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Influence of left ventricular hypertrophy on detection of coronary artery disease using exercise echocardiography
RISK
STRATIFICATION
AND
PROGNOSIS
Influence of Left Ventricular Hypertrophy on Detection of Coronary Artery Disease Using Exercise Echocardiography
The Limited Efficacy of Exercise Radionuclide Ventriculography in Assessing Prognosis of Women With Coronary Artery Disease
T.H. Marwick, J. Torelli, K. Harjai, 6. Halurka, F.J. Pashkow, W.J. Stewart J.D. Thomas. Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH. j Am Coll Cardiol 1995;26:llBO-6.
M. Moriel, A. Rozanrki, J. Klein, D.S. Berman, C.N.B. Men. Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles CA. Am ] Cardiol 1995;76:1030-5.
Increasing numbers of women are undergoing stress testing for coronary artery disease evaluation. Limited study is available as to its efficacy in women. Four hundred nineteen patients with coronary artery disease (74 women and 345 men) referred for exercise radionuclide ventriculography between 1979 and 1986 were evaluated in a prospective cohort evaluation with 5-year follow-up. Exercise radionuclide ventriculographic variables were analyzed and compared between women and men. The prognostic efficacy of exercise radionuclide ventriculography was assessed separately for women and men among patients with coronary artery disease by Kaplan-Meier cumulative survival curves, univariate Cox regression analyses, and hierarchical stepwise Cox regression analyses. Overall, women demonstrated higher resting and peak left ventricular ejection fraction response to exercise than men. Ninety-six of 419 patients (23%) had cardiac events at 5-year follow-up. Although left ventricular response to exercise conveyed prognostic information in the combined and male populations (multivariate hierarchical analyses chi-square 11, p = 0.001 for delta left ventricular ejection fraction and chi-square 10, p = 0.002 for worsening exercise wall motion score), these variables were not found to be prognostically useful in women, Women with coronary artery disease demonstrated a worsened functional status, evidenced by greater compromise of exercise capacity, despite having less extensive anatomic disease than their male counterparts. We conclude that sex-related differences in left ventricular response to exercise limit the prognostic utility of exercise ventriculography in women with coronary artery disease.
Objectives: This study examined the influence of left ventricular hypertrophy on the accuracy of exercise electrocardiography and echocardiography for detection of coronary artery disease. Background: Electrocardiographic repolarization abnormalities caused by left ventricular hypertrophy compromise the diagnostic accuracy of exercise electrocardiography but not of exercise echocardiography. The relative merits of these investigations are less well defined in patients with hypertrophy but without electrocardiographic (ECG) changes. Methods: We prospectively evaluated 147 consecutive patients without prior myocardial infarction undergoing both exercise echocardiography and coronary arteriography. Coronary stenoses >50% diameter were present in 62 patients (42%). Positive test results were defined by a new or worsening wall motion abnormality or >O.l mV of ST depression. Echocardiographic left ventricular hypertrophy was identified in 68 patients. A subgroup with clinically suspected hypertrophy was defined according to the presence of ECG evidence of hypertrophy, hypertension or aortic stenosis. Results: The overall sensitivity of exercise echocardiography exceeded that of exercise electrocardiography. Echocardiographic hypertrophy had no significant effect on the sensitivity of either test. The specificity of exercise echocardiography exceeded that of exercise electrocardiography. In patients with hypertrophy, the specificity of exercise echocardiography exceeded that of exercise electrocardiography, whereas among patients without hypertrophy, the specificities were more comparable. The accuracy of exercise echocardiography exceeded that of the exercise ECG in the overall group and in patients with hypertrophy, but this difference was less prominent in patients without hypertrophy. In patients with clinically suspected hypertrophy, exercise echocardiography demonstrated a higher sensitivity, specificity and accuracy than exercise electrocardiography. The cost incurred in the identification of coronary disease was least with a strategy involving use of the exercise echocardiogram instead of routine exercise testing in patients with known or clinically suspected left ventricular hypertrophy. Conclusions: Exercise echocardiography is more accurate than exercise electrocardiography for the detection of coronary artery disease in patients with known or clinically suspected left ventricular hypertrophy. ACC CURRENT
1OURNAL
Long-Term Prognostic Value of Exercise Testing Men and Women From the Coronary Artery Surgery Study (CASS) Registry
in
D.A. Weiner, T.J. Ryan, L Parsons, LD. Fisher, B.R. Chaitman, LT. Sheffield, F.E. Tristani. Section of Cardiology, Boston University Medical Center, Boston, MA. Am J Cardiol 1995;75:865-70.
Many prior studies involving a predominantly, male population have demonstrated the importance of exercise test results in determining the outcome of patients with coronary artery disease. The prognostic significance of exercise testing in women is unknown. In our study, a total of 3,086 men and 747 women underwent maximal treadmill exercise testing, coronary angiography, and were prospectively followed for up to 16 years. They were divided
REVIEW
26
Seotember/October
1996
STRATIFICATION
AND
PROGNOSIS
Influence of Left Ventricular Hypertrophy on Detection of Coronary Artery Disease Using Exercise Echocardiography
The Limited Efficacy of Exercise Radionuclide Ventriculography in Assessing Prognosis of Women With Coronary Artery Disease
T.H. Marwick, J. Torelli, K. Harjai, 6. Halurka, F.J. Pashkow, W.J. Stewart J.D. Thomas. Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH. j Am Coll Cardiol 1995;26:llBO-6.
M. Moriel, A. Rozanrki, J. Klein, D.S. Berman, C.N.B. Men. Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles CA. Am ] Cardiol 1995;76:1030-5.
Increasing numbers of women are undergoing stress testing for coronary artery disease evaluation. Limited study is available as to its efficacy in women. Four hundred nineteen patients with coronary artery disease (74 women and 345 men) referred for exercise radionuclide ventriculography between 1979 and 1986 were evaluated in a prospective cohort evaluation with 5-year follow-up. Exercise radionuclide ventriculographic variables were analyzed and compared between women and men. The prognostic efficacy of exercise radionuclide ventriculography was assessed separately for women and men among patients with coronary artery disease by Kaplan-Meier cumulative survival curves, univariate Cox regression analyses, and hierarchical stepwise Cox regression analyses. Overall, women demonstrated higher resting and peak left ventricular ejection fraction response to exercise than men. Ninety-six of 419 patients (23%) had cardiac events at 5-year follow-up. Although left ventricular response to exercise conveyed prognostic information in the combined and male populations (multivariate hierarchical analyses chi-square 11, p = 0.001 for delta left ventricular ejection fraction and chi-square 10, p = 0.002 for worsening exercise wall motion score), these variables were not found to be prognostically useful in women, Women with coronary artery disease demonstrated a worsened functional status, evidenced by greater compromise of exercise capacity, despite having less extensive anatomic disease than their male counterparts. We conclude that sex-related differences in left ventricular response to exercise limit the prognostic utility of exercise ventriculography in women with coronary artery disease.
Objectives: This study examined the influence of left ventricular hypertrophy on the accuracy of exercise electrocardiography and echocardiography for detection of coronary artery disease. Background: Electrocardiographic repolarization abnormalities caused by left ventricular hypertrophy compromise the diagnostic accuracy of exercise electrocardiography but not of exercise echocardiography. The relative merits of these investigations are less well defined in patients with hypertrophy but without electrocardiographic (ECG) changes. Methods: We prospectively evaluated 147 consecutive patients without prior myocardial infarction undergoing both exercise echocardiography and coronary arteriography. Coronary stenoses >50% diameter were present in 62 patients (42%). Positive test results were defined by a new or worsening wall motion abnormality or >O.l mV of ST depression. Echocardiographic left ventricular hypertrophy was identified in 68 patients. A subgroup with clinically suspected hypertrophy was defined according to the presence of ECG evidence of hypertrophy, hypertension or aortic stenosis. Results: The overall sensitivity of exercise echocardiography exceeded that of exercise electrocardiography. Echocardiographic hypertrophy had no significant effect on the sensitivity of either test. The specificity of exercise echocardiography exceeded that of exercise electrocardiography. In patients with hypertrophy, the specificity of exercise echocardiography exceeded that of exercise electrocardiography, whereas among patients without hypertrophy, the specificities were more comparable. The accuracy of exercise echocardiography exceeded that of the exercise ECG in the overall group and in patients with hypertrophy, but this difference was less prominent in patients without hypertrophy. In patients with clinically suspected hypertrophy, exercise echocardiography demonstrated a higher sensitivity, specificity and accuracy than exercise electrocardiography. The cost incurred in the identification of coronary disease was least with a strategy involving use of the exercise echocardiogram instead of routine exercise testing in patients with known or clinically suspected left ventricular hypertrophy. Conclusions: Exercise echocardiography is more accurate than exercise electrocardiography for the detection of coronary artery disease in patients with known or clinically suspected left ventricular hypertrophy. ACC CURRENT
1OURNAL
Long-Term Prognostic Value of Exercise Testing Men and Women From the Coronary Artery Surgery Study (CASS) Registry
in
D.A. Weiner, T.J. Ryan, L Parsons, LD. Fisher, B.R. Chaitman, LT. Sheffield, F.E. Tristani. Section of Cardiology, Boston University Medical Center, Boston, MA. Am J Cardiol 1995;75:865-70.
Many prior studies involving a predominantly, male population have demonstrated the importance of exercise test results in determining the outcome of patients with coronary artery disease. The prognostic significance of exercise testing in women is unknown. In our study, a total of 3,086 men and 747 women underwent maximal treadmill exercise testing, coronary angiography, and were prospectively followed for up to 16 years. They were divided
REVIEW
26
Seotember/October
1996