Significance of chest pain during treadmill exercise

LETTERS

FIGURE

c

*

A

3. Pressure tracings in a patient with a Bjwk-Shiley

prosthesis. See text

sessment of left ventricular function and the assessment of effective valve orifice area in cases with suspected prosthetic obstruction may be altered by this technique. We conclude that retrograde catheterization of the aortic Starr-Edwards prosthesis may be an acceptable, although less than ideal, method but would strongly recommend against attempting retrograde catheterization of the left ventricle across an aortic Bjork-Shiley prosthesis because of the likelihood of producing acute, massive aortic regurgitation through serious interference with the disc-closing mechanism.

detectable aortic regurgitation, as estimated from pressure changes on catheter pullback, was observed in only 3 patients.” Examination of the pressure tracings submitted by Falicov and Walsh testifies to interference with both systolic and diastolic excursion of the Bjork-Shiley prosthesis. There are elevation of left ventricular systolic and diastolic pressures and depression of both systolic and diastolic aortic pressures in the first two complexes recorded during pullback of the catheter through the valve. Once again, it must be pointed out that they used a no. 8F catheter. We believe that their letter does point out a useful word of caution in dealing with retrograde catheterization of BjorkShiley prostheses. However, this problem should be at least partially avoided by utilizing smaller catheters.

Raul E. Falicov, MD, FACC Section of Cardiology Christ Hospital Oak Lawn, Illinois Warren F. Walsh, MD University of Oregon Health Science Center Eugene, Oregon References 1. Kamh

D, Mkbaebm SF, Lm#Ou AR, col*n 6L, Woffson Q Ftetr~ bft ventrkulaf cathetwization in patlmts with an aortic valve prmthesis. Am J card101 41:893-898. 1978 2. O’Rowke RA, PeWson KL, Graunrald MSz Postoperative hemodynamic evaluation of a new fabric-covered ball-valve prosthesis. Circulation 47.48:Suppl 111-74-111-79. 1973 3. Romabmu RC, Ytilnl EL, Ww Y, Ulbhal CW: Replacement of the aortk valve wim the Stan-Edwards and suiweless (Magonm) prosthesis: cm*attve mxthemtzation results. Am J Cardiol203314-323.1967 4. ~R,Km(klmW~R-JI:Apltrclllk,~pos~lveevaluationofaatk Starr-Edwards valves. J Thaac cerdlovasc Swg x5%288-2e2.1967

REPLY

Falicov and Walsh have made the useful point that, because of its construction, a Bjork-Shiley prosthetic valve is more susceptible to interference with function during the period of time a catheter is traversing it than is a Starr-Edwards prosthesis. Our experience included a total of 27 patients, 5 of whom had a Bjork-Shiley prosthesis. We did not note any substantially increased interference with function with the latter prosthesis, but Falicov and Walsh have ignored a critical point described in our methods section. This is that we utilized either Sones or Shirey catheters, both of which taper to a no. 5F tip, or no. 5F polyethylene catheters primarily for our studies. Thus, all prostheses were crossed with smaller catheters than those used by Falicov and Walsh. In addition, they comment on our Figure 3, which shows no interference with movement of a Starr-Edwards poppet in systole. As noted in our text (on page 895), the Starr-Edwards poppets did not appear to seat completely in diastole with catheters crossing the valve. However, “hemodynamically

1064

May

1979

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Anwkrn

Journal of CARDIOLOGY

Volume 43

Steven Wolfson, MD New Haven, Connecticut

SIGNIFICANCE

OF CHEST PAIN DURING TREADMILL EXERCISE

The paper by Cole and Ellestadl on the significance of chest pain during treadmill exercise contains potentially important information, but we think that several points should be clarified. The 7 year mortality rate was only 27 percent in the patients with both an abnormal electrocardiogram and typical angina pectoris during exercise; according to previous findings and the reported data,’ such patients are very likely to have significant coronary artery disease, and the expected mortality would be much greater than that observed (Bruschke et al2 reported a 7 percent annual mortality rate). The inclusion of an undefined number of women could contribute to these findings but is not likely to be the only explanation. The true positive rate for women with pain and electrocardiographic abnormalities during exercise was only I7 percent; although it is widely recognized that the diagnosis of coronary artery disease is not easy to establish in women, the reported fiie is incredibly low and raises questions about the definition of angina pectoris in that study. We3 recently reported that in patients with suspected coronary artery disease, the history taken before the exercise test was of great diagnostic value and that, among the patients with a typical history of angina pectoris, the occurrence of chest pain during the exercise test itself did not add much information. All patients described by Cole and Ellestad were certainly carefully questioned before the exercise test and it would be very important to know how this information relates to prognosis. It would indeed be unfair to attribute to exercise testing a diagnostic and prognostic value that is probably already present in the history. J.M. Detry, MD M.F. Rousseau, MD St. Luc University Hospital Division of Cardiology University of Louvain Brussels, Belgium

1. Cofo JF, EMsfad Yn: Si@fiwnce of chest pain dving treadmill exercise: cowelatIon with COTOIWYevents. Am J Cardi 41:227-232.1978 2. EiMchk.AvaRouan~6mnFy:Progressstudyof590 comxuUve nomqical of camwy difollowed 6-B yawn. I. Artwlogaphii carewions. Clraiiatkn 47:1147-1153. 1973 3. Detq JMR, Kv6a BN, Goeyna J, 6oGfmx 8,6raamw LA, R-au MF: Diagnostic valw of histuy md mmdmal exerctse v inmmmdwommsuspected of coronary heart disease. Circulation 56~756-761.1977