Cardiovascular risk factor(s) prevalence in Greek hypertensives. Effect of gender and age.

The aim of this study was to determine cardiovascular (CV) risk factors (RFs) and target organ damage clustering in 21280 Greek hypertensives stratified by gender and age. Glycemic and lipid profile were determined, left ventricular mass index, estimated gromerular filtration rate (eGFR), 10-years CV risk according to Framingham risk score (FRS) and HeartScore (HS) were calculated. Only 10.2% of patients had no concomitant RFs, 53.1% had one (48.8% dyslipidemia, 3.4% smoking, 0.9% diabetes), 32.9% had two (26% dyslipidemia and smoking, 6.6% dyslipidemia and diabetes, 0.3% smoking and diabetes) and 3.7% had all four traditional RFs. Obesity was present in 30%, metabolic syndrome in 38%, low eGFR in 24% and left ventricular hypertrophy in 49%. Mean FRS risk was 35% for males, 24.1% for females whereas in high risk (>20%) were 68.7 and 50.7%, respectively (P<0.0001). Mean HS risk was 8.4% for males, 6.2% for females whereas in high risk (>5%) were 48.6 and 36.2%, respectively (P<0.0001). Age was correlated to pulse pressure, eGFR, left ventricular mass index and CV risk (P<0.0001). Ageing increased the risk difference between genders for total (P=0.001) but not for fatal events (P=nonsignificant). In conclusion, as RFs cluster in hypertensives, CV risk calculation should guide treatment decisions.

Exercise duration as a determinant of vascular function and antioxidant balance in patients with coronary artery disease.

BACKGROUND: Exercise improves the clinical outcome of patients with coronary artery disease (CAD); however, the ideal exercise duration for each patient remains unclear. OBJECTIVE: To investigate the effects of exercise duration on arterial elastic properties and antioxidant/pro-oxidant mechanisms in patients with CAD. DESIGN, SETTING, PATIENTS, INTERVENTIONS: Sixty male patients with CAD were randomised into two groups, and underwent exercise for 30 min or 60 min in a crossover design with 2 weeks' wash-out period. In all participants aortic and radial blood pressures (BP) and arterial elastic properties (augmentation index (AIx)/pulse wave velocity (PWV)) were determined at baseline and 24 h after exercise. Plasma malonyldialdehyde (MDA) and superoxide dismutase (SOD)1 and SOD2 levels were also measured. RESULTS: Exercise had no effect on aortic and radial BP (p=NS for all). Walking for 30 min improved AIx (from 33.79 ± 0.91% to 31.73 ± 0.86%, p<0.001) and PWV (from 9.26 ± 0.95 m/s to 9.06 ± 0.21 m/s, p<0.001), while exercise for 60 min had adverse effects on vascular stiffness (for AIx: from 33.37 ± 0.93% to 33.73 ± 1.05%, p=NS and for PWV: from 9.25 ± 0.19 m/s to 9.37 ± 0.21 m/s, p < 0.05 mainly in older patients). Exercise for 60 min was associated with a significant 20% increase in MDA levels (p<0.05). Exercise had no effects on SOD1 levels, however it significantly increased SOD2 levels after 30 min (from 2.26 ± 0.22 ng/mL to 2.36 ± 0.18 ng/mL, p < 0.05) but not after 60 min (p=NS). Conclusion Shorter exercise duration was associated with favourable antioxidant and vascular effects, while longer exercise blunted these beneficial effects and was accompanied by adverse effects on vascular function, mainly in older coronary patients. Further studies are required to explore the hypothesis that a more individualised approach to the selection of the appropriate exercise programme should be considered for patients with CAD.

Effects of ischemia on P wave dispersion and maximum P wave duration during spontaneous anginal episodes.

P wave dispersion (P dispersion), defined as the difference between the maximum and the minimum P wave duration, and maximum P wave duration (P maximum) are electrocardiographic (ECG) markers that have been used to evaluate the discontinuous propagation of sinus impulses and the prolongation of atrial conduction time, respectively. To study the effects of myocardial ischemia on P dispersion and P maximum, 95 patients with coronary artery disease (CAD) and typical angina pectoris and 15 controls with angina like symptoms underwent 12-lead surface ECG during and after the relief of pain. During pain and during the asymptomatic period, P maximum and P dispersion were calculated from the averaged complexes of all 12 leads. P dispersion increased significantly during spontaneous angina (45+/-17 ms) compared to the asymptomatic period (40+/-15 ms), P < 0.001 only in the patient group. Both P maximum and P dispersion showed higher values during angina in those patients who developed diffuse ischemia, as estimated with ST segment changes in multiple ECG leads. P dispersion showed higher values during the anginal episode in patients with left ventricular dysfunction, independently of the presence of a previous myocardial infarction. Atrial conduction abnormalities, as estimated with P maximum and particularly P dispersion, are significantly influenced by myocardial ischemia in patients with CAD and spontaneous angina.

Significance of exercise-induced simultaneous ST-segment changes in lead aVR and V5.

This study was undertaken to investigate the ability of the exercise-induced ST depression in lead V5 and concomitant ST elevation in lead aVR for the identification of the significantly narrowed coronary artery in patients with single vessel disease. We studied 229 consecutive patients who developed the aforementioned exercise-induced electrocardiographic changes. All underwent Thallium-201 scintigraphy and coronary arteriography. Patients were divided into three groups. In group A, 58 patients with ST depression in V5 and ST elevation in aVR, in group B 149 patients with ST depression in V5 without ST elevation in aVR, and in group C 22 patients with ST elevation in aVR without ST depression in V5 induced with exercise, were included. In group A, 81% of the patients while in group B, 29% and in group C only 18% of the patients had left anterior descending artery disease. According to Thallium-201 scintigraphy, 80% of the group A, 27% of the group B and 12% of the group C patients developed myocardial ischemia in areas supplied by the left anterior descending artery. Thus, exercise-induced ST depression in V5 and concomitant ST elevation in aVR, may detect left anterior descending artery significant stenosis in patients with single vessel disease.

QRS prolongation on the signal-averaged electrocardiogram versus ST-segment changes on the 12-lead electrocardiogram: which is the most sensitive electrocardiographic marker of myocardial ischemia?

BACKGROUND: ST-segment changes and QRS prolongation are electrocardiographic (ECG) markers of myocardial ischemia. HYPOTHESIS: This study was undertaken to investigate the appearance of QRS duration changes with or without concomitant ST-segment changes during a typical anginal episode. METHODS: For this purpose, 126 patients underwent 12-lead surface ECG and signal-averaged electrocardiogram (SAECG) during typical anginal pain as well as at the time the patient was asymptomatic. In both periods, QRS duration and ST-segment changes were evaluated. All patients underwent cardiac catheterization. RESULTS: Of the 126 patients, 108 (86%) had coronary artery disease (CAD), whereas the remaining 18 (14%) patients had normal coronary arteriograms. During typical anginal pain, 75 of the 108 (70%) patients with CAD and 2 of the 18 (11%) patients with normal coronary arteriograms developed QRS prolongation, whereas 60 of the 108 (56%) patients with CAD and 2 of the 18 (11%) patients with normal coronary vessels developed ST-segment changes. Thus, the sensitivities of QRS prolongation measured by SAECG and of ST-segment changes on the surface ECG for the detection of myocardial ischemia were found to be 70 and 56%, respectively, (p < 0.01), whereas the specificities were both found to be 89% (p = NS). CONCLUSIONS: During typical anginal pain, QRS prolongation on the SAECG is more sensitive than are ST-segment changes on the ECG for the detection of myocardial ischemia.

Exercise-induced ST-segment changes in lead V1 identify the significantly narrowed coronary artery in patients with single-vessel disease: correlation with thallium-201 scintigraphy and coronary arteriography data.

We investigated the correlation of exercise-induced ST-segment changes in lead V1, with the detection of the significantly narrowed vessel that induced ischemia during exercise in myocardial areas supplied by this vessel. We studied 198 patients who underwent exercise testing, thallium-201 scintigraphy, and coronary arteriography. The patients were divided into three groups. In group 1 (ST-segment elevation in lead V1), 84% had left anterior descending coronary artery disease (P<.001); in group 2 (ST-segment depression in lead V1), 76% had right coronary artery disease (P<.001); and in group 3 (no ST-segment changes in lead V1), there were no significant differences concerning the narrowed vessel. Thallium-201 scintigraphy data confirmed the existence of the reversible perfusion defect(s) in an area(s) of myocardium supplied by the respective coronary arteries (P<.001). Exercise-induced ST-segment elevation or depression in V1 may identify the obstructed vessel in patients with single-vessel disease and without prior myocardial infarction.

Improved detection of coronary artery disease by exercise electrocardiography with the use of right precordial leads.

BACKGROUND: Exercise electrocardiography is an perfect test for the detection of coronary artery disease. We attempted to improve the diagnostic accuracy of exercise testing as a noninvasive method for the detection of coronary artery disease by using a combination of the left and right precordial leads. METHODS: We studied 245 patients (218 men and 27 women) ranging from 32 to 74 years of age (mean [+/-SD], 52+/-8) who underwent treadmill exercise testing, thallium-201 scintigraphy, and coronary arteriography. During exercise testing, each patient had one electrocardiogram recorded with the standard 12 leads and 3 right precordial leads (V3R, V4R, and V5R), with the results for each set of leads recorded and analyzed separately. RESULTS: On the basis of coronary arteriography, 34 patients had normal coronary arteries, 85 had single-vessel disease, 84 had two-vessel disease, and 42 had three-vessel disease. The sensitivities of the standard 12-lead exercise electrocardiogram, exercise electrocardiography incorporating right precordial leads, and thallium-201 scintigraphy were 52 percent, 89 percent, and 87 percent, respectively, for the detection of single-vessel disease; 71 percent, 94 percent, and 96 percent for the detection of two-vessel disease; 83 percent, 95 percent, and 98 percent for the detection of three-vessel disease; and 66 percent, 92 percent, and 93 percent for the detection of any coronary artery disease. The specificities of the three methods for the detection of any coronary artery disease were 88 percent, 88 percent, and 82 percent, respectively. CONCLUSIONS: Use of right precordial leads along with the standard six left precordial leads during exercise electrocardiography greatly improves the sensitivity of exercise testing for the diagnosis of coronary artery disease.

Ischemia-induced reflex sympathoexcitation during the recovery period after maximal treadmill exercise testing.

BACKGROUND: Heart rate variability (HRV) analysis is problematic during maximal treadmill exercise testing (ET) due to rapidly changing heart rate. HYPOTHESIS: The aim of this study was to assess HRV spectral components during treadmill ET in patients with coronary artery disease (CAD) and in healthy controls, and to search for possible differences between the two groups. METHODS: Thirty patients with CAD and 30 age-matched healthy controls underwent symptom-limited ET and continuous electrocardiographic monitoring. For adequate assessment of HRV during maximal ET, we calculated the HRV measures [normalized units (NU)]--low-frequency (0.040-0.150 Hz) power (LF), high-frequency (0.150-0.400 Hz) power (HF), and the LF/HF ratio--from all the sequential stages of the ET with limited changes (20 beats/min) in heart rate (stress 80-100, 100-120, 120-140, 140-160, 160-180/recovery 180-160, 160-140, 140-120, 120-100, 100-80). RESULTS: Both LF and HF were found to decrease gradually during ET and to increase during the recovery period in both patients and controls (p < 0.001). LF values were higher during the recovery period than during the respective stages of exercise time in both patients and controls, and LF/HF ratio was higher during recovery in patients only. CONCLUSIONS: During maximal ET (1) vagal tone withdraws during the exercise time and increases during the recovery period; (2) the sympathetic activity predominates during the recovery period, especially in patients with CAD and exercise-induced myocardial ischemia. This finding raises the possibility of ischemia-induced cardiocardiac sympathetic excitatory reflexes.

Exercise-induced ST-segment variability may discriminate false positive tests.

The clinical value of exercise-induced variations in ST-segment depression and R wave amplitude in consecutive sinus beats was studied in 160 patients who had a positive treadmill exercise test with the Bruce protocol. The patients, all of whom underwent cardiac catheterization, included 100 with coronary artery disease (CAD) (group with true positive test) and 60 with normal coronary arteries (group with false positive test). Minimal or no exercise-induced variations in the magnitude of ST-segment depression despite variations in R wave amplitude were observed in 84 of the 100 patients with CAD and in only 9 of the 60 patients with normal coronary arteries (P < .0001). Significant exercise-induced variations in ST-segment depression were observed in only 16 of 100 patients with CAD and in 51 of 60 patients with normal coronary arteries (P < .0001). The coefficient of variation of R wave amplitude was similar in both groups (no statistical significance), while the coefficient of variation of ST-segment depression was much greater in the patients with normal coronary arteries than in those with CAD (P < .0001). It is concluded that variability of ST-segment depression at peak exercise may discriminate false positive from the true positive exercise tests, improving the diagnostic ability of the method.

Reliability of the exercise-induced ST-segment changes to detect restenosis three months after coronary angioplasty: significance of the appearance in other leads.

BACKGROUND: Exercise-induced ST-segment changes 3 months after angioplasty may sometimes show a false-positive result. METHODS: We therefore analyzed the ST changes observed during the exercise tests performed before and 3 months after angioplasty in 118 patients with single-vessel coronary artery disease. RESULTS: Ninety-two (78%) of the 118 patients had ST changes in the same lead before and after angioplasty, whereas the remaining 26 (22%) patients had ST changes in other leads in the postangioplasty test when compared with the preangioplasty exercise test. Restenosis was found in 44 (48%) of the 92 patients with ST changes in the some lead but in only four (15%) of the 26 patients with ST changes in other leads. CONCLUSIONS: Exercise-induced ST-segment changes are not reliable markers of restenosis 3 months after angioplasty. ST-segment changes observed in other leads after angioplasty compared with the preangioplasty exercise test may show a false-positive result.

Reliability of exercise-induced ST segment changes to detect restenosis 3 months after coronary angioplasty: significance of the appearance in other leads.

Exercise-induced ST-segment changes 3 months after angioplasty sometimes may show a false-positive result. We therefore analyzed the ST changes observed during the exercise tests performed before and 3 months after angioplasty in 118 patients with single-vessel coronary artery disease. Ninety-two (78%) of the 118 patients had ST changes in the same lead before and after angioplasty, whereas the remaining 26 (22%) patients had ST changes in other leads in the postangioplasty exercise test when compared with the preangioplasty test. Restenosis was found in 44 (48%) of the 92 patients with ST changes in the same lead but in only 4 (15%) of the 26 patients with ST changes in other leads. We conclude that exercise-induced ST segment changes are not reliable markers of restenosis 3 months after angioplasty. ST segment changes observed in other leads after angioplasty may show a false-positive result when compared with the preangioplasty exercise test.

Assessment of time domain and spectral components of heart rate variability immediately before ischemic ST segment depression episodes.

In an attempt to study autonomic function during the 5-minute period preceding ischemic ST segment depression (decreases ST) episodes, we selected 138 decreases ST episodes, without preceding decreases ST during the last 15 minutes before each episode, from the Holter tapes of 35 patients with multivessel coronary artery disease. For the 5-minute period preceding each decreases ST episode, we calculated the following heart rate variability (HRV) indices; the mean RR interval (RR5), the standard deviation of all RR intervals (SD Index5), the corresponding coefficient of variation (CV5), and the natural log (Ln) of the spectral components, total power at 0.000 to 0.400 Hz (TP5), low frequency power at 0.040 to 0.150 Hz (LF5), high frequency power at 0.150 to 0.400 Hz (HF5), and the ratio of the low to high frequency power (LF5/HF5). As HRV indices of the 24-hour period, we calculated the respective RR, SD Index, CV, LnTP, LnLF, LnHF, and Ln LF/HF. RR5, SD Index5, CV5, and Ln TP5 were all significantly lower than RR (t = -5.343, p = 3.7 x 10(-7)), SD Index (t = -19.091, p = 1.99 x 10(-40)), CV (t = -15.780, p = 1.28 x 10(-32)), and LnTP (t = -3.210, p = 0.0016), respectively. LnHF5 was inversely correlated with the magnitude of the decreases ST; r = -0.174, P < 0.05, and CV5 was inversely correlated with the natural log (Ln) of the ischemic event duration; r = -0.183, P < 0.05. Analogous results were obtained for both the painful and silent decreases ST episodes. It is concluded that HRV is decreased during the 5-minute period preceding decreases ST episodes, and is inversely related with the magnitude and the duration of the *ST.

Effect of beta-blockade on exercise capacity in hypertensive subjects: a one-year double-blind study of celiprolol and metoprolol.

To assess the effect of beta-blocker antihypertensive therapy on exercise capacity, 40 patients randomized to celiprolol 200 mg and metoprolol 100 mg daily in a double-blind fashion were studied after a month of placebo and a year of active treatment. Both drugs normalized office blood pressure and produced echocardiographic and electrocardiographic left ventricular hypertrophy regression. In symptom-limited maximal stress tests before and after treatment, exercise duration increased with (p < 0.0001) celiprolol (513-700 seconds) and metoprolol (520-634 seconds), although more with the former (p = 0.02). Resting heart rate was reduced with both, more with metoprolol (p < 0.001), while heart rate at peak exercise was reduced similarly with both medications (p < 0.005). Blood pressure at peak exercise was reduced with both celiprolol (217-184 mmHg; p = 0.0002) and metoprolol (218-185 mmHg, p < 0.0001) to a similar degree (p = NS). Exercise parameters were not related to patient age or the degree of left ventricular hypertrophy regression (p = NS). It is concluded that beta-blocker antihypertensive therapy improves exercise capacity, decreasing heart rate and blood pressure responses to stress, irrespective of left ventricular structural changes.

Exercise-induced QRS duration changes in patients with coronary artery disease-appearing "walkthrough" angina.

Two patients with coronary artery disease appearing as "walkthrough" angina underwent a treadmill exercise test. During the exercise, the patients appeared to have anginal pain associated with ST-segment depression and increased QRS duration. As the patients continued walking, anginal pain disappeared and a concomitant lessening in ST-segment depression and QRS prolongation was observed. Thus, the fact that the onset of angina was associated with ST-segment depression and prolonged QRS duration, while the disappearance of angina was associated with a decrease in ST-segment depression and QRS prolongation, is indicative of the effect of exercise-induced myocardial ischemia on QRS duration.

Significance of R wave changes in exercise-induced supraventricular extrasystoles. Angiographic correlates.

To evaluate the clinical significance of observed R wave amplitude changes in exercise-induced supraventricular extrasystoles in comparison to the preceding sinus beat, 94 patients catheterized for possible coronary artery disease (CAD) were studied. Significant CAD was documented in 63 patients--34 with myocardial infarction (group A1) and 29 without (group A2)--whereas 31 patients had normal coronary arteries or coronary lesions less than 30% (group B). All patients underwent treadmill stress testing using the Bruce protocol within a month after cardiac catheterization. R wave amplitude increased or remain unchanged in extrasystole (R(x-s) > or = 0) in patients with CAD, while it decreased (negative R(x-s) in patients without significant CAD (P < .0001). In patients with CAD R(x-s) values were positively related to the number of obstructed coronary arteries (P < .01), while no significant difference was found between groups A1 and A2. The correlations of R wave amplitude changes in extrasystoles were significant with coronary obstruction score values (r = .82 and .85 in groups A1 and A2, respectively) and with left ventricular ejection fraction values (r = -.88, -.86 and -.90 in groups A1, A2, and B, respectively). R(x-s) > or = 0 value had a sensitivity of 79% and a specificity of 90% for CAD detection, while sensitivity was higher (89%) and specificity was lower (57%) for the prediction of left ventricular dysfunction. It is concluded that R(x-s) > or = 0 value is indicative of CAD, multivessel disease, and poor left ventricular performance, while its negative value is combined with minimal or no CAD and normal ejection fraction values.

Exercise-induced S-wave prolongation in left anterior descending coronary artery stenosis.

Myocardial ischemia may decrease conduction velocity and produce QRS prolongation in the surface electrocardiogram. In cases with normal intraventricular conduction, areas of the myocardium contributing to the development of the S wave receive blood from all 3 major coronary arteries, whereas in left anterior hemiblock or right bundle branch block, most of the blood supply to the areas of the myocardium contributing to the development of the S wave is from the left anterior descending (LAD) coronary artery. To test the hypothesis that the S wave will be prolonged with exercise only in patients with LAD coronary artery stenosis and left anterior hemiblock or right bundle branch block, 88 patients with normal intraventricular conduction, 66 with left anterior hemiblock and 36 with right bundle branch block were studied. Sixty-four, 32 and 21 patients had LAD, right and left circumflex coronary artery stenoses, respectively. In patients with normal coronary arteries, S-wave duration decreased with exercise regardless of the status of ventricular conduction. In patients with coronary artery disease and normal intraventricular conduction, the S wave was prolonged slightly with exercise, but in those with left anterior hemiblock and right bundle branch block, it was prolonged significantly (12.5 +/- 6 and 10.4 ms, respectively) only in those with LAD, but not in those with circumflex or right coronary artery stenosis. S-wave prolongation in patients with LAD coronary artery stenosis and left anterior hemiblock or right bundle branch block most likely is related to exercise-induced ischemia in the areas of the myocardium contributing to the development of the S wave.

New coronary artery disease index based on exercise-induced QRS changes.

Exercise-induced changes in Q, R, and S wave amplitudes have been reported to detect coronary artery disease but with low specificity, low sensitivity, or both; it was hypothesized that their incorporation into a composite index (Athens QRS score) might improve specificity and sensitivity. For this purpose 246 patients were analyzed retrospectively and 160 prospectively. All patients underwent maximal exercise testing with a standard Bruce protocol and coronary arteriography as part of the diagnostic evaluation for possible or definite coronary artery disease. The Athens QRS score was decreased as the number of obstructed coronary arteries increased (normal coronary arteries = 7.85 +/- 5.23 mm, one-vessel disease = 5.2 +/- 5.3 mm, two-vessel disease = -0.85 +/- 5.4 mm, three-vessel disease = -3.5 +/- 5.8 mm; p less than 0.0001); the score was unrelated to exercise-induced ST segment depression, and negative (less than 0) scores were always associated with coronary artery disease. An Athens QRS score of 5 mm predicted coronary artery disease with sensitivity ranging from 75% to 86% and a specificity ranging from 73% to 79%, values higher than those of the Q wave (75% and 50%, respectively), R wave (65% and 55%), and S wave (70% and 10%) and of the ST segment depression (62% and 70%). It is concluded that exercise-induced changes in the QRS complex provide a useful index not only for the diagnosis but also for the assessment of severity of coronary artery disease.

Significance of ST segment depression in exercise-induced supraventricular extrasystoles.

The significance of exercise-induced ST segment depression in supraventricular extrasystoles (STx), in the preceding sinus beats (STs), as well as the significance of the difference between the two of them (STx-s), was studied in 96 patients with angiographically documented coronary artery disease (CAD) (group A)--34 with myocardial infarction (group A1) and 62 without (group A2)--compared to 37 subjects with normal coronary arteries (group B). All patients had supraventricular extrasystoles during exercise testing, the results of which were positive in 72 (75%) patients in group A and six (16.2%) patients in group B (sensitivity 75%, specificity 84%). Among patients in group A STx was greater than STs (1.7 +/- 1.0 vs 1.2 +/- 0.8 mm; p less than 0.001), and STx-s was positive in 70 (sensitivity 73%), whereas in group A2 there were 44 patients with these values (sensitivity 71%). Among patients in group B no statistically significant difference was found between STx and STx (0.4 +/- 0.6 vs 0.6 +/- 0.7 mm; p = NS), whereas STx-s was positive in three (specificity 92%). Among the 24 patients in group A with false negative results of exercise tests, 15 (62.5%) had a positive STx-s, whereas of the 17 patients in group A2 with false negative results, 10 (58.8%) had a positive STx-s. Among the six patients in group B with false positive exercise test results, the STx-s was positive in two.(ABSTRACT TRUNCATED AT 250 WORDS)