Usefulness of a quantitative analysis of the recovery phase patterns of the ST-segment depression in the diagnosis of coronary artery disease.

PURPOSE: To assess the diagnostic value of the recovery phase patterns of the ST-segment depression in patients referred for chest pain. PATIENTS AND METHODS: Continuous plots of ST-segment depression against heart rate during exercise and recovery were constructed within a population of 160 consecutive symptomatic patients who all had undergone catheterization (80 with > or = 1 stenosis > or = 50%). We used a new quantitative method of measurement allowing all kinds of rate recovery loops (even the so-called "intermediate" loops) to be considered for analysis. The measurements of the heart rate (HR)-adjusted ST-segment depression were performed at 20 and 60 ms from the J point, providing two different values of a quantified recovery loop index (RLI): RLI 20 and RLI 60. RESULTS: Both RLI showed a higher specificity (0.81 +/- 0.04 and 0.74 +/- 0.05, respectively) than did the standard criterion (0.65 +/- 0.10), but the difference was significant regarding RLI 20 only (P = 0.011). As to the sensitivity, no significant differences were found among all of the criteria (0.74 +/- 0.05, 0.80 +/- 0.04, 0.76 +/- 0.05, respectively). The timing of measurements of the RLI within the repolarization phase did not affect their overall accuracy (0.77 +/- 0.03 for both RLI). The values of the receiver-operating characteristic (ROC) curve areas were significantly greater for both RLI (0.83 +/- 0.06 and 0.84 +/- 0.06 respectively) than for the standard criterion (0.75 +/- 0.07; P < 0.02). Finally, both RLI allowed to differentiate accurately the study subjects according to the number of diseased vessels, whereas the standard criterion could only distinguish between CAD patients and subjects with normal angiograms. CONCLUSION: The quantitative analysis of the rate recovery phase patterns appears to be useful for the diagnosis of coronary heart disease and the assessment of its severity in symptomatic patients.

Comparison of the diagnostic accuracy of different methods of measurement of heart rate-adjusted ST-segment depression during exercise testing for identification of coronary artery disease.

Within a population of 160 consecutive symptomatic patients who all had undergone catheterization (80 with > or = 1 stenosis > or = 50%), we compared the accuracy of different computerized measurements of the exercise-induced changes in ST-segment: (1) the standard criterion (> or = 0.1 mV flat/downsloping ST depression or > or = 0.15 mV upsloping depression, both 60 ms after the J point); (2) heart rate (HR)-adjusted ST-segment depression (ST/HR index measured at 0, 20, 40, 60, and 80 ms from the J point); (3) the HR-adjusted ST integral (ST/HR integral measured from 0 to 40 ms and from 40 to 80 ms after the J point). None of the ST/HR indexes or integrals were found to have a significantly greater sensitivity than the standard criterion. On the contrary, all ST/HR indexes and integrals showed a higher specificity (0.78 to 0.89) than did the standard criterion (0.65); moreover, the earlier the measurement within the repolarization phase, the better the overall accuracy: 0.71 for the standard criterion, 0.83 (p < 0.001), 0.80 (p < 0.01), 0.78 (p < 0.02), 0.78 (p < 0.02), 0.74 (p = NS) for the ST/HR indexes at 0, 20, 40, 60, and 80 ms, respectively; 0.81 (p < 0.001) and 0.78 (p < 0.02) for the ST/HR integrals calculated from 0 to 40 and from 40 to 80 ms, respectively. Consistently, the receiver-operating characteristic curve areas of ST/HR at 0, 20, and 40 ms were greater than those of ST/HR at both 60 and 80 ms. These findings are divergent from some other results given in published reports. We conclude that the accuracy of all exercise criteria is influenced by the population analyzed: our patients were representative of those currently seen by clinicians.

[Coronary artery disease in hypertensive patients: improvement of the diagnostic value of exercise test by heart rate adjusted ST segment depression]. / Insuffisance coronarienne de l'hypertendu: amélioration de la valeur diagnostique de l'épreuve d'effort par ajustement du sous-décalage de ST à la fréquence cardiaque.

UNLABELLED: Hypertensive patients complaining of chest pain often have a normal coronary angiogram despite a pathological exercise tolerance test. The aim of the present study was to establish whether the prevalence of these "false-positive" tests could be lowered by adjusting ST segment depression for exercise-induced increase in heart rate. METHODS: 60 hypertensive patients, mean age 59 years, with typical or atypical chest pain, underwent both a symptom-limited exercise test and a coronary angiogram within a median period of 1 day. The ST segment depression was measured every 20 ms from the J point. A stepwise discriminant analysis was performed: a canonical variable took into account the Detrano index, the quantified rate-recovery loop index (QRL index) as well as the presence of a LV hypertrophy (Romhilt Estes Score). RESULTS: [table: see text] CONCLUSION: in hypertensive patients with chest pain, the specificity and the positive predictive value of exercise test are significantly improved by adjusting ST segment depression for heart rate both during effort and recovery and by taking into account the score of Romhilt Estes on the baseline ECG recording.

[Improvement of the diagnostic value of exercise test by heart-rate adjusted segment depression. Value of ST 20/HR index]. / Amélioration de la valeur diagnostique de l'épreuve d'effort par le sous-décalage du segment ST rapporté à la fréquence cardiaque. Intérêt de l'index ST 20/FC.

One of the new criteria of positivity of exercise stress testing proposed by Detrano and Kligfield is the ST/HR index, obtained by calculating the ratio of additional ST depression on exercise over the corresponding variation in the heart rate. These authors reported that this ratio improved the diagnostic value of the exercise stress test with respect to the traditional ST segment depression, but that the proportion depended on whether the index was measured 80 or 60 ms after the J point. The object of this study was to assess the diagnostic performance of the ST/HR index measured 0, 20, 40, 60 and 80 ms after the J point by automatic analysis and to compare these five diagnostic indices with the classical ST segment depression (standard criterion) by ROC graphs and the Mac Nemar test. One hundred consecutive patients (73 men and 27 women) all symptomatic, underwent submaximal or symptom-limited exercise stress testing and accepted coronary angiography. The prevalence of greater than or equal to 50% coronary stenosis on at least one main vessel was 48%. None had previous myocardial infarction. The ROC graphs and areas under the curve demonstrated generally the superiority of the ST/HR index over the standard criteria. The optimal diagnostic performance was observed when the index was calculated 20 ms after the J point (ST 20/HR index).(ABSTRACT TRUNCATED AT 250 WORDS)

[Thrombus of the left auricle: a rarely noticed cause of systemic embolism. Apropos of an echocardiographic case report]. / Thrombus de l'auricule gauche: une cause rarement décelée d'embolie systémique. A propos d'une observation échocardiographique.

The authors report the case of a 70 year old woman who had 3 episodes of acute ischaemia of the lower limbs in the space of 2 months. She was admitted to the Cardiology Unit after the second embolism: successive ECG recordings showed signs of the sick sinus syndrome justifying permanent pacing and anti-arrhythmic and anticoagulant therapy. The standard 2D echocardiographic views showed no signs of intracardiac disease, but a modified high short axis view demonstrated an oblong thrombus in the left auricle. Unfortunately, therapeutic non-compliance led to a third episode of embolism 2 weeks later; a repeat 2D echocardiogram showed the left auricle to be completely free of thrombosis. The authors review the medical literature of this condition. Echocardiography only began to play a useful diagnostic role from 1984 when technical improvements and the use of new and more appropriate views of the left auricle were introduced.

[Increase in the amplitude of R waves in exertion: a bad diagnostic criterion for coronary insufficiency]. / Augmentation d'amplitude des ondes R à l'effort: un mauvais critère diagnostique de l'insuffisance coronarienne.

91 symptomatic patients were given an exercise test on a bicycle ergometer and a coronary arteriography test within a delay of 31 days. Of the patients (13 females and 78 males), 35 presented with a normal coronary arteriography and 56 presented with a pathological coronary arteriography (16 of whom had a history of myocardial infarction). We have studied the diagnostic value of several parameters taking into account changes in R waves upon exercise in V4 V5 V6 and changes in S waves in V1 V2. The most reliable parameter is also the easiest to calculate: it is considered positive when the R wave measured in V5 increases or does not change in the minute following cessation of exercise, as compared with the reference trace; it is considered negative when the R wave decreases. This criterion has a specificity of 60 per cent and a sensitivity of 71.4 per cent, and its diagnostic value is not improved by exclusion of patients with a history of infarction, or by exclusion of treated subjects or females. The horizontal or downsloping depression of the ST-segment has the same sensitivity but a better specificity (74%). Literature data are contradictory: some authors report that changes in the R wave upon exercise have a better predictive value than changes in the ST-segment, whereas an equal number of authors consider that the ST-segment is more informative. These differences of opinion result from methodological disparities and the large number of physiopathological elements affecting the amplitude of R waves.

[Aneurysms of the interauricular septum. Review of the literature apropos of 8 cases]. / Les anévrysmes du septum interauriculaire. Revue de la littérature à propos de huit cas.

The authors present 8 cases of aneurysms of the interauricular septum (AIAS). The diagnosis was established in all cases by two-dimensional echocardiography (E2D) which was requested, three times following a cerebral vascular accident (CVA). The AIAS manifest themselves as localised "hernias" of the inter-auricular septum, mobile during the cardiac cycle. Their topography was strictly right inter-auricular in 6 cases, whereas in the other 2 patients the AIAS passed into the left atrium at protosystole and returned to the right atrium at telesystole. Catheterization with angiography was carried out 5 times: the inter-auricular septum was crossed 4 times without gasometric reasons for an associated shunt; the AIAS was opacified in all cases. An anti-coagulant treatment was prescribed for 3 patients who had suffered a CVA, and for a fourth presenting numerous supraventricular extrasystoles which were sometimes grouped. A review of the literature of the last fifty years enabled a compilation of 93 cases of AIAS to be made, 49 of which had been examined by E2D, 35 had had a hemodynamic and angiographic exploration and 47 an anatomical and/or surgical confirmation. The main results obtained are described and commented on. The diagnostic, etiopathological and prognostic problems raised by the "updating" of this pathology are discussed.

[Comparison between amiodarone and disopyramide in the treatment of ventricular extrasystoles]. / Comparaison de l'amiodarone et du disopyramide dans le traitement des extrasystoles ventriculaires.

The authors have compared the anti-arrhythmic activity and tolerance of disopyramide and amiodarone in the treatment of ventricular extrasystoles (VES) by using two quantitative methods of assessment. The stability of the rhythmic disorder was confirmed by two control Holter recordings in 20 patients without treatment, 16 of whom were bearers of an organic cardiopathy. The ventricular extrasystole was greater than 90 VES/hour in 18 patients. After the first control, Holter recording, each patient was treated successively with 400 mg of disopyramide/day in 4 doses for average period of 31 days, then a second Holter control recording without treatment, then 600 mg/day of amiodarone for 8 days followed by a maintenance dose varying from 200 to 400 mg/day: this second period of treatment lasted for an average of 38 days. The reduction of the number of VES was greater than 65 percent (SAMI criterion) in 2 of the 20 patients treated with disopyramide and in 13 of the 20 patients treated with amiodarone. Using the method of variance analysis, disopyramide was found to be efficacious in 5 cases out of 20 and amiodarone in 15 cases out of 20. Both methods indicate that the greater efficacy of amiodarone is statistically significant (p less than 0.01). All of those who did not respond to amiodarone were also non-responders to disopyramide.

[Activity and tolerance of a new anti-arrhythmia drug, Cibenzoline (Cipralan), administered orally)]. / Etude de l'activité et de la tolérance d'un nouvel anti-arythmique, la Cibenzoline (Cipralan), administré par voie orale.

The authors studied the effect of a new anti-arrhythmic agent, the Cibenzoline in 9 patients suffering from numerous ventricular extrasystoles (on average 8 extrasystoles/minute). Efficacy was considered to be excellent in 3 cases (complete disappearance of extrasystoles) good in 3 cases (more than 90% decrease in the number of extrasystoles) and poor in 3 cases (these concerned two patients also resistant to all other anti-arrhythmic agents and one patient with an extreme variability of his arrhythmia from one day to another day). Clinical and biological tolerance was excellent. Electrocardiographic parameters in general remained stable, apart from in one case of severe cardiomegaly. The general rules usually accepted for adequate evaluation of the efficacy of an anti-arrhythmic agent are reviewed and discussed.

[The jugular pulse in constrictive pericarditis. Correlations between hemodynamics and external recordings]. / Le jugulogramme des péricardites constrictives. Corrélation entre l'hémodynamique et les enregistrements externes

The contours and chronologic changes of the jugular pulse curve have been studied in relation with 15 cases of constrictive pericarditis and compared with 17 cases of normal jugulogram. The diastolic venous collapse was found in 8 of 15 cases only. On the contrary, the pulse contour was normal in three cases, while the haemodynamic results were intensely abnormal. Inversely, some tracings with a diastolic venous collapse did not correspond to pericardial construction. More specific signs for cardiac restriction were looked for on the side of chronologic changes. The method of synchronous tracings makes it possible to measure the Q-Y, S2-Y and S2-V intervals. A significant correlation was established between the values of the Q-Y and S2-Y intervals and the mean right atrial pressure. By comparison with normal jugular vein tracings, each interval was given three zones of value (normal, intermediate, pathological). One may thus determine that pericardial constriction is severe when a minimum of two intervals was pathological, the third one having an intermediate value. Pericardial constriction was moderate when two parameters were pathological and the third normal, or when one parameter only was pathological, the other two having intermediate values. In all other cases, there was no pericardial constriction, whatever the contour of the jugular venous curve.