Significance of the Walk-Through Angina Phenomenon during Exercise Testing

Abstract

Out of 3,900 patients who performed an exercise test at our clinic, 3 patients demonstrated a walk-through phenomenon (WTP), defined as the occurrence of mild angina during the first stages of exercise with disappearance of chest pain at higher workloads despite a greater pressure-rate product. 2 patients had variant angina, one with normal coronary arteries and the other with single vessel disease, while the third patient had stable exertional angina and a severe coronary artery disease with occlusion of two major vessels retrogradely filled by collateral channels. Repeat exercise tests failed to reproduce constantly the WTP in the 2 patients with variant angina, while in the third patient the phenomenon was repeatedly induced by exercise testing. Thus the WTP, although rarely found during exercise testing, can be observed in two subsets of patients. In variant angina the WTP is not reproducible and is probably due to coronary spasm, spontaneously subsiding during exercise. In patients with exertional angina and severe coronary artery disease, the WTP can be repeatedly observed during exercise and is likely to be secondary to a delayed vasodilation of collateral vessels. The clinical characteristics of the patients and the response to repeat exercise tests may be useful in identifying the different pathogenetic mechanisms.

Improvement of ST Segment Depression by Gradual Recruitment of Collateral Circulation

“…These patients had the ability to continue walking after the on set of angina with eventual disappearance or lessening of anginal pain associated with im provement of the ischemic ST segment de pression. Gavazzi et al [3] also reported a case who had a severe coronary artery dis ease with occlusion of 2 major vessels retrogradely filled by collateral channels.…”

“…The walk-through phenomenon is explained by a gradual increase in blood supply to the jeopardized myocardium in the presence of unchanged or increased myocardial oxygen requirement [1][2][3]. This is accomplished by two different mechanisms.…”

Pre-infarction angina – a problem more common than one might think. Role of general practitioners according to the 2019 ESC Clinical Practice Guidelines

“…Bywa też, że podczas trwania wysiłku ból mija i pacjent kontynuuje aktywność bez dolegliwości (walk-through angina). Nie jest znany dokładny mechanizm tych zjawisk, choć większość badaczy wiąże je z hartowaniem mięśnia sercowego przez niedokrwienie (preconditioning) (5)(6)(7) . Wysiłkowe bóle dławicowe pojawiają się zwykle, gdy blaszka miażdżycowa zajmuje co najmniej 50% średnicy światła tętnicy nasierdziowej.…”

Objective electrocardiographic documentation of ‘walk- through angina’ phenomenon during treadmill stress electrocardiography using Bruce protocol

“…In 'walk -through angina' phenomenon, patient develops angina in the initial phase of exertion, However, if the patient continues to walk, angina gradually disappears. [1][2][3][4][5][6][7] Appreciation of this phenomenon is important because relief in anginal discomfort with continuation of effort may mislead the patient as well as a clinician against the diagnosis of angina on effort. This is important because this phenomenon can occur even in the presence of severe coronary artery disease.…”

“…This is important because this phenomenon can occur even in the presence of severe coronary artery disease. 3,4 Appreciation in also important because some of these patients may show significant improvement in exercise tolerance with exercise training. 4 Documentation of walk-through phenomenon during exercise testing is rare.3 Mac Alpin and Kattus 14 studied twelve patients of angina.…”