The exercise test in variant angina: results in 114 patients (original) (raw)
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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.
Submaximal exercise testing after stabilization of unstable angina pectoris
Journal of the American College of Cardiology, 1984
To determine the prognostic value of exercise testing in patients with unstable angina pectoris, 125 hospitalized patients were prospectively evaluated soon after stabilization of their pain. Exercise testing was performed after exclusion of acute myocardial infarction and a pain-free period of at least 3 days (mean +/- SD 3.9 +/- 1.4). No complications were noted during or immediately after exercise testing. A positive test (angina or greater than or equal to 1 mm ST segment depression, or both) was noted in 60 patients (48%). During a 1 year follow-up period, 52 (87%) of these 60 patients had an unfavorable outcome (American Heart Association class III or IV angina, recurrent unstable angina, coronary artery bypass surgery, acute myocardial infarction or cardiac death) compared with 19 (29%) of the 65 patients with a negative test (p less than 0.001). The sensitivity and specificity of exercise testing in predicting outcome were 73 and 85%, respectively. The predictive value of a positive test was 87% and that of a negative test was 71%. Angina by itself during the exercise test was a reliable predictor of severe angina (class III or IV angina) at follow-up (sensitivity 92%, specificity 89%, positive predictive value 83% and negative predictive value 95%; p less than 0.001). The findings were not significantly affected by beta-adrenergic blocking agents or digitalis in the study sample. Thus, in patients with unstable angina which has been stabilized, the results of early submaximal exercise testing may be useful in predicting outcome in the first year after hospital discharge. Patients with a positive test result should be considered for further diagnostic studies.
Circulation, 1979
Four patients with variant angina pectoris exhibited reproducible exercise-induced chest pain and ST-segment elevation. Coronary arterial spasm was documented with arteriography during exercise-induced ST-segment elevation (three patients) or after intravenous administration of ergonovine maleate (one patient). Our observations show that in patients with variant angina exercise can trigger coronary arterial spasm, thus inducing anginal pain and ST-segment elevation.
Journal of the American College of Cardiology, 1988
The reldion of siteat ischemia in patients with stable angina to known predictors of severity of coronary dii on exercise stress testing and coronaq angiography is poorly de&d. TLL issue was therefore examined with use ef HOW ekctmmdiipldc (ECG) recordi, treadmill exe&se t&3 Plrd ongiographic i&xes ill 102 patients (not takiq antian&al therapy) and the results were compared with Hdter and tre&niU findings in 42 vohmteers. A total d 159 is&e& episodes (90% silent) were identikd during 2,503 h on Hotter recordiig in 97 patients (mean duration per episode 22.7 + 147 min; range 1 to 234). H&r recordings had a 92% specificity and an 80% positive predictive value, hut a sensitivity of only 37% and a ~@ve predictive value of 27% for coronary dii. sixty-three patients (Group I) had no i&e& on Hdter recordhtg, 22 (Group 11) bad a cumulative duration of 1 to 60 lain&l h and in 12 (Group 111) ischensia exceeded 60 r&O4 h. There WPJ no sigNkant correlation between There is now compelling evidence that spontaneous episodes of transient myocardial ischemia in the absence of symptoms occur in unstable as well as stable coronary syndromes (I-6). Although such asymptomatic episodes. termed "silent cumutative is&e& duratien 011 Helter recur&g exercise duration OT time to ST segmeut depressien 011 treadmill exercise. In genera& th pitter tk msm coronary wssels invelved coronary artery stenosis i!xhemiaaItdtkEolQer on Ho&et recnrdiqg. irmpef3ive of the severity of carenary dii, in about 25% of Hotter w ia each angiographii category there were no ischemic epkodes. The 12 patients in Group III (isehemia duration Ml mid24 h) had a If&d greater probabitity of having three vesselorieft-dfscoseaada4 er probability of h&g a frigllcr proxhd ry slenosis index (p C 8.&33 zr#l p C 0.@4, respectively). Thus, evidcnre of prdoqgd ischenda oa Mter ECG recording increases the liktlikood that a pa&eat has mnttivessei coronary diiase hut its absence is Or We predictive value. (J Am Cd Ctwdkd 1988;I2:M9-76~
Unstable angina, myocardial infarction and sudden death after an exercise stress test
International Journal of Cardiology, 1989
We performed coronary angiography within 95 minutes of the onset of symptoms in seven patients with an acute coronary event after an exercise stress test. The test was normal in six patients. Previous angiography in four patients revealed no evident or moderate obstructive coronary arterial disease. After the test, unstable angina developed in two patients, acute myocardial infarction in four and ventricular fibrillation in one, who was successfully resuscitated. At acute angiography the coronary artery involved was occluded in four and sub-totally obstructed in three. In three cases, coronary occlusion was due to thrombosis, vasospasm, or both. In six vessels there was an eccentric lesion, which is consistent with a ruptured plaque. These findings show that physical exercise can unexpectedly provoke an acute coronary event with sub-total or total occlusion of a previous angiographically normal or moderately obstructed coronary artery. The mechanism is probably related to exercise-induced plaque rupture which can produce coronary (sub)occlusion by coronary thrombosis, spasm, or both.
Journal of Electrocardiology, 1998
The aim of this study was to investigate exercise-induced ST-segment depression in subjects with a 120-ms or shorter PR segment and normal coronary arteries. A population of 86 individuals who demonstrated ST-segment depression of 1.5 mm or more on treadmill testing and had a subsequent normal coronary arteriography was classified into two groups. Group A (n = 71) comprised those with a normal PR interval on baseline electrocardiogram I60.9 ± 14.8 ms (mean + 1 SD), and group B (n = 15) comprised those with a 120-ms or shorter PR interval I13-8.8 ms (mean-+ 1 SD). All subjects had undergone a symptom-limited treadmill test by the standard Bruce protocol (mainly for evaluation of chest pain or angina-like pain), during which they demonstrated ST depression of 1.5 mm or more in either lead II, lead V2, or lead Vs. All had normal or near normal coronary arteries on angiography. In the subjects with short PR segments and angiographically normal coronaries, a trend of greater ST-segment depression during treadmill testing as compared with control subjects was observed in lead Vs. In the same group, ST-segment depression at the 9th minute of exercise was more prevalent in lead V5 than in lead II or V2.