Pathogenic FBN1 mutations in 146 adults not meeting clinical diagnostic criteria for Marfan syndrome: further delineation of type 1 fibrillinopathies and focus on patients with an isolated major criterion.

Mutations in the FBN1 gene cause Marfan syndrome (MFS) and have been associated with a wide range of milder overlapping phenotypes. A proportion of patients carrying a FBN1 mutation does not meet diagnostic criteria for MFS, and are diagnosed with "other type I fibrillinopathy." In order to better describe this entity, we analyzed a subgroup of 146 out of 689 adult propositi with incomplete "clinical" international criteria (Ghent nosology) from a large collaborative international study including 1,009 propositi with a pathogenic FBN1 mutation. We focused on patients with only one major clinical criterion, [including isolated ectopia lentis (EL; 12 patients), isolated ascending aortic dilatation (17 patients), and isolated major skeletal manifestations (1 patient)] or with no major criterion but only minor criteria in 1 or more organ systems (16 patients). At least one component of the Ghent nosology, insufficient alone to make a minor criterion, was found in the majority of patients with isolated ascending aortic dilatation and isolated EL. In patients with isolated EL, missense mutations involving a cysteine were predominant, mutations in exons 24-32 were underrepresented, and no mutations leading to a premature truncation were found. Studies of recurrent mutations and affected family members of propositi with only one major clinical criterion argue for a clinical continuum between such phenotypes and classical MFS. Using strict definitions, we conclude that patients with FBN1 mutation and only one major clinical criterion or with only minor clinical criteria of one or more organ system do exist but represent only 5% of the adult cohort.

[Recurrent delayed pericarditis after pacemaker implantation: a post-pericardiotomy-like syndrome?]. / Une péricardite retardée récidivante après implantation de pacemaker: un équivalent de syndrome de Dressler?

INTRODUCTION: Pacemaker implantation is a usual technique in cardiology which may be followed by acute pleural effusion and delayed unusual pericarditis. CASE REPORT: We reported the case of a 67 year-old man hospitalized for faintness. Rhythmical auricular disease was diagnosed and pacemaker was implanted without immediate complication. Though pericarditis with tamponade at the day 21 will require emergency pericardiotomy surgery. A recurrent pericarditis at day 45 was treated with anti-inflammatory drugs without relapse at the end of the treatment. DISCUSSION: Repeated delayed pericarditis after pacemaker surgery may be compared to the Dressler syndrome which occurs after myocardial infarction.

Intramural neovascularization and haemorrhages are major long-term effects of intravascular gamma-radiation after stenting.

Structural changes that might influence the structural integrity of the vessel in response to intravascular brachytherapy (IVB) and stenting were examined, focus being on the importance of neovascularization in rabbit stented arteries. Stents were implanted in the infrarenal aortas of rabbits, immediately followed by gamma IVB or a sham radiation procedure, and the arteries harvested at 6 months. Labelling for von Willebrand factor showed an increase in adventitial and medial neovascularization in irradiated versus control arteries group (5.04+/-0.89 versus 1.51+/-0.23 mm(-2), respectively; p=0.004). Moreover, intramedial haemorrhages (free hemosiderin deposition) and inflammation (macrophages) were only observed in irradiated arteries. No significant change in expression of matrix metalloproteinase 1, 2 or 3 was observed between the irradiated and control group while collagen content decreased in the irradiated versus the control group (10.05%+/-1.48% versus 31.92%+/-3.12%, respectively; p<0.001). The study supports the hypothesis that IVB associated with stenting induces late deleterious effects on the medial layer, characterized by formation of intramural neovessels, haemorrhages and a decrease in collagen content.

["Spontaneous" rupture of the left iliac vein complicating Cockett's syndrome]. / Rupture "spontanée" de la veine iliaque gauche compliquant un syndrome de Cockett.

The case history reported concerns a female patient aged 42 years for whom the clinical picture was that of a blue phlebitis (phlegmatia caerulea dolens), associated with a state of shock evoking a severe pulmonary embolus. The absence of echocardiographic dilatation of the right cavities, and the appearance of a left iliac fossa mass, steered the diagnosis towards internal haemorrhage. Emergency laparotomy allowed diagnosis and treatment of a so-called spontaneous rupture of the left iliac vein, a rare condition for which 20 cases have been reported in the literature. Re-operation performed 24 hours afterwards for the absence of venous return allowed the discovery of Cockett's syndrome with ascending thrombosis, requiring cross-venous bypass associated with the creation of an arterio-venous fistula in order to maintain permeability. One year afterwards the appearance of signs of cardiac insufficiency led to the closure of this fistula.

[Is there an increased risk for cardiovascular disease in HIV-infected patients on antiretroviral therapy?]. / Les patients infectés par le virus de l'immunodéficience humaine sous traitement antirétroviral ont-ils un risque cardiovasculaire accru?

There is a growing concern about an increased risk for cardiovascular disease in HIV infected patients receiving antiretroviral therapy (ART). This risk could be related to metabolic abnormalities associated with long-term use of antiretroviral drugs. In fact, well recognized cardiovascular risk factors such as hypertension, dyslipidaemia, diabetes mellitus and central fat deposition are increasingly seen in HIV patients on ART. These factors can also be associated with non reversible risk factors, such as male sex, age greater than 40 years and family history of premature coronary artery disease. In addition, cigarette smoking and sedentary lifestyle may predispose these patients to significant cardiovascular disease. A direct atherogenic effect of HIV infection itself or antiretroviral drugs is unlikely. Epidemiological studies have suggested an increased risk for coronary artery disease in HIV infected persons; nevertheless, only long term follow-up could confirm this statement. Despite these uncertainties, it seems reasonable to identify and manage cardiovascular risk factors in HIV infected patients.

Topical 3.0% diclofenac in 2.5% hyaluronan gel in the treatment of actinic keratoses.

BACKGROUND: Actinic keratoses (AKs) are epidermal skin lesions with the potential to develop into invasive squamous cell carcinoma (SCC). Treatment at an early stage may prevent development of SCC. Current treatment options are highly destructive and associated with significant side-effects. Early studies with topical diclofenac were encouraging and led to its evaluation for the treatment of actinic keratosis. Previous studies have demonstrated that 3% diclofenac in 2.5% hyaluronan gel is effective and well tolerated in the treatment of AK. The present study was designed to further explore the therapeutic potential of this gel. METHODS: This randomized, double-blind, placebo-controlled trial involved outpatients with a diagnosis of five or more AK lesions contained in one to three 5 cm(2) blocks. Patients received either active treatment (3% diclofenac gel in 2.5% hyaluronan gel) or inactive gel vehicle (hyaluronan) as placebo (0.5 g b.i.d. in each 5 cm(2) treatment area for 90 days). Assessments included the Target Lesion Number Score (TLNS), Cumulative Lesion Number Score (CLNS), and Global Improvement Indices rated separately by both the investigator (IGII) and patient (PGII). RESULTS: Results obtained from 96 patients at follow up (30 days after end of treatment) indicated that a significantly higher proportion of patients who received active treatment had a TLNS = 0 compared to the placebo group (50% vs. 20%; P < 0.001). There was also a significant difference between the two groups in CLNS, with 47% of patients in the active treatment group having a CLNS = 0 compared with only 19% in the placebo group (P < 0.001). The proportion of patients with an IGII score of 4 (completely improved) at follow-up was 47% in the active treatment group compared with only 19% in the placebo group (P < 0.001); for PGII these values were 41% vs. 17%, P < 0.001. Both treatments were well tolerated, with most adverse events related to the skin. CONCLUSIONS: Topical 3% diclofenac in 2.5% hyaluronan gel was effective and well tolerated for the treatment of AK.

[Magnetic resonance imaging of dilatation of the ascending aorta after repair of coarctation of the aorta]. / Etude de la dilatation de l'aorte ascendante par résonance magnétique nucléaire après réparation de la coarctation de l'aorte.

The authors studied the risk factors for dilatation of the ascending aorta in patients operated for coarctation of the aorta. A prospective study of the diameters of the ascending aorta by magnetic resonance imaging was undertaken in 46 patients with an average age of 30 months (range 6 days to 11 years) at surgery, and 10 years of age (6 months to 31 years) at the time of the investigation. The diameters were measured at the level of the sinus of Valsalva, at the sino-tubular junction, and compared with reference tables with respect to body surface area. Twenty six per cent of patients had dilatation of the ascending aorta. The predisposing factors were investigated. Age, type of surgery, postoperative hypertension. Doppler gradient in the isthmic region, anatomical appearances of the repair observed by MRI were not predictive of this complication. On the other hand, age of patients at MRI and bicuspid aortic valves (present in 66% of cases) (p < 0.05) were significant risk factors. These results indicate that regular follow-up by echocardiography or MRI of the diameter of the ascending aorta is necessary in patients operated for coarctation of the aorta and with bicuspid aortic valves.

Progressive decreases in nuclear retinoid receptors during skin squamous carcinogenesis.

Retinoids are essential for normal skin growth, differentiation, and apoptosis and are active pharmacologically in the prevention and treatment of skin cancers and other lesions. Retinoid effects are mediated mainly by retinoic acid receptors (RARs) and retinoid X receptors (RXRs), which act as transcription factors to alter gene expression. Using in situ hybridization, we analyzed the expression of RARs and RXRs in normal sun-exposed skin (n = 85), squamous cell carcinoma (SCC; n = 28), and actinic keratosis [AK (a precursor to SCC); n = 38]. The expressions of five receptors (RAR-alpha and -gamma and RXR-alpha, -beta, and -gamma) were moderate to very strong in normal skin, with higher expressions in spinous and granular layers than in the basal layer. RAR-beta expression was weak or absent in normal and lesion samples. All five receptors expressed in the skin were suppressed progressively from normal skin to premalignant skin (AK) to invasive skin SCC. Specific receptor decreases in lesions relative to normal skin ranged from 75% (RXR-beta) to 96% (RAR-alpha) in SCC and from 37% (RAR-gamma) to 68% (RXR-beta) in AK. The degree of suppression of RXR-alpha and RAR-gamma, the two predominant retinoid receptors in skin, was relatively less for RXR-alpha (58% versus 86%; P = 0.015) and relatively greater for RAR-gamma (37% versus 89%; P = 0.0001) between AK and SCC, suggesting that suppression of RXR-alpha may be an earlier event and expression of RAR-gamma may be a later event of multistep squamous skin carcinogenesis. Our results indicate that suppressed expression of retinoid receptors occurs early (in AK) and is associated with progression of squamous skin carcinogenesis to SCC.

[Secondary effects of brachytherapy in the treatment of coronary restenosis]. / Effets secondaires de la curiethérapie dans le traitement de la resténose coronaire.

Brachytherapy is proposed for the treatment or prevention of coronary restenosis with encouraging results, especially in intra-stent restenosis. The results of the first clinical studies show benefit, for example those of the American SCRIPPS trial with a 3 year follow-up. However, recent reports in the literature have described secondary effects associated with this technique: 1) stenoses occurring at the limits of the irradiated segments which are attributed to a proliferative effect of low doses on damaged tissue; 2) late occlusions at the irradiated site: their incidence is estimated at 9% at 6 months. The mechanisms of these thromboses are not understood but delayed re-endothelialisation probably plays a rôle; 3) finally, irradiation is associated with uncovered dissection probably related to delayed healing. Other long-term trials are necessary to provide a more complete assessment of the secondary effects of brachytherapy, especially with regards to their mechanisms, prevention and treatment.

Medication adherence: a key factor in effective management of rosacea.

Rosacea is a chronic condition associated with relapses. Unsuccessful treatment is predicated, in part, on suboptimal adherence with the medication regimen. Motivating long-term compliance remains a challenge. The literature on adherence with rosacea medication is scant, but data from other diseases suggest that a multifactorial approach combining nonpharmacologic and adherence-enhancing pharmacologic interventions appears to offer the greatest success. The variety of topical metronidazole formulations that are relatively well tolerated and convenient to administer has been a notable advance in rosacea management. The dermatologist, by emphasizing the importance of adherence with therapy, can do much to facilitate this most critical behavior.

Cornifying Darier's disease.

A 48-year-old Caucasian man recounted the onset of keratotic papules on the trunk at the age of 8 years, with subsequent spread to the forearms, scalp, and forehead. His most severe disease was present on the legs. He complained of pain, itching, and noted exacerbations in the summer and with sweating. The family history was negative. On physical examination, the most striking finding was that of extensive, markedly hyperkeratotic plaques on the lower legs >(Fig. 1). His scalp, forehead, chest, and back exhibited mild involvement, with scattered brown keratotic papules, while his forearms showed mildly hyperkeratotic plaques. Flat-topped brown papules were present on the dorsum of the hands, with a few keratotic papules on the palms, and a few nails with distal notching and red longitudinal streaks. There were no palmar pits or oral mucosal lesions. A shave biopsy was performed of a plaque on the leg, and showed a papillomatous and markedly hyperkeratotic lesion >(Fig. 2). Suprabasal acantholysis in the elongated rete produced characteristic lacunae. The acantholysis was associated with dyskeratosis including corps ronds and grains >(Fig. 3). Together, these features were characteristic of Darier's disease. Treatment years earlier with topical retinoids, topical steroids, topical keratolytics, and multiple oral antimicrobials had been unsuccessful, and isotretinoin had been discontinued due to elevated triglycerides. Treatment was initiated with acitretin and, after 3 months, mild improvement was noted

[Randomized comparison of 4F and 6F catheters for diagnostic coronary angiographies via the femoral approach]. / Comparaison randomisée des cathéters 4 F versus 6 F pour la réalisation des coronarographies diagnostiques par voie fémorale.

The use of 6F catheters has been validated for coronary angiography. The use of small-caliber catheters is a more recent development. The aim of this study was to assess the feasibility, the cost and complications of coronary angiography using the femoral approach with 4F catheters. The authors undertook a randomized prospective study of 4F Care Infiniti catheters (N = 100) and 6F Spertorque Plus catheters (N = 100) in hospitalised patients. Criteria of non-inclusion were valvular pathology, acute myocardial infarction, aorto-coronary bypass or aorto-femoral bypass procedures. No statistical difference was observed between the two groups with respect to feasibility, to duration of the procedure, or of irradiation or to cost. The quality of the angiograms was good except in one patient in the 4F group; 4 patients in the 6F group required a 4F catheter to complete their examination. Left ventricular catheterisation was more difficult with 4F catheters (p = 0.016). Use of 4F catheters was associated with injection of significantly less contrast (p = 0.00007), reduced the duration of compression (p < 10(-6)) and its complications (p = 0.004). The authors conclude that 4F catheters are safe and well tolerated. They are associated with less patient morbidity, without any loss in quality of the angiogrammes. Other studies in valvular heart disease and after coronary bypass surgery should lead to the generalisation of their use in all coronary patients.

Phase I study of cinchonine, a multidrug resistance reversing agent, combined with the CHVP regimen in relapsed and refractory lymphoproliferative syndromes.

Overexpression of P-glycoprotein (P-gp) in cancer cells reduces intracellular accumulation of various anticancer drugs including anthracyclines and vinca alkaloids. This multidrug resistance (MDR) phenotype can be reversed in vitro by a number of non-cytotoxic drugs. We have identified the quinine's isomer cinchonine as a potent MDR reversing agent, both in vitro and in animal models. Here, we report an open phase I dose escalation trial in patients with refractory or relapsed malignant lymphoid diseases. Cinchonine dihydrochloride was administered by continuous i.v. infusion for 48 h and escalated over five dose levels ranging from 15 to 35 mg/kg/d. Cinchonine infusion started 24 h before i.v. doxorubicin (25 mg/m2), vinblastine (6 mg/m2), cyclophosphamide (600 mg/m2) and methylprednisolone (1 mg/kg/d) (CHVP regimen) and lasted for 24 h after chemotherapy infusion. Thirty-four patients received 87 cycles of CHVP/cinchonine. The MTD of cinchonine administered by continuous i.v. infusion was 30 mg/kg/d. Prolonged cardiac repolarization was the main dose-limiting toxicity. No ventricular arrhythmia including 'torsade de pointes' was observed. An MDR reversing activity was identified in the serum from every patient and correlated with cinchonine serum level. When infused at 30 mg/kg/d, cinchonine demonstrated a limited influence on doxorubicin pharmacokinetic. We conclude that i.v. infusion of cinchonine might be started 12 h before MDR-related chemotherapy infusion and requires continuous cardiac monitoring but no reduction of cytotoxic drug doses.

Dobutamine stress echocardiography identifies anthracycline cardiotoxicity.

BACKGROUND: Anthracyclines are effective anti-cancer agents, but their therapeutic value is limited by their myocardial toxicity. We assessed the physiological responses of stress echocardiography at low doses of dobutamine (DSE) in patients treated with anthracycline. METHODS AND RESULTS: In a prospective study, 28 patients were studied before and 1 month after the end of chemotherapy. All patients had normal ejection fraction (EF) at rest before therapy and the mean dose of anthracycline was 212+/-15 mg/m(2). Echocardiographic Doppler studies were performed before and during dobutamine infusion (5 and 10 microg/kg per min). Rest echocardiography demonstrated a significant decrease of EF between the two examinations in ejection fraction (67+/-3% vs. 61+/-3%, P<0.001). The increase of the EF during dobutamine infusion was higher after chemotherapy compared to the initial examination (19+/-3% vs. 29+/-3%: P<.05). No difference in EF was observed at 10 microg/kg per min between before and after chemotherapy. In contrast, at rest no difference in diastolic parameters was observed between the two examinations. Moreover, a significant decrease of the peak E and the ratio E/A was observed during dobutamine infusion after chemotherapy (93+/-4 cm/s vs. 79+/-5 cm/s and 1.3+/-0.1 vs. 1.0+/-0.1, respectively;P<0.05). CONCLUSION: Stress echocardiography may prove to be a sensitive technique and useful non-invasive approach for evaluating subclinical anthracycline cardiotoxicity.

[Ten-year experience with heart transplantation (1987-1997)]. / Bilan de dix années de transplantation cardiaque (1987-1997).

OBJECTIVES: Analyze ten years experience with heart transplantation at the Dijon University Hospital and determine which parameters control mid and long term outcome. PATIENTS AND METHODS: One hundred thirty six heart transplantations were performed over a 10 year period (1987-1997) in 118 men and 18 women aged 51-87 years. Heart transplantation was indicated on the basis of the following criteria: ejection fraction *20%, pulmonary arteriole resistance < 6 Wood units, peak oxygen uptake < 14 l/kg/min. The Shumway or anatomic technique was used. The triple immunosuppressive protocol combined corticosteroids, azathioprine and cyclosporin. The same team conducted the post-transplantation follow-up with regular programmed consultations in addition to those requested by the general practitioner, the cardiologist or the patient. Follow-up was oriented according to the clinical situation (blood chemistry, cell counts, cyclosporinemia, search for infection, echocardiography, endomyocardial biopsy, coronarography). RESULTS: Five patients (3.6%) died when still on the waiting list. Absolute emergency transplantation was performed for patients (28.1%) including 8 (5.9%) after circulatory assist. Hospital mortality was 11.7% and late mortality was 16.1%. Actuarial survival was 78% at 1 year, 71% at 5 years and 69% at 10 years. Among the survivors, 94% were taking two, three or even four drugs for hypertension. Cyclosporin levels decreased and creatinine levels increased. Episodes of rejection were minimal: 86.57% of the biopsies were * grade 1 and 4.45% * grade 2. Cytomegalovirus infection was documented and treated in 7.55% of the cases. Incidence of graft coronary artery disease was 3.4% at 1 year, 6.5% at 2 years and 7.9% at 3 years. CONCLUSION: Our follow-up structure where the same small team conducts regular examinations together with our approach to heart transplantation appears to be the main factor leading to the quality results obtained in this series.

Intrapulmonary artery and intrabronchial migration and extraction of a fragment of J-shaped atrial pacing catheter.

A fragment of a fractured Telectronics Atrial Accufix 330-801 lead asymptomatically perforated the adjacent bronchus and was detected on routine chest X-ray. The metallic fragment was located by chest CT scan and bronchial fluoroscopy to lie between the right lobar bronchus and the pulmonary artery, confirming bronchial perforation. The foreign body was removed without complication by direct visualisation with rigid bronchoscopy.

Comparison of epirubicin and doxorubicin cardiotoxicity induced by low doses: evolution of the diastolic and systolic parameters studied by radionuclide angiography.

BACKGROUND: Previous studies have demonstrated that epirubicin (EPI) has a lower propensity to produce cardiotoxic effects than doxorubicin (DXR) at high doses. HYPOTHESIS: The aim of the study was to compare the cardiotoxicity induced by low doses of EPI and DXR in patients before and 1 month after the end of chemotherapy. METHOD: In a prospective study, 99 patients with a mean age of 51 +/- 12 years and without cardiac disease were studied before and 1 month after the end of chemotherapy. Group 1 included 38 patients receiving 246 +/- 96 mg/m2 of DXR and Group 2 included 61 patients receiving EPI with and equivalent dose of 219 +/- 92 mg/m2 of DXR. Ejection fraction (EF) of the left ventricle (LV), peak ejection rate (PER), and peak filling rate (PFR) [expressed in end-diastolic volume/s (EDV/s)] were evaluated by gated radionuclide angiography; PFR/PER were also calculated. RESULTS: Moderate and similar alterations of left ventricular ejection fraction were shown for low doses of anthracyclines. The EF of the LV decreased from 57 +/- 6% to 54 +/- 6% for DXR group (Group 1) (p = 0.005), and from 58 +/- 5% to 55 +/- 5% for the EPI group (Group 2)(p = 0.001). The PER of the left ventricle fell from 3.08 +/- 0.46 EDV/s to 2.79 +/- 0.49 in Group 1 (p = 0.004) and from 2.98 +/- 0.50 to 2.73 +/- 0.34 EDV/s in Group 2 (p = 0.001). In contrast, no significant alteration of PFR appeared in Group 2 (from 2.72 +/- 0.51 to 2.62 +/- 0.41 EDV/s) for the equivalent dose of anthracycline, while PFR of the LV dropped from 2.82 +/- 0.76 (EDV/s) to 2.41 +/- 0.55 after doxorubicin (p = 0.004). No difference was found between 1 and 12 months after the end of the treatment in 25 patients in Group 1 and 28 patients in Group 2. These results confirm the advantage of EPI over DXR in terms of cardiotoxicity and help explain the relationship of cellular damage mechanisms with the functional parameters of nuclear investigation. CONCLUSION: A possible explanation for specific alteration after DXR could be the increased production of semiquinone free radicals, which are known to induce membrane damage and, consequently, myocardial edema and diastolic alteration.

[Comparison of gas exchange and hemodynamic variables during 2 types of exercise tests. Cycle-ergometry and the ergometric table]. / Comparaison des échanges gazeux et des variables hémodynamiques au cours de deux types d'épreuves d'effort. Cycloergomètre et table ergométrique.

The development of stress echocardiography on an ergometric table has increased the number of stress tests in the decubitus position, whereas most of the information currently available concerns stress tests in the sitting position or on the treadmill. In order to study the influence of this position of stress testing, the authors compared the results obtained in a series of 15 patients without cardiac disease (Group I) and another series of 15 coronary patients (Group II) undergoing the two types of stress testing, in the vertical position on a bicycle ergometer and in the lateral decubitus position on the ergometric table. Effort tolerance on the bicycle ergometer was significantly greater in terms of work load (202 +/- 35 vs 180 +/- 36 watts (p < 0.001) in the controls, and 120 +/- 32 vs 106 +/- 22 watts (p < 0.05) in the coronary group), of duration of effort (19 +/- 3 vs 16 +/- 3 minutes (p < 0.001) in the controls and 10 +/- 3 vs 8 +/- 2 minutes (p < 0.05) in the coronary patients), of heart rate (190 +/- 10 vs 172 +/- 21 beats/min (p < 0.005) in controls and 118 +/- 19 vs 111 +/- 14 beats/min (p < 0.05) in the coronary patients). On the other hand, blood pressure and O2 saturation tended to be greater during exercise in the decubitus position: SBP 200 +/- 23 vs 196 +/- 27 mmHg (NS) in the controls and 158 +/- 21 vs 166 +/- 23 mmHg (NS) in the coronary patients; DBP 97 +/- 10 vs 102 +/- 27 mmHg (NS) in the controls and 85 +/- 6 vs 90 +/- 10 mmHg (NS) in the coronary patients; O2 sat 96.8 +/- 1 vs 97.6 +/- 0.8% (p < 0.05) in the coronary patients. The anaerobic threshold and peak VO2 were much higher during exercise in the sitting position: oxygen consumption at the threshold 14.8 +/- 3.8 vs 12.6 +/- 2.3 ml.kg-1.min-1 (p < 0.01), peak VO2 22.2 +/- 5.9 vs 18.8 +/- 4.7 ml.kg-1.min-1 (p < 0.01) in the coronary patients. The results of this study show that the cardiovascular stimulation obtained in the decubitus position is not identical to that obtained by traditional exercise stress testing, particularly in coronary patients.