In this series, although women comprised the minority of patients referred with chest pain, a diagnosis of normal coronary arteries was five times more common in women than men. Risk factor analysis and exercise testing were of limited value in predicting coronary artery disease in women. There was no sex bias regarding revascularisation procedures, and outcome was similar. A diagnosis of non-cardiac chest pain in patients with normal coronary arteries was of little benefit to the patient with regard to morbidity.
The pathogenesis of the limiting symptoms in patients with chronic heart failure, shortness of breath and fatigue on exercise, are poorly understood. We analysed data from 222 incremental symptom limited exercise tests to determine whether there were differences between patients stopped by breathlessness or fatigue. One hundred and sixty patients were stopped by breathlessness and 62 by fatigue. There was no differences between the two groups in underlying diagnosis or in exercise performance (peak oxygen consumption 15.66 (+/- 5.62) ml.kg-1.min-1 in the fatigue group, 15.13 (+/- 4.64) in the breathless group). The ventilatory response as assessed by ventilatory response to carbon dioxide production (VE/VCO2 slope) was not different between the two groups (2.61 (+/- 0.96) in the fatigue group, 3.03 (+/- 1.23) in the breathless group: P = ns). There were no differences between the two groups in left ventricular dimensions, left ventricular ejection fraction or left ventricular end-diastolic pressure. The limiting symptoms of breathlessness and fatigue in chronic heart failure are two sides of the same coin. Any pathophysiological explanation of exercise limitation in chronic heart failure must unify these two symptoms.
(19%) had an adverse event (cardiac deaths (n = 3), non-fatal myocardial infarction (n = 6) and, emergency revascularisation (n = 31)). Both admission ECG ST depression (P = 0.02), and transient ischaemia (P < 0.001) predicted an increased risk of non-fatal myocardial infarction or death, while no patients with a normal ECG died or had a myocardial infarction. Adverse outcome was predicted by admission ECG ST depression (regardless of severity) (odds ratio (OR) 3-41) (P < 0.001), and maintenance P blocker treatment (OR 2.95) (P < 0.01). A normal ECG predicted a favourable outcome (OR 0.38) (P = 0.04), while T wave or other ECG changes were not predictive of outcome. Transient ischaemia was the strongest predictor of adverse prognosis (OR 4.61) (P < 0.001), retaining independent predictive value in multivariate analysis (OR 2.94) (P = 0.03), as did maintenance ,B blocker treatment (OR 2.85) (P = 0.01) and admission ECG ST depression, which showed a trend towards independent predictive value (OR 2.11) (P = 0.076). Conclusions-Patients with unstable angina and a normal admission ECG have a good prognosis, while ST segment depression predicts an adverse outcome. Transient myocardial ischaemia detected by continuous ST segment monitoring in such patients receiving optimal medical treatment provides prognostic information additional to that gleaned from the clinical characteristics or the admission ECG.
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