False suspicion of coronary heart disease: a 7 year follow-up study of 36 apparently healthy middle-aged men.

Abstract

Latent coronary heart disease was suspected in 115 of 2014 apparently healthy middleaged men after a baseline cardiovascular survey. One hundred five of these men underwent angiography and 36 were found to have normal coronary arteries (group 1). A 7 year follow-up survey revealed that: (1) three had died of sudden cardiac death, (2) four had received a diagnosis of cardiomyopathy, (3) one had developed aortic dilatation/aortic regurgitation since the baseline survey, (4) they all had a significantly more rapid decline in their physical performance and maximal heart rate levels from the time of the baseline survey to follow-up than did randomly selected normal controls (group 2), and (5) thallium study results were normal in both groups (27 and 26 patients), but technetium ventriculography revealed a subnormal increase in ejection fraction during exercise (< 5% units) in 14 of 27 group 1 subjects and in 4 of 26 group 2 subjects. Thus, incipient heart disease may be present in subjects in whom coronary angiographic examination has removed a previous suspicion of coronary heart disease.Circulation 68, No. 3, 490-497, 1983. EXERCISE ELECTROCARDIOGRAPHIC (ECG) testing is valuable in the evaluation of patients with chest pain and as a screening procedure in apparently healthy subjects. For the purpose of this study, performed 6 to 9 years after the one described above, the "angionegatives" were assigned to group I, and the men participating as control subjects (group 2) were selected as follows. Each time one of the men from group I was examined, the next man to be examined was designated a normal control subject, provided he belonged to the normal CIRCULATION

Asymptomatic Myocardial Ischemia in Diabetes and Its Relationship to Diabetic Neuropathy: An Exercise Electrocardiography Study in Middle-Aged Diabetic Men

“…22 The clinical significance of a positive exercise test in asymptomatic subjects is controversial because it may occur in the absence of coronary artery disease on angiography. 1523 However, some patients with a positive exercise test but normal coronary arteriograms subsequently develop clinical heart disease, 24 and many have mild cardiac dysfunction suggestive of cardiomyopathy. 24 ' 25 It is possible, therefore, that the increased incidence of a positive exercise test in diabetic patients is partly related to a subclinical cardiomyopathy.…”

“…1523 However, some patients with a positive exercise test but normal coronary arteriograms subsequently develop clinical heart disease, 24 and many have mild cardiac dysfunction suggestive of cardiomyopathy. 24 ' 25 It is possible, therefore, that the increased incidence of a positive exercise test in diabetic patients is partly related to a subclinical cardiomyopathy. 26 ' 27 Although abnormal myocardial metabolism in diabetes might also give rise to an increased frequency of false-positive exercise tests, our follow-up data indicate that the risk of developing coronary heart disease is at least as great in diabetic patients with a positive test as it is in nondiabetic subjects, and it seems unlikely, therefore, that a false-positive test is more common in diabetic patients.…”

The utility of a ‘non-significant’ coronary angiogram

“…This is curious given that the bulk of available data within the literature supports medical therapy over early intervention in the majority of stable patients (18). However, there are a number of plausible explanations for this: First, the negative (and positive) predictive value of investigations including the exercise treadmill test, stress echocardiogram and nuclear scintigraphy are far from ideal and can result in diagnostic uncertainty, particularly as each provides physiological rather than anatomical data (19)(20)(21); Second, increasing pressure on rapid patient throughput in the healthcare system has led to a 'one-stop' clinic approach, where a definitive management plan is formulated at the initial clinic visit; third, there has been a progressive shift in many healthcare systems (including ours) towards a more 'defensive' style of medical practice with anatomical-imaging often being considered essential for diagnostic certainty (22). Interestingly, the approach of direct referral for angiography without preprocedural non-invasive assessment (at least in those with typical angina and high pretest probability (> 67%) for coronary disease) is advocated by some current guidelines for management of stable angina pectoris (1).…”

Noninvasive Testing of Silent Myocardial Ischemia

“…The majority of asymptomatic patients with an abnormal exercise test, who have no risk factors, will not have coronary disease, according to Bayes' Theorem; however, in some of the published studies [6,8] this has not turned out to be the case. These contradictions man date careful interpretation of exercise testing results in this population.…”

“…The epidemiological data from the Seat tle Heart Watch study of Bruce et al [7] indicate testing those with risk factors is most productive. Erikssen et al [8] did angiographies on 105 asymptomatic patients, because during a screening test they were found to have exercise-induced ST depression. These authors found abnormal coronary arteries in 69 patients with a predic tive value of 69 %.…”