post-exercise to peak exercise systolic blood pressure ratio: a new marker of myocardial Ischaemia

To assess the usefulness of the post-exercise [recovery] to the peak exercise systolic blood pressure ratio [RSBP/PSBP] in the diagnosis of coronary heart disease [CHD], 100 patients [94 M and 6 F, mean age 49 +/- 8.7 yrs] were examined by ECG exercise test and coronary angiography. The series was divided into 3 groups: group I [40 pts, mean age 51 +/- 6.8 yrs] symptomatizing by typical chest pain but depicting nonspecific ST-T changes in the resting ECG; group II[40 pts, mean age 51.5 +/- 7.8 yrs] either known to have CHD in the form of a previous documented myocardial infarction, or preliminarily presenting a very high index of suspicion of CHD in the form of typically ischaemic ST-T changes in the resting ECG; and group III [20 pts, mean age 44 +/- 7.2 yrs] presenting with atypical chest pain but without resting ECG changes whatsoever. In group I, coronary angiography displayed single vessel disease [I VD] in 24 pts [60%], two-vessel disease [2VD] in 13 pts [32.5%] and triple vessel disease [3VD] in 3 pts [7.5%]; in group II, 23 pts [57.5%] had 1VD, 15 pts[375%] had 2VD and 2 pts [5%] had 3VD, whereas all patients in group III were proven to have normal coronary arteries. The duration of exercise test was significantly longer in group III than in both groups I and II. Patients in group III achieved a significantly higher level of maximal SBP than those of groups I and II [p = 0.0104]. An abnormal RSBP/PESBP ratio was defined as recovery SBP to peak exercise SBP ratio > 1, 0.9 and 0.8 at 1, 2 and 3 minutes of recovery respectively. An abnormal ratio was disclosed by 35 pts [87.5%] of group 1, 37 pts [92.5%] of group II and 3 pts [15%] of group III. On the other hand, chest pain during exercise testing occurred in 26 pts [65%] of group I, 28 pts [70%] of group II and 6 pts [30%] of group III. Significant ST-T displacement during exercise testing was developed in 23 pts [57.5%] of group I, 26 pts [65%] of group II and 4 pts [20%] of group III [these ST-T alterations were only typically ischaemic in the first 2 groups]. The RSBP/PSBP ratio has successfully detected CHD with a sensitivity of 85%, specificity of 70%, positive predictive value of 90%, negative predictive value of 68% and diagnostic accuracy of 85%: The sensitivity of exercise-induced chest pain in detecting CHD was only 67% the specificity was 70% positive predictive value 90% negative predictive value 35% and diagnostic accuracy 68% whereas the sensitivity, specificity, positive predictive value negative predictive value and diagnostic accuracy of exercise induced ST changes in the detection of CHD were 61%, 70%, 90%, 34% and 65% respectively. For combined ST changes and chest pain the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 90%, 72%, 93.5%, 70% and 88% respectively. It is noteworthy that 85% of patients with 1VD, 88% of those with 2VD and 100% of those. with 3VD have displayed an abnormal RSBP/PSBP ratio. Thus, the RSBP/PSBP ratio supercedes either exercise-induced angina or ST changes in the sensitivity of detection of CHD. Nevertheless, the combination of exercise angina and ST changes is more sensitive than the RSBP/PSBP in detecting CHD. The ratio exhibited a diagnostic accuracy in identifying patients with CHD that is comparable to ST changes and chest pain. Moreover, the RSBE/PSBP correlated well with the severity of CHD. The ratio is not, however, meant to replace the classical hallmarks of myocardial ischaemia during ECG stress testing, it might be rather perceived as an adjunct to those classical time-honoured criteria

Left atrial spontaneous echo contrast before and after percutaneous mitral balloon valvuloplasty: an echocardiographic study

Left atrial spontaneous echo contrast [SEC] is a marker of blood stagnation in the left atrium in mitral valve disease and a forerunner of cardiogenic thromboembolism. To assess the effect of mitral balloon valvuloplasty on SEC visualization in the left atrium [LA] in rheumatic mitral valve disease, 30 patients with rheumatic mitral stenosis [MS] [7 males and 23 females, mean age 30 +/- 10.5 years] were studied by transthoracic echocardiography [TTE] including M-mode, two-dimensional, continuous and pulsed wave Doppler with colour flow mapping for the detection of associated or consequent mitral regurgitation [MR]; as well as transoesophageal echocardiography [TEE] prior to and within one week after balloon valvuloplasty [BV] of the mitral valve. Measurements of LA dimensions, mitral valve area [MVA], mitral valve score [MVS], mean transvalvular pressure gradient [MPG] and fractional shortening [FS] were carried out. TEE was utilized to detect SEC in the LA and determine its grade, as well as to rule out the likelihood of thrombus formation in the LA or left atrial appendage [LAA] and to measure the thickness of the interatrial septum [IAS]. TTE failed to detect SEC in all patients and proved insensitive in this respect. The impact of BV was manifested by a significant reduction of the LA diameter, a significant increase in FS, a significant increase in the 2-D estimated MVA and in the Doppler-estimated MVA and a reduction of MPG. Before BV, only 9 patients [30%] depicted an evidence of associated grade I MR, whereas after BV 21 patients depicted MR of grade 1[80.9%] and grade 11[19.1%], while the remaining 9 patients [30%] revealed no trace of MR. Before BV, a SEC was displayed in all patients [100%], 13 [43.3%] having +1 SEC. 8 patients [26.7%] having +2 SEC and 9 patients [30%] having +3 SEC; whereas after BV, only 9 patients [30%] had SEC. 6 among them [66.7%] depicting +1 SEC and 3 [33.3%] depicting +2 SEC. Thus, 21 patients [70%] were free of SEC post-BV. Before BV, the grade of SEC was a function of cardiac rhythm [the majority of patients with atrial fibrillation "AF" displayed +3 SEC vs. +1 and +2 SEC in those with sinus rhythm], mean transmitral pressure gradient [the higher the MPG the higher the grade of SEC] and fractional shortening [the lower the FS the higher the grade of SEC. p=0.03]. The rate of resolution of SEC post-BV was a function of age, fractional shortening, MPG across the mitral valve, cardiac rhythm [SEC was more common in association with AF than with sinus rhythm] and mitral regurgitation [SEC was more common in patients with MR]; whereas gender and LA diameter exhibited no striking influence on the rate of resolution of SEC post-BV. It was concluded that TEE is greatly superior to TTE in detecting SEC in patients with rheumatic MS pre- and post-BV, that the frequency of SEC detection is related to cardiac dysrhythmia, particularly chronic AF, MPG across the mitral valve, FS and age of the patient. Successful BV is associated with a significant resolution in SEC or reduction in its grade due to the establishment of a wider MVA, hence a lower MPG, better ventricular filling and higher FS. The visualization of SEC should be considered as a prothrombotic state warranting anticoagulation

Gender difference in exercise endurance and diagnostic yield of the electro cardiographic stress test in a relatively homogenous sample of Egyptian patients with clinically stable coronary artery disease

To assess gender difference in exercise endurance and diagnostic yield of ECG stress test in a relatively homogeneous sample of Egyptian patients with clinically stable coronary artery disease [CAD], 30 patients [15 males and 15 females] with stable angina pectoris and normal ventricular function and established single vessel CAD diagnosed by coronary arteriography and proved to have 75% cross sectional narrowing of the involved artery were subjected to treadmill exercise ECG stress testing using a modified Bruce protocol. Exercise-limiting symptoms, stage reached, peak heart rate [HR], peak systolic blood pressure [SBP], peak double product, percentage of target heart rate [THR], metabolic achievement [in term of metabolic equivalents "METs"], ST segment trends and endurance score [derived from the image reached and the ultimate value of METs achieved] were estimated. It was concluded that male and female patients of comparable age, BMI, severity of CAD and ventricular function depicted significant gender differences in exercise endurance, exertional chronotropic and metabolic achievement. Moreover, diagnostic ST segment shift during exercise as well as in the overall diagnostic yield of the treadmill ECG stress test in favor of the male group