Regulation of cardiac ion channels by transcription factors: Looking for new opportunities of druggable targets for the treatment of arrhythmias.

Cardiac electrical activity is governed by different ion channels that generate action potentials. Acquired or inherited abnormalities in the expression and/or function of ion channels usually result in electrophysiological changes that can cause cardiac arrhythmias. Transcription factors (TFs) control gene transcription by binding to specific DNA sequences adjacent to target genes. Linkage analysis, candidate-gene screening within families, and genome-wide association studies have linked rare and common genetic variants in the genes encoding TFs with genetically-determined cardiac arrhythmias. Besides its critical role in cardiac development, recent data demonstrated that they control cardiac electrical activity through the direct regulation of the expression and function of cardiac ion channels in adult hearts. This narrative review summarizes some studies showing functional data on regulation of the main human atrial and ventricular Na+, Ca2+, and K+ channels by cardiac TFs such as Pitx2c, Tbx20, Tbx5, Zfhx3, among others. The results have improved our understanding of the mechanisms regulating cardiac electrical activity and may open new avenues for therapeutic interventions in cardiac acquired or inherited arrhythmias through the identification of TFs as potential drug targets. Even though TFs have for a long time been considered as 'undruggable' targets, advances in structural biology have led to the identification of unique pockets in TFs amenable to be targeted with small-molecule drugs or peptides that are emerging as novel therapeutic drugs.

Nuevos bloqueadores de los canales de calcio en el tratamiento de la hipertensión arterial / New calcium channel blockers for the treatment of hypertension

Los canales de calcio dependientes del voltaje tipo L tienen un papel clave en la regulación del tono vascular y en el control de la presión arterial, y los bloqueadores de los canales de calcio (BCC) de este tipo (BCC-L) se utilizan ampliamente como antihipertensivos. Los canales tipo T regulan el tono vascular de las arteriolas de resistencia y la secreción de renina y aldosterona, y los canales tipo N, expresados en los terminales nerviosos simpáticos, regulan la liberación de catecolaminas. Comparados con los BCC-L, los BCC de los canales L/N y L/T disminuyen la presión intraglomerular, mejoran la hemodinámica renal y producen una mayor reducción de la proteinuria, incluso en pacientes ya tratados con inhibidores del sistema renina-angiotensinaaldosterona. Por tanto, los BCC de los canales L/T y L/N podrían presentar una nueva alternativa en pacientes hipertensos con insuficiencia renal, aunque son necesarios estudios comparativos a largo plazo para confirmar que estas diferencias se traducen en una mejora de los resultados clínicos

L-type voltage-gated calcium channels play a key role in the regulation of arterial vascular smooth muscle tone and blood pressure levels and L-type calcium channel blockers (CCBs) are widely used antihypertensive drugs. Additionally, T-type channels regulate vascular tone in small-resistance vessels and renin and aldosterone secretion, and N-type channels, expressed in sympathetic nerve terminals, regulate the release of neurotransmitters. As compared with L-type CCBs, L/N- and L/T-type CCBs decreased intraglomerular pressure, improved renal hemodynamics and provided a greater decrease in proteinuria even in patients already treated with renin-angiotensin-aldosterone inhibitors. Thus, dual L/N- and L/T-type CCBs may exhibit therapeutic advantages over L-type blockers in hypertensive patients with chronic kidney disease. However, further large-scale, long-term comparative trials are needed to confirm that these differences translate into an improvement in clinical outcomes

Gender differences in the effects of cardiovascular drugs.

Although sex-specific differences in cardiovascular medicine are well known, the exact influences of sex on the effect of cardiovascular drugs remain unclear. Women and men differ in body composition and physiology (hormonal influences during the menstrual cycle, menopause, and pregnancy) and they present differences in drug pharmacokinetics (absorption, distribution, metabolism, and excretion) and pharmacodynamics, so that is not rare that they may respond differently to cardiovascular drugs. Furthermore, women are also less often treated with evidence-based drugs thereby preventing optimization of therapeutics for women of all ages, experience more relevant adverse drug reactions than men, and remain underrepresented in most clinical trials. Thus, current guidelines for prevention, diagnosis, and medical treatment for cardiovascular diseases are based on trials conducted predominantly in middle-aged men. A better understanding of these sex-related differences is fundamental to improve the safety and efficacy of cardiovascular drugs and for developing proper individualized cardiovascular therapeutic strategies both in men and women. This review briefly summarizes gender differences in the pharmacokinetics and pharmacodynamics of cardiovascular drugs and provides recommendations to close the gaps in our understanding of sex-specific differences in drug efficacy and safety.

[New calcium channel blockers for the treatment of hypertension]. / Nuevos bloqueadores de los canales de calcio en el tratamiento de la hipertensión arterial.

L-type voltage-gated calcium channels play a key role in the regulation of arterial vascular smooth muscle tone and blood pressure levels and L-type calcium channel blockers (CCBs) are widely used antihypertensive drugs. Additionally, T-type channels regulate vascular tone in small-resistance vessels and renin and aldosterone secretion, and N-type channels, expressed in sympathetic nerve terminals, regulate the release of neurotransmitters. As compared with L-type CCBs, L/N-and L/T-type CCBs decreased intraglomerular pressure, improved renal hemodynamics and provided a greater decrease in proteinuria even in patients already treated with renin-angiotensin-aldosterone inhibitors. Thus, dual L/N-and L/T-type CCBs may exhibit therapeutic advantages over L-type blockers in hypertensive patients with chronic kidney disease. However, further large-scale, long-term comparative trials are needed to confirm that these differences translate into an improvement in clinical outcomes. © 2017 SEHLELHA. Published by Elsevier España, S.L.U. All rights reserved.

Investigational calcium channel blockers for the treatment of hypertension.

INTRODUCTION: Voltage-gated Ca2+ channels are the primary route of Ca2+ entry in vascular smooth muscle cells, playing a key role in the regulation of arterial tone and blood pressure. Since the 60´s, L-type Ca2+ channel blockers (CCBs) have been widely used for the treatment of hypertension. Areas covered: T-type Ca2+ channels regulate vascular tone in small-resistance vessels and aldosterone secretion, and N-type channels expressed in sympathetic nerve terminals regulate the release of neurotransmitters. We performed a literature search in MEDLINE, PubMed and ClinicalTrials.gov to identify eligible studies published between January 2001 and March 2016 and reviewed the antihypertensive and renoprotective effects of four CCBs with different pharmacological profiles: azelnidipine (L-type), cilnidipine (L-/N-type) and benidipine and efonidipine (L-/T-type CCBs). Despite similar blood pressure lowering effects, L/N- and L/T-type CCBs, compared with L-type CCBs, decreased intraglomerular pressure, improved renal hemodynamics and provided a greater decrease in proteinuria even in patients already treated with renin-angiotensin-aldosterone inhibitors. Expert opinion: Dual L/N- and L/T-type CCBs may exhibit therapeutic advantages over L-type blockers in hypertensive patients with chronic kidney disease. Because clinical trials supporting these advantages present important biases, further large-scale, long-term comparative trials are needed to confirm that these differences translate into improved clinical outcomes.

An update on atrial fibrillation in 2014: From pathophysiology to treatment.

Atrial fibrillation (AF) is the most frequently encountered cardiac arrhythmia. The trigger for initiation of AF is generally an enhanced vulnerability of pulmonary vein cardiomyocyte sleeves to either focal or re-entrant activity. The maintenance of AF is based on a "driver" mechanism in a vulnerable substrate. Cardiac mapping technology is providing further insight into these extremely dynamic processes. AF can lead to electrophysiological and structural remodelling, thereby promoting the condition. The management includes prevention of stroke by oral anticoagulation or left atrial appendage (LAA) occlusion, upstream therapy of concomitant conditions, and symptomatic improvement using rate control and/or rhythm control. Nonpharmacological strategies include electrical cardioversion and catheter ablation. There are substantial geographical variations in the management of AF, though European data indicate that 80% of patients receive adequate anticoagulation and 79% adequate rate control. High rates of morbidity and mortality weigh against perceived difficulties in management. Clinical research and growing experience are helping refine clinical indications and provide better technical approaches. Active research in cardiac electrophysiology is producing new antiarrhythmic agents that are reaching the experimental clinical arena, inhibiting novel ion channels. Future research should give better understanding of the underlying aetiology of AF and identification of drug targets, to help the move toward patient-specific therapy.

New antihypertensive drugs under development.

Hypertension is the most common cardiovascular disease and remains the most prevalent risk factor for cardiovascular diseases and a major cause of death worldwide. Despite the large number of antihypertensive drugs available, in the majority of patients blood pressure still remains not optimally controlled and persists at high risk of cardiovascular complications. The limitations of current therapies have stimulated the research and development of new classes of antihypertensive agents, with different mechanisms of action, that provide a better blood pressure control, greater protection against organ damage, better tolerability and more effective prevention of cardiovascular diseases. However, essential hypertension is a multifactorial and multigenic disorder, which means that various mechanisms contribute to a greater or lesser extent to increase BP. Recent advances in the understanding of the multiple and complex cellular signalling pathways that modulate vascular smooth muscle cell contraction and growth involved in the regulation of vascular tone and in hypertension-induced end-organ damage have provided valuable insight in identifying new therapeutic targets. This article reviews new antihypertensive drugs under development, focusing on their mechanisms of action and possible advantages compared with traditional drugs.

Doctor-patient communication issues for international medical graduates: research findings from Australia.

INTRODUCTION: Understanding the impact of culture on medical communication is particularly important for international medical graduates (IMGs) who enter health systems from different cultures of origin. This article presents data on IMGs' perception of the impact of cultural factors on IMG doctor-patient communication during their integration into the Australian health system. METHODS: The methodology used was a descriptive qualitative methodology, using iterative, open-ended, in-depth interviews with a sample of 30 IMGs employed at a hospital in Brisbane, Queensland, Australia. RESULTS: According to subjects' comments, understanding patient-centered communication is a major challenge faced by IMGs during integration in the Australian health system. They perceive that this difficulty is associated with the major shift from the culture of their country of origin (described as paternalistic doctor-dominated communication system; standard practice to talk to the family and not the patient) to the very different health care culture of Australia (perceived to be more educated and informed consumers that demand high levels of information and discussion). The findings detail IMGs' experience with learning about patient-centered communication at the point of arrival, during integration and practice. Subjects' perceived the need to provide education on patient-centered communication for IMGs integrating into the Australian health system. CONCLUSION: There is a significant need for IMGs to be educated in cultural issues including doctor-patient communication practices in Australia.

Dronedarone.

Atrial fibrillation (AF), the most common cardiac arrhythmia, is associated with substantial morbidity and mortality. Dronedarone is an amiodarone-like benzofuran which lacks the iodine moiety and presents a methane sulfonyl group that decreases its lipophilicity, thus shortening the half-life and decreasing tissue accumulation. Like amiodarone, dronedarone blocks multiple cardiac ion channels and ß-adrenoceptors, presenting electrophysiological characteristics of all four Vaughan Williams classes of antiarrhythmic drugs. In clinical trials, dronedarone has been found effective for both rhythm and rate control. Dronedarone was more effective than placebo in maintaining sinus rhythm in patients with paroxysmal and/or persistent AF and was also effective for ventricular rate control during AF recurrences, providing incremental rate control on top of standard drugs in permanent AF. Furthermore, in the ATHENA trial, dronedarone reduced the incidence of hospitalization due to cardiovascular events or death in patients with nonpermanent AF. Even when dronedarone was less effective than amiodarone in decreasing AF recurrence, it had a better safety profile, being devoid of thyroid, pulmonary and neurological toxicity. This review analyzes the electrophysiological and pharmacological properties, as well as the efficacy and safety of dronedarone in patients with atrial fibrillation.

New investigational drugs for the management of acute heart failure syndromes.

Acute heart failure syndromes (AHFS) enclose a broad spectrum of conditions with different clinical presentations, heart failure history, pathophysiology, prognosis and treatment. AHFS represent a major public health problem because of their high prevalence, high rates of mortality and readmissions and significant healthcare costs, and a therapeutic challenge for the clinicians because management strategies vary markedly. Traditionally used drugs for the treatment of AHFS, including diuretics, vasodilators and positive inotropics, improve clinical signs and symptoms as well as hemodynamics, but present important limitations, as they fail to reduce and may even increase in-hospital and postdischarge mortality, especially in patients with coronary artery disease. Thus, we need new pharmacological agents to not only improve signs and symptoms and cardiac performance, but also improve both short- and long-term outcomes (hospitalizations/survival). In the last decade, significant efforts have been made to identify new therapeutic targets involved in the genesis/progression of AHFS and to develop new therapeutic strategies that may safely improve outcomes. As a result, several new families of drugs have been developed and are currently studied in experimental models and in Phase II and III clinical trials, in an attempt to define their efficacy and safety profiles as well as their precise role in the treatment of AHFS patients. This review firstly analyzes the main clinical applications and limitations of conventional drugs, and then focuses on the mechanisms of action and effects of recently approved drugs and of new investigational agents on signs, symptoms, hemodynamics and outcomes in AHFS patients.

Effects of MiRP1 and DPP6 beta-subunits on the blockade induced by flecainide of Kv4.3/KChIP2 channels.

BACKGROUND AND PURPOSE: The human cardiac transient outward potassium current (Ito) is believed to be composed of the pore-forming Kv4.3 alpha-subunit, coassembled with modulatory beta-subunits as KChIP2, MiRP1 and DPP6 proteins. beta-Subunits can alter the pharmacological response of Ito; therefore, we analysed the effects of flecainide on Kv4.3/KChIP2 channels coassembled with MiRP1 and/or DPP6 beta-subunits. EXPERIMENTAL APPROACH: Currents were recorded in Chinese hamster ovary cells stably expressing K(V)4.3/KChIP2 channels, and transiently transfected with either MiRP1, DPP6 or both, using the whole-cell patch-clamp technique. KEY RESULTS: In control conditions, Kv4.3/KChIP2/MiRP1 channels exhibited the slowest activation and inactivation kinetics and showed an 'overshoot' in the time course of recovery from inactivation. The midpoint values (Vh) of the activation and inactivation curves for Kv4.3/KChIP2/DPP6 and Kv4.3/KChIP2/MiRP1/DPP6 channels were approximately 10 mV more negative than Vh values for Kv4.3/KChIP2 and Kv4.3/KChIP2/MiRP1 channels. Flecainide (0.1-100 microM) produced a similar concentration-dependent blockade of total integrated current flow (IC50 approximately 10 microM) in all the channel complexes. However, the IC50 values for peak current amplitude and inactivated channel block were significantly different. Flecainide shifted the Vh values of both the activation and inactivation curves to more negative potentials and apparently accelerated inactivation kinetics in all channels. Moreover, flecainide slowed recovery from inactivation in all the channel complexes and suppressed the 'overshoot' in Kv4.3/KChIP2/MiRP1 channels. CONCLUSIONS AND IMPLICATIONS: Flecainide directly binds to the Kv4.3 alpha-subunit when the channels are in the open and inactivated state and the presence of the beta-subunits modulates the blockade by altering the gating function.

Effects of atorvastatin and simvastatin on atrial plateau currents.

Recent evidence has shown that the inhibitors of the 3-hydroxy-3-methylglutaryl coenzyme A reductase (statins) might exert antiarrhythmic effects both in experimental models and in humans. In this study we analyzed the effects of atorvastatin and simvastatin acid (SVA) on the currents responsible for the duration of the plateau of human atrial action potentials: hKv1.5, Kv4.3, and L-type Ca(2+) (I(Ca,L)). hKv1.5 and Kv4.3 currents were recorded in transfected Ltk(-) and Chinese hamster ovary cells, respectively, and I(Ca,L) in mouse ventricular myocytes, using whole-cell patch-clamp. Atorvastatin and SVA produced a concentration-dependent block of hKv1.5 channels (IC(50)=4.5+/-1.7 microM and 5.7+/-0.03 microM, respectively) and shifted the midpoint of the activation and inactivation curves to more negative potentials. Importantly, atorvastatin- and SVA-induced block was added to that produced by quinidine, a drug that blocks hKv1.5 channels by binding to their pore cavity. Atorvastatin and SVA blocked Kv4.3 channels in a concentration-dependent manner (IC(50)=13.9+/-3.6 nM and 7.0+/-0.8 microM, respectively). Both drugs accelerated the inactivation kinetics and shifted the inactivation curve to more negative potentials. SVA (10 nM), but not atorvastatin, also blocked I(Ca,L) producing a frequency-dependent block that, at 2 Hz, reached a 50.2+/-1.5%. As a consequence of these effects, at nanomolar concentrations, atorvastatin lengthened, whereas SVA shortened, the duration of mouse atrial action potentials. The results suggest that atorvastatin and SVA alter Kv1.5 and Kv4.3 channel activity following a complex mechanism that does not imply the binding of the drug to the channel pore.

Propafenone modulates potassium channel activities of vascular smooth muscle from rat portal veins.

We have studied the effects of the class Ic antiarrhythmic propafenone on K+ currents in freshly isolated smooth muscle cells from rat portal veins and on the spontaneous contractions in whole tissues. Under Ca2+-free conditions, when cells were clamped at -80 mV (whole-cell configuration) depolarizing steps from -80 to +50 mV induced a family of K+ currents (I(Ktotal)) that mainly comprised the delayed rectifier current [I(K(V))], whereas when held at -10 mV only small-amplitude, noninactivating, currents (I(NI)) were recorded. Propafenone (10 microM) markedly inhibited I(Ktotal), but at potentials positive to +30 mV it also induced a noisy outwardly rectifying current [I(BK(Ca))] that was abolished by iberiotoxin (0.1 microM). Inhibition of I(Ktotal) by propafenone was concentration-dependent (EC50 = 0.059 +/- 0.009 microM). Propafenone also inhibited the transient outward current [I(K(A))] and ATP-sensitive potassium current [I(K(ATP))] induced by levcromakalim (10 microM). Inhibition of I(K(V)), I(K(A)), and I(K(ATP)) by propafenone was voltage-independent. In Ca(2+)-containing conditions propafenone inhibited I(K(V)) and I(BK(Ca)) and immediately abolished spontaneous outward transient K+ currents. In whole veins, propafenone behaved as the K(V) inhibitor 4-aminopyridine, increasing the amplitude and duration of spontaneous contractions. Propafenone also inhibited the inhibitory effects of the K(ATP) channel opener levcromakalim on spontaneous contractions. These results indicate that in vascular smooth muscle cells, propafenone inhibits K(V), K(A), BK(Ca), and K(ATP) channels. These actions correlated with its effects on mechanical activity in whole portal veins.

Pulmonary artery vasoconstriction but not [Ca2+]i signal stimulated by thromboxane A2 is partially resistant to NO.

To characterize the thromboxane A2 (TXA2) -induced resistance to the vasodilator effects of the nitric oxide (NO)/cGMP pathway in pulmonary arteries, we have studied the effects of the NO donor sodium nitroprusside on intracellular calcium concentration ([Ca2+]i) and contractile force recorded simultaneously in isolated piglet pulmonary arteries loaded with fura-2 and contracted with norepinephrine or the TXA2 mimetic U46619 and by activation of protein kinase C (PKC) with phorbol 12-myristate 13-acetate. In the TXA2 mimetic- and phorbol 12-myristate 13-acetate plus norepinephrine-stimulated arteries, nitroprusside exhibited lower vasodilator efficacy (and lower potency in the TXA2 mimetic-stimulated arteries) but similar reductions in [Ca2+]i compared with arteries activated by norepinephrine. The nonselective serine/threonine kinase inhibitor staurosporine, but not the selective inhibitor of PKC bisindolylmaleimide, potentiated the relaxation of nitroprusside in the TXA2 mimetic-stimulated arteries. In conclusion, the resistance to NO/cGMP-induced vasodilation in arteries stimulated by TXA2 and PKC involves a reduced ability of the Ca2+-independent mechanisms for smooth muscle vasodilation. The resistance to NO in arteries stimulated by TXA2 is sensitive to staurosporine but not to bisindolylmaleimide, suggesting the involvement of an activation of a serine/threonine kinase distinct from PKC.

Bupivacaine effects on hKv1.5 channels are dependent on extracellular pH.

1. Bupivacaine-induced cardiotoxicity increases in hypoxic and acidotic conditions. We have analysed the effects of R(+)bupivacaine on hKv1.5 channels stably expressed in Ltk(-) cells using the whole-cell patch-clamp technique, at three different extracellular pH (pH(o)), 6.5, 7.4 and 10.0. 2. Acidification of the pH(o) from 7.4 to 6.5 decreased 4 fold the potency of R(+)bupivacaine to block hKv1.5 channels. At pH(o) 10.0, the potency of the drug increased approximately 2.5 fold. 3. Block induced by R(+)bupivacaine at pH(o) 6.5, 7.4 and 10.0, was voltage- and time-dependent in a manner consistent with an open state block of hKv1.5 channels. 4. At pH(o) 6.5, but not at pH(o) 7.4 or 10.0, R(+)bupivacaine increased by 95+/-3 % (n=6; P<0.05) the hKv1.5 current recorded at -10 mV, likely due to a drug-induced shift of the midpoint of activation (DeltaV=-8.5+/-1.4 mV; n=7). 5. R(+)bupivacaine development of block exhibited an 'instantaneous' component of block at the beginning of the depolarizing pulse, which averaged 12.5+/-1.8% (n=5) and 4.6+/-1.6% (n=6), at pH(o) 6.5 and 7.4, respectively, and that was not observed at pH(o) 10.0. 6. It is concluded that: (a) alkalinization of the pH(o) increases the potency of block of R(+)bupivacaine, and (b) at pH(o) 6.5, R(+)bupivacaine induces an 'agonist effect' of hKv1.5 current when recorded at negative membrane potentials.

Vasorelaxant effects of the bioflavonoid chrysin in isolated rat aorta.

Chrysin relaxed the contractions induced by noradrenaline in isolated endothelium-intact rat aortic rings (IC(50) = 16 +/- 4 microM). Endothelium removal and N(G)-nitro-L-arginine methyl ester inhibited this relaxant effect. Chrysin potentiated the relaxation to acetylcholine under control conditions or after incubation with the superoxide anion generator hypoxanthine/xanthine oxidase. It also potentiated the relaxation induced by 3-morpholino-sydnonimine, sodium nitroprusside, and 8-bromoguanosine-3':5'-cyclic-monophosphate. Therefore, vasorelaxation induced by chrysin in the rat aorta is endothelium- and NO-dependent. This effect is mediated by the prevention of O(2)(-)-induced inactivation of endothelial derived NO and also by the potentiation of cGMP-induced vasodilatation.

Effects of chronic quercetin treatment on hepatic oxidative status of spontaneously hypertensive rats.

The effects of chronic administration of an oral daily dose of quercetin (10 mg Kg(-1)), the most abundant dietary flavonoid, were investigated on hepatic oxidative status in spontaneously hypertensive rats and normotensive Wistar Kyoto rats. Decreased liver glutathione peroxidase activity, increased liver total glutathione levels and increased both hepatic and plasmatic malondialdehyde concentrations were observed in spontaneously hypertensive rats when compared to Wistar Kyoto rats. In spontaneously hypertensive rats, treatment with quercetin for 5 weeks reduced blood pressure, increased glutathione peroxidase activity and reduced both plasma and hepatic malondialdehyde levels. However, none of these effects were observed in Wistar Kyoto rats. In conclusion, quercetin shows both antihypertensive and antioxidant properties in this model of genetic hypertension.

[Angiographic correlates of the high-risk criteria for conventional exercise testing and the Duke treadmill score]. / Correlación angiográfica de los criterios de alto riesgo para ergometría convencional y el índice de Duke.

OBJECTIVE: To compare the sensitivity, the specificity, the positive and negative predictive value and the predictive accuracy of the Duke Treadmill Score, the Spanish Society of Cardiology (SEC) and American College of Cardiology/American Heart Association (ACC/AHA) high-risk criteria for exercise testing in the detection of left main disease, three vessel disease and two vessel disease involving the proximal left anterior descending artery. PATIENTS AND METHOD: A cohort of 199 patients (age 75 years) consecutively admitted to hospital for unstable angina was studied. All patients underwent an exercise stress test and coronariography. RESULTS: The SEC high-risk Criteria showed a sensitivity of 69.2% and a specificity of 49.0%. The ACC/AHA high-risk Criteria demonstrated a sensitivity of 98.1% and a specificity of 23.8% and the Duke Treadmill Score presented a sensitivity of 30.8% and a specificity of 90.5%. In patients with moderate risk in the Duke Treadmill Score we found a sensitivity of 62.9% and a specificity of 39.8% for the SEC high-risk criteria, while the ACC/AHA high-risk Criteria presented a sensitivity of 100.0% and a specificity of 5.8%. CONCLUSIONS: The ACC/AHA high-risk Criteria showed a higher sensitivity while the Duke Treadmill Score presented a higher specificity for the detection of left main disease, three vessel disease and two vessel disease involving the proximal left anterior descending artery. The ACC/AHA and SEC high-risk Criteria were found to be very useful in the group of patients with moderate risk in the Duke Treadmill Score.