The value of exercise testing for the diagnosis of coronary artery disease is disputed but very few studies have taken advantage of all recent improvements, namely computer averaging of the ECG signals, multivariate analysis of the data, a compartmental diagnostic approach and probabilistic interpretation of the results. These methods were tested in a group of 387 men who had a computer-assisted multistage maximal exercise test; none had a history of myocardial infarction. In 284 symptomatic patients, the diagnosis was made by arteriography; 103 ostensibly healthy men were also included. The computer-averaged ECG signals (X, Y, Z) recorded at maximal exercise, maximal heart rate, blood pressure and workload, and the onset of angina pectoris during exercise were submitted to a multivariate stepwise discriminant analysis. The pretest likelihood for CAD was calculated from age and history; the post-test likelihood was calculated from Bayes' theorem and the average information content of several diagnostic methods was assessed in categorical and compartmental models. By multivariate analysis, 5 variables collected at maximal exercise were selected, namely the heart-rate, the ST60 segment level, the onset of angina during the test, the workload and the slope of the ST segment in lead X. The average information content of the analysis using 5 variables was 44% in a categorical model versus 55% in a compartmental model (P less than 0.001). For comparison, the information content of the analysis using the ST60 segment level alone was only 16% in the categorical model and 27% in the compartmental model. The clinical value of these diagnostic methods (categorical versus compartmental, univariate versus multivariate) was assessed by a probabilistic classification of the patients. The classification provided by the analysis of the ST60 segment changes was barely better than that one provided by the simple history. The probabilistic use of a multivariate and compartmental analysis of the data led to a significantly better and more accurate classification of the patients (83% of correct classification).

To assess local myocardial relaxation abnormalities in patients with coronary artery disease, local myocardial left ventricular wall stress was computed in nine normal subjects and in 22 patients with coronary artery disease. In normal left ventricles, the rate of decrease in isovolumic local stress was not significantly different from the rate of decrease in isovolumic pressure, and the residual wall stress at the end of isovolumic relaxation was uniformly low. In patients with coronary artery disease, the residual wall stress was increased both in infarcted areas and in noninfarcted areas perfused by stenosed arteries (43 ± 31 and 30 ± 19 kdyne/cm2, respectively, vs 9 + 5 kdyne/cm2 in normal areas; p < .001). Circulation 69, No. 4, 696-702, 1984. ABNORMALITIES in left ventricular relaxation and diastolic filling are more common in patients with coronary artery disease. 1-6 Some investigators suggest that these impairments might play an important pathophysiologic role by reducing coronary perfusion and ventricular compliance and by augmenting filling pressures.7 Many studies have therefore been performed to quantify these alterations and their response to interventions such as calcium-antagonist therapy, positive inotropic stimulation, or coronary angioplasty. -10 For practical reasons, all these studies focused on global indexes of left ventricular relaxation such as the time course of decrease in isovolumic pressure'1 2 4. 5. 10 or the dynamics of the rapid filling.3 6 8, However, experimental and clinical studies in ischemic heart disease have shown asynchronous wall motion and wall thinning during early diastole."'7 Furthermore, Lud- Received Nov. 8, 1983; accepted Dec. 15, 1983. Presented in part at the 56th Scientific Sessions of the American Heart Association, Anaheim, 1983. brook et al.'7 observed that in patients with coronary artery disease, impaired global left ventricular relaxation was consistently accompanied by asynchronous protodiastolic wall motion. Such an inhomogeneity of diastolic behavior suggests that global indexes can only imperfectly quantify the abnormalities in diastolic function. Recently, Janz'6 proposed a formula to compute local myocardial stress, which could be easily applied to angiographic data. This approach allows changes in geometric factors and wall thickness to be taken into account during assessment of relaxation. The purpose of this study was therefore to compute local myocardial wall stress in normal subjects and in patients with coronary artery disease and to determine whether clinically important information could be derived from this analysis. Patients and methodsThirty-one patients were retrospectively selected for this study because their left ventricular angiograms showed a good definition of wall thickness in inferior and anterior left ventricular walls. Of these patients, nine (mean age 46 years, range 37 to 60) who had atypical chest pain but completely normal ventriculograms and coronary arteries were considered normal control subjects. Twe...

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1 The effects ofintravenous nicardipine (2.5 mg) on the left ventricular (LV) inotropic state, LV metabolism, and coronary haemodynamics were analysed in 22 patients with angina pectoris. 2 Measurements were made at fixed heart rate (atrial pacing), under basal state, and during a cold pressor test. 3 After nicardipine, coronary blood flow and oxygen content in the coronary sinus increased significantly. 4 The indices of inotropic state increased slightly, and the rate of isovolumic LV pressure fall improved. 5 Myocardial oxygen consumption was unchanged despite the significant reduction in pressure-rate product, but LV lactate uptake increased, particularly during the cold pressor test. 6 When nicardipine was administered after propranolol, the indices of inotropic state were unaffected. 7 The lack of direct effect of nicardipine on LV inotropic state was further confirmed by intracoronary injection of 0.1 and 0.2 mg in a separate group of 10 patients. 8 It is concluded that the nicardipine-induced coronary dilatation seems to improve perfusion and aerobic metabolism in areas with chronic ischaemia, resulting in reduced lactate production and augmented oxygen consumption. Keywords angina pectoris coronary vascular resistance inotropic state myocardial metabolism nicardipine vasodilatation

The computed tomographic (CT) findings in six patients with periportal tuberculous adenitis were reviewed retrospectively to analyze the main morphologic features of the disease. In all patients, hypodense lymph nodes were observed close to the porta hepatis, with peripheral enhancement seen after administration of contrast material. In one patient, this hypodense adenopathy was associated with homogeneous, normally enhancing lymph nodes. These different features on the CT scans could signify the evolving pathologic stages of the disease, with early noncaseating granulomas and subsequent caseation necrosis. Recognition of these hypodense lymph nodes, especially in patients at risk, should help optimize the correct diagnosis of periportal tuberculous adenitis.