Arrhythmogenic response to isoproterenol testing vs. exercise testing in arrhythmogenic right ventricular cardiomyopathy patients.

Aims: To compare the arrhythmic response to isoproterenol and exercise testing in newly diagnosed arrhythmogenic right ventricular cardiomyopathy (ARVC) patients. Methods and results: We studied isoproterenol [continuous infusion (45 µg/min) for 3 min] and exercise testing (workload increased by 30 W every 3 min) performed in consecutive newly diagnosed ARVC patients. Both tests were evaluated with regard to the incidence of (i) polymorphic premature ventricular contractions (PVCs) and couplet(s) or (ii) sustained or non-sustained ventricular tachycardia (VT) with left bundle branch block [excluding right ventricular outflow tract VT]; and compared to a control group referred for the evaluation of PVCs without structural heart disease. Thirty-seven ARVC patients (63.5% male, age 38 ± 16 years) were included. The maximal sinus rhythm heart rate achieved during isoproterenol testing was significantly lower compared to exercise testing (149 ± 17 bpm vs. 166 ± 19 bpm, P < 0.0001). However, the incidence of polymorphic ventricular arrhythmias was much higher during isoproterenol testing compared to exercise testing [33/37 (89.2%) vs. 16/37 (43.2%), P < 0.0001]. Interestingly, isoproterenol testing was arrhythmogenic in all 15 patients in whom baseline PVCs were reduced or suppressed during exercise testing. During both isoproterenol and exercise testing, control group presented a low incidence of ventricular arrhythmias compared to ARVC patients (8.1% vs. 89.2%, P < 0.0001 and 2.7% vs. 43.2%, P < 0.0001, respectively). Conclusions: The incidence of polymorphic ventricular arrhythmias is significantly higher during isoproterenol compared to exercise testing in newly diagnosed ARVC patients, suggesting its potential utility for the diagnosis.

A useful and easy to develop combined stress test for myocardial perfusion imaging: Regadenoson and isometric exercise, preliminary results.

BACKGROUND: Regadenoson, a selective A2a receptor agonist, is a vasodilator increasingly used in myocardial perfusion imaging. Adjunction of isometric exercise is a simple method that could improve side effect profile while providing better image quality. METHODS: Patients undergoing SPECT MPI were prospectively enrolled in handgrip-Regadenoson (HG-Reg test, N = 20) and Regadenoson (Reg) stress test (N = 40). Investigator blinded to stress test analyzed clinical data and images. RESULTS: Heart rate (HR) increase was statistically higher in the HG-Reg group (27 vs 22 bpm, P = .019). Decrease in SBP was less frequent in the HG-Reg group than in the Reg group (55% vs 85.5%, P = .005), there were less drops >10 mmHg (45% vs 77.7%, P = .012). During stress testing, fewer subjects reported at least one side effect in the HG-Reg compared to Reg group (70% vs 92.5%, P = .021). Images were more often classified as good in the HG-Reg group (75% vs 52.5% in the Reg group, P = .25). CONCLUSIONS: Adjunction of handgrip exercise to Regadenoson administration is a well-tolerated and easy method, without loss of time. Furthermore, image quality seems to be better.

[Complete atrioventricular block following long term treatment with chloroquine]. / Bloc auriculo-ventriculaire complet après prise de chloroquine au long cours.

Antimalarial agents are routinely used in the management of connective tissues diseases and various skin disorders. Ophthalmologic, neurological and digestive side effects of antimalarial agents are well known. However, cardiac toxicity is uncommon. We report a 49-year-old patient, treated with chloroquine for 21 years for a systemic lupus erythematosus and a discoid lupus, who presented a complete atrioventricular block that required implantation of a cardiac pacemaker in emergency. This patient did not have significant cardiovascular past medical history. Investigations excluded known causes of atrioventricular block and chloroquine toxicity was diagnosed. This case report illustrates the cardiotoxicity of synthetic antimalarial agents. A regular cardiovascular monitoring (especially with electrocardiogram) could be useful in patients receiving long-term treatment with antimalarial agents.

[Comparative study of exercise-induced ischaemia in coronaropathy and aortic stenosis]. / Etude comparative de l'ischémie d'effort entre patients coronariens et patients atteints de rétrécissement aortique.

OBJECTIVE: To compare exercise and recovery data between a population of patients with proven CAD and patients with pure aortic stenosis (AS). PATIENTS AND METHODS: Exercise testing results (bicycle ergometry) of 45 patients with AS (34 men, 66+/-12 years, 56+/-20 mmHg peak-to-peak gradient and valve area 0.78+/-0.48cm2) were compared to exercise testing results of 50 patients with CAD (41 men, 65+/-9 years, greater or equal to 70% stenosis on one vessel in 62%, two vessels in 30%, three vessels in 8%). RESULTS: During exercise, 38% patients with AS and 82% patients with CAD had clinical symptoms. In the AS group, exercise duration was longer, heart rate (HR) was higher, maximal systolic and diastolic blood pressure were lower than in CAD group. The increase of systolic blood pressure was lower in the AS group (34+/-21 mmHg versus 47+/-27 mmHg, p<0.02). Maximal load achieved was not significantly different. Exercise ST depression appeared in 76% of AS group and 88% of CAD group (NS). No difference was found in ST depression, Detrano index and ST segment/HR slope. During recovery, no difference was found in HR variations. Clockwise rotation of the ST/HR recovery loop was more frequent in CAD group (35 patients versus 19 patients, p<0.001). CONCLUSION: Most of the exercise and recovery data are similar in patients with AS and CAD. Significant discriminating criteria were the increase of systolic blood pressure during exercise and ST/HR recovery loop.

[The best of cardiac rehabilitation in 2006]. / L'essentiel de l'année 2006 en réadaptation cardiaque et cardiologie du sport.

The meta-analysis showing the benefits of physical training revisited: Taylor examined only the cardiac rehabilitation trials of exercise intervention alone (versus usual care) and demonstrated that cardiac mortality is 28 % reduced and exercise appears to have an independent mortality benefit. An economic evaluation of cardiac rehabilitation: a systematic review of 15 economic evaluations. Evidence to support the cost-effectiveness of supervised cardiac rehabilitation compared with usual care in myocardial infarction and heart failure was identified. But further well-designed trials are required. Pronostic value of some variables determined by exercise testing entering cardiac rehabilitation and after physical training. A beneficial effect of physical training versus usual care on BNP and neurohormones in patients with chronic heart disease. Patients on beta blockers after myocardial infarction: determination of a more accurate training heart frequency derived from the classical Karvonen's formula. The combination of trimetazidine with exercise training provides greater improvements in functional capacity, left ventricular function and the endothelium-dependent relaxation of the brachial artery than exercise training alone in patients with ischaemic cardiomyopathy referred for cardiac rehabilitation. Guidelines for resistance exercise after cardiac event: a new paradigm less restrictive, safe and efficient to accelerate patients' return to daily activities. Recommendations for participation in leisure-time physical activity and competitive sports for patients with ischaemic heart disease: the result of consensus among experts from the ESC study group of sports cardiology.

[Exercise test in athletes]. / Epreuves d'effort chez les sportifs.

The particularities of exercise tests in athletes concern mainly the exertion protocols adapted to their increased physical capacities and the interpretation of ECG tracing which can sometimes be very special at rest and also misleading during exercise. In the great majority of cases, the test used is both cardiac and pulmonary, in order to assess the aerobic capacities, the maximal aerobic power, and the determination of ventilation thresholds (programming and follow-up of training...). More infrequently, the test is used to detect cardiovascular diseases, especially during a longitudinal follow-up of high-level athletes, or to exclude it in case of cardiovascular symptoms, atypical resting ECG or even in case of suspicion of disease (arrhythmia, cardiac chamber hypertrophy or dilation at echocardiography). In more aged sportsmen (athletes masters), exercise tests performed are usually required for screening coronary heart disease. In this case the test protocols should be more adapted for screening than for the assessment of sportive capacities.

[Survey of cardiovascular risk assessment and the behaviour of a sporting population]. / Enquête sur les comportements et l'évaluation du risque cardiovasculaire dans une population de sportifs.

In order to better understand the risk factors and behaviour of a general sports population, a questionnaire was handed to 603 consecutive sportsmen of various disciplines during a specific sports medicine consultation and a half-marathon. Among the discovered risk factors, smoking was the most common (19.3% for the entire study population), predominantly in the youngest group (26%). A resting ECG had been performed very frequently within the previous year in those over 40 years (86.5%), but less often in the younger sportsmen (44.8%). An exercise test had also very often been performed in those aged over 40 years (69.2 vs 10.6%). Behaviour associated with cardiovascular risk was common. Undertaking physical activity while febrile (58%) and smoking just before or after exertion (13.1%) were widespread behaviours. This population appeared casual in its approach to possibly suspicious cardiac symptoms of exercise, particularly the females and paradoxically the subjects doing the most sport. Lastly, only a minority of sportsmen knew the telephone number for the emergency medical service (45%) or claimed to be competent at first aid (32%). This survey underlines a practice relatively in accordance with the recommendations for detecting cardiovascular pathology, but shows a failure of preventive education.

Effect of atrioventricular synchronous pacing on cardiac output determined by CO2 rebreathing at constant submaximal exercise.

This study compared cardiac output assessed by a noninvasive CO2 rebreathing method at identical submaximal exercise and heart rate response in patients undergoing DDD or VVI pacing. Our results did not show any hemodynamic superiority of AV synchronous pacing.

The benefit of graded physical exercise in chronic heart failure.

A new program of rehabilitation is less demanding on cardiac output than standard programs. Twenty-five patients with chronic heart failure (ejection fraction [EF]: 0.26 +/- 0.10) were randomized into 2 groups: a control group with 13 patients and a rehabilitation group of 12 patients. In the control group, 2 did not complete the study (cancer, cardiac transplantation). For the 11 others, the different parameters studied were comparable at day 0 with group R and did not significantly change over 3 months outside of a spontaneous improvement in endurance performance by 22%. In the rehabilitation group (40 sessions over 90 days; specialized equipment) there were no incidents. Tolerance was excellent (heart rate during sessions less than 115 bpm) and all functional parameters improved. Training did not modify the isotopic ejection fraction. The quality of life score increased respectively by 52% (p less than 0.0001 in comparison with the control group) and by 63% (p less than 0.0001); 80% of the patients requested that training be prolonged. The functional improvement obtained by purely peripheral effect had no adverse effect on the heart.

Cardiorespiratory response to exercise after venous switch operation for transposition of the great arteries.

STUDY OBJECTIVES: This study reports on the cardiorespiratory response to graded exercise in patients after venous switch operation for transposition of the great arteries. DESIGN: Several small studies have documented a diminished exercise tolerance after Mustard repair for transposition of the great arteries, little information exists, however, about long-term cardiorespiratory exercise performance in patients who have had the Senning procedure. PATIENTS: This prospective study reports on the serial long-term (mean, 11 +/- 2.8 years) cardiopulmonary exercise performance of 43 patients (age, 12 +/- 3.1 years) who underwent a Senning procedure, with no significant postoperative abnormalities. Forty-three matched healthy children were also studied as a control group. MEASUREMENTS AND RESULTS: All underwent exercise testing (Bruce protocol) with metabolic gas exchange to determine parameters at 3 min, anaerobic threshold, similar heart rate (150 beats/min), and peak exercise. Time of exercise was 10.5 +/- 1.9 min in patients and 13.4 +/- 2 min in control subjects (p = 0.0001). Overall, patients reached 73% of peak oxygen uptake achieved by control subjects (32.6 +/- 5.6 vs 44.7 +/- 6 mL/kg/min). Chronotropic response (188 +/- 15.7 vs 166.5 +/- 19.6 beats/min [p = 0.0001]) and oxygen pulse (7.4 +/- 2.9 vs 10.7 +/- 4.2 mL/beat [p = 0.0002]) were lower in patients at peak exercise. Patients had a greater respiratory response to exercise: both respiratory rate and ventilatory equivalent for carbon dioxide were significantly higher at all stages of exercise. Exercise capacity assessed by peak oxygen uptake was correlated with time elapsed since surgical repair (r = 0.48; p = 0.001). CONCLUSIONS: It is concluded that even in asymptomatic patients, exercise endurance and respiratory response are generally altered as much as 11 +/- 2.8 years after venous switch operation, although early surgical repair is predictive of a better long-term functional result.

Comparison of treadmill and bicycle exercise in patients with chronic heart failure.

The general opinion that treadmill exercise elicits circulatory reserve more than bicycle exercise derives from studies conducted in normal subjects or subjects with coronary artery disease. To investigate if this also occurs in patients with chronic heart failure (CHF), 40 patients (mean ejection fraction: 26 +/- 9 percent) with normal pulmonary function underwent in random order both treadmill (Naughton modified protocol, holding on handrails permitted) and bicycle (10 W/min) maximal exercise over a 1-week period. Peak oxygen uptake (19.6 +/- 5.3 vs 17.6 +/- 5.1 ml/min/kg, p < 0.0001), ventilatory threshold (14.4 +/- 4.7 vs 12.0 +/- 3.5 ml/min/kg, p < 0.0001), and minute ventilation (59 +/- 18 vs 55 +/- 15 L/min, p < 0.05) were greater on treadmill than on bicycle. Heart rate, systolic blood pressure, breathing rate, respiratory exchange ratio, perceived exertion scale, and lactate were identical. The coefficient of the correlation between oxygen uptake and time was greater with bicycle than with treadmill (r = 0.97 +/- 0.04 vs 0.90 +/- 0.07, p < 0.001). Thus, treadmill exercise is more suitable for determining peak oxygen uptake in patients with CHF. However, the increase in oxygen uptake is more regular with bicycle exercise.

Comparison of the anti-anginal efficacy of nicardipine and nifedipine in patients receiving atenolol: a randomized, double-blind, crossover study.

The effects of oral nicardipine (40 mg) and nifedipine (20 mg) in combination with atenolol (100 mg) were compared with those of placebo, oral nitroglycerin (0.4 mg) and atenolol alone (100 mg) in 17 patients with stable effort angina. Patients performed symptom-limited, multistage, upright bicycle ergometric exercises with computer-assisted ECG analysis in bipolar lead CM5. Nicardipine and nifedipine were given double blind and in randomized order. In comparison with placebo (4818 +/- 2021 kpm), patients exercised longer and with a greater work load with nitroglycerin (5748 +/- 1711 kpm, P less than 0.001), the combinations of atenolol and nifedipine (6120 +/- 2274 kpm, P less than 0.05), and atenolol and nicardipine (6671 +/- 2339 kpm, P less than 0.01), but not with atenolol alone (5305 +/- 1524 kpm, P = NS). The magnitude of ST-segment depression at peak exercise with placebo (3.22 +/- 1.72 mm) was dramatically reduced with nitroglycerin (1.39 +/- 1.87 mm) but less with atenolol alone (2.95 +/- 1.83 mm, P less than 0.05) or the combinations of atenolol and nicardipine (3.05 +/- 1.51 mm, P = NS), and atenolol and nifedipine (2.45 +/- 1.25 mm, P less than 0.001). Compared to the combination of atenolol and nifedipine, that of atenolol and nicardipine produced a significantly (P less than 0.05) greater exercise tolerance (6671 +/- 2339 versus 6120 +/- 2274 kpm) but with a greater ST-segment depression at peak exercise (3.05 +/- 1.51 versus 2.45 +/- 1.29 mm, P less than 0.01).

Anti-ischemic effects of celiprolol in patients with exercise-induced angina pectoris.

The anti-ischemic properties of the new cardioselective beta-adrenoreceptor antagonist celiprolol were investigated in an open study of 12 men (mean age: 58 +/- 6.6 years) with exercise-induced angina pectoris. After all previous anti-anginal medication had been withdrawn for at least 5 half-lives, the patients received placebo, single doses of nitroglycerin buccal spray, sublingual nifedipine, celiprolol alone, and then in association with nitroglycerin and nifedipine. Exercise tests were performed on a bicycle ergometer, with continuous electrocardiographic monitoring. Significantly more work was completed after treatment with celiprolol than at baseline (5280 +/- 2500 versus 4005 +/- 1792 kpm; P less than 0.01). There were further improvements in work completed after the addition of nitroglycerin and nifedipine. Celiprolol reduced the mean resting heart rate from a baseline value of 77.1 beats/min to 69.2 beats/min (P less than 0.01). In contrast, nifedipine induced tachycardia (82.6 beats/min). At rest, all treatments significantly reduced systolic blood pressure, but only nifedipine significantly reduced diastolic blood pressure. At the completion of the exercise protocol, celiprolol reduced the maximal systolic and diastolic blood pressure (P less than 0.05) with further decreases after the addition of nifedipine. The double product was significantly decreased by celiprolol compared with control, nitroglycerin and nifedipine. There was a further improvement of the double product after the addition of nitroglycerin to celiprolol, but the further increase after addition of nifedipine was not significant. In conclusion, it is clear that celiprolol, both alone and in combination with nitroglycerin or nifedipine, can significantly increase the work capacity of patients with exercise-induced angina pectoris and significantly reduce myocardial oxygen consumption.

[How to and why evaluate the ischemic risk after myocardial infarction?]. / Comment et pourquoi évaluer le risque ischémique au décours d'un infarctus du myocarde?

After uncomplicated myocardial infarction, clinical and ergometric data before hospital discharge allow identification of patients at high risk of further cardiac events. These relate to the necrosed myocardium (left ventricular dysfunction, sometimes latent, and arrhythmia risk), and also to the jeopardized myocardium: the moderate sensitivity and specificity of classical exercise stress testing for the detection of this often silent ischaemia are much improved by stress radionuclide and echocardiographic techniques (exercise, dipyridamole, dobutamine. . .), the large scale indications of which remain to be validated.

[The heart and sexual activity]. / Coeur et activité sexuelle.

There has been considerable media attention surrounding the commercialisation of Sildenafil. The advice of cardiologists is often solicited before its prescription because of its potential side effects; the cardiovascular stress due to sexual activity is generally modest, both in normal subjects and coronary patients with, however, important individual variations, the "legitimate" nature of the intercourse seeming to be one of the principal factors. Recent coronary events, poorly controlled hypertension and uncompensated cardiac failure are the main contra-indications; the prescription should be based on the results of maximal exercise stress testing in patients at risk.

[Respective diagnostic value of CM5 and V5 leads in exercise tests. Comparative study of 100 cases]. / Valeur diagnostique respective des dérivations CM5 et V5 à l'effort. Etude comparative à partir de 100 observations.

The respective diagnostic values of CM5 and V5 leads in exercise tests were studied in 100 patients, 89 of whom had coronary disease. Mean maximum ST depression and mean R wave amplitude at rest and at peak exertion were very much greater with CM5 than with V5 (p less than 0.0001). These two parameters seemed to vary concurrently. The contribution of both leads to the diagnosis in terms of sensitivity is probably the same; the more severe the coronary disease, the more pronounced the ST depression on CM5 tracings as compared to V5 tracings. A significant ST depression (1 mm) also appears more rapidly on the bipolar MC5 lead.

[Exercise test and ventricular tachycardia: the French experience]. / Epreuve d'effort et tachycardies ventricularies: l'expérience française.

The incidence of severe ventricular arrhythmia requiring electric shock or prompt intravenous therapy was evaluated during or immediately after 458,000 exercise tests performed in 46 french centres between 1975 and 1985; 177,000 tests were performed exclusively in cardiac patients during supervised exercise training sessions. Sixty cases of severe arrhythmia (ventricular fibrillation 23, ventricular tachycardia 35, asystole 2) occurred (1/7600 tests). One or several electric shocks were necessary in 35 cases. Six patients died (1/76,333 tests), 2 of them during training sessions; 5 had phase II or III myocardial infarction, and the 6th patient had moderately tight valvular aortic stenosis. The five coronary patients were taking various anti-arrhythmic drugs. Among the 54 survivors, 14 were lost sight of and 4 died, 2 of these suddenly including one who passed away during a bicycle ride. All others are alive after a 3.25 +/- 2.9 years follow-up. The association of a multiple-vessel disease with an extensive fibrous plaque is a syndrome that is highly sensitive but fortunately little specific in predicting severe arrhythmia during exercise tests.

[Diagnostic value of amplitude variations of the Q wave during computerized stress electrocardiogram]. / Valeur diagnostique des variations d'amplitude de l'onde Q à l'électrocardiogramme d'effort informatisé.

Variations in the amplitude of the Q wave in lead CM5 during computerised exercise stress testing were studied in 220 patients and compared with the results of coronary angiography. The average amplitude of the Q wave increases during exercise in athletes (n = 30) from 3 +/- 2.75 mm to 4.72 +/- 2.35 mm (p less than 0.01), and in subjects without coronary artery disease (n = 49) from 0.92 +/- 1.05 mm to 1.75 +/- 1.62 mm (p less than 0.01). The Q wave did not vary significantly during exercise in patients with coronary disease but without previous infarction (n = 88) (0.70 +/- 0.91 mm to 0.62 +/- 0.85 mm). The amplitude of the Q wave did tend to decrease in patients with previous myocardial infarction (n = 83) from 1.96 +/- 2.05 mm to 1.35 +/- 1.26 mm (p less than 0.05). It is therefore possible to define a new diagnostic criterion of coronary disease: "the exercise stress test is said to be positive (delta q+) when the Q wave tends to decrease or remains stable during exercise, and negative (delta q-) when the Q wave amplitude increases during exercise". This criterion was tested in 49 normal and 83 coronary patients without infarction. The sensitivity (Se) was 79 p. 100 and the specificity (Sp) 65 p. 100, so correctly classifying 74 p. 100 of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Discrimination attempt between stenoses of the left trunk and tritroncular involvement using univariate and multivariate analysis of the variables of the exercise test]. / Tentative de distinction entre les sténoses du tronc gauche et les atteintes tritronculaires par l'analyse univariée et multivariée des variables de l'épreuve d'effort.

One hundred and fifty patients with more than 70 p. 100 three vessel (3V) stenosis and 69 patients with more than 50 p. 100 left main (LM) coronary artery stenosis underwent an exercise test at maximum or symptom-limited level, after discontinuing all anti-ischaemic therapies. Three comparative statistical methods were used: 1. Univariate analysis. Among the mean values of the 17 variables studied, 6 differed significantly (p less than 0.05), viz.: cardiac work performed until the appearance, on the CM5 lead, of an ST depression (STd) of 1 mm (W1) (LM = 1,002 Kpm; 3V = 1,461 Kpm) and of 2 mm (W2) (LM = 2,445 Kpm; 3V = 2,904 Kpm); maximum STd/maximum heart rate ratio; rise of systolic pressure during exercise and rise of heart rate associated with a 2 mm STd less pronounced with LM; maximum exercise capacity (W3) (LM = 2,445 +/- 1,514; 3V = 2,904 +/- 2,095 Kpm). 2. Linear discriminant function analysis. No discriminant variable could be obtained (subjects well classified 53 p. 100, ill-classified 47 p. 100). 3. Multivariate analysis, Cox's model. This method demonstrated that stenosis of the LM coronary artery is characterized by the early appearance of ischaemia rather than by its severity. After 4 minutes of exercise, 62 p. 100 of LM patients and only 28 p. 100 of 3V patients had a 1 mm ST depression. It is concluded that exercise tests do not provide a certainty of LM stenosis, but they identify patients with severe ischemia who most probably have this type of stenosis. Such patients can then be selected for coronary arteriography and operated upon as soon as possible.

[Prognostic evaluation of silent ischemia during exercise in patient with recent infarction. Italian multicenter study. SMISS Group]. / Evaluation du pronostic de l'ischémie silencieuse à l'effort chez des patients avec infarctus récent. Etude italienne multicentrique. Groupe SMISS.

AIM: The aim of the Multicenter Silent Ischemia Study (SMISS), co-ordinated by the Italian Working Group on Cardiac Rehabilitation, was to evaluate prospectively, the prognostic significance of silent myocardial ischemia during exercise testing in patients with proven ischemic cardiac disease. METHODS: Over a period of six months 4389 consecutive patients performing a maximal symptom-limited exercise testing, after drug withdrawal, were enrolled in the 73 ergometric laboratories. All patients were followed up after 12 months, at which time electrocardiogram, examination and clinical history were reassessed. Here we report the results of 1111 patients group with the recent myocardial infarction (inferior 3 months). The follow-up was completed in 1031 (93%) patients. RESULTS: The results of exercise testing were normal in 666 (64.6%) patients; angina alone in 33 (3.2%) patients; silent ischemia in 234 (22.7%) patients; symptomatic ischemia in 98 (9.5%) patients. In 270 patients (26.1%) new events occurred: angina (19.7%); myocardial infarction (3.1%; PTCA (4%); CABG (6%); cardiac death (1.4%). The total events were more common in the patients with exercise induced angina (48.5%) and in those who had exercise induced-symptomatic ischemia (48%), in respect of patients with silent ischemia (29.5%) and of those who had normal testing (20.7%) (p = 0.0001). Myocardial infarction rate was higher in patients with symptomatic ischemia (7.1%) that for those of all other groups (silent ischemia: 1.3%, angina: 3%, normal 3.2%) (p = 0.05). Moreover, the patients with symptomatic ischemia had higher incidence of CABG (p = 0.0001). The mortality rate was low among all patients and did not show differences among the groups. Only among the 31 patients (3%) with blood pressure fall was mortality higher that in patients with a normal blood pressure increase. By multivariate logistic analysis the angina induced by exercise maintained its prognostic significance for all the events, but also other variables were significant: poor exercise tolerance and, between clinical variables angina before myocardial infarction. CONCLUSION: The results showed, in patients who underwent to exercise testing after drug withdrawal, a low incidence of cardiac death and of myocardial infarction on 12 month follow-up; the patients with induced-exercise symptomatic schema had a greater risk for all cardiac events, except for death.