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Objective-To determine the diagnostic value of the exercise tolerance test (ETT) in women presenting with chest pain. Design-Prospective study of all women presenting to a centre with chest pain between 1987 and 1993 who were assessed by an ETT and coronary angiography. Setting-The outpatient clinic of one consultant cardiologist in a tertiary referral centre. Patients-Alil women referred to this outpatient clinic with chest pain were screened. For inclusion, patients had to perform ETT and undergo coronary angiography. Of the 347 referred during this period, 142 were excluded because they were unable to perform ETT or because of Q waves or other abnormalities on their resting electrocardiogram. Results-Overall the sensitivity of the ETT was 68% and the specificity was 61%, with a positive predictive value of 0-61 and a negative predictive value of 0-68. There were 42 false positive and 31 false negative ETT results (36% of the study group). The predictive value of a negative test was higher in younger women (< 52 years) than in the older group () 52 years) (P = 0.004), but the positive predictive value in the two groups was not significantly different. The predictive value of a negative test was also higher in those with two or fewer risk factors than in those with three or more risk factors (P = 0.001). The negative predictive value for those women above 52 years with three or more risk factors (24% of the study group) was only 0 25. Lack of chest pain during ETT was associated with a higher negative predictive value in the younger group than in the older women (P = 0.006).Conclusions-In women with chest pain use of the ETT was a misleading predictor of the presence or absence of coronary disease in 36% of these patients. In particular, a negative test in older women with three or more risk factors had a very low predictive value. The inclusion of risk factors and division by age can, however, be used to identify a population at intermediate risk for coronary artery disease in whom the ETT result has the highest diagnostic utility. (Heart 1996;76:156-160) Keywords: exercise test; women; chest pain; coronary angiography.Coronary disease is a common cause of morbidity and mortality in women, and is the commonest cause of death in those over the age of 65 years.' According to the Framingham study2 the prevalence of coronary artery disease in younger women is lower than in men, but the death rates of the two sexes converge in late middle age. Women with chest pain account for a considerable proportion of cardiological referrals.3Exercise testing has been a widely used screening procedure for the assessment of cardiac status for over 30 years. None the less, the value of this procedure in the screening of women to predict the presence of obstructive coronary disease has been the subject of considerable controversy.4-8 The usual electrocardiographic criteria applied in exercise testing seem less valuable in women than in men.4 In symptom free women "significant" ST segment changes are up to three times...

BRITISH MEDICAL JOURNAL10 MAY 1975 315 energy shocks were successful then. The initial shock was unsuccessful in 7%O (two out of 28) of patients with primary fibrillation, but a second shock of identical energy was successful in both patients. The success of the second shock when the initial one has failed29 may be related to the decreased impedance with successive shocks.30 Apart from allowing smaller and lighter defibrillators these lower energy shocks cause less myocardial damage.Our findings indicate the need for further investigation of the energy needed for defibrillation. Tacker et al.28 claim that defibrillators should have a much higher output capacity than they do at present, but high capacity output instruments would be much heavier, more cumbersome, and more expensive and, therefore, less generally available. If it is confirmed that lowenergy direct current shocks, particularly when repeated, will almost invariably correct ventricular fibrillation a cheap and generally available pocket defibrillator will be a possibility.

Objectives-To investigate the efficacy of transdermal glyceryl trinitrate given continuously and with a nocturnal nitrate free period.Design-Double blind placebo controlled study with two parallel limbs.Setting-Multicentre trial.Patients-52 patients randomised to receive either continuous treatment (23 patients) or intermittent treatment with an individually titrated dose (29 patients) for 14 days: both treatments were compared with placebo in a crossover fashion.Intervention-Continuous treatment with 10 mg per 24 hours of transdermal glyceryl trinitrate or intermittent transdermal glyceryl trinitrate titrated to give an arbitrary 10 mm Hg drop in systolic blood pressure (mean dose 18-2 mg) given over approximately 16 hours.Main outcome measure-Treadmill exercise stress testing and ambulatory monitoring of the ST segment after 14 days' treatment.Results-After 14 days' intermittent treatment resting supine and standing systolic blood pressure fell by 7 5 mm Hg (95% confidence interval 2-7 to 12-2) and 9 0 mm Hg (95% CI 3-4 to 14-5) respectively (p < 0-01); resting heart rate was unchanged. Mean heart rate at 1 mm ST segment depression rose by 11 9 beats/ min (CI 1-1 to 23-7) (p < 0-05), mean time to onset of angina increased by 59 seconds

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