Juan C. Yáñez

Incremental value of exercise echocardiography over exercise electrocardiography in a chest pain unit.

BACKGROUND Limited data are available on the added value of exercise echocardiography (ExEcho) over exercise electrocardiography (ExECG) in patients with suspected acute coronary syndromes (ACS) referred to a chest pain unit. We aimed to assess the incremental value of ExEcho over ExECG in this setting. METHODS ExECG and ExEcho were performed in parallel in 1052 patients with suspected ACS, nondiagnostic but interpretable electrocardiograms, and negative serial troponin results. The primary outcome was a composite of coronary death, nonfatal myocardial infarction or unstable angina with angiographic documentation of significant coronary artery disease within 6 months. RESULTS The primary outcome occurred in 2/614 patients (0.3%) with both negative ExECG and ExEcho, 3/60 (5%) with positive ExECG and negative ExEcho, 73/135 (54.1%) with negative ExECG and positive ExEcho, 106/136 (77.9%) with both positive ExECG and ExEcho, and 8/107 (7.5%) with inconclusive results. The addition of ExEcho data to a model based on clinical and ExECG data significantly increased the c statistic from 0.898 to 0.968 (change +0.070, 95% confidence interval 0.052-0.092), with a continuous net reclassification improvement of 1.56 and an integrated discrimination improvement of 22% (p<0.001). Decision curve analysis showed that a strategy of referral to coronary angiography based on ExEcho was associated with the highest net benefit and with the largest reduction in unnecessary coronary angiographies. CONCLUSION ExEcho provides significant incremental prognostic information and higher net clinical benefit than a strategy based on ExECG in patients referred to a chest pain unit for suspected ACS and negative troponin levels.

Temporal changes in the use and results of exercise echocardiography

AIMS Limited data are available regarding changes over time in referral patterns and outcomes of non-invasive cardiac stress testing. Our aim was to evaluate the temporal changes in the use and results of exercise echocardiography in our area of reference. METHODS AND RESULTS A total of 12 339 patients referred to our unit for exercise echocardiography between 1997 and 2012 were included. We divided the 16-year period into four quadrennia and evaluated the changes in clinical data, results of the tests, referrals for invasive management and outcomes. We observed a gradual decrease in the frequency of detection of myocardial ischaemia from 35.3% in1997-2000 to 25.4% in 2009-12 (P < 0.001). There was also a progressive increase in the prevalence of cardiovascular risk factors and in the frequency of non-ischaemic chest pain and dyspnoea, while the proportion of patients with prior myocardial infarction and non-interpretable electrocardiograms declined. The rate of referral to coronary angiography within 6 months decreased from 24.8% in 1997-2000 to 19.6% in 2009-12 (P < 0.001), but the rate of coronary revascularization remained almost unchanged (13.1 to 11.7%, P for the trend = 0.16). We also observed a progressive decrease in the 1-year mortality rate from 3.4 to 1% (P < 0.001). CONCLUSION Over a 16-year period, there was a gradual decrease in the frequency of myocardial ischaemia among patients referred to our unit for exercise echocardiography, which was parallel to changes in their clinical profile. However, this was not accompanied by a significant reduction in the rate of coronary revascularization.

Value of an Exercise Workload ≥10 Metabolic Equivalents for Predicting Inducible Myocardial Ischemia

Background—We sought to identify extensive ischemia on exercise echocardiography (ExE) relative to workload in patients without known coronary artery disease and to investigate whether ExE is useful in predicting outcomes in those with high exercise capacity (≥10 metabolic equivalents [METs]) plus a maximal test (≥85% of their maximal age-predicted heart rate [MAPHR]). Methods and Results—The analysis was performed on 4269 patients who underwent ExE, of whom 3995 achieved ≥85% of their MAPHR. These patients were divided according to the reached workload (<7, 7–9, or ≥10 METs) and compared for ExE results. Outcomes in the group achieving ≥10 METs plus ≥85% of their MAPHR (n=2221) were specifically assessed. Ischemia was defined as new/worsening wall motion abnormalities with exercise. ExE results were different between groups because the METs were lower. Still, among patients achieving ≥10 METs plus ≥85% of their MAPHR, 9.3% had extensive ischemia and 6% multiterritory disease. During follow-up in this subgroup, 108 patients died and 42 had a major cardiac event. Annualized mortality and major cardiac event rates were 0.84% and 0.32% in patients without ischemia versus 2.26% and 0.84% in those with ischemia, respectively (P<0.001 and P=0.002, respectively). Ischemia was an independent predictor of mortality (hazard ratio, 1.88; 95% confidence interval, 1.23–2.89; P=0.004) and major cardiac event (hazard ratio, 2.39; 95% confidence interval, 1.22–4.71; P=0.01). Conclusions—Patients without known coronary artery disease achieving ≥10 METs plus ≥85% of their MAPHR may still have ischemia. However, the low event rates even in those with ischemia limit the usefulness of imaging for assessing outcomes in this group.

Troponin levels within the normal range and probability of inducible myocardial ischemia and coronary events in patients with acute chest pain

BACKGROUND/OBJECTIVES Patients with suspected acute coronary syndromes and negative cardiac troponin (cTn) levels are deemed at low risk. Our aim was to assess the effect of cTn levels on the frequency of inducible myocardial ischemia and subsequent coronary events in patients with acute chest pain and cTn levels within the normal range. METHODS We evaluated 4474 patients with suspected acute coronary syndromes, nondiagnostic electrocardiograms and serial cTnI levels below the diagnostic threshold for myocardial necrosis using a conventional or a sensitive cTnI assay. The end points were the probability of inducible myocardial ischemia and coronary events (i.e., coronary death, myocardial infarction or coronary revascularization within 3 months). RESULTS The probability of inducible myocardial ischemia was significantly higher in patients with detectable peak cTnI levels (25%) than in those with undetectable concentrations (14.6%, p<0.001). These results were consistent regardless of the type of cTnI assay, the type of stress testing modality, or the timing for cTnI measurement, and remained significant after multivariate adjustment (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.21-1.79, p<0.001). The rate of coronary events at 3 months was also significantly higher in patients with detectable cTnI levels (adjusted OR 2.08, 95% CI 1.64-2.64, p<0.001). CONCLUSIONS Higher cTnI levels within the normal range were associated with a significantly increased probability of inducible myocardial ischemia and coronary events in patients with suspected acute coronary syndromes and seemingly negative cTnI.

Effect of Age on the Need for Pacemaker Implantation Despite Negative 24‐Hour Holter Monitoring in Individuals with Syncope

ers, and one (11%) access to a medical illustrator to help develop instruction. In conclusion, a small grants program is an effective way to develop and implement innovative curricula in geriatric content. A program with modest funding can have a sustained effect locally and the potential for dissemination. Keys to success include a process that clearly defines the educator’s curricular goals, a targeted needs assessment, implementation commitment from important stakeholders (e.g., course director, department chair), and formalized collaboration with geriatrics faculty.

Age‐Related Variations in Ventricular Response Rate in Individuals with Persistent or Permanent Atrial Fibrillation

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Left ventricular torsion during exercise in patients with and without ischemic response to exercise echocardiography.

INTRODUCTION AND OBJECTIVES Left ventricular torsion decreases during transmural myocardial ischemia, but the effect of exercise on left ventricular torsion has not been widely studied. We hypothesized that exercise-induced ischemia may impair left ventricular torsion. Therefore, our aim was to study the effects of exercise on left ventricular torsion in patients with an ischemic response to exercise echocardiography and in patients with a normal response. METHODS A retrospective analysis was performed in 172 patients with ejection fraction ≥ 50% who were referred for exercise-echocardiography and studied by speckle imaging at rest, peak and postexercise. Torsion was defined as apical rotation - basal rotation (in degrees) / left ventricular length (in centimeters). A total of 114 patients had a normal exercise echocardiography and 58 patients had an ischemic response to exercise echocardiography. RESULTS Patients with ischemic response to the test exhibited less basal rotation at peak exercise (+0.30° [2.39°] vs -0.65° [2.61°] in the normal group; P = .03), whereas peak apical rotation was similar (ischemic response to the test, 7.80° [3.51°]; normal response, 7.27° [3.28°]; P =.36). Torsion at peak exercise was also similar (1.07° [0.60°] in the ischemic response to the test group vs 1.16° [0.57°] in normal group; P =.37). A more impaired peak basal rotation was found in patients with anterior or anterior+posterior involvement (anterior ischemic response, +1.22° [2.45°]; anterior + posterior ischemic response, -0.20° [2.25°]; posterior ischemic response, -0.71° [1.96°]; normal response, -0.65° [2.60°]; P =.02). CONCLUSIONS Basal rotation at peak exercise is impaired in patients with an ischemic response to exercise echocardiography, particularly in those with anterior involvement. Apical rotation and torsion are similar to those in patients with normal exercise echocardiography.

Exercise Echocardiography Findings and Outcome in Patients with RightVentricular Dilation not Related to Left-Sided Heart Disease

Objective: Symptoms may be similar in patients with heart or lung disease. Thus, patients with lung disease are occasionally referred for evaluation by exercise echocardiography (ExE). We aimed to study the clinical, ExE data and outcome of patients with right ventricular (RV) dilation not explained by left ventricular (LV) heart disease. Methods: Retrospective analysis of RV dysfunctional data in absence of LV heart disease in patients submitted to an ExE. Results: Data on RV dilation in absence of LV heart disease were found in 21 of 18,400 ExE studies (0.11%). In 4 of the 21 patients (19%) RV function and systolic pulmonary artery pressure were normal at rest. However, exercise induced RV dysfunction and/or elevated systolic pulmonary artery pressure in all of these 4 patients. During follow-up of 5.2 ± 5.7 years 11 patients died (52%), most of them of respiratory causes (73%), being pulmonary thromboembolism (PTE) (38%) the most frequent final diagnosis. Conclusion: RV dysfunction in absence of LV disease is rare among patients referred for ExE. ExE is of value as sometimes abnormalities on RV function arise only with exercise

Exercise left ventricular ejection fraction predicts events in right bundle branch block

ABSTRACT Objective Interpretation of the electrocardiogram (ECG) during exercise is not easy in patients with right bundle branch block (RBBB). Also, the value of exercise echocardiography (ExE) for predicting outcome in them has not been addressed. We sought to assess its prognostic value in patients with RBBB and known/suspected coronary disease. Design Retrospective analysis of data on 703 patients with RBBB who were submitted to a clinically-indicated ExE. The end points were overall mortality and combined myocardial infarction and cardiovascular mortality. Results During follow-up (4.1 ± 4.5 years) there were 130 deaths and 108 combined events. Independent predictors of combined events were history of coronary artery disease (hazard ratio [HR] = 2.37, 95% Confidence Interval [CI] = 1.24–4.52, p = 0.009) resting wall motion score index (HR = 2.14, 95% CI = 1.12–4.10, p = 0.02), metabolic equivalents (HR = 0.89, 95% CI = 0.93–0.97, p = 0.007), Δ in double product with exercise (HR = 0.96, 95% CI = 0.92–1.00, p = 0.036) and Δ in left ventricular ejection fraction (LVEF) with exercise (HR = 0.97, 95% CI = 0.94–0.99, p = 0.01). Neither positive clinical nor ECG exercise testing was predictive. Combined event rates were 3.3% in patients with ΔLVEF > 5%, 4.7% in those with ΔLVEF between 1–5% and 8.2% in those with no increase (Δ < 1%). Conclusions A decrease in LVEF during exercise is predictive of serious events in patients with RBBB.

Heart Rate Range and All‐Cause Mortality in Older Adults

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