Cardiovascular risk associated with long-term anabolic-androgenic steroid abuse: an observational study from Norway

Background The use of anabolic-androgenic steroids (AAS) has become highly prevalent among recreational weightlifters. Numerous case reports have suggested an association between AAS use and a vast range of different cardiovascular diseases, including sudden cardiac death (SCD) and coronary artery disease (CAD). Few clinical studies have evaluated the risk of SCD and the prevalence of CAD in individuals with long-term AAS use. Purpose To evaluate the risk of ventricular arrhythmias and the prevalence of CAD among men with long-term AAS use. Methods Strength-trained men with at least three years of cumulative AAS use were recruited from recreational gyms. The control group consisted of strength-trained competing athletes who self-reported never using any performance enhancing drugs (non-users). AAS use was verified by sophisticated blood and urine analyses. Study participants went through a comprehensive cardiovascular evaluation including exercise ECG, 24 h ECG, heart rate variability (HRV) measures, signal averaged ECG (SAECG) and QT dispersion (QTd). Coronary computed tomography angiography (CCTA) was performed in AAS users. Not all participants had all tests. Results We included 51 AAS users and 21 non-users. Median age (25th-75th percentile) was 33 (29–37) years in the user group and 33 (29–42) years in the non-user group. Forty-eight (94%) of the users had been using AAS for five years or more. Characteristics are presented in the table. AAS users had significantly lower HDL values compared to non-users (p<0.001). No signs of ischemia or arrhythmias were detected during exercise ECG, however maximal exercise capacity was lower than in the control group and also compared to age-standardized values. A considerable, but statistically non-significant reduction was seen in overall HRV estimated as the standard deviation of the RR intervals for normal sinus beats (SDNN) (p=0.05). No difference was seen regarding left ventricular late potentials or QTd (table). Eight (19%) of the forty-two AAS users undergoing CCTA had at least a mild degree of CAD, and four of them three-vessel disease. Conclusion No ECG-findings indicated an increased risk of ventricular arrhythmias among the long-term AAS users. However, their maximal exercise capacity was lower than in controls, and one fifth of the long-term AAS users had verified CAD on CT coronary angiography. FUNDunding Acknowledgement Type of funding sources: None. Table 1

A DETECTION SYSTEM OF EXERCISE ELECTROCARDIOGRAM

ABSTRACT Introduction: A new exercise electrocardiogram (ECG) detection system was investigated in this study to diagnose and analyze cardiopulmonary function and related diseases in a comprehensive and timely manner and improve the accuracy of diagnosis. Besides, its reliability and clinical applicability were judged. Objective: A new type of exercise ECG detection system was constructed by adding parameters such as respiratory mechanics, carbon dioxide, and oxygen concentration monitoring based on the traditional ECG detection system. Methods: The new system constructed in this study carried out the ECG signal detection, ECG acquisition module, blood pressure and respiratory mechanics detection and conducted a standard conformance test. Results: The heart rate accuracy detected by the exercise ECG system was greatly higher than that of the doctor's manual detection (P < 0.05). The accuracy of the new exercise ECG detection system increased obviously in contrast to that of the manual detection result (P < 0.05). The key technical index input noise and input impedance test results (24.5 μV and 12.4 MΩ) of the exercise ECG detection system conformed to the standard (< 30 μV and > 2.5 MΩ). The common-mode rejection and sampling rate test results (103.5 dB and 515 Hz) of key technical indicators in the exercise ECG detection system were all in line with the standards (≥89 dB and ≥500 Hz). Conclusion: The complete exercise ECG detection system was constructed through the ECG acquisition module, blood pressure detection, and respiratory mechanics detection module. In addition, this system could be applied to detect ECG monitoring indicators with high accuracy and reliability, which could also be extensively adopted in clinical diagnosis. Level of evidence II; Therapeutic studies - investigation of treatment results.

Errors during the exercise test for the diagnosis of Coronary heart disease: negative result in the presence of three-vessel coronary artery disease

The exercise ECG test is traditionally the first choice in patients with suspected CHD, as the most accessible, despite the fact that its sensitivity and specificity are 68 % and 77 %, respectively. Description of a clinical case of multivessel coronary artery disease in a patient with a negative result of exercise ECG test is presented.

Myocardial Ischemia in the Management of Chronic Coronary Artery Disease

For many years, stress-induced myocardial ischemia has been considered important in the management of chronic coronary artery disease. Early evidence focused on the exercise ECG and the Duke treadmill score. In the 1970s, randomized clinical trials, which compared coronary artery bypass surgery to medical therapy, enrolled patients who were very different from contemporary practice and had inconsistent results. Surgery appeared to be of greatest benefit in high-risk patients defined by anatomy (such as left main disease) or stress-induced ischemia. However, randomized clinical trials of revascularization versus contemporary medical therapy over the past 20 years have been surprisingly negative. Nuclear cardiology substudies from these trials reported inconsistent results. Two observational studies from a single-center provided the best evidence for the use of stress-induced ischemia to identify patients who were most likely to benefit from revascularization. The recently completed ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) was designed to test the hypothesis that revascularization would improve outcomes in patients with moderate-severe ischemia on stress testing. Unfortunately, 14.2% of the randomized patients had either mild or no ischemia on core lab review. Nearly one-quarter of the patients were randomized on the basis of an exercise ECG without imaging. The negative results of the trial reflect the long-term population decline in coronary artery disease and abnormal stress tests, as well as improvements in patient outcome due to optimal medical therapy. Topics requiring further research are presented. The implications of the trial for the use of both stress imaging and coronary computed tomography angiography in clinical practice are examined.

Recognition System Using Fusion Normalization Based on Morphological Features of Post-Exercise ECG for Intelligent Biometrics

Although biometrics systems using an electrocardiogram (ECG) have been actively researched, there is a characteristic that the morphological features of the ECG signal are measured differently depending on the measurement environment. In general, post-exercise ECG is not matched with the morphological features of the pre-exercise ECG because of the temporary tachycardia. This can degrade the user recognition performance. Although normalization studies have been conducted to match the post- and pre-exercise ECG, limitations related to the distortion of the P wave, QRS complexes, and T wave, which are morphological features, often arise. In this paper, we propose a method for matching pre- and post-exercise ECG cycles based on time and frequency fusion normalization in consideration of morphological features and classifying users with high performance by an optimized system. One cycle of post-exercise ECG is expanded by linear interpolation and filtered with an optimized frequency through the fusion normalization method. The fusion normalization method aims to match one post-exercise ECG cycle to one pre-exercise ECG cycle. The experimental results show that the average similarity between the pre- and post-exercise states improves by 25.6% after normalization, for 30 ECG cycles. Additionally, the normalization algorithm improves the maximum user recognition performance from 96.4 to 98%.

Abstract 14953: Temporal Trends in Non-invasive Diagnostic Tests for Ischemic Heart Disease Among Us Adults Age 64 Years or Younger: Results From the Marketscan Survey, 2010-2018

Introduction: Heart disease is the leading cause of death in the U.S. Ischemic heart disease (IHD) accounts for two thirds of heart disease deaths. Non-invasive cardiovascular tests (NITs) are often the first step to establish an IHD diagnosis. Methods: We analyzed 2010-2018 IBM® MarketScan® Commercial Databases. NITs including exercise ECG, stress echocardiography, CT coronary artery calcification score (CT-CAC), single-photon emission computerized tomography (SPECT), cardiac CT angiography (CTA), nuclear positron emission tomography/myocardial perfusion imaging (PET/MPI), stress MRI, were identified using current procedural terminology (CPT) codes. IHD using ICD 9/10 codes (410-414, 429.2/I20-I25) and chest pain (786.59/R07.89) or unspecified chest pain (786.50/R07.9) were identified. The 2000 Census population was used to calculate the age standardized prevalence. Results: The data included 20,726,587 individuals (48.1% men, mean age (standard deviation) of 49.1 (13.5) years), among which 67,339 had a diagnosis of IHD or chest pain in 2018. The age standardized prevalence of the overall population that had at least one of the 7 tests is 1.60% in 2018, down from 2.47% in 2010. The responding prevalence for those with IHD or chest pain was 54.3% in 2018 and 61.6% in 2010. Exercise ECG was the most utilized test for the overall population: 0.94% in 2018 down from 1.31% in 2010; SPECT was second most often used with 0.75% in 2018 and 1.24% in 2010. However, SPECT was the most often utilized test among those with CHD or chest pain: 38.2% in 2018, down from 45.0% in 2010, and exercise ECG second most often with 32.6% in 2018 and 34.9% in 2010. An increase in use of CT-CAC, PET/MPI, and CTA tests was observed since 2010, but the prevalence of all were low in 2018. 0.02%. 0.01%, and 0.04% for the overall population and 0.20%, 0.95% and 3.20% for those with IHD or chest pain, respectively. Conclusions: Almost 2% of the general younger US adult population and over half of those with IHD or chest pain had undergone at least one of 7 NITs in 2018. While the utilization of overall NITs for both the general population and those with IHD or chest pain has declined since 2010, it has increased for CT-CAC, PET/MPI, and CTA but still less than 1% for CT-CAC and PET/MPI..

Real world cost and health outcomes of patients presented with chest pain in England: which is the most cost-effective first-line test?

Background The National Institute for Health and Care Excellence (NICE) updated their guidance for the management of patients with stable chest pain and recommended that all patients undergo computed tomography coronary angiography (CTCA). This update has sparked a great deal of debate, and was followed by upgrade of CTCA into a Class I indication in the recent ESC guidelines. The cost-effectiveness of using CTCA as first line investigation is still unclear. Purpose To describe the current clinical pathway of patients with stable chest pain presented to outpatient clinics, assess the compliance with the updated NICE guideline, and explore the costs and health outcomes of different non-invasive diagnostic tests in real-world clinical setting. Methods We used data of 4,297 patients who attended chest pain clinics in Oxford between 1 January 2014 and 31 July 2018. Data included clinical presentation (e.g. age and previous cardiovascular conditions), diagnostic tests, outpatient visits, hospitalization, and hospital mortality and was compared between 6 alternative first-line diagnostic tests. Multinomial regressions were performed to estimate the probability of receiving each alternative and the associated cost after adjusting for clinical presentation. A decision tree was developed to describe the clinical pathway for each alternative first-line diagnostic in terms of subsequent diagnostic tests and treatments and to estimate the associated costs and life days. Results The proportion of patients who received CTCA as first line diagnostic test increased from 1% in 2014 to 17% in 2018, while the publication of the updated NICE guidelines in 2016 led to a threefold increase in this proportion. CTCA is less likely to be provided as a first-line diagnostic to patients who are younger age, males, smokers, and have angina, PVD, or diabetes. The standardised rate of hospital admission was the lowest in the exercise ECG cohort (0.35 admissions per 1,000 life-days) followed by the CTCA cohort (0.40 admissions per 1,000 life-days) while the latter cohort had the lowest standardised rate of cardiovascular treatment (2.74% per 1,000 life days). Stress echocardiography and MPS were associated with higher costs compared with CTCA, other ECG, and exercise ECG after adjusting for clinical presentation and days of follow-up. CTCA is the pathway most likely to be cost-effective, even compared to exercise ECG, while the other diagnostic alternatives are dominated (i.e. they cost more for less life-days). Conclusions Currently, the updated NICE guidelines for stable chest pain are implemented only to a fifth of the cases in England. Our findings support existing evidence that CTCA is the most-cost effective first-line diagnostic test for this population. Hopefully, this will inform the debate around the implementation of the guidelines and help commissioning and clinical decision processes worldwide. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research Oxford Biomedical Research Centre

Chest pain of unknown coronary origin: can exercise ECG testing contribute to long-term risk prediction on top of vasodilator stress cardiac magnetic resonance?

Background The prognostic value of both exercise ECG testing (ExECG) and vasodilator stress cardiac magnetic resonance (VS-CMR) is well-known in patients with chest pain of unknown coronary origin. However, it is unknown whether performing both techniques can improve the risk stratification of these patients. Purpose We aim to confirm the additive prognostic value of ExECG and VS-CMR in a real-world cohort of patients with chest pain of unknown coronary origin. Methods We retrospectively included 288 patients in which ExECG and VS-CMR had been subsequently performed within one year. Clinical, ExECG and VS-CMR variables were registered. We performed univariate and multivariate analysis to check for the association of variables with the risk of MACE, defined as a combined endpoint of acute coronary syndrome (ACS), admission for heart failure (aHF) or all-cause death. Results During a mean follow-up of 4.2±2.15 years, we registered 27 MACE (15 ACS, 8 aHF and 8 all-cause deaths). The history of hypertension, previous coronary artery disease and/or coronary artery bypass grafting, lower maximal heart rate during ExECG (maxHR) and more extensive ischemic burden (segments with perfusion defects -PD- on stress first-pass perfusion) and myocardial necrosis (number of segments with necrosis at late gadolinium enhancement imaging) associated with the MACE endpoint. However, the only independent predictors of MACE were maxHR during ExECG (HR 0.98 [0.96–0.99], p=0.01) and more extensive segments with PD in the VS-CMR (HR 1.2 [1.07–1.34], p=0.002). We identified the best cut-off using the Youden index derived from receiver operating characteristics (ROC) analysis to predict MACE - it was ≤130bpm for maxHR during ExECG and ≥2 segments with PD on VS-CMR. These cathegories allowed us to stratify the annualized rate of MACE, which was very low (0.97%/year) in patients with normal maxHR and no PD on VS-CMR, intermediate in patients with only abnormal maxHR (1.98%/year) or PD on VS-CMR (3.24%/year) and high in patients with both abnormal maxHR and segments with PD (6.26%/year). Adding maxHR to the multivariable model including stress-induced PD by VS-CMR significantly improved the predictive power of MACE as derived from the continuous reclassification improvement index (0.47 [0.10–0.81], p&lt;0.05). Conclusions ExECG and VS-CMR can have an additive prognostic value to predict the long-term risk of MACE in patients with chest pain of unknown coronary origin. Patients with maxHR during ExECG ≤130bpm and ≥2 segments with PD on VS-CMR are at the highest risk of MACE. Figure 1. MACE risk stratification. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and by Generalitat Valenciana (GV/2018/116).