Value of non-apical echocardiographic views in the up-grading of patients with aortic stenosis.

Purpose. Echocardiography assessment from apical five-chamber view (A5CV) is the standard technique for aortic stenosis (AS) grading. Data on non-apical views, such as right parasternal (RPV), subcostal (SCV) and suprasternal notch (SSNV), is scarce and constitutes the aim of our study. Methods. We designed an observational study that included patients with AS recruited prospectively in whom the stenosis was graded by echocardiography from A5CV and non-apical view. The value of non-apical views in up-grading the stenosis severity (primary objective), the prognostic relevance of such reclassification and the feasibility and reproducibility of non-apical views assessment (secondary objectives) was evaluated. Results. Feasibility of AS appraisal from RPV, SCV and SSNV was 78%, 81% and 56%, respectively (SCV vs SSNV, p = .009). AS were up-graded from non-apical views according to peak gradient, mean gradient, area and indexed area by 24%, 17%, 24% and 22%, respectively (p < .0001). Non-apical views reclassified from non-severe to severe AS, from low gradient severe to high gradient severe AS and from non-critical to critical AS 19%, 23% and 3% of cases (p < .0001). The 4-years hard cardiac events rate was 41% in patients with non-severe AS, 67% in patients with severe AS from non-apical views, 68% in patients with severe AS from A5CV and 80% in patients with severe AS from A5CV and non-apical views (p < .001). Reproducibility of AS evaluation from non-apical views was fair to excellent (intraclass correlation coefficients: SSNV = 0.44, RPV = 0.61, SCV = 0.92). Conclusion. Assessment of AS from non-apical views is feasible, reproducible and valuable over A5CV; its use is encouraged.

Comparison of two strategies in a chest pain unit: stress echocardiography and multidetector computed tomography.

INTRODUCTION AND OBJECTIVES: This study aimed to compare stress echocardiography (SE) and multidetector computed tomography (MCT) in patients admitted to a chest pain unit to detect acute coronary syndrome (ACS). METHODS: A total of 203 patients with ≥ 1 cardiovascular risk factor, no ischemic electrocardiogram changes and negative biomarkers were randomized to SE (n=103) or MTC (n=100). The primary endpoint was a combination of hard events (death and nonfatal myocardial infarction), revascularizations, and readmissions during follow-up. The secondary endpoint was the cost of the 2 strategies. RESULTS: Invasive angiography was performed in 61 patients (34 [33%] in the SE group and in 27 [27%] in the MCT group, P=.15). A final diagnosis of ACS was made in 53 patients (88% vs 85%, P=.35). There were no significant differences between groups in the primary endpoint (42% vs 41%, P=.91), or in hard events (5% vs 7%, P=.42). There were no significant differences in overall cost, but costs were lower in patients with negative SE than in those with negative MCT (€557 vs €706, P <.02). CONCLUSIONS: No significant differences were found in efficacy and safety for the stratification of patients with a low to moderate probability of ACS admitted to a chest pain unit. The cost of the 2 strategies was similar, but cost was significantly lower for SE on comparison of negative studies.

Economic evaluation of complete revascularization versus stress echocardiography-guided revascularization in the STEACS with multivessel disease.

INTRODUCTION AND OBJECTIVES: Economic studies may help decision making in the management of multivessel disease in the setting of myocardial infarction. We sought to perform an economic evaluation of CROSS-AMI (Complete Revascularization or Stress Echocardiography in Patients With Multivessel Disease and ST-Segment Elevation Acute Myocardial Infarction) randomized clinical trial. METHODS: We performed a cost minimization analysis for the strategies (complete angiographic revascularization [ComR] and selective stress echocardiography-guided revascularization [SelR]) compared in the CROSS-AMI clinical trial (N=306), attributable the initial hospitalization and readmissions during the first year of follow-up, using current rates for health services provided by our health system. RESULTS: The index hospitalization costs were higher in the ComR group than in SelR arm (19 657.9±6236.8 € vs 14 038.7±4958.5 €; P <.001). There were no differences in the costs of the first year of follow-up rehospitalizations between both groups for (ComR 2423.5±4568.0 vs SelR 2653.9±5709.1; P=.697). Total cost was 22 081.3±7505.6 for the ComR arm and 16 692.6±7669.9 for the SelR group (P <.001). CONCLUSIONS: In the CROSS-AMI trial, the initial extra economic costs of the ComR versus SelR were not offset by significant savings during follow-up. SelR seems to be more efficient than ComR in patients with ST-segment elevation acute coronary syndrome and multivessel disease treated by emergent angioplasty. Study registred at ClinicalTrial.gov (Identifier: NCT01179126).

Angiographically Guided Complete Revascularization Versus Selective Stress Echocardiography-Guided Revascularization in Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Disease: The CROSS-AMI Randomized Clinical Trial.

BACKGROUND: Recent trials suggest that complete revascularization in patients with acute ST-segment-elevation myocardial infarction and multivessel disease is associated with better outcomes than infarct-related artery (IRA)-only revascularization. There are different methods to select non-IRA lesions for revascularization procedures. We assessed the clinical outcomes of complete angiographically guided revascularization versus stress echocardiography-guided revascularization in patients with ST-segment-elevation myocardial infarction. METHODS: We performed a randomized clinical trial in patients with multivessel disease who underwent a successful percutaneous coronary intervention of the IRA to test differences in prognosis (composite end point included cardiovascular mortality, nonfatal reinfarction, coronary revascularization, and readmission for heart failure after 12 months of follow-up) between complete angiographically guided revascularization (n=154) or stress echocardiography-guided revascularization (n=152) of the non-IRA lesions in an elective procedure before hospital discharge. RESULTS: The trial was prematurely stopped after the inclusion of 77% of the planned study population. As many as 152 (99%) patients in the complete revascularization group and 44 (29%) patients in the selective revascularization group required a percutaneous coronary intervention procedure of a non-IRA lesion before discharge. The primary end point occurred in 21 (14%) patients of the stress echocardiography-guided revascularization group and 22 (14%) patients of the complete angiographically guided revascularization group (hazard ratio, 0.95; 95% CI, 0.52-1.72; P=0.85). CONCLUSIONS: In patients with ST-segment-elevation myocardial infarction and multivessel disease, stress echocardiography-guided revascularization may not be significantly different to complete angiographically guided revascularization, thereby reducing the need for elective revascularization before hospital discharge. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01179126.

Tratamiento de la obstrucción del tracto de salida en la miocardiopatía hipertrófica mediante reparación mitral: «miectomía sin miectomía» / Mitral repair as a treatment of outflow tract obstruction in hypertrophic cardiomyopathy: "myectomy without myectomy"

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IAM secundario a compresión coronaria por hematoma periaórtico / AMI secondary to coronary compression by a periaortic pematoma

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The causes, consequences, and treatment of left or right heart failure.

Chronic heart failure (HF) is a cardiovascular disease of cardinal importance because of several factors: a) an increasing occurrence due to the aging of the population, primary and secondary prevention of cardiovascular events, and modern advances in therapy, b) a bad prognosis: around 65% of patients are dead within 5 years of diagnosis, c) a high economic cost: HF accounts for 1% to 2% of total health care expenditure. This review focuses on the main causes, consequences in terms of morbidity, mortality and costs and treatment of HF.

Obliteración auricular izquierda por un aneurisma de aorta secundario a una disección aórtica crónica / Left atrial obliteration due to an aortic aneurysm secondary to chronic aortic dissection

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[Contrast-induced nephropathy and acute renal failure following emergent cardiac catheterization: incidence, risk factors and prognosis]. / Nefropatía inducida por contraste y fracaso renal agudo tras cateterismo cardiaco urgente: incidencia, factores de riesgo y pronóstico.

INTRODUCTION AND OBJECTIVES: The aim was to investigate the incidence and prognosis of, and predictive factors for, acute renal failure following emergent cardiac catheterization. METHODS: The study involved 602 consecutive patients who underwent emergent cardiac catheterization. Acute renal failure (ARF) was defined as an increase in serum creatinine level > or =0.5 mg/dL within 72 hours following the procedure. Predictive factors for and the prognosis of ARF were evaluated in an initial cohort of 315 patients, and a risk score was derived. The risk score was validated in a second cohort of 287 patients. The median (interquartile) follow-up time was 1.3 years (0.8-2.0 years). RESULTS: Seventy-two of the 602 patients (12.0%) developed ARF. In the initial cohort of 315 patients, the following factors were predictors of ARF: cardiogenic shock at admission (odds ratio [OR] 4.56), diabetes mellitus (OR 2.98), time to reperfusion >6 hours (OR 3.18), anterior myocardial infarction (OR 2.61), baseline serum creatinine level > or =1.5 mg/dL (OR 3.51), and baseline serum urea level > or =50 mg/dL (OR 3.00). A risk score based on these variables was constructed in which cardiogenic shock = 3 points and each of the remaining variables = 2 points. Patients in the validation cohort were divided into five risk categories: in those with 0 points, the incidence of ARF was 1.2%; with 2-3 points, 8.7%; with 4-5 points, 12.5%; with 6-7 points, 46.2%; and with > or =8 points, 66.7% (P< .0001). Cox regression analysis showed that ARF was a powerful predictor of total mortality (hazard ratio [HR] 5.97, 95% confidence interval [CI] 2.54-14.03; P< .0001) and of a major cardiovascular event (HR 3.29, 95% CI 1.61-6.75; P=.001). CONCLUSIONS: The incidence of ARF after emergent cardiac catheterization is high. Cardiogenic shock, diabetes mellitus, myocardial infarction location, time to reperfusion, and serum creatinine and urea levels are predictors of ARF. Patients who developed this complication had higher mortality and major cardiovascular events rates.

Nefropatía inducida por contraste y fracaso renal agudo tras cateterismo cardiaco urgente: incidencia, factores de riesgo y pronóstico / Contrast-induced nephropathy and acute renal failure following emergent cardiac catheterization: incidence, risk factors and prognosis

Introducción y objetivos. Nuestro objetivo fue analizar la incidencia, los factores predictores y el pronóstico de la insuficiencia renal aguda (IRA) tras un cateterismo cardiaco urgente. Métodos. Estudiamos a 602 pacientes consecutivos sometidos a cateterismo urgente. Se definió IRA como un incremento absoluto del valor de creatinina sérica ≥ 0,5 mg/dl en las 72 h siguientes al procedimiento. En una primera cohorte de 315 pacientes evaluamos los factores predictores y el pronóstico de IRA y elaboramos una clasificación de riesgo, que validamos en una segunda cohorte de 287 pacientes. La mediana (rango intercuartílico) de seguimiento fue de 1,3 (0,8-2) años. Resultados. De los 602 pacientes, 72 (12%) desarrollaron IRA. En la cohorte de 315 pacientes, los predictores independientes de IRA fueron: shock cardiogénico al ingreso (odds ratio [OR] = 4,56), diabetes mellitus (OR = 2,98), tiempo a la reperfusión > 6 h (OR = 3,18), localización anterior del infarto (OR = 2,61) y valores basales de creatinina ≥ 1,5 mg/dl (OR = 3,51) y de urea sérica ≥ 50 mg/dl (OR = 3). Se construyó una clasificación de riesgo usando esas variables (shock cardiogénico = 3 puntos; demás variables = 2 puntos); los pacientes de la cohorte de validación fueron clasificados en 5 categorías de riesgo: 0 puntos, el 1,2% de incidencia de IRA; 2-3 puntos, el 8,7%; 4-5 puntos, el 12,5%; 6-7 puntos, el 46,2%; ≥ 8 puntos, el 66,7% (p < 0,0001). En el análisis de regresión de Cox, la IRA resultó ser un poderoso predictor de mortalidad (hazard ratio [HR] = 5,97; intervalo de confianza [IC] del 95%, 2,54-14,03; p < 0,0001) y de eventos cardiovasculares mayores (HR = 3,29; IC del 95%, 1,61-6,75; p = 0,001). Conclusiones. La incidencia de IRA tras un cateterismo urgente es elevada. El shock cardiogénico, la diabetes mellitus, la localización del infarto, el tiempo a la reperfusión y la creatinina y la urea séricas son predictores de IRA. Los pacientes que desarrollaron esta complicación presentaron mayor tasa de mortalidad y de eventos cardiovasculares mayores (AU)

Introduction and objectives. The aim was to investigate the incidence and prognosis of, and predictive factors for, acute renal failure following emergent cardiac catheterization. Methods. The study involved 602 consecutive patients who underwent emergent cardiac catheterization. Acute renal failure (ARF) was defined as an increase in serum creatinine level ≥0.5 mg/dL within 72 hours following the procedure. Predictive factors for and the prognosis of ARF were evaluated in an initial cohort of 315 patients, and a risk score was derived. The risk score was validated in a second cohort of 287 patients. The median (interquartile) follow-up time was 1.3 years (0.8­2.0 years). Results. Seventy-two of the 602 patients (12.0%) developed ARF. In the initial cohort of 315 patients, the following factors were predictors of ARF: cardiogenic shock at admission (odds ratio [OR] 4.56), diabetes mellitus (OR 2.98), time to reperfusion >6 hours (OR 3.18), anterior myocardial infarction (OR 2.61), baseline serum creatinine level ≥1.5 mg/dL (OR 3.51), and baseline serum urea level ≥50 mg/dL (OR 3.00). A risk score based on these variables was constructed in which cardiogenic shock = 3 points and each of the remaining variables = 2 points. Patients in the validation cohort were divided into five risk categories: in those with 0 points, the incidence of ARF was 1.2%; with 2­3 points, 8.7%; with 4­5 points, 12.5%; with 6­7 points, 46.2%; and with ≥8 points, 66.7% (P<.0001). Cox regression analysis showed that ARF was a powerful predictor of total mortality (hazard ratio [HR] 5.97, 95% confidence interval [CI] 2.54­14.03; P<.0001) and of a major cardiovascular event (HR 3.29, 95% CI 1.61­6.75; P=.001). Conclusions. The incidence of ARF after emergent cardiac catheterization is high. Cardiogenic shock, diabetes mellitus, myocardial infarction location, time to reperfusion, and serum creatinine and urea levels are predictors of ARF. Patients who developed this complication had higher mortality and major cardiovascular events rates (AU)

[Prognostic value of treadmill exercise echocardiography]. / Valor pronóstico de la ecocardiografía de ejercicio en cinta rodante.

INTRODUCTION AND OBJECTIVES: Exercise echocardiography (EE) is useful for diagnosing coronary disease, but little is known about its value for risk stratification. We aimed to determine: a) whether data from EE supplemented clinical data and data from exercise testing and resting echocardiography in predicting cardiac events; and b)whether the number and location of abnormal regions and their responses to exercise influenced risk stratification. PATIENTS AND METHOD: The 2,436 patients referred for EE were followed up for 2.1+/-1.5 years. Some 120 serious cardiovascular events (i.e., non-fatal myocardial infarction or cardiovascular death) occurred before revascularization. RESULTS: In 1203 patients (49%), EE gave abnormal results. There were 89 events in patients with an abnormal result (7.3%) and 31 in those with a normal result (2.5%; P<.0001). Multivariate analysis of clinical data, and data from exercise testing, resting echocardiography, and EE showed that male sex (RR=1.7; 95% CI, 1.1-2.8; P=.02), metabolic equivalents or METs (RR=0.9; 95% CI, 0.86-0.98; P=.01), peak heart rate x blood pressure (RR= 0.9;95% CI, 0.9; P=.002), resting wall motion score index (RR=2.5; 95% CI, 1.5-4.1; P<.0001), and number of abnormal regions at peak exercise (RR=1.4; 95% CI, 1.2-1.7; P<.0001) were independently associated with the risk of a serious event (final model chi2, 170; incremental P<.0001). The same variables, excluding sex, were independently associated with cardiovascular death (final model chi2, 169; incremental P=.01). CONCLUSIONS: Exercise echocardiography supplements clinical data and data from exercise testing and resting echocardiography in patients with known or suspected coronary artery disease.

Valor pronóstico de la ecocardiografía de ejercicio en cinta rodante / Prognostic value of treadmill exercise echocardiography

Introducción y objetivos. Aunque la ecocardiografía de ejercicio es útil para el diagnóstico de la enfermedadcoronaria, hay menos datos referentes a su valor pronóstico. El objetivo de este estudio fue esclarecer: a) si hay un valor incremental de la ecocardiografía en el pico del ejercicio respecto a las variables clínicas, la prueba de esfuerzo y la ecocardiografía en reposo, y b) si el número y la localización de los territorios afectados, así como el tipo de respuesta al ejercicio, influyen en la estratificación. Pacientes y método. En 2.436 pacientes referidos para ecocardiografía de ejercicio se realizó un seguimiento de 2,1 ±1,5 años. Hubo 120 eventos (infarto no fatal o muerte cardiovascular) antes de la revascularización. Resultados. La ecocardiografía fue anormal en 1.203p acientes (49%). Hubo 89 eventos en pacientes con resultado anormal (7,3%) frente a 31 con resultado normal (2,5%; p < 0,001). Mediante un análisis multivariable de variables clínicas, de la prueba de esfuerzo y de la ecocardiografía en reposo y ejercicio encontramos que las variables asociadas de manera independiente con el riesgo deeventos eran: ser varón (riesgo relativo [RR] = 1,7; intervalo de confianza [IC] del 95%, 1,1-2,8; p = 0,02), los equivalentes metabólicos o MET (RR = 0,9; IC del 95%, 0,9-1,0;p = 0,01), el producto frecuencia cardíaca × presión arterial(RR = 0,9; IC del 95%, 0,9-1,0; p = 0,02), el índice de motilidad segmentaria basal (RR = 2,5; IC del 95%, 1,5-4,1; p <0,0001) y el número de territorios afectados (RR = 1,4; ICdel 95%, 1,2-1,7; p < 0,0001) (χ² final = 170, valor incremental de la ecocardiografía en el máximo esfuerzo; p <0,0001). Las mismas variables, excepto el sexo, estaban asociadas con la muerte (χ² final = 169, valor incremental de la ecocardiografía de ejercicio; p = 0,01). Conclusiones. La ecocardiografía en el máximo ejercicio incrementa el valor pronóstico de las variables clínicas, la prueba de esfuerzo y la ecocardiografía de reposo

Introduction and objectives. Exercise echocardiography (EE) is useful for diagnosing coronary disease, but little is known about its value for risk stratification. We aimed to determine: a) whether data from EE supplemented clinical data and data from exercise testing and resting echocardiography in predicting cardiac events; and b)whether the number and location of abnormal regions and their responses to exercise influenced risk stratification. Patients and method. The 2,436 patients referred for EE were followed up for 2.1±1.5 years. Some 120 serious cardiovascular events (i.e., non-fatal myocardial infarctionor cardiovascular death) occurred before revascularization. Results. In 1203 patients (49%), EE gave abnormal results. There were 89 events in patients with an abnormalresult (7.3%) and 31 in those with a normal result (2.5%; P<.0001). Multivariate analysis of clinical data, and data from exercise testing, resting echocardiography, and EE showed that male sex (RR=1.7; 95% CI, 1.1-2.8; P=.02),metabolic equivalents or METs (RR=0.9; 95% CI, 0.86-0.98; P=.01), peak heart rate × blood pressure (RR= 0.9;95% CI, 0.9; P=.002), resting wall motion score index(RR=2.5; 95% CI, 1.5-4.1; P<.0001), and number of ab-normal regions at peak exercise (RR=1.4; 95% CI, 1.2-1.7; P<.0001) were independently associated with the risk of a serious event (final model χ², 170; incremental P<.0001). The same variables, excluding sex, were independently associated with cardiovascular death (final model χ², 169; incremental P=.01). Conclusions. Exercise echocardiography supplements clinical data and data from exercise testing and resting echocardiography in patients with known or suspected coronary artery disease

[Exercise echocardiography to differentiate dilated cardiomyopathy from ischemic left ventricular dysfunction]. / Ecocardiografía de ejercicio para diferenciar la miocardiopatía dilatada de la disfunción ventricualr por cardiopatía isquémica.

OBJECTIVES: Previous studies have shown the usefulness of dobutamine echocardiography to differentiate dilated cardiomyopathy (DC) from ischemic left ventricular dysfunction (ILVD), but no studies have been made using exercise echocardiography (EE). We hypothesized that most patients with DC have some contractile reserve and experience an increase in left ventricular ejection fraction (LVEF) during exercise, as opposed to patients with ILVD. Differences in response to EE may be useful to clinically differentiate between these two entities. PATIENTS AND METHOD: Between 1 March 1995 and 1 March 2001, we performed 4,133 EE studies on 3,830 patients. Of 289 patients (8%) with moderate or severe LV dysfunction (biplane LVEF < 41% and left ventricular end-diastolic diameter > 5.2 cm), 207 were excluded: 111 for a history of myocardial infarction; 28 for scarring on echocardiography (regional akinesia/dyskinesia with thinning and/or increased brightness); 13 for previous revascularization procedures; 9 for aortic valve disease; 11 for a known cause of cardiomyopathy; and 35 for not undergoing angiography. The study group was therefore composed of 82 patients who were encouraged to perform maximal treadmill EE. EE criteria for ILVD were either impaired regional wall motion (RWM) or a decrease/no change in LVEF from baseline to peak exercise, while criteria for DC were RWM improvement/no change and LVEF increase. The ILVD group was formed by 39 patients with stenosis >/= 70% diameter stenosis of a major epicardial coronary artery or major branch vessel. The remaining 43 patients constituted the DC group. RESULTS: The number of coronary risk factors (ILVD 2.0 1.1; DC 1.9 1.1), baseline LVEF (ILVD 30 7; DC 30 8), and exercise-induced angina (ILVD 23%; DC 14%) did not differ between groups (p = NS). ILVD patients achieved less Mets (6.6 3.1 vs 8.3 2.8; p < 0.05), had a lower heart rate x systolic blood pressure product (22 5 vs 27 7; p < 0.001), and developed regional and/or global LV dysfunction more frequently (79 vs 28%; p < 0.001). Sensitivity, specificity, positive and negative predictive values and global accuracy for ILVD detection were 79% (95% CI: 70-88), 72% (95% CI: 63-81), 72% (95% CI: 63-81), 79% (95% CI: 67-85), and 76% (95% CI: 69-83), respectively. CONCLUSION: Global and/or regional LV function impairment with exercise is accurate in identifying patients with ILVD. This method could reduce the need for invasive procedures.

Ecocardiografía de ejercicio para diferenciar la miocardiopatía dilatada de la disfunción ventricular por cardiopatía isquémica / Exercise echocardiography to differentiate dilated cardiomyopathy from ischemic Left Ventricular Dysfunction

Objetivos. Aunque la ecocardiografía con dobutamina diferencia la miocardiopatía dilatada (MD) de la disfunción ventricular debida a cardiopatía isquémica (DVCI), no existen estudios al respecto con ecocardiografía de ejercicio (EE). Con la hipótesis de que los pacientes con MD pueden tener reserva contráctil, al contrario que aquellos con DVCI, hemos estudiado a enfermos con disfunción ventricular (DV) izquierda sometidos a EE. Entre 1995 y 2001 realizamos 4.133 EE a 3.830 pacientes. De 289 enfermos con DV (fracción de eyección ventricular izquierda [FEVI] por método biplano 5,2 cm) se excluyó a 207: 111 por historia de infarto de miocardio; 28 por necrosis (acinesia-discinesia con adelgazamiento o brillo aumentado); 13 por revascularización; 9 por valvulopatía aórtica; 11 por causa conocida de miocardiopatía, y 35 por ausencia de coronariografía. Pacientes y método. Por tanto, el grupo de estudio estaba formado por 82 pacientes que fueron estimulados a realizar EE máxima en cinta: 39 pacientes con estenosis > 69 per cent en una arteria epicárdica principal o una rama importante formaban el grupo de DVCI y el resto (n = 43), el de MD. El criterio para DVCI era empeoramiento de la motilidad segmentaria o descenso o igual FEVI con el ejercicio, mientras que el criterio para MD era mejoría o ausencia de cambio en la motilidad segmentaria y aumento de la FE. Resultado. El número de factores de riesgo coronario (DVCI, 2,0 ñ 1,1; MD, 1,9 ñ 1,2), FEVI basal (DVCI, 30 ñ 7; MD, 30 ñ 8) y porcentaje de aparición de angina (DVCI, 23 per cent; MD, 14 per cent) eran similares (p = NS), mientras que los pacientes con DVCI alcanzaron menos Mets (6,6 ñ 3,1 frente a 8,3 ñ 2,8; p < 0,05) y producto frecuencia cardíaca × presión arterial (22 ñ 5 frente a 27 ñ 7; p < 0,001), y desarrollaron disfunción regional o global más frecuentemente (79 frente a 28 per cent; p < 0,001). La sensibilidad, el especificidad, el valor predictivo positivo y negativo y la precisión diagnóstica para DVCI fueron del 79 per cent (IC del 95 per cent, 70-88), 72 per cent (63-81), 72 per cent (63-81), 79 per cent (6785) y 76 per cent (69-83).Conclusión. En conclusión, una respuesta de empeoramiento de la función ventricular con el ejercicio identifica a los pacientes con DVCI con razonable precisión diagnóstica. La EE puede reducir, por tanto, la necesidad de procedimientos invasivos (AU)