The effect of estrogen compared to estrogen plus progesterone on the exercise electrocardiogram

Results: Ischemia was present on DSE in 98 patients and either false-negative or false-positive DSE were present in 35. Sensitivity, specificity and accuracy were highest for patients with normal geometry and CH and lower for CR and EH. Accuracy for detecting CAD was 85%, 86%, 64% and 61% for normal geometry, CH, EH and CR, respectively. DSE accuracy was greatest for patients in the fourth quartile of cESS and mESS compared to patients with lower end-systolic stress during DSE. Conclusion: Low ESS and CR or EH all reduce the accuracy of DSE for detection of CAD. Perspective: This highly detailed study of left ventricular geometry and systolic performance provides some clues as to situations in which the clinician may suspect that a false-positive or negative result may occur with DSE. The relationship to both the development of lower ESS and the presence of either CR or EH suggests that occult myocardial abnormalities may be the source of erroneous diagnostic results. WA

Conclusion: Detection of LAD patency and myocardial perforators with CDFI provides valuable information regarding the integrity of myocardial perfusion following AMI and correlates with a higher likelihood of recovery of function. Perspective: This detailed, non-invasive evaluation of the LAD and its myocardial perforators following AMI builds nicely on the high resolution capability of current ultrasound scanners. If confirmed in a larger series of patients and if demonstrated to be widely applicable in the general population, this rapid, easy to employ technique may serve as a highly valuable tool for real-time determination of LAD patency following AMI. WA

The Effect of Estrogen Compared to Estrogen Plus Progesterone on the Exercise Electrocardiogram Bokhari S, Bergmann SR. J Am Coll Cardiol 2002;40:1092– 6. Study Question: To assess the impact of hormone replacement therapy (HRT) on the accuracy of the stress ECG in postmenopausal females. Methods: Retrospective review of stress ECG and myocardial perfusion imaging (MPI) in 140 consecutive postmenopausal females studied for suspected coronary artery disease (CAD). All study subjects had normal resting ECGs. HRT status was: no HRT, n⫽31; estrogen alone (ERT), n⫽75; estrogen plus progesterone (EPRT), n⫽34. Results: There were no significant differences among the three groups in age, cardiovascular risk factors (hypertension, diabetes, cholesterol, smoking), exercise duration, heart rate or peak blood pressure attained. Using MPI as a standard, the exercise ECG had a sensitivity of 54%, 57% and 56% for detecting CAD in the no HRT, EPRT and ERT groups. Specificity was 78%, 80% and 46%, respectively. Conclusions: HRT with estrogen alone increases the falsepositive rate of stress ECG in postmenopausal females, an effect that can be negated by addition of progesterone to the regime. The overall sensitivity for detecting CAD is low, suggesting a uniform need for imaging studies in postmenopausal females, irrespective of HRT status. Perspective: This retrospective observational study confirms the previously reported low overall accuracy of routine stress ECG in postmenopausal females. Furthermore it demonstrates that isolated estrogen replacement may result in even worsened overall accuracy, in large part because of a remarkably low specificity of under 50%. The mechanism by which concurrent progesterone therapy, as part of HRT, reverses this phenomenon remains to be determined. In view of the recent controversy regarding the value of HRT for prevention of cardiovascular events, one can anticipate that many patients will be withdrawn from HRT in the near future, which may lead to a change in stress ECG characteristics in patients who had been evaluated previously. The clinician should be aware that the change in ECG behavior during exercise may be related to withdrawal of HRT rather than a true change in the patient’s clinical status. WA

Coronary Recanalization in Anterior Myocardial Infarction: The Open Perforator Hypothesis Voci P, Mariano E, Pizzuto F, Puddu PE, Romeo F. J Am Coll Cardiol 2002;40:1205–13. Study Question: Using transthoracic color Doppler flow imaging (CDFI) to detect myocardial perforators arising from the left anterior descending coronary artery (LAD) in patients’ status post anterior myocardial infarction (AMI). Methods: 61 patients with AMI underwent CDFI to access the patency of the distal LAD and presence and number of myocardial perforators following AMI. Therapy included lytics in 28, stenting in 20 and neither in 13. Subjects were classified into four recanalization groups including; I⫽closed LAD, no perforators; II⫽open LAD, no perforators; III⫽open LAD, perforators in 1–2 segments; IV⫽open LAD, perforators in 3– 4 segments. Patients were followed for recovery of LV function as manifest by ejection fraction (EF), wall motion score index (WMSI) and enddiastolic and end-systolic volume indices (EDVI, ESVI). Coronary arteriography was used to characterize flow in the LAD by TIMI grading. Results: Coronary arteriography was performed in 60 patients, 53 of whom who had an open LAD. The LAD was considered open in 53 by CDFI and closed in 8. Compared to angiography, there was one false positive and one falsenegative resulting in sensitivity, specificity and accuracy of 87%, 98% and 99%, respectively, for CDFI. The absence of perforators was exclusively seen in patients with TIMI 0 flow. The presence of perforators in the apical septal segment was exclusively seen in TIMI III flow but occurred in only 41% of cases. The recanalization group had greater predictive ability for recovery of LV function than did TIMI grade.

ACC CURRENT JOURNAL REVIEW Jan/Feb 2003

39