Objectives:The aim of this study was to assess the diagnostic value of exercise stress testing to detect coronary heart disease (CHD) in the group of patients with metabolic syndrome.
Design and methods: 2803 patients without prior diagnosis of CHD and identified metabolic syndrome were investigated. Subjects underwent electrocardiogram (ECG) stress testing and, depending on the results, coronary angiography and/or coronary computed tomography angiography to detect hemodynamically significant stenosis. CHD was confirmed, if lumen narrowing ≥ 50% of coronary arteries was found.
Results: Exercise stress testing was interpreted as positive in 12% patients (71.7% women and 28.3% men). CHD was diagnosed in 45 patients (1.6%), 23 of them had positive exercise stress testing. ECG stress testing was more frequently positive in patients, who had typical/atypical anginal chest pain, dyspnea and/or non-anginal chest pain, in comparison to asymptomatic patients (16.6% vs 8.9%, p <0.001). CHD was more often diagnosed in symptomatic patients compared to patients with no symptoms (6.1% vs 0.7%, p < 0.001, women 5.3% vs 0.6%, p < 0.001, men respectively 8% vs 0.8%, p < 0.001).
Conclusions: Diagnostic value of exercise stress testing for detecting CHD is limited in population with metabolic syndrome. CHD was more prevalent in patients with chest pain or dyspnea than in asymptomatic patients.
 Wannamethee SG, Shaper AG, Lennon L, Morris RW. Metabolic syndrome vs Framingham Risk Score for prediction of coronary heart disease, stroke, and type 2 diabetes mellitus. Arch Intern Med 2005;165:2644–50.
 Mottillo S, Filion KB, Genest J, Joseph L, Pilote L, Poirier P, et al. The metabolic syndrome and cardiovascular risk: a systematic review and meta-analysis. J Am Coll Cardiol 2010;56:1113–32.
 Zhang Y, Bao M, Dai M, Zhong H, Li Y, Tan T. QT hysteresis index improves the power of treadmill exercise test in the screening of coronary artery disease. Circ J 2014;78:2942–9.
 Dowsley T, Al-Mallah M, Ananthasubramaniam K, Dwivedi G, McArdle B, Chow BJW. The role of noninvasive imaging in coronary artery disease detection, prognosis, and clinical decision making. Can J Cardiol 2013;29:285–96.
 Pasierski T, Szwed H, Malczewska B, Firek B, Kośmicki M, Rewicki M, et al. Advantages of exercise echocardiography in comparison to dobutamine echocardiography in the diagnosis of coronary artery disease in hypertensive subjects. J Hum Hypertens 2001;15:805–9.
 Jian-ling S, Ying Z, Yu-lian G, Li-juan Xiong, Ji-hong G, Xiao-ying L. Coronary heart disease diagnosis bases on the change of different parts in treadmill exercise test ECG. Cell Biochem Biophys 2013;67:969–75.
 Sharma K, Kohli P, Gulati M. An update on exercise stress testing. Curr Probl Cardiol 2012;37:177–202.
 Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793–800.
 Banerjee A, Newman DR, Van den Bruel A, Heneghan C. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. Int J Clin Pract 2012;66:477–92.
 Canpolat U, Özer N. Noninvasive cardiac imaging for the diagnosis of coronary artery disease in women. Anadolu Kardiyol Derg 2014;14:741–6.
 Abdallah MS, Spertus JA, Nallamothu BK, Kennedy KF, Arnold SV, Chan PS. Symptoms and angiographic findings of patients undergoing elective coronary angiography without prior stress testing. Am J Cardiol 2014;114:348–54.
 Lauer M, Froelicher ES, Williams M, Kligfield P. Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2005;112:771–6.
 Chou R. Cardiac screening with electrocardiography, stress echocardiography, or myocardial perfusion imaging: advice for high-value care from the American College of Physicians. Ann Intern Med 2015;162:438–47.
 Laucevičius A, Rinkūnien ėE, Skorniakov V, Petrulionien ė Z, Kasiulevičius V, Jatužis D, et al. High-risk profile in a region with extremely elevated cardiovascular mortality. Hellenic J Cardiol 2013;54:441–7.
 Myers J, Arena R, Franklin B, Pina I, Kraus WE, McInnis K, et al. Recommendations for clinical exercise laboratories a scientific statement from the American Heart Association. Circulation 2009;119:3144–61.
 Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40:1531–40.
 Hill J, Timmis A. Exercise tolerance testing. BMJ 2002;324:1084–7.
 Hoang KC, Ghandehari H, Lopez VA, Barboza MG, Wong ND. Global coronary heart disease risk Assessment of individuals with the metabolic syndrome in the U.S. Diabetes Care 2008;31:1405–9.
 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012;126:e354–471.
 Kohli P, Gulati M. Exercise stress testing in women going back to the basics. Circulation 2010;122:2570–80.
 Chang SM, Nabi F, Xu J, Pratt CM, Mahmarian AC, Frias ME, et al. Value of CACS compared with ETT and myocardial perfusion imaging for predicting long-term cardiac outcome in asymptomatic and symptomatic patients at low risk for coronary disease. JACC Cardiovasc Imaging 2015;8:134–44.
 Shaw LJ. The exercise test is alive and well when coupled with coronary calcium scoring. JACC Cardiovasc Imaging 2015;8:145–7.
 Sicari R, Nihoyannopoulos P, Evangelista A, Kasprzak J, Lancellotti P, Poldermans D, et al. Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC). Eur J Echocardiogr 2008;9:415–37.
 Albers AR, Krichavsky MZ, Balady GJ. Stress testing in patients with diabetes mellitus diagnostic and prognostic value. Circulation 2006;113:583–92.
 Jang JY, Sohn IS, Kim JN, Park JH, Park CB, Jin ES, et al. Treadmill exercise stress echocardiography in patients with no history of coronary artery disease: a single-center experience in Korean population. Korean Circ J 2011;41:528–34.
 Grünig E, Mereles D, Benz A, Hansen A, Kübler W, Kuecherer H. Contribution of stress echocardiography to clinical decision making in unselected ambulatory patients with known or suspected coronary artery disease. Int J Cardiol 2002;84:179–85.
 Southard J, Baker L, Schaefer S. In search of the false-negative exercise treadmill testing evidence-based use of exercise echocardiography. Clin Cardiol 2008;31:35–40.
 Gentile R, Vitarelli A, Schillaci O, Laganà B, Gianni C, Rossi-Fanelli F, et al. Diagnostic accuracy and prognostic implications of stress testing for coronary artery disease in the elderly. Ital Heart J 2001;2:539–45.
 Maffei E, Palumbo A, Martini C, Cuttone A, Ugo F, Emiliano E, et al. Stress-ECG vs. CT coronary angiography for the diagnosis of coronary artery disease: a “real-world” experience. Radiol Med 2010;115:354–67.
 Pontone G, Andreini D, Bartorelli AL, Bertella E, Cortinovis S, Mushtaq S, et al. A long-term prognostic value of CT angiography and exercise ECG in patients with suspected CAD. JACC Cardiovasc Imaging 2013;6:641–50.
 Hamilton-Craig C, Fifoot A, Hansen M, Pincus M, Chan J, Walters DL, et al. Diagnostic performance and cost of CT angiography versus stress ECG – A randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE). Int J Cardiol 2014;177:867–73.
 Douglas PS, Hoffmann U, Patel MR, Mark DB, Al-Khalidi HR, Cavanaugh B, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 2015;372:1291–300.
 Greulich S, Bruder O, Parker M, Schumm J, Grün S, Schneider S, et al. Comparison of exercise electrocardiography and stress perfusion CMR for the detection of coronary artery disease in women. J Cardiovasc Magn Reson 2012;14:36.
 Belardinelli R, Lacalaprice F, Tiano L, Muçai A, Perna GP. Cardiopulmonary exercise testing is more accurate than ECG-stress testing in diagnosing myocardial ischemia in subjects with chest pain. Int J Cardiol 2014;174:337–42.
 Mitu O, Roca M, Leon MM, Mitu F. Predictive value of a positive exercise stress testing and correlations with cardiovascular risk factors. Rev Med Chir Soc Med Nat Iasi 2014;118:57–62.
 Wackers FJT, Young LH, Inzucchi SE, Chyun DA, Davey JA, Barrett EJ, et al. Detection of silent myocardial ischemia in asymptomatic diabetic subjects: the DIAD study. Diabetes Care 2004;27:1954–61.
 Balady GJ, Larson MG, Vasan RS, Leip EP, O’Donnell CJ, Levy D. Usefulness of exercise testing in the prediction of coronary disease risk among asymptomatic persons as a function of the Framingham risk score. Circulation 2004;110:1920–5.