The purpose of this report is to provide revised standards and guidelines for the exercise testing and training of individuals who are free from clinical manifestations of cardiovascular disease and those with known cardiovascular disease. These guidelines are intended for physicians, nurses, exercise physiologists, specialists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. This report is in accord with the “Statement on Exercise” published by the American Heart Association (AHA).1

These guidelines are a revision of the 1995 standards of the AHA that addressed the issues of exercise testing and training.2 An update of background, scientific rationale, and selected references is provided, and current issues of practical importance in the clinical use of these standards are considered. These guidelines are in accord with the American College of Cardiology (ACC)/AHA Guidelines for Exercise Testing.3

### The Cardiovascular Response to Exercise

Exercise, a common physiological stress, can elicit cardiovascular abnormalities that are not present at rest, and it can be used to determine the adequacy of cardiac function. Because exercise is only one of many stresses to which humans can be exposed, it is more appropriate to call an exercise test exactly that and not a “stress test.” This is particularly relevant considering the increased use of nonexercise stress tests.

### Types of Exercise

Three types of muscular contraction or exercise can be applied as a stress to the cardiovascular system: isometric (static), isotonic (dynamic or locomotory), and resistance (a combination of isometric and isotonic).4,5 Isotonic exercise, which is defined as a muscular contraction resulting in movement, primarily provides a volume load to the left ventricle, and the response is proportional to the size of the working muscle mass and the intensity of exercise. Isometric exercise is defined as a muscular contraction without movement (eg, handgrip) and imposes greater pressure than volume …

Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association

Methods We conducted a multicenter study to examine the accuracy of 64-row, 0.5-mm multidetector CT angiography as compared with conventional coronary angiography in patients with suspected coronary artery disease. Nine centers enrolled patients who underwent calcium scoring and multidetector CT angiography before conventional coronary angiography. In 291 patients with calcium scores of 600 or less, segments 1.5 mm or more in diameter were analyzed by means of CT and conventional angiography at independent core laboratories. Stenoses of 50% or more were considered obstructive. The area under the receiver-operating-characteristic curve (AUC) was used to evaluate diagnostic accuracy relative to that of conventional angiography and subsequent revascularization status, whereas disease severity was assessed with the use of the modified Duke Coronary Artery Disease Index. Results A total of 56% of patients had obstructive coronary artery disease. The patient-based diagnostic accuracy of quantitative CT angiography for detecting or ruling out stenoses of 50% or more according to conventional angiography revealed an AUC of 0.93 (95% confidence interval [CI], 0.90 to 0.96), with a sensitivity of 85% (95% CI, 79 to 90), a specificity of 90% (95% CI, 83 to 94), a positive predictive value of 91% (95% CI, 86 to 95), and a negative predictive value of 83% (95% CI, 75 to 89). CT angiography was similar to conventional angiography in its ability to identify patients who subsequently underwent revascularization: the AUC was 0.84 (95% CI, 0.79 to 0.88) for multidetector CT angiography and 0.82 (95% CI, 0.77 to 0.86) for conventional angiography. A per-vessel analysis of 866 vessels yielded an AUC of 0.91 (95% CI, 0.88 to 0.93). Disease severity ascertained by CT and conventional angiography was well correlated (r = 0.81; 95% CI, 0.76 to 0.84). Two patients had important reactions to contrast medium after CT angiography. Conclusions Multidetector CT angiography accurately identifies the presence and severity of obstructive coronary artery disease and subsequent revascularization in symptomatic patients. The negative and positive predictive values indicate that multidetector CT angiography cannot replace conventional coronary angiography at present. (ClinicalTrials.gov number, NCT00738218.)

/pdf/diagnostic-performance-of-coronary-angiography-by-64-row-ct-3zffdrg47c.pdf

Diagnostic Performance of Coronary Angiography by 64-Row CT

http://www.area-c54.it/public/accaha%202007%20guidelines%20on%20perioperative%20cardiovascular%20evaluation%20and%20care%20for%20noncardiac%20surgery.pdf

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

http://unmhospitalist.pbworks.com/f/ACC+Preoperative+risk+2008.pdf

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(11)61335-4.pdf

Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial

Background— Dobutamine stress MR (DSMR) is highly accurate for the detection of inducible wall motion abnormalities (IWMAs) Adenosine has a more favorable safety profile and is well established for the assessment of myocardial perfusion We evaluated the diagnostic value of IWMAs during dobutamine and adenosine stress MR and adenosine MR perfusion compared with invasive coronary angiography Methods and Results— Seventy-nine consecutive patients (suspected or known coronary disease, no history of prior myocardial infarction) scheduled for cardiac catheterization underwent cardiac MR (15 T) After 4 minutes of adenosine infusion (140 μg · kg−1 · min−1 for 6 minutes), wall motion was assessed (steady-state free precession), and subsequently perfusion scans (3-slice turbo field echo-echo planar imaging; 005 mmol/kg Gd-BOPTA) were performed After a 15-minute break, rest perfusion was imaged, followed by standard DSMR/atropine stress MR Wall motion was classified as pathological if ≥1 segment showed IWMAs

Comparison of Dobutamine Stress Magnetic Resonance, Adenosine Stress Magnetic Resonance, and Adenosine Stress Magnetic Resonance Perfusion

A 60-year-old white man initially presented to the outpatient clinic in 2002 complaining of atypical chest pain during the last 6 months. A resting ECG showed high R waves and giant negative T waves in the anterior leads (Figure). Cardiovascular magnetic resonance (CMR) showed the typical appearance of apical hypertrophic cardiomyopathy (Figure, A and B). Delayed enhancement imaging did not show relevant scar tissue during the baseline study (Figure, C and D). The patient was put on a β-blocker and an angiotensin-converting enzyme inhibitor and was asked to come back for a follow-up examination 2 years later. 



Left, …

Progressive Myocardial Fibrosis in a Patient With Apical Hypertrophic Cardiomyopathy Detected by Cardiovascular Magnetic Resonance

A rare case of a primary fibrosarcoma of the liver infiltrating the right heart is described in a 72-year-old woman The patient presented with a history of progressive dyspnea and ascites and her general condition was poor Preoperative cardiac magnetic resonance (CMR) imaging revealed a large mass, which originated from the liver and had infiltrated the right atrium via the inferior vena cava The patient underwent tumor resection yet died shortly afterwards Histologically the mass was classified as a fibrosarcoma with positive immunostaining for vimentin We report the CMR imaging characteristics in this uncommon case Preoperative CMR proved to be useful for clinical decision making and the planning of surgery

Primary fibrosarcoma of the liver infiltrating the right atrium of the heart.

Purpose. Different centers and vendors use different sequences and contrast agent application schemes for MR myocardial perfusion imaging. The purpose of this study was to evaluate the role of different sequences, dosages, and injection speeds of contrast media for semiquantitative MR-perfusion assessment. Methods. In a pilot study with 58 consecutive patients three of the most commonly used sequences for MR myocardial perfusion imaging (T1-GrE, GrE-EPI or SSFP) were compared to each other in terms of peak myocardial enhancement and image quality. For the main part of the study dynamic first pass MR perfusion imaging (Philips Intera CV, Best, the Netherlands) was performed in 24 patients using the most favorable sequence from the pilot study (SSFP) after peripheral i.v. administration of Gd-BOPTA during adenosine stress. Two doses (0.05 mmol/kg bw and 0.025 mmol/kg bw) and four different injection speeds (8, 4, 3, 2 ml/s) were used. Signal intensity time curves were determined in the LV and myocardial seg...

Determinants of myocardial response in CMR perfusion imaging using Gd-BOPTA (Multihance).

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Papers

Comparison of Dobutamine Stress Magnetic Resonance, Adenosine Stress Magnetic Resonance, and Adenosine Stress Magnetic Resonance Perfusion

Progressive Myocardial Fibrosis in a Patient With Apical Hypertrophic Cardiomyopathy Detected by Cardiovascular Magnetic Resonance

Primary fibrosarcoma of the liver infiltrating the right atrium of the heart.

Determinants of myocardial response in CMR perfusion imaging using Gd-BOPTA (Multihance).