Christos A. Fourlas

QRS score improves diagnostic ability of treadmill exercise testing in women.

ObjectiveThe accuracy of treadmill exercise testing to detect coronary artery disease is limited in women. This study was undertaken to evaluate whether QRS score can improve the accuracy of treadmill exercise testing in women. MethodsThe study population consisted of 114 women with angina-like symptoms, who underwent both treadmill exercise testing and coronary angiography. The impact of QRS score on the standard ST-segment based diagnostic ability of treadmill exercise testing to detect coronary artery disease was studied. ResultsIncorporation of QRS score in standard ST-segment diagnostic criteria significantly enhanced sensitivity (from 59 to 80%), specificity (from 40 to 94%) and diagnostic accuracy (from 50 to 87%) of treadmill exercise testing. The QRS score was shown to reduce significantly the false-positive results from 60 to 6%. Furthermore, QRS score accuracy was correlated with the extent of coronary artery disease. The diagnostic ability of QRS score was greater both among patients with normal and impaired systolic function of the left ventricle. ConclusionsQRS score can improve the limited diagnostic accuracy of treadmill exercise testing in women, by predominantly decreasing the high prevalence of false-positive results.

Significance of QRS Duration Changes in the Evaluation of ST-Segment Depression Presenting Exclusively During the Postexercise Recovery Period

Background: The aim of this study was to evaluate the contribution of QRS prolongation in the diagnosis of coronary artery disease (CAD) in patients with exercise‐induced ST‐segment depression exclusively during the recovery period.

ST Segment “Hump” during Exercise Testing and the Risk of Sudden Cardiac Death in Patients with Hypertrophic Cardiomyopathy

Background: The appearance of a discrete upward deflection of the ST segment termed “the ST hump sign” (STHS) during exercise testing has been associated with resting hypertension and exaggerated blood pressure response to exercise.

Mild Cyanosis due to Coexistence of Congenitally Corrected Transposition of the Great Arteries and Gerbode-Type Defect

towards the left atrium just underneath the tricuspid annulus (arrow in fi g. 1 ). In order to delineate the characteristics of this second jet, intravenous contrast agent infusion was performed. After opacifi cation of the right atrium ( fi g. 2 A) and left ventricle ( fi g. 2 B), a small amount of contrast entered the left atrium just below the tricuspid valve A 24-year-old woman with no history of cardiovascular disease presented in our clinic complaining of exertional dyspnea, progressively deteriorating during the last months. Her physical examination was remarkable for mild cyanosis and tachycardia. On auscultation of the heart, she had a holosystolic murmur audible at the left fourth intercostal space accompanied by a thrill. Auscultation of the lungs was normal. Chest radiograph revealed a slightly enlarged cardiac silhouette. The electrocardiogram showed mild sinus tachycardia with Q waves in the right precordial leads and absence of Q waves in the left precordial leads. On echocardiographic examination, the diagnosis of congenitally corrected transposition of the great arteries (L-TGA) was established: The ventricle that was found to be under the left atrium was a right ventricle. The ventricle under the right atrium was a left ventricle. The vessel that was originating from the left ventricle was a pulmonary artery, and the vessel originating from the right ventricle was the aorta. The right ventricle, which was positioned on the left side of the heart and functioned as a systemic ventricle, was dilated with moderately reduced contractility. A moderate-tosevere tricuspid regurgitation was demonstrated through color Doppler examination ( fi g. 1 ). A second small jet, vertically traversing the tricuspid regurgitation jet, was also revealed. It seemed to originate from the (anatomically) left ventricle and point Received: June 21, 2005 Accepted: July 25, 2005 Published online: October 27, 2005

Role of right-sided chest leads in the detection of multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction.

ObjectiveTo evaluate the improvement of diagnostic ability of exercise testing to detect multivessel coronary artery disease in patients with extended Q-wave anterior myocardial infarction, using additional right-sided chest leads. MethodsFifty-two consecutive patients with Q-wave anterior myocardial infarction underwent exercise testing, using the standard 12 and the additional right-sided (V3R, V4R, V5R) chest leads, thallium-201 scintigraphy and coronary arteriography. ResultsTwenty-one (40%) patients had one-vessel disease, 18 (35%) had two-vessel disease and 13 (25%) had three-vessel disease. The sensitivities of the standard 12-lead exercise testing and its combination with the additional right-sided chest leads were 24% (5/21) versus 28% (6/21) for the detection of one-vessel disease (P: NS), 33% (6/18) versus 83% (15/18) for the detection of two-vessel disease (P<0.05) and 38% (5/13) versus 92% (12/13) for the detection of three-vessel disease (P<0.05), respectively. In thallium-201 scintigraphy, 29 of the 31 (94%) patients with multivessel coronary artery disease demonstrated reversible ischemia. The usual 12-lead exercise testing could detect ischemia in 11 (35%) of these 31 patients, while the addition of the right-sided chest leads could detect ischemia in 27 (87%) of them (P<0.05). ConclusionsThe additional right-sided chest leads significantly improve the low sensitivity of the usual exercise testing to detect multivessel coronary artery disease in patients with previous extended Q-wave anterior myocardial infarction.

Duration of treadmill exercise testing combined with QRS score predicts adverse cardiac outcome at long-term follow-up.

ObjectiveTotal exercise duration and abnormal QRS score values are treadmill exercise testing (TET) prognostic parameters that have been shown to be significantly and independently associated with cardiac mortality. We evaluated the prognostic value of a new index (M score, Michaelides score) incorporating TET duration and QRS score values in a simple index. MethodsIn this study, we included 626 patients, who underwent TET and coronary arteriography. Cardiac catheterization showed the presence of coronary artery disease in 64.3% of these patients. The M score was calculated by adding the value of the Athens QRS score to the duration of TET (in minutes). The outcome measure was a composite of myocardial infarction or death. Patients were prospectively followed for 38±21 months (median 36 months). ResultsThe composite endpoint was more frequent among the patients of the 1st quartile (M-score values <−5.8). In univariate analysis, mortality of the first-quartile patients was significantly higher (14 vs. 1.1%, P<0.001). In multivariate Coxs regression analysis for age, sex, diabetes, smoking status, hypertension, hypercholesterolemia, maximum ST depression at TET, angina during TET, coronary artery disease on angiography, and echocardiographic left ventricular ejection fraction, the first quartile of M-score values was found to be independently associated with the composite endpoint (relative risk = 3.26, 95% confidence interval = 2.01–5.29, P<0.001). ConclusionThis study shows that a new index termed the M score, which incorporates QRS score and exercise duration, predicts mortality and occurrence of myocardial infarction at long-term follow-up of high-risk individuals, independently of TET-induced ST-segment changes.

Correlation of modification of heart rate recovery with adaptation to myocardial ischemia in a model of sequential exercise testings.

Background: Heart rate recovery (HRR) has been identified as a reliable predictor of cardiac mortality, correlated with autonomic tone. In a model of sequential exercise testings, we investigated the reproducibility of HRR and the association between HRR modification and myocardial adaptation to ischemia.

Exercise testing in asymptomatic patients with heterozygous familial hypercholesterolaemia

ObjectiveFamilial hypercholesterolaemia (FH) is a frequent genetic disorder in Europe, affecting one in 500 people in its heterozygous form. Both homozygous and heterozygous forms are correlated with increased incidence of cardiovascular events. MethodsWe investigated clinical and biochemical parameters possibly associated with the results of exercise testing (ET) in asymptomatic patients with heterozygous FH. The study population was derived from outpatients of the Lipid Center in our department and consisted of 194 patients with heterozygous FH who had no medical history of coronary artery disease (CAD) or angina-like symptoms and who had agreed to undergo ET. ResultsSex, body mass index, smoking status, diabetes mellitus, family history of CAD, presence of xanthomas and total cholesterol, triglyceride, low-density and high-density lipoprotein cholesterol, apolipoproteins A and B and lipoprotein (a) levels did not differ significantly between patients with positive and negative ET. Higher fibrinogen levels, arterial hypertension and family history of CAD were more frequent among patients with positive ET. However, in multivariate analysis adjusted for all the aforementioned variables, only high fibrinogen levels were significantly and independently associated with a positive result of ET. ConclusionsLipid and coronary risk factor profiles do not seem to predict exercise-induced myocardial ischaemia in asymptomatic patients with heterozygous FH. However, in this high-risk population for cardiovascular events, fibrinogen levels are an independent predictor of positive ET. The adverse effects of FH on the cardiovascular system may be partly mediated by coagulability factors, whose role in the management of FH patients remains to be fully clarified.

Detection of Multivessel Disease Post Myocardial Infarction Using an Exercise‐Induced QRS Score

Objective: The aim of this study was to investigate the ability of Athens QRS score values to detect stenoses in other coronary arteries than the obstructed ones (which caused the myocardial infarction [MI]) in patients with a history of MI.