Feasibility of hybrid telerehabilitation as a component of the Managed Care after Acute Myocardial Infarction (MC-AMI) program in a 12-month follow-up: experience from a single center.

INTRODUCTION: Managed Care after Myocardial Infarction (MC­AMI [KOS-Zawal]), a comprehensive care program dedicated to patients after myocardial infarction, was implemented in Poland in 2017. Hybrid cardiac telerehabilitation (HTR) is a unique component of MC­AMI. OBJECTIVES: We evaluated the feasibility of HTR as a component of MC­AMI and assessed its safety and acceptance by patients. One­year all­cause mortality among the patients participating and not participating in MC­AMI was analyzed. PATIENTS AND METHODS: The MC­AMI group included 114 patients who underwent a 5­week HTR program comprising telemonitored Nordic walking training sessions, and who completed the entire 12­month MC­AMI program. The influence of HTR on the physical capacity was assessed by comparing the stress test results before and after HTR. After HTR, the patients completed a satisfaction survey to assess their acceptance of the program. The non-MC­AMI group was formed using propensity score matching to compare 1­year all­cause mortality between the patients participating and not participating in MC-AMI. RESULTS: HTR significantly improved the functional capacity assessed in the stress test and was well­received by the patients. In the study group, nonfatal non-ST­segment elevation myocardial infarction, elective coronary percutaneous intervention, and cardiovascular hospitalization occurred in 0.9%, 2.6% and 6.1% of the patients, respectively. There were no deaths among the MC­AMI participants, whereas in the non-MC­AMI group, 1­year all­cause mortality was 3.5%. The log­rank test comparing the survival probabilities of matched groups, estimated by the Kaplan-Meier method, showed heterogeneity of the curves (P = 0.04). CONCLUSIONS: HTR as a component of MC­AMI was a feasible, safe, and well­accepted form of cardiac rehabilitation. Participation in MC­AMI including HTR was associated with a significantly lower risk of 1­year all­cause mortality, as compared with not taking part in the rehabilitation program.

The Assessment of the Quality of Life in Patients with Rheumatoid Foot.

BACKGROUND: The negative effects of rheumatoid arthritis (RA) are multi-dimensional. Foot deformities lead to disability, pain, and impaired quality of life. OBJECTIVE: Identifying the difficulties in functioning rheumatoid foot and assessing the quality of life in this aspect. MATERIALS AND METHODS: The material included 50 patients of Rheumatology Policlinic of the Central Clinical Hospital of Interior Affairs in Warsaw and a matched control group of 50 individuals without RA. The degree of foot joint damage was assessed using the Manchester scale, lower limb movement and quality of life using the American Orthopedic Foot and Ankle Society Score and HAQ. RESULTS: The duration of symptoms was 16.0 ± 8.9 years. High activity of RA measured by the DAS was observed in 20% of patients, moderate in 26%, and low in 54%. The most common foot deformities were: hammer toes (82%), longitudinal flat feet (74%), and hyperkeratosis (56%). The least frequent were: stiff toe (38%) and overlapping fingers (28%). In the RA group, the outcomes of the FAOS questionnaire were statistically significantly worse than in the control group in all categories (p<0.001). The worst-rated domain was the sport and recreation subscale (median 55.0), the best daily activity (median 86.8). The strongest relationship was demonstrated between the FAOS and HAQ indices. Spearman's HAQ correlation coefficient with the ADL subscale was r=-0.85, p<0.001; with the QOL, sport/recreation and pain subscales moderate, it was r=-0.72; r= 0.71, p <0.001. CONCLUSION: Lower limb movement function and quality of life are worse in RA patients; pain accompanies climbing and descending stairs; running and jumping require effort.

Comparison of the prognostic value of frailty assessment tools in patients aged ≥ 65 years hospitalized in a cardiac care unit with acute coronary syndrome.

BACKGROUND: Frailty is associated with adverse events in elderly patients with acute coronary syndrome (ACS). Our aim was to compare the prognostic value of four frailty scales in patients aged ≥ 65 years hospitalized with ACS in a cardiac care unit (CCU). METHODS: Patients aged ≥ 65 years with ACS were included. Frailty was assessed using the Fried frailty scale (reference standard), the Edmonton Frail Scale (EFS), the FRAIL scale, and the Clinical frailty scale (CFS). The primary end point was all-cause mortality and the secondary end point was unscheduled rehospitalization. RESULTS: One hundred and seventy four patients aged ≥ 65 years with ACS were recruited. The median follow-up was 637.5 days. Frailty was identified in 41.4%, 40.2%, 39.1% and 36.3% patients by the Fried frailty scale, EFS, FRAIL scale and CFS, respectively. The agreement coefficients were 0.88, 0.86, and 0.79 for the FRAIL scale, EFS and CFS, respectively. In the Cox regression model, frailty was associated with all-cause mortality regardless of the scale used (univariate: hazard ratio [HR] 95% CI = 10.5, 2.4-46.8 Fried frailty scale; 12.0, 2.7-53.4 FRAIL scale; 7.1, 2.0-25.2 EFS; 8.3, 2.4-29.6 CFS. Multivariate: HR = 5.1, 1.1-23.8 Fried frailty scale; 5.7, 1.2-26.8 FRAIL scale; 3.7, 1.0-14.0 EFS; 4.2, 1.1-15.9 CFS). The FRAIL scale had the highest HR. In the univariate analysis, frailty was associated with unscheduled rehospitalization (HR = 3.2, 1.7-6.0 Fried frailty scale; 3.4, 1.8-6.3 FRAIL scale; 3.5, 1.8-6.6 EFS; 3.1, 1.7-5.8 CFS). In the multivariate analysis, only the EFS independently predicted unscheduled rehospitalization (HR = 2.2, 1.1-4.63). CONCLUSIONS: Frailty assessed by the Fried frailty scale, FRAIL scale, EFS and CFS is associated with all-cause mortality and unscheduled rehospitalization in elderly patients hospitalized in a CCU with ACS. The adjusted HR of the FRAIL scale for all-cause mortality was the highest among the scales compared, whereas the EFS was an independent predictor of unscheduled rehospitalization. These data should be taken into consideration when choosing a frailty assessment tool.

Computed tomography assessment of the aortic root morphology in predicting the development of paravalvular leak following transcatheter aortic valve implantation.

Introduction: Transcatheter aortic valve implantation (TAVI) is an effective treatment of significant aortic stenosis. Paravalvular leaks (PVLs) are one of the most common complications after the procedure. Objectives: The aim of this study was to assess whether the aortic root morphology affects the occurrence of PVL after TAVI. Patients and methods: We enrolled 50 patients with bicuspid and 50 patients with tricuspid aortic valve who underwent multislice computed tomography (MSCT) and transthoracic echocardiography prior to TAVI. The dimensions of the aortic root were assessed by MSCT. PVL after TAVI was assessed by transthoracic echocardiography. Patients were divided in 2 groups according to the PVL severity: less than moderate PVL (n = 80) and moderate or worse PVL (n = 20), and comparisons between the groups were performed. Results: Patients with at least moderate PVL, compared with those with less than moderate PVL, had greater mean (SD) area (5.2 [1.1] cm2 vs 4.7 [0.8] cm2; P = 0.02), perimeter (8.4 [0.9] cm vs 7.9 [0.7] cm; P = 0.01), and long axis (29.5 [2.7] mm vs 28 [2.7] mm; P = 0.04) of the aortic annulus and greater mean (SD) area (5.3 [1.3] cm2 vs 4.7 [1.1] cm2; P = 0.04) and perimeter (8.6 [1.1] cm vs 8.1 [0.9] cm; P = 0.02) of the left ventricular outflow tract. In multivariable analysis, bicuspid aortic valve disease, interventricular septum hypertrophy, greater left ventricular outflow tract, and postdilatation were significant predictors of moderate PVL following TAVI. Conclusions: The assessment of the aortic root morphology with MSCT can be helpful in predicting PVL after TAVI.

Assessment of ECG during hybrid comprehensive telerehabilitation in heart failure patients-Subanalysis of the Telerehabilitation in Heart Failure Patients (TELEREH-HF) randomized clinical trial.

BACKGROUND: Exercise training in heart failure (HF) patients should be monitored to ensure patients' safety. Electrocardiographic (ECG) telemonitoring was used to assess the safety of hybrid comprehensive telerehabilitation (HCTR). OBJECTIVE: Analysis of ECG recorded during HCTR in HF patients. METHODS: The TELEREH-HF multicenter, randomized, controlled trial enrolled 850 HF patients with New York Heart Association class I-III and left ventricular ejection fraction of ≤40%. This subanalysis focuses on 386 patients (aged 62 ± 11 years, LVEF 31 ± 7%) randomized to HCTR. HCTR was telemonitored with a device allowing to record 16-s fragments of ECG and to transmit the data via mobile phone network to the monitoring center. ResultsIn 386 patients, 16,622 HCTR sessions were recorded and 66,488 ECGs fragments were evaluated. Sinus rhythm was present in 320 (83%) and permanent atrial fibrillation (AF) in 66 (17%) patients, respectively. The most common arrhythmias were ventricular and atrial premature beats, recorded in 76.4% and 27.7% of the patients, respectively. Non-sustained ventricular tachycardia (21 episodes in 8 patients) and paroxysmal AF episodes (6 in 4 patients) were rare. None of the analyzed demographic and clinical characteristics was predictive for onset of the new arrhythmias on exercise. CONCLUSION: Telerehabilitation in HF patients was safe without the evidence for symptomatic arrhythmias requiring discontinuation of telerehabilitation. Only one mildly symptomatic paroxysmal AF episode led to the short-term suspension of the training program. The most common arrhythmias were atrial and ventricular premature beats. These arrhythmias did not result in any changes in rehabilitation and therapy regimens.

Assessment of the left atrial appendage morphology in patients after ischemic stroke - The ASSAM study.

BACKGROUND: The ASSAM study was designed to evaluate the association between left atrial appendage (LAA) morphology and stroke risk in patients with atrial fibrillation (AF). METHODS: The study included 85 randomly chosen AF patients with acute ischemic stroke matched with 84 AF without stroke. All patients had left atrial (LA) computed tomography performed to analyze LAA anatomy. RESULTS: Patients in the stroke group had a larger LAA volume (10.22 [7.83-13.62] vs. 9.33 cm3 [7.33-11.47], p = 0.046], greater distance from LAA ostium to the first LAA bend (9.25 ± 3.85 vs. 7.23 ± 2.95 mm, p = 0.0002), and more frequently had round LAA ostium shape (11.8 vs. 1.2%, p = 0.005). According to a multivariable model, significant predictors of ischemic stroke were distance from LAA ostium to the first LAA bend (OR 1.202 [1.065-1.356], p = 0.003), LAA ostium round shape of (OR 16.813 [1.857-152.231], p = 0.012), LAA ostium surface area (OR 0.612 [0.457-0.819], p = 0.009), and cactus LAA morphology (OR 2.739 [1.176-6.380], p = 0.016). After adjusting for CHA2DS2-VASc score, only the distance from LAA ostium to the first LAA bend remained a significant risk factor for stroke (OR 1.154 [1.014-1.314], p = 0.03). CONCLUSIONS: The distance from LAA ostium to the first bend of the LAA was independently associated with stroke risk in patients with AF. Whether this parameter may help improve identification of patients at risk of ischemic stroke, needs to be confirmed in larger studies.

Titin-Related Dilated Cardiomyopathy: The Clinical Trajectory and the Role of Circulating Biomarkers in the Clinical Assessment.

Titin truncating variants (TTNtv) are known as the leading cause of inherited dilated cardiomyopathy (DCM). Nevertheless, it is unclear whether circulating cardiac biomarkers are helpful in detection and risk assessment. We sought to assess 1) early indicators of cardiotitinopathy including the serum biomarkers high-sensitivity cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in clinically stable patients, and 2) predictors of outcome among TTNtv carriers. Our single-center cohort consisted of 108 TTNtv carriers (including 70 DCM patients) from 43 families. Clinical, laboratory and follow-up data were analyzed. The earliest abnormality was left ventricular dysfunction, present in 8, 26 and 47% of patients in the second, third and fourth decade of life, respectively. It was followed by symptoms of heart failure, linked to NT-proBNP elevation and severe left ventricular systolic dysfunction, and later by arrhythmias. Hs-cTnT serum levels were increased in the late stage of the disease only. During the median follow-up of 5.2 years, both malignant ventricular arrhythmia (MVA) and end-stage heart failure (esHF) occurred in 12% of TTNtv carriers. In multivariable analysis, NT-proBNP level ≥650 pg/mL was the best predictor of both composite endpoints (MVA and esHF) and of MVA alone. In conclusion, echocardiographic abnormalities are the first detectable anomalies in the course of cardiotitinopathies. The assessment of circulating cardiac biomarkers is not useful in the detection of the disease onset but may be helpful in risk assessment.

Can Circulating Cardiac Biomarkers Be Helpful in the Assessment of LMNA Mutation Carriers?

Mutations in the lamin A/C gene are variably phenotypically expressed; however, it is unclear whether circulating cardiac biomarkers are helpful in the detection and risk assessment of cardiolaminopathies. We sought to assess (1) clinical characteristics including serum biomarkers: high sensitivity troponin T (hsTnT) and N-terminal prohormone brain natriuretic peptide (NT-proBNP) in clinically stable cardiolaminopathy patients, and (2) outcome among pathogenic/likely pathogenic lamin A/C gene (LMNA) mutation carriers. Our single-centre cohort included 53 patients from 21 families. Clinical, laboratory, follow-up data were analysed. Median follow-up was 1522 days. The earliest abnormality, emerging in the second and third decades of life, was elevated hsTnT (in 12% and in 27% of patients, respectively), followed by the presence of atrioventricular block, heart failure, and malignant ventricular arrhythmia (MVA). In patients with missense vs. other mutations, we found no difference in MVA occurrence and, surprisingly, worse transplant-free survival. Increased levels of both hsTnT and NT-proBNP were strongly associated with MVA occurrence (HR > 13, p ≤ 0.02 in both) in univariable analysis. In multivariable analysis, NT-proBNP level > 150 pg/mL was the only independent indicator of MVA. We conclude that assessment of circulating cardiac biomarkers may help in the detection and risk assessment of cardiolaminopathies.

Additive Value of High-Density Lipoprotein Cholesterol and C-Reactive Protein Level Assessment for Prediction of 2-year Mortality After Transcatheter Aortic Valve Implantation.

Available prediction models are inaccurate in elderly who underwent transcatheter aortic valve implantation (TAVI). The aim of present study was to analyze the separate and combined prognostic values of baseline HDL-C and C-reactive protein (CRP) levels in patients treated successfully with TAVI who had complete 2-year follow-up. We analyzed 334 patients treated with TAVI from 01/2010 to 07/2017 who had measurements of HDL-C and CRP on admission or during qualification for the procedure. Baseline HDL-C ≤46 mg/dl (areas under the curve [AUC] = 0.657) and CRP ≥0.20 mg/dl (AUC = 0.634) were predictive of 2-year mortality. After stratification with both cutoffs, patients with low HDL-C and concomitant high CRP most often had LVEF ≤50% and were high risk as per EuroSCORE II. Those with isolated CRP elevation had the lowest frequency of LVEF ≤50%, but more sarcopenia (based on psoas muscle area). After adjustment in the multivariate analysis for other identified predictors including EuroSCORE II and statin therapy, isolated HDL-C ≤46 mg/dl (identified in 40 patients) and isolated CRP ≥0.20 mg/dl (n = 109) were both independent predictors of 2-year mortality (hazard ratio [HR] = 2.92 and HR = 2.42, respectively) compared with patients with both markers within established cutoffs (n = 105) who had the lowest 2-year mortality (9.5%). Patients with both markers exceeding cutoffs (n = 80) had the highest risk (HR = 4.53) with 2-year mortality of 42.5%. High CRP was associated with increased mortality within the first year of follow-up, whereas low HDL-C increased mortality in the second year. The combination of both markers with EuroSCORE II enhanced mortality prediction (AUC = 0.697). In conclusion, low baseline HDL-C and high CRP jointly contribute to the prediction of increased all-cause mortality after TAVI.

AssesSment of the left atrial appendage morphoLogy in patients aAfter ischaeMic Stroke - the ASSAM study protocol.

Stroke remains the most dangerous and frightening complication of atrial fibrillation (AF). A causal relationship between ischaemic stroke and atrial arrhythmias such as AF or atrial flutter has been well established. Numerous factors predisposing to peripheral embolism in patients with AF have been well established and included in the CHA2DS2-VASc score. Although proper anticoagulation minimises the risk attributable to "known" risk factors, stroke may still occur. Thus, "unknown" risk factors may play an important role in stroke risk stratification in patients with AF. We assume that one of the important "unknown" risk factor is the left atrial appendage morphology. The ASSAM study is planned to include 100 patients after ischaemic stroke or transient ischaemic attack (TIA) and known status of anticoagulation at the time of stroke. The control group will consist of 100 patients scheduled for AF ablation without a history of stroke or TIA.

Patient's age rather than severity of the arrhythmia influences the cost of medical treatment of atrioventricular nodal or atrioventricular reciprocating tachycardia.

PURPOSE: Radiofrequency ablation (RFA) is considered the treatment of choice in cases of atrioventricular nodal reciprocating tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). Published studies suggest a considerable time gap between the onset of the arrhythmia, correct diagnosis, and RFA which may reach 10-15 years. The cost of medical treatment during that period may be substantial. The aim of the study was to calculate the annual direct medical cost of medical treatment of patients with AVNRT and AVRT and identify potential factors influencing this cost. METHODS: Based on the consumption of particular resources and the unit costs of services in 2013, we calculated the annual direct medical cost of care for patients with AVNRT and AVRT in Poland. We adopted the public payer's and societal perspectives. Data on health resources was collected with a structured questionnaire and medical records of patients scheduled for RFA. Additional analyses were performed to identify factors influencing this cost. RESULTS: We enrolled 82 patients: mean age 43.9 ± 14.1 years old and mean symptom duration before the RFA 13.0 ± 11.3 years. The median annual cost of medical treatment was 546 USD [312-957], 411 € [278-786], and 616 USD [369-1044], 464 € [235-721], for the public payer and the common perspective, respectively, with hospitalizations being the main cost component. In multivariate analysis, only the age of the patient significantly influenced this cost. CONCLUSIONS: The annual cost of medical treatment of AVNRT or AVRT is substantial and dependent on the age of the patient rather than the severity of the arrhythmia (NCT01594814).

Reliability of focused cardiac ultrasound by novice sonographer in preoperative anaesthetic assessment: an observational study.

BACKGROUND: Use of preoperative echocardiography may help to identify patients with increased cardiac risk, who may benefit from modification of perioperative plan. The objective of our study was to evaluate the reliability of preoperative focused cardiac ultrasound (FoCUS) performed by an anaesthetist with basic ultrasound training and its impact on patient's management. METHODS: The prospective observational study was conducted in 159 adult patients, scheduled for elective operations. Cardiac ultrasound was performed by one anaesthetist with a limited experience of FoCUS. A simple, mnemonic scheme was used for the final reporting of each study. The same scheme was used by a cardiologist who produced an independent report based on digital video loops stored in the machine memory. Anaesthetists in-charge made final perioperative plan. Comparative analysis of anaesthetist and cardiologist performed ultrasound report was made. The incidence of modification of initial perioperative plan resulting from FoCUS report was analyzed. RESULTS: The average time required to complete the examination was 182 s 95% CI [173-190]. Images of quality adequate to answer all questions from the scheme were obtained in 97.5% (155/159) of patients. There was strong agreement between the anaesthetist and the cardiologist in 97.8% (2274/2325) of the examined categories. In two categories (global and regional left ventricle contractility impairment) statistically significant discrepancies between both diagnosticians were confirmed (p McNemar <0.04). When compared with the cardiologist's assessment the agreement of the anesthetist's diagnosis had sensitivity of 0.84, specificity 0.99, positive predictive value 0.78 and negative predictive value 0.99. Kappa statistics showed good agreement between both examining doctors (κ = 0.797). Based on ultrasound findings, the preliminary anaesthetic plan was changed in relation to 20.8% (33/159) of patients. CONCLUSIONS: An anaesthetist with limited training in FoCUS can perform a reliable preoperative examination which alters the perioperative management.

Prospective assessment of cytokine IL-15 activity in patients with refractory atrial fibrillation episodes.

AIMS: Inflammatory state is considered a risk factor of atrial fibrillation (AF) occurrence. The aim of this study was a prospective evaluation of the inflammation parameters in patients with different forms of AF without structural heart disease. METHODS AND RESULTS: One hundred fifty-eight patients with paroxysmal/persistent AF (87; 55.1% men, mean age 65.8±9.6 years) without structural heart disease were enrolled in the study. Inflammatory parameters: WBC, ESR, hs-CRP, IL-6, IL-15 and TNF-alpha were measured at baseline and after one year follow-up. Despite frequent AF episodes median values of WBC, ESR and C-reactive protein at baseline and after follow up were within normal ranges. There were no significant differences between WBC, ESR and hs-CRP regarding AF types. In patients who developed permanent AF form (n=14) hs-CRP concentrations were higher at baseline: 0.35 (IQR1: 0.09 IQR: 0.61) vs 0.15 (IQR1: 0.07 IQR: 0.29), p<0.01. Nevertheless, after one year's observation these differences were not significant. Among all cytokines were studied only IL-15 was significantly correlated with the number of AF episodes (r=0.26), mean (IQ1-IQ3): 10 (3-30) vs 60 (50-100), p=0.00681. CONCLUSION: Basic inflammatory markers were not changed in patients with refractory atrial fibrillation episodes in prospective one year's observation. Only cytokine IL-15 was correlated to numbers of AF episodes. It's potential role as a marker of arrhythmia deserves further evaluation.

Gender-related differences in outcomes and resource utilization in patients undergoing radiofrequency ablation of supraventricular tachycardia: results from Patients' Perspective on Radiofrequency Catheter Ablation of AVRT and AVNRT Study.

AIMS: The aim of this study was to describe gender-related differences in clinical presentation, radiofrequency ablation (RFA) outcomes, and healthcare resource utilization in a group of patients with atrioventricular nodal reciprocating tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT). METHODS AND RESULTS: This was a single-centre, prospective, cohort study which enroled 82 patients undergoing RFA of AVNRT or AVRT. At baseline, all patients received a clinical assessment and completed questionnaires concerning: socioeconomic status, disease-specific symptoms (Patient Perception of Arrhythmia Questionnaire; PPAQ), health-related quality of life (HRQoL) (EQ-5D-3L), and healthcare resource utilization. Two months after RFA, the clinical assessment was repeated and subjects completed PPAQ and EQ-5D-3L. Follow-up was completed by 64 patients, 41 (64%) women. At baseline, there were no significant differences in baseline characteristics, except AVNRT prevalence, and HRQoL by gender but women reported higher severity of symptoms on PPAQ than men (2.8 vs. 2.4 points, P < 0.001). At 2 months after RFA, women still reported higher severity of symptoms (1.8 vs. 0 points; P = 0.02) on PPAQ and more heart skipping than men (54 vs. 13%; P = 0.0014); differences in EQ-5D-3L index and EQ-VAS were insignificant. There was no significant difference in healthcare resource utilization during the year preceding RFA, but antiarrhythmic drugs were significantly more often prescribed to women pre-procedure (30 vs. 8%; P = 0.022). CONCLUSION: There is a small but significant gender-related difference in outcome of RFA in patients with AVNRT or AVRT measured with a disease-specific instrument. No significant difference in HRQoL or access to healthcare resources between women and men was found.

Searching for the optimal strategy for the diagnosis of stable coronary artery disease. Cost-effectiveness of the new algorithm.

BACKGROUND: Coronary arteriography is still widely accepted as a gold standard for the diagnosis of coronary artery disease (CAD), despite emerging methods such as multi-slice computed tomography. None of the presently available non-invasive diagnostic tests is perfect. The aim of the article was to make a comparison of the value and limitations of history, resting electrocardiography, exercise electrocardiography and dobutamine stress echocardiography in the diagnosis of CAD, and to create a simple algorithm for non-invasive diagnosis of CAD to optimize indications for coronarography. METHODS: Prospective, multicentre trial. The collection of clinical data, resting electrocardiography, exercise treadmill electrocardiography, dobutamine stress echocardiography and catheterization data was performed on 600 patients with chest pain regarded as angina pectoris and no previous history of myocardial infarction. CAD was defined as >/= 50% narrowing of at least one major vessel. Final results were obtained in 551 patients, 65% male. The studied population was divided into three groups on the basis of pre-test likelihood of CAD: 1. high (> 70%), 2. intermediate (10-70%) and 3. low (< 10%). RESULTS: Sensitivity and specificity of resting electrocardiography, exercise treadmill electrocardiography, dobutamine stress echocardiography and created algorithm were calculated: 23%, 87% and 93%, 21% and 85%, 69% and 96%, 44%, respectively. The prevalence of CAD in the studied population was 61%. CONCLUSIONS: The diagnostic value of resting electrocardiography in stable CAD is low. Dobutamine echocardiography has comparable sensitivity but significantly higher specificity than exercise treadmill test. Our algorithm is simple, reasonably cost-effective and may be useful in decision making. When the probability of CAD is high, non-invasive testing is not indicated before coronary angiography; when it is intermediate or low, a first choice test should be different in female (stress echocardiography) and male (exercise electrocardiography). (Cardiol J 2007; 14: 544-551).