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VALUE OF EXERCISE TESTING FOR SCREENING ASYMPTOMATIC MEN FOR LATENT CORONARY-ARTERY DISEASE

PROGRESS IN CARDIOVASCULAR DISEASES 1976年第4期18卷 265-276页

作者： FROELICHER, VF THOMPSON, AJ LONGO, MR TRIEBWASSER, JH LANCASTER, MC USAF SCH AEROSP MEDINTERN MED BRANCHDEPT NGICLIN SCI DIVBROOKS AFBTX 78235

Treadmill exercise testing identifies a group of men at high risk for coronary atherosclerotic heart disease. However, the predictive value and sensitivity limitations are obvious. An abnormal electrocardiographic response does not absolutely predict the presence of coronary atherosclerotic heart disease, and a normal response does not rule out this possibility. Thus in appropriate instances when the minimal risk of coronary angiography is justified this procedure can be used to determine the anatomic correlation of exercise-induced functional ST-segment changes.

关键词：航天医学心律失常心性/病因学侧支循环冠状血管造影术冠心病/诊断冠心病/诊断显像误诊心电描记术/标准评价研究(主题) 运动试验/标准随访研究普查/方法危险成年人人类男(雄)性

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Diagnostic exercise tests on 4000 consecutive men

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AMERICAN HEART JOURNAL 2001年第1期142卷 127-135页

作者： Prakash, M Myers, J Froelicher, VF Marcus, R Do, D Kalisetti, D Froning, J Atwood, JE VA Palo Alto Hlth Care Syst Cardiol Div 111C Palo Alto CA 94304 USA Vet Affairs Palo Alto Hlth Care Syst Long Beach CA USA Stanford Univ Med Ctr Div Cardiovasc Med Palo Alto CA 94304 USA Univ Calif Irvine Irvine CA USA

Objective Our purpose was to report the prevalence of abnormal treadmill test responses and their association with mortality in a large consecutive series of patients referred For standard diagnostic exercise tests, with testing performed and reported in a standardized fashion. Background Exercise testing is widely performed, but an analysis of responses has not been presented for a large number of consecutive tests performed on patients referred for diagnosis of cardiac disease. Methods All patients referred for evaluation at 2 university-affiliated Veterans Affairs Medical Centers who underwent exercise treadmill tests for clinical indications between 1987 and 2000 were determined to be dead or alive according to the Social Security Death Index after a mean 5.9-year follow-vp. Patients with established heart disease tie, prior coronary bypass surgery, myocardial infarction, or congestive heart failure) were excluded from analyses. Clinical and exercise test variables were collected prospectively according to standard definitions;testing and data management were performed in a standardized fashion with a computer-assisted protocol. All-cause mortality was used as the end point for Follow-up. Standard survival analysis was performed, including Kaplan-Meier curves and a Cox hazard model. Results After the exclusions, 3974 men (mean age 57.5 +/- 11 years) had standard diagnostic exercise testing over the study period with a mean of 5.9 (+/-3.7) years of follow-up (64% of all tested). There were no complications of testing in this clinically referred population, 82% of whom were referred for chest pain, risk factors, or signs and symptoms of ischemic heart disease. Five hundred forty-nine (14%) had a history of typical angina. indications for testing were in accordance with published guidelines. A total of 545 died, yielding an annual mortality rate of 1.8%. The Cox hazard model chose the following variables in rank order os independently associated with time to death:

关键词：卡方分布数据收集/标准运动试验/标准心脏病/诊断心脏病/死亡率患病率比例危险度模型前瞻性研究存活率分析退伍军人老年人人类男(雄)性中年人

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Statistical methods to improve the precision of the treadmill exercise test

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第4期36卷 1274-1279页

作者： Stewart, RAH Kittelson, J Kay, IP Univ Otago Dept Med Dunedin New Zealand Univ Otago Dept Social & Prevent Med Dunedin New Zealand

OBJECTIVES The study systematically compared different measures of ST segment depression from the treadmill exercise test. BACKGROUND The value of the treadmill exercise test for objectively measuring treatment effects is limited by random error in the measurement of ST depression and may be biased by regression to the mean or by the decision to terminate the test. METHODS Treadmill exercise was performed in 21 subjects with ischemic heart disease 1 h after isosorbide dinitrate 10 mg or placebo in a double-blind randomized crossover study. a 12-lead electrocardiogram (ECG) was recorded every 30 s during and at peak exercise. The relative sample size needed to detect the nitrate effect was compared for different summary measures of ST depression. RESULTS The ST depression measured from a single unmatched lead at longest equivalent sub-maximal exercise needed the lowest sample size to detect the nitrate effect in paired comparisons (p = 0.000006). Averaging over multiple leads or times did not improve detection of the nitrate effect. The rate of increase in ST depression (in mm/min) calculated by linear regression needed a similar sample size (x1.32, 95% CI 0.62 to 2.58). A larger sample size was needed for ST depression at peak exercise (x2.9, CI 1.3, 11.1) and exercise duration (x4.5, CI 1.5, 38). Time to 1-mm ST depression was the least efficient measurement (relative sample size x15.5, CI 1.6, >1000). Comparison of matched leads resulted in >2-fold differences in estimates of the nitrate effect because of bias from regression to the mean. CONCLUSIONS Maximal ST depression at longest equivalent sub-maximal exercise and the maximal rate of increase in ST depression had less bias and random variation than did other commonly used measures. The rate of increase in ST depression is preferred because it call be calculated in either paired or unpaired studies. CT Am Coil Cardiol 2000;36:1274-9) (C) 2000 by the American College of Cardiology.

关键词：投药口服交叉研究数据说明统计诊断鉴别双盲法心电描记术/药物作用心电描记术/方法运动试验/标准硝酸异山梨酯/投药和剂量心肌缺血/诊断心肌缺血/病理生理学结果可重复性疾病严重程度指数血管舒张药/投药和剂量老年人人类中年人

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A pilot study to assess the safety of dobutamine stress echocardiography in the emergency department evaluation of cocaine-associated chest pain

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ANNALS OF EMERGENCY MEDICINE 2001年第1期38卷 42-48页

作者： Dribben, WH Kirk, MA Trippi, JA Cordell, WH Indiana Univ Dept Emergency Med Indianapolis IN 46204 USA Indiana Univ Sch Med Indianapolis IN USA Indiana Poison Ctr Indianapolis IN USA Methodist Hosp Dept Cardiol Indianapolis IN USA

Study objective: Chest pain in the setting of cocaine use poses a diagnostic dilemma. Dobutamine stress echocardiography (DSE) is a widely available and sensitive test for evaluating cardiac ischemia. Because of the theoretical concern regarding administration of dobutamine in the setting of cocaine use, we conducted a pilot study to assess the safety of DSE in emergency department patients with cocaine-associated chest pain. Methods: A prospective case series was conducted in the intensive diagnostic and treatment unit in the ED of an urban tertiary-care teaching hospital. Patients were eligible for DSE if they had used cocaine within 24 hours preceding the onset of chest pain and had a normal ECG and tropinin I level. Patients exhibiting signs of continuing cocaine toxicity were excluded from the study. Ail patients were admitted to: the hospital for serial testing after the DSE testing in the intensive diagnostic and treatment unit. Results: Twenty-four patients were enrolled. Two patients had inadequate resting images, one DSE was terminated because of inferior hypokinesis, another DSE was terminated because of a rate-related atrial conduction deficit, and 1 patient did not reach the target heart rate. Thus, 19 patients completed a DSE and reached their target heart rates. None of the patients experienced signs of exaggerated adrenergic response, which was defined as a systolic blood pressure of greater than 200 mm Mg or the occurrence of tachydysrhythmias (excluding sinus tachycardia). Further suggesting lack of exaggerated adrenergic response, 13 (65%) of 20 patients required supplemental atropine to reach their target heart rates. Conclusion: No exaggerated adrenergic response was detected when dobutamine was administered to patients with cocaine-related chest pain.

关键词：强心药/诊断应用胸痛/化学诱导胸痛/病理生理学胸痛/超声检查可卡因相关性障碍/并发症诊断鉴别多巴酚丁胺/诊断应用超声心动描记术/方法超声心动描记术/标准心电描记术急诊处理/方法急诊处理/标准运动试验/方法运动试验/标准心率/药物作用高血压/化学诱导心肌缺血/化学诱导心肌缺血/病理生理学心肌缺血/超声检查试点项目前瞻性研究安全拟交感神经药/诊断应用心动过速/化学诱导成年人人类中年人

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Development and validation of a simple exercise test score for use in women with symptoms of suspected coronary artery disease

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AMERICAN HEART JOURNAL 2002年第5期144卷 818-825页

作者： Morise, AP Lauer, MS Froelicher, VF W Virginia Univ Dept Med Cardiol Sect Sch MedHSC S Morgantown WV 26506 USA Cleveland Clin Fdn Dept Cardiol Cleveland OH 44195 USA VA Palo Alto Hlth Care Syst Palo Alto CA USA

Background, Recently revised American College of Cardiology/American Heart Association guidelines for exercise electrocardiography (ExECG) have suggested that ExECG scores be used to assist in management decisions in patients with suspected coronary artery, disease (CAD). Methods We used 442 women who underwent both ExECG and coronary angiography (CAD greater than or equal to1 lesion with greater than or equal to50% stenosis;CAD prevalence was 32%) to derive an ExECG score including clinical and ExECG variables. By use of logistic regression analysis, variables were selected and relative weights were determined. Variable codes multiplied by respective weights were summed to produce a final ExECG score. The score was validated in separate populations concerning angiographic as well as prognostic end points. Results Clinical variables selected and their weights included age (5), symptoms (2), diabetes (2), smoking (2), and estrogen status (1). ExECG variables selected and their weights included ST depression (2), exercise heart rate (4), and Duke Angina Index (3). For the validation group, score ranges are shown with the prevalence of CAD: <20=0/5 or 0%, 20-29=3/26 or 11%, 30-39=20/56 or 36%,,40-49=33/81 or 41%, 50-59=24/49 or 49%, 60-69=22/32 or, 69%, and >70=7/7 or 100%. Frequency of death within 3 predetermined subgroups was as follows: low <40=3/1237 (0.2%), intermediate 40-60=9/383 (2.3%), high >60=4/54(7%);P<.0001. Conclusion A simple ExECG score was developed for use specifically in women. When evaluated in separate cohorts, the score stratified women with suspected coronary disease into groups with a gradually increasing frequency of coronary disease and death.

关键词：冠心病/诊断冠心病/死亡率运动试验/标准参考标准回归分析危险因素疾病严重程度指数性别因素成年人女(雌)性人类中年人

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The effect of resting ST segment depression on the diagnostic characteristics of the exercise treadmill test

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第5期35卷 1206-1211页

作者： Fearon, WF Lee, DP Froelicher, VF Stanford Univ Med Ctr Div Cardiovasc Med Stanford CA 94305 USA Vet Affairs Palo Alto Hlth Care Syst Stanford CA USA

OBJECTIVES The aim of this study is to demonstrate the effect of resting ST segment depression on the diagnostic characteristics of the exercise treadmill rest. BACKGROUND Previous studies evaluating the effect of resting ST segment depression on the diagnostic characteristics of exercise treadmill test have been conducted on relatively small patient groups and based only on visual electrocardiogram (ECG) analysis. METHODS A retrospective analysis of data collected prospectively was performed on consecutive patients referred for evaluation of chest pain. One thousand two hundred eighty-two patients without a prior myocardial infarction underwent standard exercise treadmill tests followed by coronary angiography, with coronary artery disease defined as a 50% narrowing in at least une major epicardial coronary artery. Sensitivity, specificity, predictive accuracy and area under the curve of the receiver operating characteristic (ROC) plots were calculated for patients with and without resting ST segment depression as determined by visual or computerized analysis of the baseline ECG. RESULTS Sensitivity of the exercise treadmill test increased in 206 patients with resting ST segment depression determined by visual ECG analysis compared with patients without resting ST segment depression (77 +/- 7% vs. 45 +/- 4%) and specificity decreased (48 +/- 12% vs. 84 +/- 3%). With computerized analysis, sensitivity of the treadmill test increased in 349 patients with resting ST segment depression compared with patients without resting ST segment depression (71 +/- 6% vs. 42 +/- 4%) and specificity decreased (52 +/- 9% vs. 87 +/- 3%) (p < 0.0001 for all comparisons). There was no significant difference in the area under the curve of the ROC plots (0.66-0.69) or the predictive accuracy (62-68%) between the four subgroups. CONCLUSIONS The diagnostic accuracy and high sensitivity of the exercise treadmill test in a large cohere of patients with resting ST segment depression and no pr

关键词：胸痛/病因学冠状血管造影术冠心病/分类冠心病/并发症冠心病/诊断数据说明统计糖尿病并发症心电描记术/标准运动试验/标准高胆固醇血症/并发症高血压/并发症结果可重复性回顾性研究危险因素敏感性与特异性信号处理计算机辅助吸烟/副作用人类男(雄)性中年人

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Accuracy of imaging technologies in the diagnosis of acute cardiac ischemia in the emergency department: A meta-analysis

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 471-477页

作者： Ioannidis, JPA Salem, D Chew, PW Lau, J New England Med Ctr Div Clin Care Res Evidence Based Practice Ctr Boston MA 02111 USA

Study objective: We sought to quantitatively evaluate the evidence on the diagnostic performance of imaging technologies (including rest and stress echocardiography and technetium-99m sestamibi scanning) far the diagnosis of acute cardiac ischemia and acute myocardial infarction in the emergency department. Methods: We conducted a systematic review and meta-analysis of the English-language literature published between 1966 and December 1998. Both prospective and retrospective studies qualified for the assessment of diagnostic performance. Diagnostic performance was assessed by means of random-effect estimates of test sensitivity, specificity, and the diagnostic odds ratio and was summarized by using summary receiver-operating characteristic curves. Results: Diagnostic accuracy was evaluated in 10 studies of rest echocardiography, 2 studies of dobutamine stress echocardiography, and 6 studies of technetium-99m sestamibi scanning, However, only 3 rest echocardiography and 5 technetium-99m sestamibi studies evaluated patients strictly in the ED setting. Patient populations were often highly selected to represent low- or moderate-risk groups. When limited to ED studies, rest echocardiography showed excellent sensitivity of 93% (95% CI, 81% to 97%) and goad specificity of 66% (95% CI, 43% to 83%). The results were similar when all studies were considered, including data from reports of admitted patients and patients sent to the cardiac care unit. There was insufficient literature on stress echocardiography in the ED to properly assess the technology. Technetium-99m sestamibi scanning also showed excellent sensitivity (range, 91.5% to 100%) and good specificity (range, 49.3% to 84.4%) for acute myocardial infarction;for acute cardiac ischemia, the random-effects pooled sensitivity was 89% (95% CI, 73% to 96%), and the pooled specificity was 77% (95% CI, 63% to 87%). Conclusion: For selected low- and moderate-risk patient groups, echocardiography and technetium-99m sestami

关键词：急性病偏倚(流行病学) 诊断显像/方法诊断显像/标准超声心动描记术/标准急诊处理/方法急诊处理/标准循证医学运动试验/标准心肌梗死/诊断心肌梗死/流行病学心肌缺血/诊断心肌缺血/流行病学比值比患病率前瞻性研究可重复性结果研究设计回顾性研究危险因素敏感性与特异性 99m锝甲氧基异丁基异腈/诊断应用技术评估生物医学人类

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Diagnosing acute cardiac ischemia in the emergency department: A systematic review of the accuracy and clinical effect of current technologies

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ANNALS OF EMERGENCY MEDICINE 2001年第5期37卷 453-460页

作者： Lau, J Ioannidis, JPA Balk, EM Milch, C Terrin, N Chew, PW Salem, D New England Med Ctr Div Clin Care Res Evidence Based Practice Ctr Boston MA 02111 USA

Study objective: Acute cardiac ischemia (ACI) encompasses the diagnoses of unstable angina pectoris and acute myocardial infarction (AMI). Accurate diagnosis and triage of patients with ACI in the emergency department should increase survival for these patients and reduce unnecessary hospital admissions. Methods: We conducted a systematic review of the English-language literature published between 1966 and December 1998 on the accuracy and clinical effect of diagnostic technologies for ACI. We evaluated prospective and retrospective studies of adult patients who presented to the ED with symptoms suggesting ACI. Outcomes were diagnostic performance (test sensitivity and specificity) and measures of clinical effect. Meta-analyses were performed when appropriate. A decision and cost-effectiveness analysis was conducted that investigated Various diagnostic strategies used in the diagnosis of ACI in the ED. Results: We screened 6,667 abstracts, reviewed 407 lull articles, and included 106 articles in the main analysis. Single measurements of biomarkers at presentation to the ED have low sensitivity for AMI, although they have high specificity. Serial measurements greatly increase the sensitivity for AM[ while maintaining their excellent specificity. Diagnostic technologies to evaluate ACI in selected populations, such as electrocardiography, sestamibi perfusion imaging, and stress EGG, may have very good to excellent sensitivity;however, they have not been sufficiently studied. The Goldman Chest Pain Protocol has good sensitivity (about 90%) for AMI but has not been shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical effect study performed. Its applicability to patients with unstable angina pectoris has not been evaluated. The use of an Acute Cardiac Ischemia-Time-Insensitive Predictive instrument led to the appropriate triage of 97% of patients with ACI presenting to the ED and reduced unnecessary hospita

关键词：急性病心绞痛不稳定型/诊断费用效益分析决策支持技术心电描记术/经济学心电描记术/标准急诊处理/经济学急诊处理/方法急诊处理/标准循证医学运动试验/经济学运动试验/标准医院费用/统计学和数值数据住院/统计学和数值数据住院时间/统计学和数值数据心肌梗死/诊断前瞻性研究可重复性结果回顾性研究敏感性与特异性技术评估生物医学治疗结果伤病员分拣/经济学伤病员分拣/方法伤病员分拣/标准成年人人类

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On the uniformity of cardiopulmonary exercise testing in chronic heart failure

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AMERICAN HEART JOURNAL 2001年第3期142卷 384-387页

作者： Myers, J Vet Affairs Palo Alto Hlth Care Syst Div Cardiovasc Med Palo Alto CA USA Stanford Univ Palo Alto CA 94304 USA

Peak oxygen uptake during exercise (peak VO2) has evolved to become a vital component of the risk paradigm in patients with chronic heart failure (CHF), particularly in the context of considering patients for transplantation listing. Over the last 10 years, dozens of studies have been published demonstrating that peak VO2 is a strong univariate or multivariate predictor of outcomes in CHF. Although “outcomes” have differed in these studies, in many instances peak VO2 has outperformed clinical, invasive hemodynamic and other exercise data in predicting risk.1 Such information is extremely important today given the large and widening gap between available donor hearts and potential transplant recipients.

关键词：运动试验/标准心脏移植氧耗量病人遴选试验预期值预后参考值可重复性结果危险性评估疾病严重程度指数人类

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Validation of a specific activity questionnaire to estimate exercise tolerance in patients referred for exercise testing

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AMERICAN HEART JOURNAL 2001年第6期142卷 1041-1046页

作者： Myers, J Bader, D Madhavan, R Froelicher, V Stanford Univ Palo Alto Vet Affairs Med Ctr Div Cardiol Palo Alto CA 94304 USA Boston Univ Med Ctr Div Cardiol Boston MA USA

Background Physical activity and symptom questionnaires have been used as surrogates for exercise testing to estimate a patient's functional capacity and to individualize an exercise testing protocol in accordance with exercise testing guidelines. To validate these approaches, they must be compared with measured oxygen uptake (peak VO2). Methods Before exercise testing was performed, a brief, self-administered questionnaire (Veterans Specific Activity Questionnaire [VSAQ]) was given to 337 patients referred for exercise testing for clinical reasons. The VSAQ was used to estimate exercise tolerance on the basis of symptoms during daily activities to individualize ramp rates on the treadmill so that the test duration would be approximately 10 minutes. Clinical and demographic variables were added to the VSAQ responses in a stepwise regression model to determine their ability to predict both directly measured peak VO2 and peak metabolic equivalents (METs) predicted from the treadmill workload. Results The mean exercise time was 9.6 +/- 3 minutes. Responses to the VSAQ and age were the strongest predictors of both measured and predicted exercise capacity. Small but significant contributions to the explanation of variance in bath measured and estimated METs were made by resting heart rate, forced expiratory volume in I second expressed as a percentage of normal, exercise capacity predicted for age, and body mass index. The multiple R values from the regression equations for measured and estimated METs were 0.58 and 0.72, respectively. Conclusions Estimating a patient's symptoms associated with daily activities along with age are the strongest predictors of a patient's exercise tolerance. The VSAQ, combined with pretest clinical data, predicts the estimated MET value from treadmill speed and grade better than directly measured METs do. When used for estimating a patient's symptom limits to individualize ramp rates on a treadmill, this approach yields an appropriate test d

关键词：日常生活活动运动(Exercise)/生理学运动试验/标准运动耐量/生理学用力呼气量模型统计学多元分析氧耗量预后问卷调查女(雌)性人类男(雄)性中年人

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