title: Abnormal left ventricular contractile response to exercise in the absence of obstructive coronary artery disease is associated with resting left ventricular long-axis dysfunction.
abstract: BACKGROUND
  The etiology of reduced left ventricular (LV) ejection fraction after exercise, without obstructive coronary artery disease or other established causes, is unclear. The aims of this study were to determine whether patients undergoing treadmill stress echocardiography with this abnormal LV contractile response to exercise (LVCRE) without established causes have resting LV long-axis dysfunction or microvascular dysfunction and to determine associations with this abnormal LVCRE.
  
  
  METHODS
  Of 5,275 consecutive patients undergoing treadmill stress echocardiography, 1,134 underwent cardiac computed tomography angiography or invasive angiography. Having excluded patients with obstructive coronary artery disease, hypertensive response, submaximal heart rate response, resting LV ejection fraction < 50%, and valvular disease, 110 with "abnormal LVCRE" and 212 with "normal LVCRE" were analyzed. Resting mitral annular velocities were measured to assess LV long-axis function. Myocardial blush grade and corrected Thrombolysis In Myocardial Infarction frame count were determined angiographically to assess microvascular function.
  
  
  RESULTS
  Comparing normal LVCRE with abnormal LVCRE, age (mean, 59.7 ± 11.1 vs 61.4 ± 10.0 years), hypertension (53% vs 55%), diabetes (16% vs 20%), and body mass index (mean, 29.1 ± 5.4 vs 29.5 ± 6.4 kg/m(2)) were similar (P > .05). Abnormal LVCRE had reduced resting LV long-axis function with lower septal (mean, 6.1 ± 1.9 vs 7.7 ± 2.2 cm/sec) and lateral (mean, 8.1 ± 2.9 vs 10.4 ± 3.0 cm/sec) e' velocities (P < .001) and larger resting left atrial volumes (mean, 37.3 ± 10.1 vs 31.1 ± 7.2 mL/m(2), P < .001). On multivariate analysis, female gender (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.15-1.99; P < .001), exaggerated chronotropic response (OR, 1.49; 95% CI, 1.09-2.05; P < .001), resting left atrial volume (OR, 2.38; 95% CI, 1.63-3.47; P < .001), and resting lateral e' velocity (OR, 1.70; 95% CI, 1.22-2.49; P = .003) were associated with abnormal LVCRE, but not myocardial blush grade or corrected Thrombolysis In Myocardial Infarction frame count.
  
  
  CONCLUSIONS
  An abnormal LVCRE in the absence of established causes is associated with resting LV long-axis dysfunction and is usually seen in women.
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia. Electronic address: arthur.nasis@monashhealth.org.
authors.forename: Arthur
authors.initials: A
authors.lastname: Nasis
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Stuart
authors.initials: S
authors.lastname: Moir
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Ian T
authors.initials: IT
authors.lastname: Meredith
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Timothy L
authors.initials: TL
authors.lastname: Barton
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Nitesh
authors.initials: N
authors.lastname: Nerlekar
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Dennis T
authors.initials: DT
authors.lastname: Wong
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Brian S
authors.initials: BS
authors.lastname: Ko
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: James D
authors.initials: JD
authors.lastname: Cameron
authors.affiliation: Monash Cardiovascular Research Centre, MonashHEART, Monash Health and Monash University Department of Medicine (MMC), Melbourne, Australia.
authors.forename: Philip M
authors.initials: PM
authors.lastname: Mottram
mesh_terms: D017677:Age Distribution; D015984:Causality; D015897:Comorbidity; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D005080:Exercise Test / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008875:Middle Aged; D015203:Reproducibility of Results; D012307:Risk Factors; D012680:Sensitivity and Specificity; D017678:Sex Distribution; D014463:Ultrasonography; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D014739:Victoria / Q000453:epidemiology
keywords: Coronary angiography; Exercise echocardiography; Microvascular dysfunction; Myocardial function