Exercise Testing and Training in Coronary Heart Disease

This study on "Exercise testing and training in coronary heart disease" is a remarkable compilation of numerous research studies, primarily from labora­ tories in Europe and the United States over the last decade or more. The topic reflects a growing awareness of and concern about the rapidly expanding understanding of the pathophysiology of coronary atherosclerotic heart disease. Since muscular exercise increases aerobic metabolism of myocardial and working skeletal muscles, greater flow of oxygenated blood is required by each; yet underlying vascular disease restricts these responses. This implicit paradox is here considered forthrightly. Examination of these relationships in symptomatic patients requires care and caution, because of the potential and occasionally real risks entailed. Accordingly, indirect assessment, particularly by noninvasive techniques, becomes increasingly important to detecting and monitoring - for the safety of the patients studied - the evidence of myocardial ischemia and impairment of left ventricular function under stress. Adequate assessment requires well-designed experimental studies to quantify true relationships and to measure the limits of functional capacity and the mechanisms of its impairment. Further­ more, alterations can be induced by therapy, whether this be pharmacological, medical or surgical, or achieved by physical reconditioning through exercise training. Not only is the cardiovascular system impaired by discrete and diffuse vascular lesions at central sites, but the degree of impairment is dynamic rather than static.

I: Physiological Considerations.- Cardiovascular Response To Exercise.- A. Dynamic leg exercise..- 1. Increased transport of oxygen..- 2. Widening of the total ?-v02 difference..- 3. Redistribution of the cardiac output..- 4. Adaptative mechanisms..- B. Isometric exercise..- C. Prolonged and repeated exercise..- D. Environmental factors..- E. Influence of sex and age..- Coronary Blood Flow and the Determinants Of MyoCardial Oxygen Consumption.- A. The regulation of the coronary blood flow..- 1. Metabolic factors..- 2. Physical factors..- 3. Neural and neurohumoral factors..- B. Determinants of myocardial oxygen consumption..- 1. Intramyocardial tension..- 2. Contractile state of the myocardium..- 3. Heart rate..- 4. Other factors..- 5. Indices reflecting myocardial oxygen requirements..- II: Exercise Electrocardiography.- Pathophysiology of Ischemic Electrocardiographic Changes with Exercice..- A. Hemodynamic determinants..- B. Metabolic factors..- Methods in Exercise Electrocardiography..- A. Type of exercise tests..- 1. Single-stage tests..- 2. Multistage tests..- B. Technical aspects. Leads systems..- C. Risks of exercise testing. Precautions..- Criteria for Interpretation..- A. Ischemic ST depression..- B. Slowly ascending ST depression..- C. ST segment elevation..- D. Other criteria..- E. Observer variation. Need for quantification..- Diagnostic and Prognostic Power of Exercise Electrocardiography..- A. Documented coronary heart disease..- 1. Master’s double two-step test..- 2. Multistage tests..- 3. False negative responses..- 4. False positive responses..- B. Latent coronary heart disease..- C. Miscellaneous conditions..- 1. Rheumatic heart disease..- 2. Hypertension..- 3. Congenital abnormalities of the coronary arteries..- 4. « Non specific » electrocardiographic abnormalities..- Influence of Therapeutics on Exertional Electrocardiogram.- A. Nitroglycerin..- B. Beta blocking agents..- C. Digitalis..- D. Physical training..- E. Surgical myocardial « revascularisation »..- III: Physical Work Capacity In Coronary Heart Disease.- Physical Work Capacity Of Healthy Subjects..- A. Methods..- 1. Direct measurement of maximal oxygen intake..- 2. Prediction of maximal oxygen intake..- B. Physiological implications of maximal oxygen intake..- 1. Influence of age, sex and weight..- 2. Maximal oxygen intake and capacity for prolonged work..- Physical Work Capacity of Coronary Patients..- A. Coronary patients without angina pectoris..- 1. Maximal heart rate..- 2. Cardiac output..- 3. Filling pressure of the left ventricle..- 4. Stroke volume..- 5. Calculated maximal hemodynamic data..- B. Coronary patients with angina pectoris..- 1. Pathophysiology of angina pectoris..- 2. Factors modifying the anginal threshold..- IV: Physical Training In Coronary Heart Disease.- Physiological Characteristics Of Athletes..- A. Maximal cardiac output..- B. Maximal arterio-venous oxygen difference..- C. Dimensions of the oxygen transport system..- D. Effects of aging..- E. Former athletes..- Physical Training of Healthy Sedentary Subjects..- A Maximal oxygen intake..- 1. Initial level of physical fitness..- 2. Intensity of physical training..- 3. Influence of age and sex..- B. Hemodynamic responses at the maximal exercise level..- C. Submaximal exercise data..- D. Heart volume..- E. Mechanisms of action of physical training..- Physical Training of Coronary Patients..- A. Methods..- 1. Selection of patients..- 2. Intensity of physical training..- 3. Types of exercises..- 4. Risks of physical training..- B. Resting and submaximal exercise data..- 1. Heart rate..- 2. Cardiac output..- 3. Distribution of cardiac output..- C. Physical work capacity..- 1. Patients without angina pactoris..- 2. Angina patients..- D. Unsolved questions..- Conclusions.- Conclusions (French).