Submaximal exercise testing after stabilization of unstable angina pectoris (original) (raw)
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The exercise test in variant angina: results in 114 patients
Circulation, 1981
One hundred fourteen patients with variant angina performed bicycle exercise stress tests, and were divided into three groups. Group 1 included 37 patients with a normal exercise test. Coronary arteriography revealed absence of significant coronary stenoses in 18 patients, one-vessel disease in 17 and involvement of two or more vessels in two. Group 2 consisted of 40 patients who had ST-segment elevation during or just after exercise. Coronary arteriography in these cases revealed absence of significant coronary stenoses in nine patients, one-vessel disease in 18 and disease of two or more vessels in 13. Group 3 included 37 patients who had ST-segment depression during exercise. Absence of coronary artery disease was found in only two patients, one-vessel disease was found in 19 and disease of two or more vessels was found in 16. Sixty-one patients repeated the exercise test after a mean of 18 months after hospital discharge. Exercise-induced ST-segment elevation was no longer prese...
European Heart Journal, 2000
Aims To evaluate the prognostic implications of results from exercise testing, and of antianginal treatment among patients with chronic stable angina pectoris. Material and Methods Out of 809 patients in the Angina Prognosis Study In Stockholm (APSIS), 731 (511 men) performed evaluable exercise tests before and after 1 month on double-blind treatment with metoprolol or verapamil. During a median follow-up of 40 months, 32 patients suffered a cardiovascular death and 29 a non-fatal myocardial infarction. Results Prognostic implications of results from exercise tests were assessed in a multivariate Cox model which included sex, previous myocardial infarction, hypertension and diabetes mellitus. Maximal ST-segment depression, especially if d2 mm and occurring after exercise, as well as exercise duration independently predicted cardiovascular death. Similar results were obtained for the combined end-point of cardiovascular death+myocardial infarction. Among patients with a positive exercise test at baseline, verapamil reduced the maximal ST-depression more markedly than metoprolol (P<0•01). However, when the treatment given and treatment effects on ST-segment depression were added to the Cox model, no impact on prognosis could be detected for either cardiovascular death alone or combined with myocardial infarction. Anginal pain carried no prognostic information. Conclusion Marked ST-segment depression during and after exercise, and a low exercise capacity independently predicted an adverse outcome in patients with stable angina pectoris, whereas anginal symptoms had no predictive value. Short-term treatment effects on ischaemia did not seem to influence prognosis. Post-exercise ischaemia should be examined carefully when evaluating patients with stable angina pectoris.
2008
Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
Journal of the American College of Cardiology, 1991
From the Halhlrnm tovsca• ulCuNiulngy. Royal Prince Alfred Hospital. Camperdowa. Sydney. su,onlia. Dr. wiko, wa, supported by a Ratgradna Medical Res est, Schulanhip from The Nat,aeaI Hens Fnundmien. The 'in, y eau ,pi anad in pmt by a grant-in11d from The N:aiarsl HeAth and Medical Research C,nn it of na,lrara.
The American Journal of Cardiology, 1987
The prognostic information of clinical variables and a predischarge exercise test was studied in 400 patients (282 men, 118 women) admitted to the coronary care unit with suspected unstable coronary artery disease, that is, recurring chest pain of new onset, increasing angina1 pain in formerly stable angina pectoris or suspected nontransmural acute myocardial infarction. Forty-nine coronary events occurred in the 278 men who performed the exercise test during the following year, whereas only 5 coronary events occurred among the 118 women. The only variable of prognostic importance in women was nontransmural myocardial infarction. In men, the clinical variables increasing age, duration of angina, ST-or T-segment changes on the rest electrocardiogram and increasing angina or nontransmural myocardial infarction as inclusion criteria were associated with increased occurrence of coronary artery bypass surgery, transmural myocardial infarction or cardiac death. Findings of ST-segment depression, limiting chest pain or low rate-pressure product during the exercise test were of greater value than any clinical variable in prediction of coronary artery bypass surgery, transmural myocardial infarction or cardiac death. Within all clinical subgroups of men, the results of the exercise test had an additive predictive value for future coronary events. Combinations of clinical data and exercise test results enabled the best identification of patients with high or low risk for coronary events. (Am J Cardiol 1987;59:208-214) P atients admitted to the coronary care unit because of chest pain but without development of an acute transmural myocardial infarction have an uncertain prognosis. Some of these patients have unstable coronary artery disease [CAD), that is, angina pectoris of recent onset, deterioration of formerly stable (effort-induced) angina or nontransmural myocardial infarctionl-3; others have a less threatening cause of chest pain. Thus, some patients with chest pain in whom unstable CAD is suspected have large areas of j eopardized myocardiurn and probably a high risk of complications,1Js4-7 whereas others have a large coronary flow reserve
Circulation, 1980
The effect of exercise on resting hemodynamics and the reproducibility of clinical and hemodynamic events during two successive exercise periods 25 minutes apart were evaluated in 20 patients with stable angina pectoris. Comparison of the resting data during the first and second control periods (C1 and C,) separated by a period of exercise showed that the values for heart rate (HR) were higher (76 i 11 vs 79 4 11 beats/min [mean + SD]; p < 0.05), while brachial arterial systolic pressure (BASP) (142 + 13 vs 137 : 13 mm Hg; p < 0.05), brachial arterial mean pressure (BAMP) (103 + 10 vs 99 i 9 mm Hg; p < 0.05), pulmonary arterial mean pressure (PAMP) (22 i 5 vs 18 i 5 mm Hg; p < 0.01), and left ventricular end-diastolic pressure (LVEDP) (18 ± 4 vs 15 ± 4 mm Hg; p < 0.001) were lower during C,. Angina was experienced by all 20 patients during both exercise studies (Ex, and Ex,) and the group mean values for the duration of exercise to angina, ST-segment depression, HR and rate-pressure product at the onset of angina were similar during Ex1 and Ex,. However, in five of the 20 patients, exercise duration to angina varied by 60 seconds or more during the two exercise studies and two of these patients had to be exercised at higher work loads to induce angina during Ex2. Comparison of hemodynamic data at the onset of angina induced by Ex1 and Ex, showed that the group values for LVEDP (29 ± 6 vs 25 : 6 mm Hg), PAMP (33 ± 8 vs 29 i 10 mm Hg), BASP (167 ± 15 vs 162 i 16 mm Hg) and BAMP (120 : 10 vs 115 i 10 mm Hg were lower (p < 0.02) during Ex,. Clinical and electrocardiographic events and HR, rate-pressure product and cardiac output during two successive exercise periods were reproducible, but LVEDP and PAMP were consistently lower during the Ex,. These results should be considered when the effects of therapeutic interventions are being studied during invasive exercise testing in angina pectoris.
BMJ, 2008
Objective To determine whether resting and exercise electrocardiograms (ECGs) provide prognostic value that is incremental to that obtained from the clinical history in ambulatory patients with suspected angina attending chest pain clinics. Design Multicentre cohort study. Setting Rapid access chest pain clinics of six hospitals in England. Participants 8176 consecutive patients with suspected angina and no previous diagnosis of coronary artery disease, all of whom had a resting ECG recorded. 4848 patients with a summary exercise ECG result recorded (positive, negative, equivocal for ischaemia) comprised the summary ECG subset of whom 1422 with more detailed exercise ECG data recorded comprised the detailed ECG subset. Main outcome measure Composite of death due to coronary heart disease or non-fatal acute coronary syndrome during median follow-up of 2.46 years. Results Receiver operating characteristics curves for the basic clinical assessment model alone and with the results of resting ECGs were superimposed with little difference in the C statistic. With the exercise ECGs the C statistic in the summary ECG subset increased from 0.70 (95% confidence interval 0.68 to 0.73) to 0.74 (0.71 to 0.76) and in the detailed ECG subset from 0.74 (0.70 to 0.79) to 0.78 (0.74 to 0.82). However, risk stratified cumulative probabilities of the primary end point at one year and six years for all three prognostic indices (clinical assessment only; clinical assessment plus resting ECG; clinical assessment plus resting ECG plus exercise ECG) showed only small differences at all time points and at all levels of risk. Conclusion In ambulatory patients with suspected angina, basic clinical assessment encompasses nearly all the prognostic value of resting ECGs and most of the prognostic value of exercise ECGs. The limited incremental value of these widely applied tests emphasises the need for more effective methods of risk stratification in this group of patients.
The value of routine non-invasive tests to predict clinical outcome in stable angina
European Heart Journal, 2003
Background Chronic stable angina is a common condition, but considerable differences exist in the likelihood of acute coronary events such as CHD death, non-fatal myocardial infarction (MI) and unstable angina between individual patients. Effective risk prediction is necessary for optimum management. The aim of this study was to identify clinical features and non-invasive test parameters associated with high risk of these coronary events in stable angina and compose a clinically useful model to predict adverse outcomes in this population. Methods Six hundred and eighty-two patients with stable angina and a positive exercise test (1 mm ST depression) from the Total Ischaemic Burden European Trial (TIBET) study, were studied. Resting ECG, exercise tolerance testing and echocardiography were performed at baseline, off anti-anginal therapy. The patients were then randomised to treatment with atenolol, nifedipine or a combination of both. Clinical follow up continued for an average of 2 years (range 1-3 years). Results and conclusions Prior MI or prior CABG were the clinical parameters associated with adverse outcome in patients with stable angina and a positive exercise test. On the ECG, left ventricular hypertrophy was predictive, and on echocardiogram, increased left ventricular dimensions were predictive of adverse events. When combined with time to ischaemia on exercise testing in a simple clinically applicable table these factors could be used to predict of 2 year probability of events for an individual patient.