Exercise stress test

The safety of G-CSF stimulation in patients with CAD has been questioned in two recent studies. Hill et al. [138] report the results of administration of 10 mcg/kg/day of G-CSF for 5 days in patients with chronic CAD n = 16). There was no clinical benefit as assessed by exercise stress testing and dobuta-mine cardiac MRI. Additionally two patients in the G-CSF group developed serious adverse events related to the therapy (one non-ST elevation MI one MI causing death). Zbinden et al. [139] also tested the efficacy of the same G-CSF dose in patients with chronic CAD ( = 7). The invasive endpoint collateral flow index was significantly better in the G-CSF treated patients when compared to the placebo group. However, two patients in the G-CSF treated group developed acute coronary syndrome during treatment. 

All patients were asked to return to the investigative site for a clinical visit four weeks one-week postprocedure to repeat clinical labs and monitor acute clinical events. All patients were contacted by telephone by the investigative site at three months one week for a safety evaluation. All subjects were required to return to the investigative site for a repeat coronary angiography whether they were experiencing symptoms or not. If a patient had a positive exercise stress test at any time up to and including his required follow-up, a repeat angiogram was performed. 

Transient myocardial ischemia was evaluated in 112 patients undergoing the Bruce protocol exercise stress testing. Technetium tetrofosmin scans were obtained and BNP levels were assessed before, during, and four hours after exercise (13). If patients had no inducible ischemia, BNP levels were low at baseline, 43 pg/mL, and unchanged during and after exercise. However, in patients with inducible ischemia, BNP levels rose from a median 62 to 92 pg/mL and nearly returned to baseline at four hours postexercise, Patients with severe ischemia had median BNP levels at baseline, 101 pg/mL and increased to 123 pg/mL, These were still elevated four hours postexercise to I 15 pg/mL, Differences were based on the BNP levels, Patients with no ischemia (43 pg/mL), mild to moderate ischemia (60-92 pg/mL), and severe ischemia (101 pg/mL) were statistically different, These differences were increased with exercise stress (13),... 

Cardiologic evaluation (i.e., exercise stress testing and echocardiography) may guide patient management Moderate to severe valve disease... 

Lastly, the VR lead may also be useful in detecting multivessel disease during the exercise stress test (Michaelides et al, 2003). 

The occurrence of false-positive cases of ST-segment depression during an exercise stress test has already been addressed. These are due to different causes (hyperventilation, drugs, etc.) or are of unknown origin (Table 4.5 and Figure 4.58). In some circumstances (neurocirculatory asthenia, hyperventilation, etc.), their origin is unknown or difficult to explain. 

If necessary, other complementary tests should be carried out (chestX-ray, exercise stress test, echocardiography and other imaging techniques). When... 

Some sophisticated techniques (CMTCE) or isotopic techniques are not available in the emergency department of majority of the centres. However, X-ray, exercise stress test, repeated determination of troponin levels and even an echocardiographic study can be performed in many of them. An exercise stress test should be carried out to clarify diagnostic doubts but only when a proper history and review of previous ECG recordings, if available, have ruled out that the patient is clinically unstable. The few serious problems that may arise during the practice of exercise test in these patients usually occur because these considerations have not been borne in mind (Ellestad, 2004). An example of the usefulness of the exercise stress test in a... 

In a small percentage of cases diagnosis is not clearly performed, and the patient s evolution sometimes provides the solution. When the clinical picture, the ECG recording, the enzymatic levels and the exercise stress test are not conclusive and the final diagnosis is an ACS, it is generally of low risk (Lee et al., 1985,1993 Pastor Torres et al, 2002). The complication rate of an ACS with a normal baseline ECG that shows no changes during a chest pain episode is quite low. On the other hand,... 

Excellent coordination with the intensive care unit and cardiology department c) The possibility of carrying out serial enzymatic determinations and, among the cardiologic complementary tests, the availability of, at least, X-rays, exercise stress test and echocardiography... 

Exercise stress testing provides important information con- cerning the likelihood and severity of coronary artery dis-... 

Chaitman B. Exercise stress testing. In Braunwald E, ed. Heart Disease A Textbook of Cardiovascular Medicine, 4th ed. Philadelphia, Saunders, 1992 161-179. 

A 48-year-old male presents to the clinic because of concerns about heart disease. He reports that his father died from a heart attack at age 46, and his older brother has also had a heart attack at age 46 but survived and is on medications for elevated cholesterol. The patient reports chest pain occasionally with ambulation around his house and is not able to climb stairs without significant chest pain and shortness of breath. The physical exam is normal, and the physician orders an electrocardiogram (ECG), exercise stress test, and blood work. The patient s cholesterol result comes back as 350 mg/dL (normal 200). The physician prescribes medication, which he states is directed at the rate-limiting step of cholesterol biosynthesis. 

The use of nuclear perfusion imaging in addition to exercise stress testing or as an alternative modality for patients unable to exercise (using pharmacologic agents) can provide important prognostic information for patients with chronic ischemic heart disease. 

Lauer MS, Francis GS, Okin PM, et al. Impaired chronotropic response to exercise stress testing as a predictor of mortality. JAMA 1999 281(6) 524—9. 

Cuocolo A, Nicolai E, Pace L, Nappi A, Sullo P, Cardei S, Argenziano L, Ell PJ, Salvatore M (1996) Technetium-99m-labeled tetrofosmin myocardial tomography in patients with coronary artery disease comparison between adenosine and dynamic exercise stress testing. J Nucl Cardiol... 

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