85% of maximal age-predicted heart rate is not a valid endpoint for exercise treadmill testing.

BACKGROUND: Exercise testing should be symptom-limited. Nevertheless, 40% of clinical laboratories applying for ICANL accreditation use 85% of maximal age-predicted heart rate (MPHR) as the primary exercise endpoint. We hypothesized that this approach importantly may underestimate exercise capacity and inducible ischemia. METHODS: Two patient cohorts were studied. 1. A prospective registry of patients referred for exercise testing. 2. A retrospective cohort of patients with positive exercise ECG. RESULTS: Of 306 registry patients, 211 (69%) continued exercising after reaching 85% MPHR to maximal HR of 101% ± 7% of MPHR. Forty-two patients (14%) stopped <1 minute after achieving 85% MPHR; 53 (17%) did not achieve 85% MPHR. More women (75%) than men (64%) achieved >85% MPHR (P = .02). Of 300 patients with positive ECG, 232 patients (77%) exercised to >85% MPHR. At 85% MPHR 144 patients (62%) had positive ECG (1.2 ± .7 mm ST depression) compared to 232 patients (100%) at peak exercise (2.3 ± .9 mm ST depression, P < .001). Mean workload at 85% MPHR was 7.3 ± 2.4 METs compared to 10.6 ± 2.8 METs at peak exercise (P < .001). CONCLUSION: Achievement of 85% MPHR is not a valid diagnostic or functional exercise endpoint because it significantly underestimates exercise capacity and inducible ischemia.

Comparison of bleeding complications with omega-3 fatty acids + aspirin + clopidogrel--versus--aspirin + clopidogrel in patients with cardiovascular disease.

Fish oil is used to lower triglycerides and for the secondary prevention of cardiovascular events in patients with coronary artery disease. Many of these patients will also be taking aspirin and clopidogrel. Any of these medications alone can increase the risk of bleeding; however, the risk of bleeding in patients taking all 3 of these medications has not been studied. We retrospectively reviewed the medical records for bleeding complications in 182 patients, most with coronary artery disease (mean age 61 +/- 11 years, 82% men) and being treated with high-dose fish oil (mean dose 3 +/- 1.25 g), aspirin (mean dose 161 +/- 115 mg), and clopidogrel (mean dose 75 mg), and in 182 age- and gender-matched controls treated with aspirin and clopidogrel alone. During a mean follow-up period of 33 months, 1 major bleeding episode occurred in the treatment group and no major bleeding episodes occurred in the control group (p = 1.0). During follow-up, 4 minor bleeding episodes (2.2%) occurred in the treatment group and 7 (3.9%) in the control group. More patients had minor bleeding complications in the control group than in the treatment group; however, the difference was not statistically significant (p = 0.5). In conclusion, high-dose fish oil is safe in combination with aspirin and clopidogrel and does not increase the risk of bleeding compared with that seen with aspirin and clopidogrel alone.