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INTRODUCTION: The exercise treadmill test is widely used in the evaluation of patients with suspected or known coronary artery disease. The typical ischemic response used to be ST-segment depression. CASE PRESENTATION: We describe a case of a 51-year-old Caucasian man with an unusual ischemic response during the exercise treadmill test: a "giant R wave" electrocardiogram pattern as a manifestation of hyperacute ischemia that resolved with sublingual nitroglycerin. Coronary catheterization showed a severe stenosis in a proximal dominant circumflex coronary artery. We hypothesize that, in this case, the "giant R wave" pattern was related to severe hyperacute ischemia due to coronary spasm superimposed on the atherosclerotic lesion, which probably caused complete occlusion of the artery. The patient was successfully treated with coronary percutaneous revascularization. CONCLUSIONS: This is a dramatic and rare ischemic response during the exercise treadmill test, in which, a rapid administration of nitroglycerin can prevent life-threatening events.
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BACKGROUND: Left ventricular ejection fraction (LVEF) is the strongest predictor of survival in patients with chronic stable angina (CSA). Inflammation plays a key role in the pathogenesis of atherosclerosis and an enhanced inflammatory status has a negative impact on patient outcome. It is not known whether a relationship exists between inflammation and LV function in patients with CSA. We therefore sought to investigate whether C reactive protein (CRP) and neopterin correlate with LV dysfunction in patients with CSA. METHODS: We assessed 181 patients with CSA who underwent diagnostic coronary angiography in our institution. High-sensitivity CRP and neopterin serum concentrations were measured immediately before angiography. RESULTS: Baseline neopterin levels - but not CRP - showed a significant inverse correlation with LVEF (r=-0.222; p=0.003 and r=-0.097; p=0.194, respectively). After adjustment for relevant confounders which included, among others, the extent and severity of coronary disease, neopterin was found to be independently associated with LVEF (B -2.36, CI 95% -4.560 to -0.176, p=0.034). Moreover, high neopterin levels were an independent predictor of LV dysfunction (LVEF <45%) (OR, 8.52, CI 95% 1.10-65.64; p=0.040). Receiver operating characteristic analysis for neopterin showed an area under the curve of 0.736 (CI 95% 0.59-0.87, p<0.009) for prediction of LV dysfunction. CONCLUSION: Increased serum neopterin concentrations inversely correlate with LVEF values and high neopterin levels are a predictor of LV dysfunction in patients with CSA, irrespective of the extent and severity of coronary artery disease. Neopterin may thus be clinically useful for patient risk stratification.
