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      Treadmill exercise testing of asymptomatic men and women without evidence of heart disease

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          Abstract

          The aim of this study was to test the hypothesis of differences in performance including differences in ST-T wave changes between healthy men and women submitted to an exercise stress test. Two hundred (45.4%) men and 241 (54.6%) women (mean age: 38.7 ± 11.0 years) were submitted to an exercise stress test. Physiologic and electrocardiographic variables were compared by the Student t-test and the chi-square test. To test the hypothesis of differences in ST-segment changes, data were ranked with functional models based on weighted least squares. To evaluate the influence of gender and age on the diagnosis of ST-segment abnormality, a logistic model was adjusted; P < 0.05 was considered to be significant. Rate-pressure product, duration of exercise and estimated functional capacity were higher in men (P < 0.05). Sixteen (6.7%) women and 9 (4.5%) men demonstrated ST-segment upslope ≥0.15 mV or downslope ≥0.10 mV; the difference was not statistically significant. Age increase of one year added 4% to the chance of upsloping of segment ST ≥0.15 mV or downsloping of segment ST ≥0.1 mV (P = 0.03; risk ratio = 1.040, 95% confidence interval (CI) = 1.002-1.080). Heart rate recovery was higher in women (P < 0.05). The chance of women showing an increase of systolic blood pressure ≤30 mmHg was 85% higher (P = 0.01; risk ratio = 1.85, 95%CI = 1.1-3.05). No significant difference in the frequency of ST-T wave changes was observed between men and women. Other differences may be related to different physical conditioning.

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          An externally validated model for predicting long-term survival after exercise treadmill testing in patients with suspected coronary artery disease and a normal electrocardiogram.

          The exercise treadmill test is recommended for risk stratification among patients with intermediate to high pretest probability of coronary artery disease. Posttest risk stratification is based on the Duke treadmill score, which includes only functional capacity and measures of ischemia. To develop and externally validate a post-treadmill test, multivariable mortality prediction rule for adults with suspected coronary artery disease and normal electrocardiograms. Prospective cohort study conducted from September 1990 to May 2004. Exercise treadmill laboratories in a major medical center (derivation set) and a separate HMO (validation set). 33,268 patients in the derivation set and 5821 in the validation set. All patients had normal electrocardiograms and were referred for evaluation of suspected coronary artery disease. The derivation set patients were followed for a median of 6.2 years. A nomogram-illustrated model was derived on the basis of variables easily obtained in the stress laboratory, including age; sex; history of smoking, hypertension, diabetes, or typical angina; and exercise findings of functional capacity, ST-segment changes, symptoms, heart rate recovery, and frequent ventricular ectopy in recovery. The derivation data set included 1619 deaths. Although both the Duke treadmill score and our nomogram-illustrated model were significantly associated with death (P < 0.001), the nomogram was better at discrimination (concordance index for right-censored data, 0.83 vs. 0.73) and calibration. We reclassified many patients with intermediate- to high-risk Duke treadmill scores as low risk on the basis of the nomogram. The model also predicted 3-year mortality rates well in the validation set: Based on an optimal cut-point for a negative predictive value of 0.97, derivation and validation rates were, respectively, 1.7% and 2.5% below the cut-point and 25% and 29% above the cut-point. Blood test-based measures or left ventricular ejection fraction were not included. The nomogram can be applied only to patients with a normal electrocardiogram. Clinical utility remains to be tested. A simple nomogram based on easily obtained pretest and exercise test variables predicted all-cause mortality in adults with suspected coronary artery disease and normal electrocardiograms.
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            Evaluation of R wave amplitude changes versus ST-segment depression in stress testing.

            Exercise ECGs and coronary angiograms were reviewed in 266 patients (81 normals and 185 with significant coronary artery disease). Thirty-three false positive and 96 false negative ST responses to stress testing were purposely chosen to determine if the R wave could reduce the number of false ST responses. R wave amplitude changes were measured in the control and in the immediate postexercise period. An increase or no change in R wave was taken as evidence of an abnormal response, while a decrease in the R wave was a normal response. The sensitivity by ST segment was 48% and the specificity was 59%. These values were low because of the large number of false positive and negative ST responses in the study. It was our purpose to determine if these lowered values could be significantly improved by the R wave. Using R wave criteria, the sensitivity was 63% (P is less than 0.01) while the specificity was 79% (P is less than 0.01). The sensitivity and specificity of stress testing can be significantly improved using R wave changes.
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              Different Prognostic Value of Exercise Electrocardiogram in Men and Women

              In 1,455 subjects (947 men and 508 women) who underwent a bicycle ergometer stress test for evaluation of atypical chest pain, the incidence of coronary events (definite myocardial infarction or sudden death) was assessed by the life table method. The follow-up period ranged from 3 to 7 years (mean 5.2 years). In men with positive exercise test (ischemic ST depression ≧ 1 mm), the 5-year incidence of coronary events was 18.3%, compared with 1.9% in negative responders. In women with positive response, the 5-year incidence of coronary events was 4.6%; in negative responders, it was 0.3%. The poor predictive value of ischemic ST responses to exercise in women is emphasized.
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                Author and article information

                Contributors
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Journal
                bjmbr
                Brazilian Journal of Medical and Biological Research
                Braz J Med Biol Res
                Associação Brasileira de Divulgação Científica (Ribeirão Preto )
                1414-431X
                December 2009
                : 42
                : 12
                : 1230-1235
                Affiliations
                [1 ] Universidade de São Paulo Brazil
                Article
                S0100-879X2009001200018
                10.1590/S0100-879X2009001200018
                b8b9274e-83fc-4531-83a7-ec96a223ba47

                http://creativecommons.org/licenses/by/4.0/

                History
                Product

                SciELO Brazil

                Self URI (journal page): http://www.scielo.br/scielo.php?script=sci_serial&pid=0100-879X&lng=en
                Categories
                BIOLOGY
                MEDICINE, RESEARCH & EXPERIMENTAL

                Medicine,General life sciences
                ST-T wave changes,Exercise stress test,Asymptomatic,Women
                Medicine, General life sciences
                ST-T wave changes, Exercise stress test, Asymptomatic, Women

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