly identifies the use of invasive pressure measurements in our approach as a limitation and proposes to replace the invasive pressure measurements by "pressocardiograms." The feasibility of this approach, by using the pressocardiography during hand-grip exercise, was examined in several studies by Manolas et al (4). The pressocardiograms resemble ventricular pressure tracings and have been used to quantify the timing of cardiac events during the cardiac cycle.…”

Echokardiographie

“…Die bessere [27,28]. Der "hand grip" ist eine einfache und hilfreiche Form der Belastung in der täglichen Routine [29][30][31]. Verschiedene Leitlinien stehen zur Verfügung, die ausführlich auf die technische Durchführung eingehen [32,33].…”